Single-incision laparoscopic cholecystectomy: initial evaluation of a large series of patients

A Comprehensive Analysis of Single-Incision Laparoscopic Cholecystectomy: Trends, Challenges, and Future Directions

Single-incision laparoscopic cholecystectomy (SILC) is a minimally invasive surgical technique introduced as an advancement to laparoscopic cholecystectomy (LC). This narrative review delves into the emergence of SILC, emphasizing its distinct advantages such as improved cosmesis, reduced postoperative pain, and potentially faster recovery compared to traditional LC. The study meticulously examines current trends and challenges in SILC, including variations in techniques and their impact on patient outcomes. Furthermore, the article sheds light on the technical intricacies and longer operative times associated with SILC. It aims to contribute valuable insights to the medical community by synthesizing existing literature and recent research findings, fostering a deeper understanding of SILC, and guiding future advancements in minimally invasive surgical approaches. The discussion extends to the learning curve, complications, and a comparative analysis between SILC and traditional LC, offering a nuanced understanding of their respective strengths and limitations. The article concludes with a forward-looking perspective, exploring future directions and innovations in SILC, including advancements in surgical techniques and the integration of innovative technologies, such as robotic assistance and in vivo robots, to enhance precision and efficacy. The call for continued research into the long-term outcomes, safety, and refined patient selection criteria emphasizes the evolving landscape of SILC and its potential to shape the future of minimally invasive abdominal surgeries.

Neural Network-Based Active Load-Sensing Scheme and Stiffness Adjustment for Pneumatic Soft Actuators for Minimally Invasive Surgery Support

To provide a stable surgical view in Minimally Invasive Surgery (MIS), it is necessary for a flexible endoscope applied in MIS to have adjustable stiffness to resist different external loads from surrounding organs and tissues. Pneumatic soft actuators are expected to fulfill this role, since they could feed the endoscope with an internal access channel and adjust their stiffness via an antagonistic mechanism. For that purpose, it is essential to estimate the external load. In this study, we proposed a neural network (NN)-based active load-sensing scheme and stiffness adjustment for a soft actuator for MIS support with antagonistic chambers for three degrees of freedom (DoFs) of control. To deal with the influence of the nonlinearity of the soft actuating system and uncertainty of the interaction between the soft actuator and its environment, an environment exploration strategy was studied for improving the robustness of sensing. Moreover, a NN-based inverse dynamics model for controlling the stiffness of the soft actuator with different flexible endoscopes was proposed too. The results showed that the exploration strategy with different sequence lengths improved the estimation accuracy of external loads in different conditions. The proposed method for external load exploration and inverse dynamics model could be used for in-depth studies of stiffness control of soft actuators for MIS support.

Single-incision laparoscopic splenectomy in children with massive splenomegaly: A prospective, monocentric pilot study

BACKGROUND

Single-incision laparoscopic splenectomy (SILS) remains a challenging procedure because of the technical difficulty. In this prospective study, we aimed to evaluate the efficacy and safety of SILS in children with massive splenomegaly.

METHODS

Pediatric patients with massive splenomegaly were recruited for SILS in a university-affiliated hospital. The data on patient demographics, clinical features, operative variables, and perioperative outcomes were collected prospectively and analyzed. According to the different surgical instruments, the patients were randomly assigned into two groups: the SILS with straight surgical instrument (SILS-S) group and the SILS with curved surgical instrument (SILS-C) group. A two-group comparative analysis was conducted using perioperative data from the different surgical instrumentation systems.

RESULTS

A total of 120 patients were included, of which 103 patients (success group, 85.83%) had complete SILS, the other 17 (failure group, 14.17%) patients were converted to open (n = 4, 3.33%) or multi-incision laparoscopic surgery (n = 13, 10.83%). The major cause for surgical failure is uncontrollable bleeding (n = 14, 82.35%), and age, height, and weight were the risk factors for failure of SILS, but none of the parameters were independent risk factors. The blood loss in the success group was less than that in the failure group, but no significant differences in other operative and outcome indicators. For SILS, the mean (±SD) operative time was 188 (±48.70) minutes, the median intraoperative blood loss (min, max) was 20 (5, 290) ml, the mean (±SD) time of first anal exhaust was 23.9 (±7.73) hours, and the mean (±SD) postoperative hospital stay was 4.72 (±1.03) days. The median pain score was 3 on 1 day, and 1 on 3 days after the operation. Postoperative complications were identified in 8 (7.77%) cases. However, there were no peri-operative deaths in this series. The SILS-C group had a significantly shorter operation time than the SILS-S group (mean ± SD, 172 ± 44.21 vs. 205 ± 47.90 min). There were no significant differences between the two groups in other perioperative data (P < 0.05).

CONCLUSION

SILS is a safe and feasible treatment in pediatric patients with massive splenomegaly, and curved surgical instrumentation has contributed to developing surgical manipulation.

Single-Port Laparoscopic and Robotic Cholecystectomy in Obesity (>25 kg/m2)

BACKGROUND AND OBJECTIVES

Single-port cholecystectomy has emerged as an alternative technique to reduce the number of ports and improve cosmesis. Few previous studies have assessed obesity-related surgical outcomes following single-port cholecystectomy. In this study, technical feasibility and surgical outcomes of single-port laparoscopic cholecystectomy (SPLC) and robotic single-site cholecystectomy (RSSC) in obese patients were investigated.

METHODS

We conducted a two-center collaborative study and retrospectively reviewed initial experiences of RSSC and SPLC in patients whose body mass index was over 25 kg/m2. Medical records of patients were reviewed. Clinical characteristics and short-term oncologic outcomes were considered and compared between SPLC and RSSC groups.

RESULTS

RSSC and SPLC were performed in 39 and 78 patients, respectively. In comparative analysis, the total operative time was longer in the RSSC group (109.92 minutes vs. 60.99 minutes; P < .001).However, requiring additional port for completion of surgical procedure was less frequent in the RSSC group (0% vs. 12.8%; P = .029). Immediate postoperative pain score was not significantly different between the two groups (4.95 vs. 5.00; P = .882). However, pain score was significantly lower in the RSSC group at the time of discharge (1.79 vs. 2.38; P = .010). Conversion to conventional multiport cholecystectomy, intraoperative bile spillage, or complication rate was not significantly different between the two groups (P > .05).

CONCLUSIONS

SPLC and RSSC could be safely performed in selected patients with high body mass index, showing no significant clinical differences.

A large-cohort comparison between single incision laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy from a single center; 2080 cases

Backgrounds/Aims

This study was conducted to verify and compare the safety and feasibility of single incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy (CLC).

Methods

A total of 2,080 patients underwent laparoscopic cholecystectomy in a single center, Konyang University Hospital, between 2010 and 2016. We retrospectively compared the demographics, perioperative outcome, and postoperative complication results between the CLC and SILC groups.

Results

Among the 2,080 patients who underwent laparoscopic cholecystectomy, 1,080 had CLC and 1,000 had SILC. When retrospectively reviewed, the SILC group had significantly higher percentages of patients who were aged under 80 years, who were women, and had the American Society of Anesthesiologist score of lower than 3 points compared to those of the CLC group. Furthermore, the CLC group had a higher percentage of patients with acute cholecystitis or empyema, whereas the SILC group had a higher percentage of patients with chronic cholecystitis. Preoperative percutaneous transhepatic gallbladder drainage insertion or H-vac insertion was more frequently conducted, bleeding loss was more common, and hospital stay was longer in the CLC group. Postoperative complications such as wound infection, biloma, bile duct injury, and duodenal perforation were not significantly different between the two groups.

Conclusions

In conclusion, if performed after preoperative patient selection such as in younger and female patients with no abdominal operation history at the time of benign gallbladder surgery, SILC can be considered feasible and safe without additional complications when compared with CLC.

Evolution of the Konyang Standard Method for single incision laparoscopic cholecystectomy: the result from a thousand case of a single center experience

Purpose

Single incision laparoscopic cholecystectomy (SILC) is increasingly performed worldwide. Accordingly, the Konyang Standard Method (KSM) for SILC has been developed over the past 6 years. We report the outcomes of our procedures.

Methods

Between April 2010 and December 2016, 1,005 patients underwent SILC at Konyang University Hospital. Initially 3-channel SILC with KSM was changed to 4-channel SILC using a modified technique with a snake retractor for exposure of Calot triangle; we called this a modified KSM (mKSM). Recently, we have used a commercial 4-channel (Glove) port for simplicity.

Results

SILC was performed in 323 patients with the KSM, in 645 with the mKSM, and in 37 with the commercial 4-channel port. Age was not significantly different between the 3 groups (P = 0.942). The postoperative hospital days (P = 0.051), operative time (P < 0.001) and intraoperative bleeding volume (P < 0.001) were significantly improved in the 3 groups. Drain insertion (P = 0.214), additional port insertion (P = 0.639), and postoperative complications (P = 0.608) were not significantly different in all groups. Postoperative complications were evaluated with the Clavien-Dindo classification. There were 3 cases (0.9%) over grade IIIb (bile duct injury, incisional hernia, duodenal perforation, or small bowel injury) with KSM and 3 (0.5%) with mKSM.

Conclusion

We evaluated the evolution of the KSM for SILC. The use of the mKSM with a commercial 4-channel port may be the safest and most effective method for SILC.

Single-site robotic cholecystectomy: comparison of clinical outcome and the learning curves in relation to surgeon experience in a community teaching hospital

BACKGROUND

The aim of this study was to analyze the experience of two surgeons who have different laparoscopic skills and case volume, with single-site robotic cholecystectomy (SSRC) and evaluate their learning curves.

METHODS

All SSRCs performed between March 2013 and April 2015 were retrospectively reviewed. The patients were divided among two surgeons based on the surgeon's level of laparoscopic skills and case volume. Surgeon 1 had experience in advanced laparoscopy while surgeon 2 had basic laparoscopic skills. Patients' demographic data, intraoperative and short-term postoperative results were assessed.

RESULTS

The analysis included 102 patients for surgeon 1 and 15 patients for surgeon 2. There were no major or minor complications in either cohort. Operative time was significantly longer for surgeon 2, conversion to laparoscopy rate was 4% for surgeon 1 compared to 20% for surgeon 2, P = 0.044, which is statistically significant.

CONCLUSIONS

SSRC is an easy and safe procedure that can be quickly learned and performed in a reproducible manner by surgeons with experienced laparoscopic skills and greater case volume.

Single-incision laparoscopic cholecystectomy using instrumental alignment in robotic single-site cholecystectomy

Purpose

There is no standardized single-incision laparoscopic cholecystectomy (SILC) technique in contrast to robot single-site cholecystectomy (RSSC). We tried to implement the array of instruments used in RSSC to SILC.

Methods

A series of 108 consecutive patients underwent SILC between September 2014 and July 2017 by 2 surgeons. The indication was benign disease of the gallbladder. The perioperative outcomes were reviewed. We used the 4-channel Glove port and conventional laparoscopic instruments.

Results

The study subjects consisted of 29 males and 79 females, and the mean age was 44.4 years (range, 16–70 years). Mean body mass index was 24.1 kg/m². The mean working time was 25.0 ± 10.7 minutes and total operation time was 44.4 ± 12.4 minutes. There were 7 cases of conversion (additional 1 port in 4 patients, additional 2 ports in 2, and conventional 4 port technique in 1). Bile spillage from the gallbladder during the procedure occurred in 17 (15.7%). There were no postoperative complications. Postoperative hospital stay was 2.0 ± 0.6 days.

Conclusion

The alignment of the instruments in a RSSC was successfully implemented into a SILC, so that an equally effective operation was possible.

Feasibility and safety of single-incision laparoscopic cholecystectomy in elderly patients: A single institution, retrospective case series

INTRODUCTION

To evaluate the feasibility and safety of single-incision laparoscopic cholecystectomy (SILC) for uncomplicated gallbladder in elderly patients.

MATERIALS AND METHODS

A retrospective analysis of 810 patients undergoing SILC from May 2009 to October 2016 at Osaka Police Hospital was performed, and the outcomes of the patients aged < 80 years and the patients ≥ 80 years were compared.

RESULTS

The median operative times of patients <80 years and patients ≥80 years were 100 min and 110 min, respectively (p = 0.4). The conversion rates to a different operative procedure (multi-port laparoscopic cholecystectomy or open cholecystectomy) were 3% (22/763) of patients < 80 years and 0% of patients ≥ 80 years (p = 0.6). Perioperative complications were seen in 6% (46/763) of patients < 80 years and 17% (8/47) of patients ≥ 80 years (p < 0.05). Pneumonia was seen in 0% (0/763) of patients < 80 years and 4% (3/47) of patients ≥ 80 years (p < 0.05). There was no mortality in either group. The median postoperative hospital stay was 4 days for patients <80 years and 5 days for patients ≥80 years (p < 0.05).

CONCLUSION

SILC for uncomplicated gallbladder could be performed for patients ≥ 80 years with acceptable morbidity and mortality as compared with the previous reports, though the complication rate of patients ≥ 80 years was higher than that of patients < 80 years.

Miniature magnetically anchored and controlled camera system for trocar-less laparoscopy

AIM

To design a miniature magnetically anchored and controlled camera system to reduce the number of trocars which are required for laparoscopy.

METHODS

The system consists of a miniature magnetically anchored camera with a 30° downward angle, an external magnetically anchored unit, and a vision output device. The camera weighs 12 g, measures Φ10.5 mm × 55 mm and has two magnets, a vision model, a light source, and a metal hexagonal nut. To test the prototype, the camera was inserted through a 12-mm conventional trocar in an ex vivo real liver laparoscopic training system. A trocar-less laparoscopic cholecystectomy was performed 6 times using a 12-mm and a 5-mm conventional trocar. In addition, the same procedure was performed in four canine models.

RESULTS

Both procedures were successfully performed using only two conventional laparoscopic trocars. The cholecystectomy was completed without any major complication in 42 min (38-45 min) in vitro and in 50 min (45-53 min) using an animal model. This camera was anchored and controlled by an external unit magnetically anchored on the abdominal wall. The camera could generate excellent image. with no instrument collisions.

CONCLUSION

The camera system we designed provides excellent optics and can be easily maneuvered. The number of conventional trocars is reduced without adding technical difficulties.

Three-Port, Two Located on the Pfannenstiel Line, Laparoscopic Cholecystectomy Comparison with Traditional Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy (LC) is seen as a gateway to minimally invasive surgery. We defined a new three-port technique with different port sites and compared the postoperative results with traditional four-port LC procedure in a case-match study. Between June 2012 and May 2013, 104 consecutive patients underwent three-port LC by same experienced surgeon. In the same center, 2963 consecutive patients underwent four-port LC, and of these 2963 patients, a matched group of 104 patients was selected. Data included patient age, gender, body mass index, American Society of Anesthesiologists score, history of abdominal operations, intraoperative data about operating time and conversion to open surgery, and postoperative data about length of hospital stay and postoperative complications were recorded prospectively. We concluded that our new three-port technique with different port sites is as feasible and safe as traditional four-port technique.

Risk factors for an additional port in single-incision laparoscopic cholecystectomy in patients with cholecystitis

Although single-incision laparoscopic cholecystectomy is now widely performed in patients with cholecystitis, some cases require an additional port to complete the procedure. In this study, we focused on risk factor of additional port in this surgery. We performed single-incision cholecystectomy in 75 patients with acute cholecystitis or after cholecystitis between 2010 and 2014 at Gunma University Hospital. Surgical indications followed the TG13 guidelines. Our standard procedure for single-incision cholecystectomy routinely uses two needlescopic devices. We used logistic regression analysis to identify the risk factors associated with use of an additional full-size port (5 or 10 mm). Surgical outcome was acceptable without biliary injury. Nine patients (12.0%) required an additional port, and one patient (1.3%) required conversion to open cholecystectomy because of severe adhesions around the cystic duct and common bile duct. In multivariate analysis, high C-reactive protein (CRP) values (>7.0 mg/dl) during cholecystitis attacks were significantly correlated with the need for an additional port (P = 0.009), with a sensitivity of 55.6%, specificity of 98.5%, and accuracy of 93.3%. This study indicated that the severe inflammation indicated by high CRP values during cholecystitis attacks predicts the need for an additional port. J. Med. Invest. 64: 245-249, August, 2017.

Safety and feasibility of single-incision laparoscopic cholecystectomy in obese patients

Background

Current literature frequently indicates that experienced laparoscopic surgeons can safely perform single-incision laparoscopic cholecystectomy, but there have been few reports evaluating the feasibility and safety of performing single-incision laparoscopic cholecystectomy for obese patients. Therefore, a large single-center database was retrospectively reviewed to evaluate the feasibility and safety of single-incision laparoscopic cholecystectomy for obese patients by comparing the outcomes of normal-weight and obese patients undergoing single-incision laparoscopic cholecystectomy.

Methods

A retrospective analysis of 608 patients undergoing SILC between May 2009 and May 2015 at Osaka Police Hospital was performed, and the outcomes of obese [body mass index (BMI) ≥ 30 kg/m²] and normal-weight patients (18.5 ≤ BMI < 25 kg/m²) were compared.

Results

Thirty-eight obese patients (mean BMI 32.5 kg/m²) were compared to 362 normal-weight patients (mean BMI 22.0 kg/m²). The American Society of Anesthesiologists (ASA) scores of the obese patients were significantly higher than those of normal-weight patients. The mean operative times in the normal-weight and the obese groups were 110 min vs. 127 min, respectively (p < 0.05). There were no significant differences in the bleeding volume and the conversion rate to a different operative procedure. Perioperative complications were seen in 6% (23/362) of the patients in the normal-weight group and 8% (3/38) of the patients in the obese group (p = 0.7). The mean postoperative hospital stay was 4.5 days for the normal-weight group and 4.4 days for the obese group (p = 0.8).

Conclusions

Single-incision laparoscopic cholecystectomy, which offers good cosmetic outcomes, seems feasible and safe in obese patients.

•

Single-incision laparoscopic cholecystectomy offers good cosmetic outcomes.

•

Single-incision laparoscopic cholecystectomy seems feasible and safe in obese patients.

A novel magnetic-driven tissue retraction device for minimally invasive surgery

INTRODUCTION

The purpose of this work is to design and validate an innovative magnetic-based device for tissue retraction for minimally invasive surgery.

MATERIAL AND METHODS

An intra-abdominal magnetic module is coupled with an extracorporeal system for establishing a stable attraction, and consequently a reliable tissue retraction. Once the retractor has been inserted into the abdomen, tissue retraction is not constrained by a fixed access port, thus guaranteeing a more flexible, safer and less invasive operation. The intra-abdominal unit is composed of an axial permanent magnet attached to a stainless-steel non-magnetic alligator clip by a traditional suturing thread. A miniaturized mechanism to adjust the length of the suturing thread for lengthening or shortening the distance between the tissue grasper and the internal magnetic unit is included. A multiphysics approach assured a dedicated design that thoroughly fulfills anatomical, physiological and engineering constraints.

RESULTS

System functionalities were demonstrated both in in-vitro and ex-vivo conditions, reaching good results and promising outcomes in terms of effectiveness and maneuverability. The retractor was successfully tested in an animal model, carrying out a whole retraction procedure.

CONCLUSION

The proposed retraction system resulted to be intuitive, reliable, robust and easy to use, representing a suitable device for MIS procedures.

Differences in mental workload between traditional and single-incision laparoscopic procedures measured with a secondary task

INTRO

The mental workload associated with laparoscopic suturing can be assessed with a secondary task that requires the same visual-spatial attentional resources. The purpose of this study was to use a secondary task to measure the incremental workload demands of single-incision laparoscopic surgery (SILS) procedures versus traditional laparoscopic procedures.

METHOD

12 surgery residents and surgical assistants who had met FLS criteria on an FLS and SILS simulator performed one trial each of peg transfer, cutting, and intracorporeal suturing tasks simultaneously with the secondary task and provided subjective workload ratings using the NASA-TLX.

RESULTS

SILS procedures resulted in lower primary and secondary task scores, p < 0.001 and higher workload ratings, p < 0.0001. Suturing resulted in lower primary (p < 0.003) and secondary task scores (p < 0.017) and higher workload ratings (p < 0.017) compared to the other tasks.

CONCLUSIONS

SILS procedures were significantly more mentally demanding than traditional laparoscopic procedures corroborated by primary and secondary tasks scores and subjective ratings.

Single incision laparoscopic cholecystectomy in geriatric patients

BACKGROUND

Laparoscopy is a surgical approach recommended for the treatment of gall bladder disease. It is recommended also in geriatric patients. Recently Single Incision Laparoscopic Cholecystectomy (SILC) has been proposed to minimize surgical trauma, recovery and hospitalization time. However, the results and advantages of SILC in the geriatric population have received minimal attention. This case series review is focused on the results of SILC in the geriatric population.

METHODS

The records of 355 patients who had undergone SILC were reviewed. This report identifies, in the entire cohort, 40 patients aged 65 years or older at the time of surgery who will be the object of this study (geriatric series). Clinical outcomes and results were evaluated. Moreover, post-operative pain of the geriatric cohort was compared to that of the entire series.

RESULTS

SILC was successfully completed for 347 out of 355 patients of the entire series, with no mortality reported. In total SILC was converted to standard laparoscopy in 10 patients (2.2%) but never to open procedure. No significant difference was found between the total cohort and the geriatric series in terms of median time of operation (61.20 min vs 68.38 min). Post-operative pain was significantly lower in geriatric patients.

CONCLUSION

SILC is an effective and safe procedure for the treatment of gallbladder disease of elderly, also in terms of post-operative pain and it represents an alternative to the standard laparoscopic approach on a routine basis.

A Novel Procedure for Single-Incision Laparoscopic Cholecystectomy-The Teres Hanging Technique Combined with Fundus-First, Dome-Down Separation

BACKGROUND

Generally, single-incision laparoscopic cholecystectomy (SILC) requires the use of articulating devices or additional trocars because of the technical difficulties caused by the lack of ergonomics. We developed a novel procedure comprising mainly two simple ideas, "the teres hanging technique combined with fundus-first, dome-down separation," which mainly uses conventional rigid laparoscopic instruments. In this study, we demonstrated our technique and retrospectively evaluated the clinical outcomes.

SUBJECTS AND METHODS

Three trocars were set through a 2.0-cm transumbilical minilaparotomy that was covered with an EZ Access™ combined with a lap protector. To create an adequate surgical field, the teres ligament was laparoscopically hung up with a suture on a straight needle. The gall bladder was then dissected through the fundus to the neck using rigid laparoscopic instruments without any additional trocars. At our institution, 18 consecutive patients underwent SILC using our technique from January 2014 to August 2015. Each patient had a symptomatic gallbladder (GB) stone or polyp. All operations were performed by surgeons who had never performed SILC until this study.

RESULTS

In all operations, our technique was successfully completed without GB perforation or other intraoperative complications. Additional trocars or open laparotomy were not required. The median operation time was 79 minutes, and blood loss was negligible. No postoperative complications were encountered.

CONCLUSIONS

Our novel procedure is safe and feasible. Even for surgeons who have never performed SILC before, our technique may become a standard for benign GB disease without requiring the use of articulating devices or additional trocars.

Risk factors for conversion to conventional laparoscopic cholecystectomy in single incision laparoscopic cholecystectomy

PURPOSE

The aim of this study was to investigate the risk factors for conversion to conventional laparoscopic cholecystectomy (CLC) in single incision laparoscopic cholecystectomy (SILC) along with the proposal for procedure selection guidelines in treating patients with benign gallbladder (GB) diseases.

METHODS

SILC was performed in 697 cases between April 2010 and July 2014. Seventeen cases (2.4%) underwent conversion to conventional LC. We compared these 2 groups and analyzed the risk factors for conversion to CLC.

RESULTS

In univariate analysis, American Society of Anesthesiologist score > 3, preoperative percutaneous transhepatic GB drainage status and pathology (acute cholecystitis or GB empyema) were significant risk factors for conversion (P = 0.010, P = 0.019 and P < 0.001). In multivariate analysis, pathology (acute cholecystitis or GB empyema) was significant risk factors for conversion to CLC in SILC (P < 0.001).

CONCLUSION

Although SILC is a feasible method for most patients with benign GB disease, CLC has to be considered in patients with acute cholecystitis or GB empyema because it is likely to result in inadequate visualization of the Calot's triangle and greater bleeding risk.

Laparoscopic single site (LESS) and classic video-laparoscopic cholecystectomy in the elderly: A single centre experience

Laparoscopic cholecystectomy (LC) is the gold-standard surgical method used to treat gallbladder diseases. Recently Laparoendoscopic single site surgery (LESS) has gained greater interest and diffusion for the surgical treatment of several pathologies. In elderly patients, just few randomized controlled trials are present in the literature that confirm the clinical advantages of LESS compared with the classic laparoscopic procedures. We present in this paper the preliminary results of this randomized prospective study regarding the feasibility and safety of LESS cholecystectomy versus classic laparoscopic technique. We demonstrated that LESS technique compared with traditional technique show some advantages like: acceptable operative times, lower post-operative discomfort and sometimes reduction added complications. In addition we also demonstrate that fewer incisions and less scarring which mean less pain, and fewer parietal complications are related to this surgical procedure. In conclusion in the elderly LESS cholecystectomy technique is to be considered a suitable alternative to traditional three-port cholecystectomy.

New advantageous tool in single incision laparoscopic cholecystectomy: the needle grasper

INTRODUCTION

During single-incision laparoscopic cholecystectomy (SILC), the gallbladder is suspended with stitches, resulting in perforation risk and difficulty in exploration.

AIM

We used the needle grasper in SILC to hang and manipulate the gallbladder.

MATERIAL AND METHODS

Sixty-five patients (43 female, 22 male) who underwent SILC between December 2013 and December 2014 were analyzed retrospectively for patient demographics, duration of operation, laparotomy or conventional laparoscopy necessity, drain use, complications, and hospital stay periods. To place the SILC port (Covidien, Inc.), the needle grasper was inserted at the right upper abdominal quadrant without an incision to hang and manipulate the gall-bladder.

RESULTS

The mean age was 47.9 ±13.068 years; the mean body mass index (BMI) was 26.94 ±3.913 kg/m². ASA scores were 1, 2, and 3. Two patients with high BMI with additional trocar use were excluded. The operations were completed without any additional trocar in 59 patients. The mean operation time was 89 ±22.41 min. Eighteen patients required a drain; all were discharged after drain removal. One patient needed re-hospitalization and percutaneous drainage and was discharged on the 9^th day. Fifty-three patients were discharged on the 1^st post-operative day. Eleven patients with drains were discharged on the 2^nd day, and 1 was discharged on the 7^th day. The mean hospital stay period was 1.26 ±0.815 days.

CONCLUSIONS

The main difficulty of SILC is to manipulate hand tools because the triangulation principle of laparoscopy use is not possible in SILC. Inserting a needle grasper into the abdominal cavity at the right subcostal area to manipulate the gallbladder helps and does not leave a visible scar.

Comparison of outcomes after single-port laparoscopic cholecystectomy in relation to patient body mass index

Background and Objectives:

Single-port laparoscopic cholecystectomy may contribute to a paradigm shift in the field of laparoscopic cholecystectomy surgery by providing patients with benefits beyond those observed after other surgical procedures. This study was designed to evaluate clinically meaningful differences in operative outcomes between obese and nonobese patients after single-port laparoscopic cholecystectomy.

Methods:

Data were collected retrospectively from 172 patients who had undergone single-port laparoscopic cholecystectomy performed by the same surgeon at a single medical center between January and December 2011. For the outcome analysis, patients were divided into nonobese and obese patient groups according to their body mass index (<25 kg/m² vs ≥25 kg/m²).

Results:

Demographic and clinical data did not differ significantly between obese patients (n = 65) and nonobese patients (n = 107). In addition, statistically significant differences pertaining to most measured surgical outcomes including postoperative hospital stay, bile spillage, additional port use, and open conversion were not detected between the groups. However, the two groups differed significantly regarding operative time such that nonobese patients had shorter operative times than obese patients (P < .05).

Conclusion:

The results of this study showed that operative time for single-port laparoscopic cholecystectomy was the only difference between obese and nonobese patients. Given this result, body mass index may not be as relevant a factor in patient selection for single-port laparoscopic cholecystectomy as previously thought.

Exclusion criteria for assuring safety of single-incision laparoscopic cholecystectomy

Despite increasing popularity of single-incision laparoscopic cholecystectomy (SILC), indication criteria assuring safety of SILC has yet to be established. In the present study, the subjects consisted of 146 consecutive patients undergoing conventional laparoscopic cholecystectomy (CLC) or SILC. SILC was indicated after excluding patients who met following criteria: age > 75 years, obesity, operative scar, cardiopulmonary diseases, acute cholecystitis, choledocholithiasis and abnormal bile duct anatomy. Thirty-four patients were excluded from the SILC candidates (moderate/high-risk CLC group). Among the 112 potential candidates, SILC was indicated for 23 patients (21%, SILC group) and the remaining 89 patients (79%) underwent CLC (low-risk CLC group). In the SILC group, operation time was longer than in the low-risk CLC group (171 [113-286] vs. 126 [72-240] min, p < 0.01), but the periods requiring painkiller was shorter. That led to reduced length of hospital stay compared to low-risk CLC group (2 [2-4] vs. 4 [2-12] days, p < 0.01). Between the low-risk CLC and moderate/high-risk CLC group, operation time was significantly longer and amount of blood loss was larger in the latter group. No complications were encountered in the SILC group. SILC can be indicated safely as far as appropriate criteria is adopted for excluding patients in whom complicated laparoscopic procedures are needed.

Single-Port Laparoscopic Liver Resection: Largest Turkish Experience

Single-port laparoscopic surgery has the advantage of a hidden scar and reduced abdominal wall trauma. Although single-port laparoscopic surgery is widely performed for other organs, its application is very limited for liver resection. Here, we report our experience with nine patients who underwent single-port laparoscopic liver resection. Nine patients underwent single-port laparoscopic liver resection for the indications of hydatid cyst, hepatocellular carcinoma, and colorectal cancer liver metastasis. Nine patients were successfully treated with single-port laparoscopic surgery. The operative time was between 60 and 240 min. The only operative complication was bleeding up to 650 mL in a patient with cirrhosis. No postoperative complications occurred. All patients were discharged earlier than usual. Single-port laparoscopic liver surgery is a challenging surgery. Surgeon with the experience of laparoscopic liver surgery should perform the single-port laparoscopic liver surgery. It is technically feasible with a good outcome in well-selected patients. Initial cases must be benign lesions to avoid jeopardizing oncological safety.

Transumbilical SILC Using Conventional Laparoscopic Instruments-Initial Experience in a Resource-Limited Setting

In the era of minimal access, single-incision laparoscopic surgery is gaining popularity. Expensive ports, disposable hand instruments and flexible endoscopes have been utilised, but they increase the cost of operation. We report our initial experience of two-trocar single-incision laparoscopic cholecystectomy (SILC) in 70 patients using conventional instruments that can be adapted as a novel technique in achieving minimal trauma and aesthetic results in resource-limited hospitals. Between September 2011 and September 2012, 70 consecutive patients underwent an attempted SILC in a single centre. The mean age of the patients was 42 years (range 18-65 years). There were 12 males and 58 females with a male-to-female ratio of 1:4.8. Transumbilical incision was used to access the abdomen, and two 10-mm ports/trocars were placed through the single incision side by side, maintaining a facial bridge of 5-8 mm in between. Gall bladder was manipulated through two strategically placed traction sutures to expose the Callot's triangle. Mean operation time in our series was 42.12 min (range 22-90 min). There was no need of additional sutures. Bleeding was minimal in nearly all cases. The mean hospital stay was 1.06 days (range 1-4 days). The post-operative analgesic requirement was one dose in 60.4 % patients. Additional port was required in two of our patients. Two patients needed conversion to open surgery. There was no major complication or mortality in our series. This technique of two-trocar SILC using conventional instruments can be adapted as a less invasive surgical procedure in resource-limited hospitals in selected group of patients. Cosmetic result, reduced pain, short hospital stay and the degree of satisfaction appear to be significant with this technique.

Endoscopically Assisted Transumbilical Single-Incision Laparoscopic Gastric Resection for GIST Treatment

PURPOSE

Complete surgical resection with negative margins without lymphadenectomy is the treatment of choice for nonmetastatic Gastrointestinal Stromal Tumors (GISTs). Laparoscopic resection of gastric GISTs <5 cm is an acceptable and oncologically feasible, safe, and effective treatment. We present our experience of an endoscopically assisted minimally invasive transumbilical single-incision laparoscopic (SILS) technique for gastric GISTs resection.

METHODS

Four patients with small gastric GISTs ≤5 cm located on the greater curvature or the anterior wall were resected with SILS by using a lesion-lifting technique under the guidance of flexible gastroscopy.

RESULTS

The technique was feasible and safe and offered significant advantages in locating the tumor and controlling the resection margins. There were no major intraoperative or postoperative complications, conversions, or tumor ruptures. Pathology showed low-risk GISTs resected with disease-free margins without tumor rupture. No recurrences have been observed.

CONCLUSION

The endoscopically assisted SILS wedge gastrectomy is a feasible, safe, and advantageous technique for the treatment of the greater curvature or anterior wall gastric GISTs.

Do height and weight affect the feasibility of single-incision laparoscopic cholecystectomy?

BACKGROUND

Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common laparoscopic procedure worldwide. Single-incision laparoscopic surgery has recently emerged as a less invasive potential alternative to conventional three- or four-port laparoscopy. However, the feasibility of single-incision laparoscopic cholecystectomy (SILC) remains unclear, and there are no rigorous criteria in the literature. Identifying patients at risk of failure of this new technique is essential. The aim of our study was to determine risk factors that may predict failure of the procedure.

METHODS

From May 2010 to March 2012, 110 consecutive patients underwent SILC and were reviewed retrospectively. The main feasibility criterion was the procedure failure rate, defined as addition of supplementary port(s) and prolonged (>60 min) operative time. The factors evaluated were age, gender, height, weight, body mass index, previous abdominal surgery, indication for surgery and gallbladder suspension.

RESULTS

There was conversion in 16 patients (14.5%), and the operative time exceeded 60 min for 20 patients (30.9%). Univariate analysis showed a significant independent association between additional port requirement and each of weight as a continuous value, weight ≥80 kg, BMI >26.5 kg/m(2) and height >172 cm. Univariate analysis also showed a significant independent association between prolonged operative duration (>60 min) and each of height and weight as continuous values, height >172 cm and previous abdominal surgery. In the multivariate analysis, only weight remained independently associated with additional port requirement, and height remained independently associated with prolonged operative duration.

CONCLUSION

Preoperative identification of the factors increasing the risk of conversion may assist surgeons in making decisions concerning the management of patients, including appropriate use of SILC.

Single-Site Robotic Cholecystectomy: Reverse-Port Technique

This study aims to introduce an alternative technique for effective single-site robotic cholecystectomy (SSRC) using a reverse port.Proper exposure of Calot's triangle is critical for safe laparoscopic cholecystectomy. Current robotic surgical systems are useful for single-site cholecystectomy. However, in exposing Calot's triangle, the gallbladder is usually retracted in a medial and upward direction, resulting in a narrow triangle. This intraoperative view is a major obstacle to safe laparoscopic cholecystectomy.From October 2013 to October 2014, 55 consecutive patients underwent SSRC by a single surgeon at Yonsei University Severance Hospital. Initially, 5 patients underwent the original robotic single site cholecystectomy technique, and the remaining 50 patients underwent robotic single site cholecystectomy using our reverse port technique.There were no differences between the SSRC-O (original port) group and the SSRC-R (reverse port) group in terms of patient age (P = 0.244), body mass index (P = 0.503), and pathologic conditions of the gallbladder (P = 0.841). Total operation time (132.6 vs 99.12 min; P = 0.009), actual dissection time (51.6 vs 30.28 min; P = 0.001), and console time (84.4 vs 50.46 min; P = 0.001) were all significantly shorter in the SSRC-R group. Mean intraoperative blood loss was minimal in both groups (20 vs 12.4 mL, P = 0.467), and bile spillage occurred in 2 patients of the SSRC-R group. There was one case of laparoscopic conversion in the SSRC-R group.The reverse port technique described in this study successfully widened Calot's triangle and improved the safety of the current robotic surgical system for single-site robotic cholecystectomy.

A randomized controlled trial comparing post-operative pain in single-incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy

INTRODUCTION

An increasing body of evidence is being published about single-incision laparoscopic cholecystectomy (SILC), but there are no well-powered trials with an adequate evaluation of post-operative pain. This randomized trial compares SILC against four-port laparoscopic cholecystectomy (LC) with post-operative pain as the primary endpoint.

METHODS

Hundred patients were randomized to either SILC (n = 50) or LC (n = 50). Exclusion criteria were (1) Acute cholecystitis; (2) ASA 3 or above; (3) Bleeding disorders; and (4) Previous open upper abdominal surgery. Patients and post-operative assessors were blinded to the procedure performed. The site and severity of pain were compared at 4 h, 24 h, 14 days and 6 months post-procedure using the visual analog scale; non-inferiority was assumed when the lower boundary of the 95% confidence interval of the difference was above -1 and superiority when p ≤ 0.05.

RESULTS

The study arms were demographically similar. At 24 h post-procedure, SILC was associated with less pain at extra-umbilical sites (rest: p = 0.004; movement: p = 0.008). Pain data were inconclusive at 24 h at the umbilical site on movement; SILC was otherwise non-inferior for pain at all other points. Operating duration was longer in SILC (79.46 vs 58.88 min, p = 0.003). 8% of patients in each arm suffered complications (p = 1.000). Re-intervention rates, analgesic use, return to function, and patient satisfaction did not differ significantly.

CONCLUSIONS

SILC has improved short-term pain outcomes compared to LC and is not inferior in both short-term and long-term pain outcomes. The operating time is longer, but remains feasible in routine surgical practice.

Tripartite comparison of single-incision and conventional laparoscopy in cholecystectomy: A multicenter trial

AIM: To compare the characteristics of two single-incision methods, and conventional laparoscopy in cholecystectomy, and demonstrate the safety and feasibility.

METHODS: Three hundred patients with gallstones or gallbladder polyps were admitted to two clinical centers from January 2013 to January 2014 and were randomized into three groups of 100: single-incision three-device group, X-Cone group, and conventional group. The operative time, intraoperative blood loss, complications, postoperative pain, cosmetic score, length of hospitalization, and hospital costs were compared, with a follow-up duration of 1 mo.

RESULTS: A total of 142 males (47%) and 158 females (53%) were enrolled in this study. The population characteristics of these three groups is no significant differences exist in terms of age, sex, body mass index and American Society of Anesthesiology (P > 0.05). In results, there were no significant differences in blood loss, length of hospitalization, postoperative complications.The operative time in X-Cone group was significantly longer than other groups.There were significant differences in postoperative pain scores and cosmetic scores at diffent times after surgery (P < 0.05).

CONCLUSION: This study shows that this two single-incision methods are safe and feasible. Both methods are superior to the conventional procedure in cosmetic and pain scores.

Single incision cholecystectomy using a clipless technique with LigaSure in a resource limited environment: The Bahamas experience

•

SILC in the third world.

•

The addition of LigaSure to enhance procedure.

•

Look at feasibility.

•

Look at cost different.

Background

Scarless/single-incision laparoscopic cholecystectomy (SILC) is a new procedure. It affords a superior cosmetic outcome when compared to conventional laparoscopic cholecystectomy. We examine the application of this technique using LigaSure via a clipless method. The present study looks at the experience of a single surgeon using this method with initial evaluation of the safety, feasibility, affordability, and benefits of this procedure.

Methods

Twenty-eight patients underwent transumbilical SILC at Doctors Hospital from January to December, 2014. The cohort included both emergency and elective patients. There was no difference in the preoperative work-up as indicated. To perform the operation, a 2–2.5-cm linear incision was made through the umbilicus and the single port platform utilized. A 10 mm 30-degree laparoscope, a 5 mm LigaSure and straight instruments were used to perform the laparoscopic cholecystectomy procedure.

Results

All patients except two were operated on successfully. Conversion was considered the placement of an additional epigastric/Right upper quadrant (RUQ) port. The conversion rate to standard LC was 7%. No patient was converted to open cholecystectomy. In the 28 successfully completed patients, the median duration of the operation was 38.5 min and estimated operative blood loss was 24 ml. Patients were commenced on liquid diet immediately on being fully conscious and after return to the ward with an estimated time of 6 h. The mean postoperative hospital stay was 1.4 days. Follow-up visits were conducted for all patients at 2-weeks intervals and continued for 6 weeks after surgery where possible. Two patients developed wound infections. All patients were satisfied with the good cosmetic effect of the surgery. The total satisfaction rate was 100%.

Conclusions

SILC is a safe and feasible technique for operating with scarless outcomes and reducing perioperative discomfort at the same time. The GelPOINTTM is a safe and feasible platform to be used. The procedure can be accomplished using regular instruments and laparoscope. Curved instruments and a bariatric length laparoscope may make the procedure easier and result in greater time saving. The addition of LigaSure™ decreases the complexity of the operation, decreases operative time and blood loss. The technique is economical in a resource-limited environment.

Application of laparoscopy in the combined surgical procedures of gynecological and digestive disorders in obese women: a retrospective cohort study

BACKGROUND

Laparoscopy surgery has been widely used for many decades and combined laparoscopic procedures have become favorable choices for concomitant pathologies in the abdomen. However, the type of combination procedures and their safety in obese women have not been well elucidated in obese women.

METHODS

Here we retrospectively reported 147 obese women underwent combined laparoscopic gynecological surgery and cholecystectomy/appendicectomy in our hospital from January 2003 to December 2011. Of the total number of patients (n = 147), various laparoscopic gynecological surgeries were combined with laparoscopic cholecystectomy in 93 patients, and were combined with laparoscopic appendectomy in the rest 54 patients. Patients' ages ranged from 24 to 55 years with an average of 33 years.

RESULTS

Our results showed that combined procedures caused various operative time and blood loss, with no difference considering the time to resume oral intake and length of hospital stay. Intraoperative complications occurred in a total of 7 patients (4.8%). None of the patients suffered from major complications after laparoscopic surgery, and minor postoperative complications occurred in 30 patients (20.4%). The follow-up period ranged from 6 to 24 months (average, 18.5 months). None of the patients developed complications during follow-up, except that one patient suffered from colporrhagia.

CONCLUSIONS

Our results further suggest that the combined abdominal laparoscopic procedures of gynecologic and general surgery are safe and economic choices for obese women, and benefit patients in many ways including lesser pain, shorter hospital stays and earlier recovery.

[Mini-laparoscopic cholecystectomy as an innovative method in minimally invasive abdominal surgery]

INTRODUCTION

In our study, we applied a mini-laparosopic approach during laparoscopic cholecystectomy (LC) (using the minimum size of trocars with the simultaneous intention to reduce their number). The advantages and disadvantages of the mini-LC approach were compared with those of traditional LC.

PATIENTS AND METHODS

During mini-LC procedures, we used 3 ports (11 mm, 5 mm, 3.5 mm). Mini-LC was performed in 10 patients, and the results were compared with those of 10 cases of traditional LCs. The two groups were homogenous in terms of gender, age, BMI and ASA classification. Comparison criteria included operative time, the need to use an extra port, conversion rate, oral analgesic requirement, early/late complications and cosmetic results.

RESULTS

There were no significant differences in terms of operative time, blood loss, hospital stay and complications. Cumulative size of incisions was 19.5 mm with mini-LC- and 41 mm in the LC group, respectively, and the tissue injury was 124.2 mm(2) and 448.2 mm(2). Cosmetic results of mini-LC were highly improved by these values. Increased oral analgetic requirements were detected in LC group.

CONCLUSION

Mini-LC is a safe procedure with outstanding cosmetic results accompanied by less oral analgetic requirements. In selected patients, it can be recommended as an alternative method of traditional LC.

Therapeutic advances: Single incision laparoscopic hepatopancreatobiliary surgery

Single-port laparoscopic surgery (SPLS) is proposed to be a step towards minimizing the invasiveness of surgery, and has since gained popularity in several surgical sub-specialties including hepatopancreatobiliary surgery. SPLS has since been applied to cholecystectomy, liver resection as well as pancreatectomy for a multitude of pathologies. Benefits of SPLS over conventional multi-incision laparoscopic surgery include improved cosmesis and potentially post-operative pain at specific time periods and extra-umbilical sites. However, it is also associated with longer operating time, increased rate of complications, and increased rate of port-site hernia. There is no significant difference between length of hospital stay. SPLS has a significant learning curve that affects operating time, rate of conversion and rate of complications. In this article, we review the literature on SPLS in hepatobiliary surgery - cholecystectomy, hepatectomy and pancreatectomy, and offer tips on overcoming potential technical obstacles and minimizing the complications when performing SPLS - surgeon position, position of port and instruments, instrument crossing position, standard hand grip vs reverse hand grip, snooker cue guide position, prevention of incisional hernia. SPLS is a promising direction in laparoscopic surgery, and we recommend step-wise progression of applications of SPLS to various hepatopancreatobiliary surgeries to ensure safe adoption of the surgical technique.

A Preliminary Study of Surgeon Stress Measures During Randomized Controlled Trials of 4-port vs. Single Incision Cholecystectomies

With various minimally invasive approaches in the field of surgery and new techniques entering rapidly, it is important to evaluate the effectiveness of these different practices. Information about the impact on both patient and provider can be gained through research investigations. Since the workload placed on the surgeon may influence patient outcomes, this study measured levels of stress and fatigue for the surgeon participating in an NIH randomized control trial of single incision versus 4-port laparoscopic cholecystectomy. Through the administration of the SURG-TLX for 22 Single-Incision Laparoscopic Cholecystectomies and 24 4-port cholecystectomies, physical workload was the only measure statistically different between 4-port and SILC (P=0.028). There was a significant difference in the duration (P=0.029) based on the procedure that was completed. Mental stress was highly correlated to many of the variables in the Surg-TLX and duration, degree of difficulty, and complexity were all highly correlated. This research shows how the SILC procedure can cause more stress on the surgeon. When the situation is combined with longer surgeries, higher complexity, and a higher degree of difficulty, the patient outcomes may be at risk.

Single incision versus standard multiport laparoscopic cholecystectomy: up-dated systematic review and meta-analysis of randomized trials

BACKGROUND AND PURPOSE

We aimed to compare single incision laparoscopic cholecystectomy (SILC) to the standard multiport technique (MLC) for clinically relevant outcomes in adults.

METHODS

Systematic review and random-effects meta-analysis of randomized trials.

RESULTS

We identified 30 trials (SILC N = 1209, MLC N = 1202) mostly of moderate to low quality. Operating time (30 trials): longer with SILC (WMD = 12.4 min, 95% CI 9.3, 15.5; p < 0.001), but difference reduced with experience - in 10 large trials (1321 patients) WMD = 5.9 (-1.3, 13.1; p = 0.105). Intra-operative blood loss (12 trials, 1201 patients): greater with SILC, but difference practically irrelevant (WMD = 1.29 mL, 0.24-2.35; p = 0.017). Procedure failure (27 trials, 2277 patients): more common with SILC (OR = 13.9, 4.34-44.7; p < 0.001), but overall infrequent (SILC pooled incidence 4.39%) and almost exclusively addition of a trocar. Post-operative pain (29 trials) and hospital stay (22 trials): no difference. Complications (30 trials): infrequent (SILC pooled incidence 5.35%) with no overall SILC vs. MLC difference. Incisional hernia (19 trials, 1676 patients): very rare (15 vs. 4 cases), but odds significantly higher with SILC (OR = 4.94, 1.26-19.4; p = 0.025). Cosmetic satisfaction (16 trials, 11 with data at 1-3 months): in 5 trials with non-blinded patients (N = 513) in favour of SILC (SMD = 1.83, 0.13, 3.52; p = 0.037), but in 6 trials with blinded patients (N = 719) difference small and insignificant (SMD = 0.42, -1.12, 1.96; p = 0.548).

DISCUSSION

SILC outcomes largely depend on surgeon's skill, but regardless of it, when compared to MLC, SILC requires somewhat longer operating time, risk of incisional hernia is higher (but overall very low) and early cosmetic benefit is modest.

CONCLUSION

From the (in)convenience and safety standpoint, SILC is an acceptable alternative to MLC with a modest cosmetic benefit.

Use of 3 mm percutaneous instruments with 5 mm end effectors during different laparoscopic procedures

BACKGROUND AND PURPOSE

With a recent focus on minimizing the visibility of scars, new techniques have been developed. Minilaparoscopy reemerged as an attractive option for surgery as it limits tissue trauma, reduces post-operative pain and improves cosmesis. This study was designed to describe our experience with percutaneous trocarless 3 mm instruments used in combination with standard 5 mm and 10 mm laparoscopic instruments in different general surgery procedures.

METHODS

We used the PSS (Percutaneous Surgical Set, Ethicon Endo surgery, Cincinnati, OH, USA) in different surgical procedures as accessory instruments in combination with standard 5 mm and 10 mm standard laparoscopic instruments.

MAIN FINDINGS

The use of percutaneous instruments was safe and feasible in all performed procedures. The surgical technique was not modified. The percutaneous instruments can assure a good grip and can be used for traction and counter-traction. No complications have been described. No pain at the site of insertion has been reported. The skin, muscle and peritoneal defects were smaller than with the 3 mm laparoscopic traditional instruments.

CONCLUSIONS

Percutaneous approach seems to be a good option in general surgery in terms of efficiency, offering better cosmetic results and good pain control.

Patient perception of single-incision laparoscopic cholecystectomy

Safety and relief of symptoms appeared to be most important to patients with gallbladder disease, whereas postprocedural aesthetics was less important.

Background and Objectives:

Single-incision laparoscopic cholecystectomy (SILC) is gradually being adopted into general surgical practice. The potential risks and benefits are still being studied, and little is known about how patients perceive this new surgical technique.

Methods:

After providing patients with basic educational materials on laparoscopic cholecystectomy (LC) and SILC, we administered a questionnaire exploring patients' perspectives of the importance of postoperative pain, scar appearance, risk of complications, and cost regarding their preference for SILC versus LC.

Results:

Among 100 patients (mean age, 43.3 years), the majority were women (85%), white (85%), college educated (77%), and privately insured (85%). Indications included biliary dyskinesia (43%), biliary colic (48%), and acute cholecystitis (9%). Patients stated that they would be somewhat or very interested in SILC if recommended by their surgeon (89%), although 35% were somewhat or very concerned about the lack of long-term results. The majority would accept no additional risk to undergo SILC. Scar appearance was somewhat or very important to <40% of patients, whereas pain was somewhat or very important to 79%. Only 27% of patients would spend >$100 to undergo SILC. When asked to rank pain, appearance, symptom resolution, personal cost, and risk of complications, 52% ranked symptom resolution, 20% ranked pain, and 19% ranked risk of complications as most important.

Conclusions:

Safety and relief of symptoms are most important to patients with gallbladder disease, whereas postprocedural esthetics was relatively unimportant and few would be willing to pay more for SILC versus LC. However, if the surgeon recommends SILC, most patients would trust this recommendation.

Two-port cholecystectomy maintains safety and feasibility in benign gallbladder diseases: a comparative study

PURPOSE

In an effort to overcome the limitations of single-port laparoscopic cholecystectomy (LC) while preserving the cosmetic benefits of reduced ports cholecystectomy, we have developed a 2-port LC that allows for the full, unrestricted use of 4 laparoscopic instruments.

METHODS

We retrospectively analyzed data of patients who had undergone either 4-port LC or 2-port LC for benign gallbladder diseases between March 2007 and March 2013. Two incisions of 2-port LC were composed of an umbilical incision as the manner of single-port laparoscopic surgery and a 5-mm epigastric incision. These two incisions were utilized for comfortable bimanual manipulation under the liver-elevated vision provided by a liver retractor.

RESULTS

During the study period, 766 patients underwent LC; 263 (34.3%) started with 4-port LC, and 503 (65.7%) started with 2-port LC. Of patients started with 2-port LC, 486 patients (96.6%) was ended up with 2-port without open conversion or addition of port(s). The two groups had similar operative time, open conversion rate, incidence of complications, analgesic requirement, and length of postoperative hospital stay. Multivariate analyses revealed that the independent factors related to prolonged operative time (≥ 90 th percentile) in 2-port LC were the presence of cholecystitis (odds ratio [OR] 2.412, 95% CI 1.246-4.668, p = 0.009) and admission through the emergency department (OR 2.132, 95% CI 1.135-4.004, p = 0.019).

CONCLUSION

This study suggests that 2-port LC for benign gallbladder diseases is as safe and feasible as 4-port LC when it is performed by surgeons trained in conventional laparoscopic techniques.

Single-incision laparoscopic cholecystectomy and overweight patients

BACKGROUND

Modifications of minimally invasive laparoscopic cholecystectomy have been achieved, including single-incision laparoscopic cholecystectomy (SILC). In the current literature, the effects of high body mass index (BMI) on the results of the surgical therapy have not been sufficiently investigated after SILC. We evaluated perioperative outcomes and postoperative complications of overweight patients who underwent SILC.

METHODS

Two hundred two patients who underwent SILC were retrospectively evaluated. The data included demographics and outcomes such as postoperative complications and postoperative hospitalization were obtained. For the outcome analyses, patients were divided into two group according to their BMI (<30 vs ≥ 30 kg/m(2)).

RESULTS

Of the 202 patients, 157 patients were in normal weight group and 45 patients were in overweight group. Mean operative time was 31.67 ± 6.4 min in overweight group and 26.6 ± 5.3 min in normal weight group. The wound infection rate for overweight and normal weight patients was 13.3 and 7.6 %, respectively. Eleven of the 202 patients (5.4 %) experienced port-site hernia (PSH).

CONCLUSIONS

This retrospective study comparing overweight and normal weight patient in SILC demonstrates that SILC is associated with the prolonged operative time, high additional port requirement, and increased wound complication rate. PSH occurrence rate was high after SILC irrespective of the body weight.

Safety and feasibility of needlescopic grasper-assisted single-incision laparoscopic cholecystectomy in patients with acute cholecystitis: comparison with three-port laparoscopic cholecystectomy

INTRODUCTION

Single-incision laparoscopic cholecystectomy (SILC) has been increasing in use steadily, and many researchers have reported the safety and feasibility of SILC. However, most studies were confined to selected patients and excluded patients with acute inflammation. In this study, we evaluated the safety and feasibility of SILC with our technique in patients with acute cholecystitis.

PATIENTS AND METHODS

Ninety-six patients with acute cholecystitis undergoing laparoscopic cholecystectomy at Uijeonbu St. Mary's Hospital (Uijeongbu, Korea) between October 2011 and December 2012 were retrospectively reviewed. SILC was performed in 49 patients, and conventional three-port laparoscopic cholecystectomy was performed in 47 patients. Patient demographics and operative outcomes were compared between groups to evaluate the safety and feasibility of SILC using our technique.

RESULTS

There were no differences between groups in demographics except for the sex ratio. SILC was more often performed in female patients (69% versus 34%, P=.001). There were no statistically significant differences between groups in terms of operation time, critical view of safety identification time, iatrogenic gallbladder perforation, port-site seroma, and postoperative hospital stay, respectively. One patient in each group required conversion to open cholecystectomy because of massive bleeding.

CONCLUSIONS

This study showed that needlescopic grasper-assisted SILC with our technique is acceptable not only in selected patients but also in patients with acute cholecystitis. Lateral and cephalad retraction using a needlescopic grasper and a snake retractor can make SILC safe and easy in acute cholecystitis through better visualization of the triangle of Calot.

Transumbilical single-incision laparoscopic distal pancreatectomy: primary experience and review of the English literature

BACKGROUND

Single-incision laparoscopic surgery (SILS) may represent an improvement over conventional laparoscopic surgery, and has been applied in many surgical procedures. However, for pancreatic surgery, experience is rather limited.

METHODS

The clinical records of 11 cases in which transumbilical single-incision laparoscopic distal pancreatectomy (TUSI-LDP) was performed at our institution since June 2009 were retrospectively analyzed, and all the literatures concerning TUSI-LDP were retrospectively reviewed.

RESULTS

All the 11 patients were female. The ages ranged from 20 to 73 years, with an average age of 38.0 years. The average body mass index (BMI) was 22.67 (18.6-26.2). Most TUSI-LDPs were successfully performed, with only one conversion to multi-incision surgery. Splenic preservation was performed in six cases. The mean operation time was 163.18 ± 63.18 minutes (range 95-300), and the mean intraoperative blood loss was 159.09 ± 181.02 ml (range 10-500 ml). The surgical wounds healed well, with good cosmetic wound healing, and the patients were discharged from hospital in a mean of 7.45 ± 1.44 days (range 5-10). Only one patient developed pancreatic leakage, which ceased spontaneously with only a drain for 61 days. The parameters were comparable with those found in the English literature.

CONCLUSIONS

These recent experiences suggest that SILS in pancreatic surgery is feasible for a select group of patients with relatively small lesions and low BMI, and that, with the gradual accumulation of surgeons' experience with SILS and improvement of laparoscopic instruments, it might become a safe option for some patients.

Quality and safety of minimally invasive surgery: past, present, and future

Adverse events because of medical errors are a leading cause of death in the United States (US) exceeding the mortality rates of motor vehicle accidents, breast cancer, and AIDS. Improvements can and should be made to reduce the rates of preventable surgical errors because they account for nearly half of all adverse events within hospitals. Although minimally invasive surgery (MIS) has proven patient benefits such as reduced postoperative pain and hospital stay, its operative environment imposes substantial physical and cognitive strain on the surgeon increasing the risk of error. To mitigate errors and protect patients, a multidisciplinary approach is needed to improve MIS. Clinical human factors, and biomedical engineering principles and methodologies can be used to develop and assess laparoscopic surgery instrumentation, practices, and procedures. First, the foundational understanding and the imperative to transform health care into a high-quality and safe system is discussed. Next, a generalized perspective is presented on the impact of the design and redesign of surgical technologies and processes on human performance. Finally, the future of this field and the research needed to further improve the quality and safety of MIS is discussed.

Remains of the day: Biliary complications related to single-port laparoscopic cholecystectomy

AIM: To assesse the rate of bile duct injuries (BDI) and overall biliary complications during single-port laparoscopic cholecystectomy (SPLC) compared to conventional laparoscopic cholecystectomy (CLC).

METHODS: SPLC has recently been proposed as an innovative surgical approach for gallbladder surgery. So far, its safety with respect to bile duct injuries has not been specifically evaluated. A systematic review of the literature published between January 1990 and November 2012 was performed. Randomized controlled trials (RCT) comparing SPLC versus CLC reporting BDI rate and overall biliary complications were included. The quality of RCT was assessed using the Jadad score. Analysis was made by performing a meta-analysis, using Review Manager 5.2. This study was based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. A retrospective study including all retrospective reports on SPLC was also performed alongside.

RESULTS: From 496 publications, 11 RCT including 898 patients were selected for meta-analysis. No studies were rated as high quality (Jadad score ≥ 4). Operative indications included benign gallbladder disease operated in an elective setting in all studies, excluding all emergency cases and acute cholecystitis. The median follow-up was 1 mo (range 0.03-18 mo). The incidence of BDI was 0.4% for SPLC and 0% for CLC; the difference was not statistically different (P = 0.36). The incidence of overall biliary complication was 1.6% for SPLC and 0.5% for CLC, the difference did not reached statistically significance (P = 0.21, 95%CI: 0.66-15). Sixty non-randomized trials including 3599 patients were also analysed. The incidence of BDI reported then was 0.7%.

CONCLUSION: The safety of SPLC cannot be assumed, based on the current evidence. Hence, this new technology cannot be recommended as standard technique for laparoscopic cholecystectomy.