Consensus statement of the consortium for LESS cholecystectomy

Retroperitoneal Bronchogenic Cyst Resected by Single-Incision Laparoscopic Surgery in an Adolescent Female: A Case Report

A 16-y-old Japanese female was referred to our hospital with a suspicion of infected retroperitoneal cyst. Abdominal CT MRI revealed a 38-mm diameter retroperitoneal cyst under the left diaphragm. Because a retroperitoneal bronchogenic cyst was suspected, total resection was planned. In addition, preoperative 3D reconstruction using multidetector CT provided a detailed location of the lesion. Based on the anatomical position, we decided that single-incision laparoscopic surgery with an anterior approach through the umbilicus would be the optimal choice. The lesion was completely resected without intraoperative complications. Histopathological examination confirmed the diagnosis of bronchogenic cyst. Postoperatively, the surgical wound became completely unnoticeable, and there was no incisional hernia or cyst recurrence at the 2-y follow-up.

Laparo-Endoscopic Single Site (LESS) cosmesis: Patients perception of body image distortion after LESS surgery

BACKGROUND

Relative to conventional laparoscopy, Laparo-Endoscopic Single Site (LESS) surgery has been associated with improved cosmesis. This study investigated preoperative and postoperative patient perceptions of LESS surgery and what factors may affect those perceptions.

METHODS

Patients undergoing LESS Surgery were queried before and after their operations. Body image and other factors were assessed preoperatively and postoperatively in 881unselected patients undergoing LESS surgery utilizing Likert scale questionnaires. Responses were collated and analyzed. Data are reported as median (mean ± SD), where appropriate.

RESULTS

881 patients studied had a median age of 59 (57 ± 15.3) years and had a median Body Mass Index of 27 (28 ± 6.2) kg/m². 65% were women. 343 (39%) had undergone a previous abdominal operation(s). Prior to LESS surgery, patients reported neutral body image scores and rated their overall appearance satisfaction as 40% (37% ± 30.7) on a Visual Analog Scale (VAS). 68% were unwilling to undergo LESS surgery if it involved more risk relative to traditional laparoscopy as safety was their number one concern. Postoperatively, patients reported a significant improvement in body image perception and safety was no longer their foremost concern.

CONCLUSION

Preoperatively, patients are most concerned with safety (e.g. risk) with secondary concerns of cost and pain but they were less concerned with their appearance. Postoperatively, safety is much, much less of an issue (because it has been achieved) and appearance is more paramount with significant improvements in their self-assessed appearance. With LESS surgery patients indicate a high level of satisfaction with cosmesis.

Enabling single-site laparoscopy: the SPORT platform

BACKGROUND

The Single Port Orifice Robotic Technology (SPORT) Surgical System by Titan Medical Inc. is designed to overcome the inherent challenges of minimally invasive single-access procedures. The aim of this preclinical study was to evaluate the feasibility of various digestive surgery procedures using this novel surgical robotic platform.

METHODS

A total of 12 minimally invasive procedures were performed on six pigs (5 cholecystectomies, 3 Nissen fundoplications, 1 splenectomy and 1 hepatic pedicle dissection) and on one human cadaver (1 cholecystectomy and 1 Nissen fundoplication), by four laparoscopic surgeons. The usability of the device was assessed by means of the modified objective structured assessment of technical skills (OSATS) score that was calculated and analyzed by two independent observers on the recorded videos. Surgeon feedback and recommendations were systematically recorded.

RESULTS

All procedures were successfully completed with the SPORT system. In general, surgeons reported to appreciate the intuitive interface and controls, the high-resolution 3D imaging, the dexterity of the end-effectors, and the ergonomic open control platform. Some features requiring optimization were also identified. The modified OSATS score demonstrated a learning curve effect for all device-related tasks.

CONCLUSIONS

A variety of abdominal procedures could be safely completed with the current SPORT prototype, in the preclinical setting. This preliminary feasibility experience is promising and encourages further development of single-port robotically assisted surgery.

Feasibility of Single-Port Cholecystectomy With Wound Retractor and a Glove in a Rural Hospital in Mexico

Laparoscopic surgery has been established as the standard therapy for symptomatic cholecystolithiasis. Now, single-port cholecystectomy is a surgical option. Due to the need of special laparoscopic instruments and devices, the cost of the surgery is significantly increased, limiting its popularity in most medical centers in developing countries, especially in rural areas. This paper's objective was to show the safety, reproducibility, and feasibility of single-port laparoscopic cholecystectomy using conventional laparoscopic equipment, a wound retractor, and a sterile glove in a rural hospital in Mexico. A prospective study was carried out from July to October 2014. Patients diagnosed with uncomplicated cholecystolithiasis who agreed to participate were operated with this technique. Complications, operative time, bleeding, evolution, and length of hospital stay were recorded. A total of 24 women went onto surgery under this approach. A mean follow-up of 71 days was completed. No incisional hernias, bile duct injuries, wound infection, nor death was presented. Surgical time and cost were not significantly increased compared to conventional laparoscopic approach. Most patient discharge was done the same day of the surgery. Single-port laparoscopic cholecystectomy is a cost-effective procedure, which can be performed in all hospitals where an Alexis retractor and conventional laparoscopic equipment is available. There was no increase of surgical morbidity. The single-port cholecystectomy is a technically feasible and safe surgical option in selected patients and can be easily performed in rural hospitals at a low cost, providing the benefits of the single incision.

Magnetic Surgery: Results From First Prospective Clinical Trial in 50 Patients

OBJECTIVE

To evaluate a new magnetic surgical system during reduced-port laparoscopic cholecystectomy in a prospective, multicenter clinical trial.

BACKGROUND

Laparoscopic instrumentation coupled by magnetic fields may enhance surgeon performance by allowing for shaft-less retraction and mobilization. The movements can be performed under direct visualization, generating different angles of traction and reducing the number of trocars to perform the procedure. This may reduce well-known associated complications of trocars, including incisional pain, scarring, infection, bowel, and vascular injuries, among others.

METHODS

A prospective, multicenter, single-arm, open-label study was performed to assess the safety and performance of a magnetic surgical system (Levita Magnetics' Surgical System). The investigational device was used during a 3-port laparoscopic technique. The primary endpoints evaluated were safety and feasibility of the device to adequately mobilize the gallbladder to achieve effective exposure of the targeted surgical site. Patients were followed for 30 days postprocedure.

RESULTS

Between January 2014 and March 2015, 50 patients presenting with benign gallbladder disease were recruited. Forty-five women and 5 men with an average age of 39 years (18-59), average body mass index of 27 kg/m (20.4-34.1) and an average abdominal wall thickness of 2.6 cm (1.8-4.6). The procedures were successfully performed in all 50 patients. No device-related serious adverse events were reported. Surgeons rated as "excellent" (90%) or "sufficient" (10%) the exposure of the surgical site.

CONCLUSIONS

This clinical trial shows that this new magnetic surgical system is safe and effective in reduced-port laparoscopic cholecystectomy.

Population-Based Studies Should not be Used to Justify a Policy of Routine Cholangiography to Prevent Major Bile Duct Injury During Laparoscopic Cholecystectomy

Iatrogenic bile duct injury at time of cholecystectomy is a rare but devastating event. A twofold higher frequency of bile duct injury during cholecystectomy without cholangiography is reported in population-based studies. Some interpret this as a cause-and-effect relationship and thus mandate routine cholangiography. A critical appraisal of population studies is required to determine whether these studies are suitable in determining the role of routine cholangiography. The literature search was performed using combinations of the forced search terms "duct injury", "population" and "cholangiography" to identify population-based studies assessing the relationship between cholangiography and iatrogenic bile duct injury. All seven population-based studies reported a numerically higher rate of bile duct injury when an intraoperative cholangiogram was not obtained during cholecystectomy. Five predate the critical view technique. Only one was limited to laparoscopic cholecystectomy. All studies identified cholangiography as a likely marker for disease severity or surgical technique. Six studies did not demonstrate a cause-and-effect relationship by not including effect modifiers. The only study to address confounders reported the same rate of injury irrespective of the use of cholangiography. Critical appraisal of population-based studies does not support their use in justifying a policy of routine cholangiography to prevent major bile duct injury.

Competence acquisition for single-incision laparoscopic cholecystectomy

Background and Objectives:

Within the past few years, there has been a push for an even more minimally invasive approach to biliary disease with the adoption of single-incision laparoscopic cholecystectomy. We sought to compare 4 individual surgeon experiences to define whether there exists a learning curve for performing single-incision laparoscopic cholecystectomy.

Methods:

We performed a retrospective review 290 single-incision laparoscopic cholecystectomies performed by a group of general surgeons, with varying levels of experience and training, at 3 institutions between May 2008 and September 2010. The procedure times were recorded for each single-incision laparoscopic cholecystectomy, ordered chronologically for each surgeon, and subsequently plotted on a graph. The patients were also combined into cohorts of 5 and 10 cases to further evaluate for signs of improvement in operative efficiency.

Results:

Of the 4 surgeons involved in the study, only 1 (surgeon 4, laparoscopic fellowship trained with <5 years' experience) confirmed the presence of a learning curve, reaching proficiency within the first 15 cases performed. The other surgeons had more variable procedure times, which did not show a distinct trend. When we evaluated the cases by cohorts of 5 cases, surgeon 4 had a significant difference between the first and last cohort. Increased body mass index resulted in a slightly longer operative time (P < .0063). The conversion rate to multiport laparoscopic surgery was 3.1%.

Conclusions:

Our results indicate that among experienced general surgeons, there does not seem to be a significant learning curve when transitioning from conventional laparoscopic cholecystectomy to single-incision laparoscopic cholecystectomy. The least experienced surgeon in the group, surgeon 4, appeared to reach proficiency after 15 cases. Greater than 5 years of experience in laparoscopic surgery appears to provide surgeons with a sufficient skill set to obviate the need for a single-incision laparoscopic cholecystectomy learning curve.

A multicenter study of initial experience with single-incision robotic cholecystectomies (SIRC) demonstrating a high success rate in 465 cases

BACKGROUND

Recently, the robotic single-site platform has been used to ameliorate the difficulties seen in single-incision laparoscopic surgery (SILC) while preserving the benefits of standard laparoscopic cholecystectomy. The purpose of this study is to describe the clinical outcomes of a large series of single-incision robotic cholecystectomy (SIRC).

METHODS

Medical records of consecutive patients who underwent SIRC were retrospectively reviewed. All procedures were performed by six surgeons at five different North American centers involved in the study. All patients included in the study underwent a cholecystectomy attempted through single site at the umbilicus, using the da Vinci(®) Surgical System (Intuitive Surgical Inc. Sunnyvale, CA).

RESULTS

A total of 465 patients met study criteria. Median age was 48 years (range 18-89); 351 (75.5 %) were female and 304 (66.4 %) were overweight or obese. Except for gender, case characteristics differed significantly by surgeon/site. Previous abdominal surgery was reported for 226 (48.6 %) cases. SIRC was successfully completed in 455 (97.8 %) cases, and there were no conversions to open surgery. Median surgical time was 52 min with a decreasing trend after 55-85 cases. Male gender, obesity and diagnoses other than biliary dyskinesia were independent predictors of longer surgical times. The complication rate was 2.6 %.

CONCLUSIONS

Our large, multicenter study demonstrates that robotic single-site cholecystectomy is safe and feasible in a wide range of patients.

YouTube as a potential training method for laparoscopic cholecystectomy

PURPOSE

The purpose of this study was to analyze the educational quality of laparoscopic cholecystectomy (LC) videos accessible on YouTube, one of the most important sources of internet-based medical information.

METHODS

The keyword 'laparoscopic cholecystectomy' was used to search on YouTube and the first 100 videos were analyzed. Among them, 27 videos were excluded and 73 videos were included in the study. An arbitrary score system for video quality, devised from existing LC guidelines, were used to evaluate the quality of the videos. Video demographics were analyzed by the quality and source of the video. Correlation analysis was performed.

RESULTS

When analyzed by video quality, 11 (15.1%) were evaluated as 'good', 40 (54.8%) were 'moderate', and 22 (30.1%) were 'poor', and there were no differences in length, views per day, or number of likes, dislikes, and comments. When analyzed by source, 27 (37.0%) were uploaded by primary centers, 20 (27.4%) by secondary centers, 15 (20.5%) by tertiary centers, 5 (6.8%) by academic institutions, and 6 (8.2%) by commercial institutions. The mean score of the tertiary center group (6.0 ± 2.0) was significantly higher than the secondary center group (3.9 ± 1.4, P = 0.001). The video score had no correlation with views per day or number of likes.

CONCLUSION

Many LC videos are accessible on YouTube with varying quality. Videos uploaded by tertiary centers showed the highest educational value. This discrepancy in video quality was not recognized by viewers. More videos with higher quality need to be uploaded, and an active filtering process is necessary.

Emerging Techniques in Minimally Invasive Surgery. Pros and Cons

New trends have emerged regarding the best minimally invasive access approaches to perform gastrointestinal surgery. However, these newer approaches are seen critically by those who demand a more strict assessment of outcomes and safety. An international panel of expert gathered at the 2014 American College of Surgeons Meeting with the goal of providing an evidence-based understanding of the real value of these approaches in gastrointestinal surgery. The panel has compared the efficacy and safety of most established approaches to gastrointestinal diseases to those of new treatment modalities: peroral esophageal myotomy vs. laparoscopic myotomy for achalasia, transgastric vs. transvaginal approach, and single-incision vs. multi-port access minimally invasive surgery. The panel found that (1) the outcome of these new approaches was not superior to that of established surgical procedures; (2) the new approaches are generally performed in few highly specialized centers; and (3) transgastric and transvaginal approaches might be safe and feasible in very experienced hands, but cost, training, operative time, and tools seem to limit their application for the treatment of common procedures such as cholecystectomy and appendectomy. Because the expected advantages of new approaches have yet to be proven in controlled trials, new approaches should be considered for adoption into practice only after thorough analyses of their efficacy and effectiveness and appropriate training.

The Effect of Product Safety Courses on the Adoption and Outcomes of LESS Surgery

BACKGROUND AND OBJECTIVES

As technology in surgery evolves, the medical instrument industry is inevitability involved in promoting the use and appropriate (ie, effective and safe) application of its products. This study was undertaken to evaluate industry-supported product safety courses in laparoendoscopic single-site (LESS) surgery, by using the metrics of surgeons' adoption of the technique, safety of the procedure, and surgeons' perception of the surgery.

METHODS

LESS surgery courses that involved didactic lectures, operative videos, operation observation, collaborative learning, and simulation, were attended by 226 surgeons. With Florida Hospital Tampa Institutional Review Board approval, the surgeons were queried before and immediately after the course, to assess their attitudes toward LESS surgery. Then, well after the course, the surgeons were contacted, repeatedly if necessary, to complete questionnaires.

RESULTS

Before the course, 82% of the surgeons undertook more than 10 laparoscopic operations per month. Immediately after the course, 86% were confident that they were prepared to perform LESS surgery. Months after the course, 77% of the respondents had adopted LESS surgery, primarily cholecystectomy; 59% had added 1 or more trocars in 0-20% of their procedures; and 73% held the opinion that operating room observation was the most helpful learning experience. Complications with LESS surgery were noted 12% of the time. Advantages of the technique were better cosmesis (58%) and patient satisfaction (38%). Disadvantages included risk of complications (37%) and higher technical demand (25%). Seventy-eight percent viewed LESS surgery as an advancement in surgical technique.

CONCLUSION

In multifaceted product safety courses, operating room observation is thought to provide the most helpful instruction for those wanting to undertake LESS surgery. The procedure has been safely adopted by surgeons who frequently perform laparoscopies. The tradeoff is in performing a more difficult technique to obtain better cosmesis for the patient. We must continue to conduct critical evaluations of product safety courses for the introduction of new technology in surgery.

The real-world application of single incision laparoscopic cholecystectomy

OBJECTIVES

Most previous studies that have investigated single incision laparoscopic cholecystectomy (SILC) are case series with limited sample sizes. We have reviewed the outcome of 500 consecutive cases of SILC performed by a single surgeon at our center.

MATERIALS AND METHODS

From April 2009 to October 2012, a single surgeon performed 1250 laparoscopic cholecystectomies for various gallbladder (GB) diseases. SILC was chosen as the surgical modality unless there was evidence of acute cholecystitis or GB empyema, the patient had a prior history of upper abdominal surgery, endoscopic sphincterotomy, or had comorbidities with an ASA score of III or higher. The clinicopathologic features and perioperative data of patients were retrospectively reviewed.

RESULTS

The mean age and BMI of included patients were 42.7 years and 23.6 kg/m(2), respectively. The mean operating time was 52 min. Patients stayed in the hospital for an average of 1.3 days postoperatively. In 55 patients, an additional 2 mm trocar was inserted for retraction of the GB. One patient was converted to an open cholecystectomy because of Mirizzi syndrome. There were no observed complications including incisional hernias in this patient population.

CONCLUSIONS

SILC is a safe, effective procedure for cholecystectomy that may be considered the main surgical strategy in select patients.

Single-site robotic cholecystectomy in a broadly inclusive patient population: a prospective study

OBJECTIVES

To describe our initial experience with single-site robotic cholecystectomy (SSRC) and its applicability to a broad segment of patients.

BACKGROUND

At the initiation of our study, there were only 3 published reports on SSRC. These initial studies had limited inclusion criteria. We present our experience with the technical aspects and patient outcomes of SSRC in a broadly inclusive patient population.

METHODS

Prospective cohort study from January 2012 to January 2013, in which 95 patients underwent SSRC. Procedural times, postoperative complications, delayed hospital discharges, and re-admissions were evaluated.

RESULTS

Patients were predominantly female (71.6%) had mean age of 45.2 ± 6.1 years and mean body mass index (BMI) of 30.1 ± 7.1 kg/m. Overall, mean total operative time (TOT) for all patients (n = 95) was 88.63 ± 32.0 (range: 49-220) minutes. SSRC was not completed in 8 (8.42%) patients: 6 conversions to laparoscopy, 1 conversion to open, and 1 aborted case. The group of patients who were able to complete SSRC (n = 87) had a mean TOT of 83.5 ± 24.5 minutes and mean operative robotic time (RT) of 39.6 ± 15.2 minutes. RT was longer in patients with intra-abdominal adhesions (P = 0.0139) and higher BMI (P = 0.03). A minority of patients required hospital admission (11.6%), readmission (6.3%), or reoperation (1.1%). No bile duct injury or death occurred.

CONCLUSIONS

SSRC is safe and has a manageable learning curve. Patient factors, such as obesity, did not significantly affect conversion rates or TOTs. SSRC is a promising new technique, which can be offered to a wide array of patients.

A novel locally operated master-slave robot system for single-incision laparoscopic surgery

PURPOSE

Single-incision laparoscopic surgery (SILS) provides more cosmetic benefits than conventional laparoscopic surgery but presents operational difficulties. To overcome this technical problem, we have developed a locally operated master-slave robot system that provides operability and a visual field similar to conventional laparoscopic surgery.

MATERIAL AND METHODS

A surgeon grasps the master device with the left hand, which is placed above the abdominal wall, and holds a normal instrument with the right hand. A laparoscope, a slave robot, and the right-sided instrument are inserted through one incision. The slave robot is bent in the body cavity and its length, pose, and tip angle are changed by manipulating the master device; thus the surgeon has almost the same operability as with normal laparoscopic surgery. To evaluate our proposed system, we conducted a basic task and an ex vivo experiment.

RESULTS

In basic task experiments, the average object-passing task time was 9.50 sec (SILS cross), 22.25 sec (SILS parallel), and 7.23 sec (proposed SILS). The average number of instrument collisions was 3.67 (SILS cross), 14 (SILS parallel), and 0.33 (proposed SILS). In the ex vivo experiment, we confirmed the applicability of our system for single-port laparoscopic cholecystectomy.

CONCLUSION

We demonstrated that our proposed robot system is useful for single-incision laparoscopic surgery.

Transareola single-site laparoendoscopic bilateral thyroidectomy

BACKGROUND

Transareola single-site endoscopic thyroidectomy has been successfully established as a surgical approach. This study investigated the feasibility and safety of transareola single-site endoscopic thyroidectomy for bilateral thyroid disease.

PATIENTS AND METHODS

Twelve patients who underwent bilateral thyroidectomy were enrolled in this study. The surgical outcomes were analyzed, including operation time, intraoperative bleeding volume, postoperative pain score, and cosmetic satisfaction score.

RESULTS

All patients underwent successful transareola single-site endoscopic bilateral thyroidectomy, and no patient was semiconverted to three-port endoscopic surgery or open surgery. Seven patients underwent bilateral partial thyroidectomy, and 5 patients underwent subtotal thyroidectomy plus contralateral partial thyroidectomy. The mean operation time was 165±23.8 minutes (range, 142-185 minutes). The mean intraoperative bleeding volume was 27.3±12.3 mL (range, 20-45 mL). The mean postoperative wound drainage was 121±45.8 mL (range, 85-137 mL). The drainage tube was removed 3-4 days after surgery. The mean visual analog scale score was 3.3±2.5 (range, 1-5) at 24 hours postoperatively. The patients were followed up for 2 month with no complaint of chest wall wound pain and numbness. The mean cosmetic satisfaction score was 9.55±0.8 (range, 8-10).

CONCLUSIONS

Transareola single-site endoscopic bilateral thyroidectomy is feasible and safe and has the advantages of high cosmetic satisfaction.

Laparoscopic Sleeve Gastrectomy with Transgastric Visualization

Background. Laparoendoscopic single-site sleeve gastrectomy is gaining acceptance. However, totally natural orifice translumenal endoscopic surgery (NOTES) in morbidly obese patients is still controversial due to safety and technical issues. To this end, we have developed a technique for sleeve gastrectomy in which the surgical field view is achieved through transgastric approach and the operating channel will eventually be through the vagina to form a dual lumen totally NOTES procedure for sleeve gastrectomy. As a step toward this approach, we performed a single abdominal incision in order to simulate the transvaginal route. This study is another step toward combined transvaginal and transgastric totally NOTES sleeve gastrectomy. Methods and Procedures. A combined NOTES and single trocar sleeve gastrectomy was performed on 8 porcine animal models. The endoscope was inserted through the gastric wall and served as the vision source for the procedure. A second endoscope was inserted via the transabdominal trocar together with the surgical instruments. Results. Sleeve gastrectomy was performed on 8 porcine models. The operative time for the first procedure was 5 hours, but after determining the technique, the time was reduced by half. Conclusion. Combined NOTES and single trocar sleeve gastrectomy is feasible in a porcine model. We achieved an excellent view of the surgical field through the transgastric approach. We believe that in the near future, combining the transgastric visualization of the surgical field together with a transvaginal approach may enable performing a total NOTES sleeve gastrectomy procedure. This hypothesis will be studied in further animal experiments before implementation in humans.

Cholecystectomy by using a surgical robotic system

Because of their frequency, hepato-biliary procedures have been the gateway for innovation to permeate into the realm of general surgery. Robotics and single-incision techniques are the latest manifestation in the evolution of minimally invasive surgery. Enthusiasm for the latter has increased due to its inarguably superior cosmetic result. Nevertheless, there are several technical disadvantages associated with this approach that have raised several concerns. The robotic platform may provide a solution to these issues. We analyze the strengths and weaknesses of the robotic system for cholecystectomy and its relation to single site technology. We review all available literature addressing robotic single site cholecystectomy. Due to the advent of specific robotic single site technology, many of the challenges commonly associated with single site cholecystectomy have been alleviated. Although this novel approach has not yet been extensively tested, the available evidence suggests that it is at least equivalent to LC in selected patients. Robotic single site cholecystectomy is safe and feasible and adequately compensates for many of the challenges commonly associated with conventional single site cholecystectomy. Large, high-quality studies are needed to further clarify the role of this procedure and its value as part of the surgeon's armamentarium.

Totally laparoscopic anterior resection with transvaginal assistance and transvaginal specimen extraction: a technique for natural orifice surgery combined with reduced-port surgery

Background

Natural orifice specimen extraction (NOSE) has been developed as a means of decreasing the incidence of surgical wound complications. However, NOSE performed using a conventional multiport technique has been reported previously. The current authors performed totally laparoscopic anterior resection with transvaginal specimen extraction (TVSE) using the reduced-port surgery (RPS) technique. The Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) and Free Access (Top Corporation, Tokyo, Japan) were attached to the transvaginal route for transvaginal assistance and smooth specimen extraction. The authors documented this simple and safe technique and its short-term results.

Methods

Data were prospectively collected for five patients who underwent totally laparoscopic anterior resection with TVSE for colorectal cancer between June 2012 and December 2012. A multiport access device (GelPOINT advanced-access platform; Applied Medical) was inserted into the navel, and a 5-mm port was inserted into the right lower quadrant to be used as a drain site. Transverse transvaginal posterior colpotomy then was performed. One ring of an Alexis ring pair was inserted into the peritoneal cavity through the vagina. The other white ring was placed outside of the vagina and then covered with a Free Access to maintain the pneumoperitoneum for insertion of a 12-mm port. Lymph node dissection and transection of the distal colon were performed with transvaginal assistance. The specimen then was extracted transvaginally. After the Alexis had been removed, the vaginal incision was closed transvaginally. End-to-end colorectal anastomosis was performed using the double-stapling technique.

Results

Transvaginal extraction was completed in all five cases. The median operation time was 235 min. One case was complicated by chyloperitoneum. The median hospital stay was 6 days. Only one patient required intravenous analgesics once on postoperative day 1. All the patients remained disease free.

Conclusion

Totally laparoscopic anterior resection using TVSE with RPS appears to be feasible, safe, and oncologically acceptable for selected cases.

Single-incision cholecystectomy: a comparative study of standard laparoscopic, robotic, and SPIDER platforms

BACKGROUND

Many series have shown the feasibility and safety of single-incision laparoscopic cholecystectomy (SILC), but this technique still has limitations such as instrument collisions and lack of triangulation. Recently, two single-incision platforms, robotic and SPIDER, have attempted to ameliorate such problems. This study aimed to compare three different techniques of single-incision cholecystectomy: standard laparoscopic, robotic, and SPIDER approaches.

METHODS

The authors retrospectively collected data from their first 166 single-incision robotic cholecystectomies (SIRCs) and compared the findings with the data from their first 166 SILCs and the first 166 s-generation SPIDER procedures. All the SILCs were performed with three trocars placed in one umbilical incision and with gallbladder retraction using a Prolene stitch on the right upper quadrant. All the robotic cases were managed using the da Vinci Single-Site Surgical System, and all the SPIDER procedures were performed using the SPIDER Surgical System.

RESULTS

The SILC, SIRC, and SPIDER groups consisted respectively of 129 (76.3%), 131 (78.9%), and 136 (81.9%) women with the respective mean ages of 44.5 ± 14.3, 51.6 ± 15.9, and 46.4 ± 15.2 years. The mean body mass indexes (BMIs) were respectively 29.1 ± 5.6, 29.4 ± 6.2, and 27.5 ± 4.8 kg/m(2), and the mean surgical times were 37.1 ± 13.3, 63.0 ± 25.2, and 52.8 ± 18.7 min. The total hospital stays were respectively 1.3 ± 5.3, 1.2 ± 2.2, and 1.5 ± 2.6 days, and complications were seen respectively in three SILC cases (1.8%), three SIRC cases (1.8%), and two SPIDER cases (1.2%).

CONCLUSIONS

The results of this study demonstrate similar results among the three platforms for most of the parameters measured. The SILC procedure appears to be superior to SIRC and SPIDER in terms of surgical time, but selection bias could be the cause. The SILS, SIRC, and SPIDER procedures all are similar in terms of complication profile. It can be concluded that SILC, SIRC, and SPIDER all are feasible and safe alternatives when used for single-incision cholecystectomy.

Single-site robotic cholecystectomy: efficiency and cost analysis

BACKGROUND

Single-incision surgery has gained in popularity, and the recent development of specialized robotic and laparoscopic instruments may remove some of the ergonomic and technical difficulties associated with this approach. However, questions of cost and efficiency remain.

METHODS

We prospectively collected perioperative outcome and efficiency (operative time, case volume) data for our single-site robotic cholecystectomy cases and retrospectively reviewed data for our single-incision laparoscopic cholecystectomy cases.

RESULTS

There were no differences in patient characteristics or perioperative outcomes between the robotic (n = 20) and laparoscopic (n = 10) groups; operative times were equivalent (84.6 vs 85.5 min; p = 0.8737) and blood loss and complications were minimal. There was a higher robotic case volume, with an average of two robotic cases (range 1-4)/day vs one/day for laparoscopic cases (range 1-1; p = 0.0306). Streamlined instrument costs were essentially equivalent.

CONCLUSIONS

Robotic single-site cholecystectomy is a safe, cost-effective alternative to single-incision laparoscopic cholecystectomy in a robot-existing model.