Single port laparoscopic cholecystectomy: which technique, which surgeon, for which patient? A study of the implementation in a teaching hospital

Detecting the Interdisciplinary Nature and Topic Hotspots of Robotics in Surgery: Social Network Analysis and Bibliometric Study

Background

With the widespread application of a robot to surgery, growing literature related to robotics in surgery (RS) documents widespread concerns from scientific researchers worldwide. Although such application is helpful to considerably improve the accuracy of surgery, we still lack the understanding of the multidiscipline-crossing status and topic distribution related to RS.

Objective

The aim of this study was to detect the interdisciplinary nature and topic hotspots on RS by analyzing the current publication outputs related to RS.

Methods

The authors collected publications related to RS in the last 21 years, indexed by the Web of Science Core Collection. Various bibliometric methods and tools were used, including literature distribution analysis at the country and institution level and interdisciplinary collaboration analysis in the different periods of time. Co-word analysis was performed based on the keywords with high frequency. The temporal visualization bar presented the evolution of topics over time.

Results

A total of 7732 bibliographic records related to RS were identified. The United States plays a leading role in the publication output related to RS, followed by Italy and Germany. It should be noted that the Yonsei University in South Korea published the highest number of RS-related publications. Furthermore, the interdisciplinary collaboration is uneven; the number of disciplines involved in each paper dropped from the initial 1.60 to the current 1.31. Surgery; Engineering; Radiology, Nuclear Medicine, and Medical Imaging; and Neurosciences and Neurology are the 4 core disciplines in the field of RS, all of which have extensive cooperation with other disciplines. The distribution of topic hotspots is in imbalanced status, which can be categorized into 7 clusters. Moreover, 3 areas about the evolution of topic were identified, namely (1) the exploration of techniques that make RS implemented, (2) rapid development of robotic systems and related applications in surgery, and (3) application of a robot to excision of tissues or organs targeted at various specific diseases.

Conclusions

This study provided important insights into the interdisciplinary nature related to RS, which indicates that the researchers with different disciplinary backgrounds should strengthen cooperation to publish a high-quality output. The research topic hotspots related to RS are relatively scattered, which has begun to turn to the application of RS targeted at specific diseases. Our study is helpful to provide a potential guide to the direction of the field of RS for future research in the field of RS.

Single-incision robotic cholecystectomy versus single-incision laparoscopic cholecystectomy: A systematic review and meta-analysis

BACKGROUND

Single-incision laparoscopic cholecystectomy (SILC) is the result of the ongoing trend to minimally invasive of laparoscopy, but some surgeons thought that the SILC can increase the risk of bile duct injure or bile spillage, and the single-incision robotic cholecystectomy (SIRC) can overcome the drawbacks of SILC. Some articles described that the SIRC had longer operative time and more cost than SILC. The advantages and disadvantages of SIRC have still not been extensively studied. We aimed to investigate the outcomes of SIRC compared to SILC and evaluate the safety and feasibility of SIRC.

METHODS

To find relevant studies, the electronic databases PubMed, MEDLINE, The Cochrane Library, and EMBASE were searched to seek information in English literature from 2011 to 2017. Studies comparing SIRC to SILC, for any indication, were included in the analysis. This systematic review and meta-analysis were performed with RevMan Version 5.3.

RESULTS

Six comparative studies (n = 633 patients) were included in our analysis. The data showed that the SIRC and SILC had equivalent outcomes for operative time [mean difference (MD) = 17.32, 95% confidence interval (CI): -8.93-43.57, P = .20], intraoperative complications [odd ratio (OR) = 0.48, 95% CI: 0.17-1.39, P = .18], postoperative complications (OR = 0.62, 95% CI: 0.21-1.86, P = .39), hospital stay (MD = -0.01, 95% CI: -0.21-0.19, P = .90), readmissions rate (OR = 0.70, 95% CI: 0.09-5.63, P = .74), and conversion rate (OR = 0.52, 95% CI: 0.14-1.96, P = .33), but total cost was statistically significant (MD = 3.7, 95% CI: 3.61-3.79, P < .00001).

CONCLUSION

SIRC is a safe and feasible procedure for cholecystectomy, and the operative time is same as SILC, but the total cost of SIRC is significantly higher than SILC.

A Comparative Study of Outcomes Between Single-Site Robotic and Multi-port Laparoscopic Cholecystectomy: An Experience from a Tertiary Care Center

BACKGROUND

The aim of this study was to compare the outcomes of single-site robotic cholecystectomy with multi-port laparoscopic cholecystectomy within a high-volume tertiary health care center.

METHODS

A retrospective analysis of prospectively maintained data was conducted on patients undergoing single-site robotic cholecystectomy or multi-port laparoscopic cholecystectomy between October 2011 and July 2014. A single surgeon performed all the surgeries included in the study.

RESULTS

A total of 678 cholecystectomies were performed. Of these, 415 (61%) were single-site robotic cholecystectomies and 263 (39%) were multi-port laparoscopic cholecystectomies. Laparoscopic patients had a greater mean BMI (30.5 vs. 29.0 kg/m²; p = 0.008), were more likely to have undergone prior abdominal surgery (83.3 vs. 41.4%; p < 0.001) and had a higher incidence of preexisting comorbidities (76.1 vs. 67.2%; p = 0.014) as compared to the robotic group. There was no statistical difference in the total operative time, rate of conversion to open procedure and mean length of follow-up between the two groups. The mean length of hospital stay was shorter for patients within the robotic group (1.9 vs. 2.4 days; p = 0.012). Single-site robotic cholecystectomy was associated with a higher rate of wound infection (3.9 vs. 1.1%; p = 0.037) and incisional hernia (6.5 vs. 1.9%; p = 0.006).

CONCLUSION

Multi-port laparoscopic cholecystectomy should remain the gold standard therapy for gallbladder disease. Single-site robotic cholecystectomy is an effective alternative procedure for uncomplicated benign gallbladder disease in properly selected patients. This must be carefully balanced against a high rate of surgical site infection and incisional hernia, and patients should be informed of these risks.

Single-Site Robotic Cholecystectomy: The Timeline of Progress

AIM

To investigate the learning curve and perioperative outcomes of single-site robotic cholecystectomy during the first 102 cases by a single surgeon.

MATERIALS AND METHODS

A retrospective review of a prospectively maintained database was performed on the first 102 cases of single-site robotic cholecystectomy. Patients were divided into five chronological groups based on the date of surgery, with 20 patients in each group except the 5th group which had 22 patients. The groups were compared by docking time, robotic dissection time, and overall surgery time. A P value of 0.05 was used as statistically significant.

RESULTS

The female to male ratio was 2:1. The mean age was 51 years (18-87) and the mean BMI was 28.26 (18-41). Overall, 69 % of the patients underwent elective cholecystectomy and 31 % required urgent surgery. In all, 17 % of patients had previous abdominal surgeries. In total, 45 % of procedures were regarded as same day surgery. The total mean length of stay was 1.97 days (0-8). The mean operative time was 110 min (36-265), mean robotic console time 70 min (26-179), and mean docking time 9 min (1-26). The overall conversion rate was 3.9 % and the complication rate was 4 %. The docking time, robotic time, and average operative time were significantly different in the first group as compared to the remaining the five groups (P = 0.001).

CONCLUSION

Single-site robotic cholecystectomy is safe in both elective and urgent conditions, and in patients with previous abdominal surgeries. It has a short learning curve.

[Drainage of amoebic liver abscess by single incision laparoscopic surgery. Report of a case]

BACKGROUND

Single incision laparoscopic surgery has increased recently due to successful results, achieved in several procedures. The aim of the present work is to present the first case in which single incision laparoscopy is used for the drainage of an amoebic liver abscess.

CLINICAL CASE

A 44-year-old man presented with intense right upper quadrant pain, generalised jaundice, tachycardia, fever, hepatomegaly and a positive Murphy's sign. Laboratory results revealed an increased plasma bilirubin, elevated alkaline phosphatase and transaminases, leucocytosis, negative viral panel for hepatitis, and positive antibodies against Entamoeba histolytica. On an abdominal computed tomography a 15 × 12.1 cm hypodense lesion was observed in the patient's liver, identified as an amoebic liver abscess. Analgesics and antibiotics were started and subsequently the patient was submitted to laparoscopic drainage of the abscess using a single port approach. Drainage and irrigation of the abscess was performed. Four days later the patient was discharged without complications.

CONCLUSION

Management of amoebic liver abscess is focused on the elimination of the infectious agent and obliteration of the abscess cavity in order to prevent its complications, especially rupture. Laparoscopic surgery has proved to be a safe and effective way to manage this entity.

Robotic surgery

BACKGROUND

Proficiency in minimally invasive surgery requires intensive and continuous training, as it is technically challenging for unnatural visual and haptic perceptions. Robotic and computer sciences are producing innovations to augment the surgeon's skills to achieve accuracy and high precision during complex surgery. This article reviews the current use of robotically assisted surgery, focusing on technology as well as main applications in digestive surgery, and future perspectives.

METHODS

The PubMed database was interrogated to retrieve evidence-based data on surgical applications. Internal and external consulting with key opinion leaders, renowned robotics laboratories and robotic platform manufacturers was used to produce state-of-the art business intelligence around robotically assisted surgery.

RESULTS

Selected digestive procedures (oesophagectomy, gastric bypass, pancreatic and liver resections, rectal resection for cancer) might benefit from robotic assistance, although the current level of evidence is insufficient to support widespread adoption. The surgical robotic market is growing, and a variety of projects have recently been launched at both academic and corporate levels to develop lightweight, miniaturized surgical robotic prototypes.

CONCLUSION

The magnified view, and improved ergonomics and dexterity offered by robotic platforms, might facilitate the uptake of minimally invasive procedures. Image guidance to complement robotically assisted procedures, through the concepts of augmented reality, could well represent a major revolution to increase safety and deal with difficulties associated with the new minimally invasive approaches.

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.

Can single incision laproscopic cholecystectomy replace the traditional four port laproscopic approach: a review

The major aim of surgeons has always been a minimalist approach towards surgery, thereby reducing the complications associated with the surgery. The gold standard treatment for cholelithiasis with cholecystitis is currently the four port laparoscopic cholecystectomy (4 PLC). Recently, a newer technique has been introduced which uses a single port, rather than the four ports, for the removal of the gall bladder laparoscopically; it is known as Single Incision Laparoscopic Cholecystectomy (SILC). This is a comparatively minimal approach towards surgery. Therefore the purpose of this review is to compare the advantages and the disadvantages of SILC versus 4PLC, and hence, to give an idea of whether SILC is ready to replace the traditional approach as the new treatment of choice.

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.

Single-port robotically assisted laparoscopic surgery

Worthy of wider evaluation

New technologies for single-site robotic surgery in hepato-biliary-pancreatic surgery

Laparoendoscopic single-site surgery (LESS) aims to reduce incision-related complications by using a single surgical access through which multiple instruments are inserted simultaneously. First descriptions of LESS procedures date back to the early 90 s, but the approach initially failed to gain popularity because of technical challenges that markedly impair the principles of laparoscopic ergonomics. In recent years LESS has been increasingly applied to hepatobiliary procedures including cholecystectomies and liver resections. However, the uptake of LESS in hepatobiliary is limited. The surgical robotic platform might play a fundamental role in facilitating the uptake of LESS by the surgical community since robotic science made it possible to develop adequate technology to deal with some of the LESS issues such as restoring surgical triangulation. In this paper the current state-of-the-art for robotic LESS applied to the hepatobiliary system and emerging technologies enabling safer LESS procedures have been reviewed and future perspectives commented on the light of our experience.

[Use of percutaneous needles in the feasability of single-port laparoscopic cholecystectomy]

INTRODUCTION

The usefulness of percutaneous needles (PN) to replace traditional assistance ports in mini-invasive techniques with a single port is analyzed and their feasibility for conducting a single port laparoscopic cholecystectomy (SPLC) is demonstrated.

MATERIAL AND METHODS

A retrospective, linear and descriptive study covering 2,431 patients with a diagnosis of acute and non-acute gallbladder disease has been conducted. The patients underwent a single port laparoscopic cholecystectomy using some type of PNs, replacing the assisting ports used in traditional laparoscopic cholecystechtomy (TLC). Based on the progressive use of PNs-reins (R), hooked needles (HN) and passing suture needles (PSN)-to carry out the SPLC technique, 3 groups have been established: A, B and C. The results were compared using a Student T test, odds ratio and CI and were analyzed by means of the SPSS software v. 13.0.

RESULTS

The use of PNs showed an increased feasibility for the laparoscopic procedure, as they were included in the surgical technique. The R were useful when carrying out the SPLC in 78% of the cases and when the HK were added, the results increased to 88%. When using the 3 types (R, HN and PSN), the results increased by 96%. Statistical significance was obtained with these values: chi 2=67.13 and P<.001; odds ratio and 95% CI became significant when comparing the B/C, A/C, and A-B/C groups.

CONCLUSIONS

The PNs, replacing the assisting ports in laparoscopy, make it possible to attain a feasibility of the process in 96% of the cases. This percentage was similar to what is achieved with the TLC, which places the one port laparoscopy surgery technique as an advantageous and economic alternative. This application of the PNs could be made extensive to other single-port techniques, with a multi-valve platform and natural orifice surgery.

Single-port versus multiport laparoscopic cholecystectomy: a prospective randomized clinical trial

PURPOSE

We report the outcomes of a randomized clinical trial of single-port laparoscopic cholecystectomy (SPLC) and multiport laparoscopic cholecystectomy (MPLC).

METHODS

Fifty-four patients (27 in each group) were randomized. A visual analog scale was used with a 10-point scale for an objective assessment of incisional pain and incisional cosmesis on postoperative days 1, 3, and 14.

RESULTS

The mean operating time was significantly longer in the SPLC. The mean cosmesis scores on postoperative days 3 (9.7 vs. 8.9, P = 0.01) and 14 (9.9 vs. 9.2, P<0.01) were significantly greater in the SPLC group than in the MPLC group. The group's mean visual analog scale scores for incisional pain, and their requirements for analgesics, did not differ significantly.

CONCLUSIONS

Although SPLC takes longer than MPLC, experienced laparoscopic surgeons can perform SPLC safely with results comparable with those for MPLC. SPLC is superior to MPLC in terms of short-term cosmetic outcomes.

Small bowel exploration and resection using single-port surgery: a safe and feasible approach

AIM

The aim of this study is to demonstrate the efficacy of wireless capsule endoscopy for preoperative identification of bleeding sources and/or small bowel tumours in surgical patients and to evaluate the feasibility of single-port surgery in the treatment of such pathologies.

METHOD

Five patients presenting with obscure gastrointestinal bleeding or/and mild small bowel obstruction were investigated to diagnose and localize the bleeding source or tumour using capsule endoscopy imaging, and, if necessary, with other investigative modalities. All patients were operated on using single-port surgery for small bowel exploration, lesion confirmation, small bowel resection and anastomosis.

RESULTS

Small bowel pathology was successfully detected by video capsule endoscopy in three of four patients, and was further substantiated by contrast CT, double-balloon endoscopy or enteroclysis. Complete small bowel exploration, intra-operative identification and oncological resection of the involved segment and anastomosis (intracorporeal and extracorporeal) was successfully performed in all five patients using single-port access without any complication, morbidity or mortality.

CONCLUSION

This study demonstrates the feasibility and safety of single-port small bowel resection performed after a high-quality preoperative localization of the tumour.

Experiences of single incision cholecystectomy

PURPOSE

Single incision laparoscopic surgery in suitable cases is preferred today because it results in less postoperative pain, a more rapid recovery period, more comfort, and a better cosmetic appearance from smaller incisions. This study aims to present our experiences with single incision laparoscopic cholecystectomy to evaluate the safety and feasibility of this procedure.

METHODS

A total of 150 patients who underwent single incision laparoscopic cholecystectomy between January 2009 and December 2011 were evaluated retrospectively. In this serial, two different access techniques were used for single incision laparoscopy.

RESULTS

Single incision laparoscopic cholecystectomy was performed successfully on 150 patients. Median operative time was 29 (minimum-maximum=5-66) minutes. Median duration of hospital stay was found to be 1.33 (minimum-maximum=1-8) days. Patients were controlled on the seventh postoperative day. Bilier complication was not seen in the early period. Five patients showed port site hernia complications. Other major complications were not seen in the 36-month follow-up period.

CONCLUSION

Operation time of single incision laparoscopic cholecystectomy is significantly shortened with the learning curve. Single incision laparoscopic cholecystectomy seems a safe method.

Single incision laparoscopic cholecystectomy is associated with a higher bile duct injury rate: a review and a word of caution

OBJECTIVE

To compare the incidence of bile duct injuries during single incision laparoscopic cholecystectomy (SILC) in relation to the accepted historic rate of 0.4% to 0.5% for standard laparoscopic cholecystectomy (SLC).

BACKGROUND

Technically, SILC is more challenging than SLC. The role and benefit of SILC in patient care has yet to be defined. Bile duct injuries have been reported in several series of SILC.

METHOD

A comprehensive database search of MEDLINE, EMBASE, CINAHL, and PubMed Central was performed to generate all reported cases of SILC to present. The search was limited to reports of 20 or more patients based on current literature of existing SILC learning curves. Data were analyzed using the Student t test and χ analyses where appropriate.

RESULTS

A total of 76 candidate studies were identified; 45 studies met inclusion criteria for an aggregate total of 2626 patients. Most SILCs were performed in the absence of acute cholecystitis (90.6%). The aggregate complication rate was 4.2%, and complications were graded according to the Dindo-Clavien Classification System. Nineteen bile duct injuries were identified for a SILC-associated bile duct injury rate of 0.72%.

CONCLUSIONS

There seems to be an increase in the rate of bile duct injuries during SILC when compared with historic rates during SLC. Because most SILCs are performed in optimal conditions, such as lack of acute inflammation, we urge caution in applying this technique to inflamed gallbladder pathology. Controlled trials are needed before conclusions are made regarding safety of SILC.

Single port versus multiple port laparoscopic cholecystectomy-a comparative study

Single port laparoscopic cholecystectomy (SPLC) was introduced to minimize postoperative morbidity and improve cosmesis. We performed a comparative study to assess feasibility, safety and perceived benefits of SPLC. Two groups of patients (104 each) with comparable demographic characteristics were selected for SPLC and multiport laparoscopic cholecystectomy (MPLC) between May 2010 to March 2011. SPLC was performed using X cone® with 5 mm extra long telescope and 3 ports for hand instruments. MPLC was performed with traditional 4 port technique. A large window was always created during dissection to obtain the critical view of safety. Data collection was prospective. The primary end points were post-operative pain and surgical complications. Secondary end points were patient assessed cosmesis and satisfaction scores and operating time. The mean VAS scores for pain in SPLC group were higher on day 0 (SPLC 3.37 versus MPLC 2.72, p = 0.03) and equivalent to MPLC group on day 1(SPLC 1.90 versus MPLC 1.79, p = 0.06). Number of patients requiring analgesia for breakthrough pain (SPLC 21.1 % versus MPLC 26.9 %, p = 0.31) was similar. Number and nature of surgical complications was similar (SPLC 17.3 % versus MPLC 21.2 %, p =0.59). Mean patient assessed cosmesis scores (SPLC 7.96 versus MPLC 7.16, p = 0.003) and mean patient satisfaction scores (SPLC 8.66 versus MPLC 8.16, p = 0.004) were higher in SPLC group indicating better cosmesis and greater patient satisfaction. SPLC took longer to perform (61 min versus 26 min, p = 0.00). Conversion was required in 5 patients in SPLC group. SPLC appears to be feasible and safe with cosmetic benefits in selected patients. However, challenges remain to improve operative ergonomics. SPLC needs to be proven efficacious with a high safety profile to be accepted as standard laparoscopic technique.

Single-incision laparoscopic cholecystectomy: is it a plausible alternative to the traditional four-port laparoscopic approach?

The current standard-of-care for treatment of cholecystectomy is the four port laparoscopic approach. The development of single incision/laparoendoscopic single site surgery (SILC/LESS) has now led to the development of new techniques for removal of the gallbladder. The use of SILC/LESS is now currently being evaluated as the next step in treatment of cholecystectomy. This review is an attempt to consolidate the current knowledge and analyze the feasibility of world-wide implementation of SILC/LESS.

Single-site robotic cholecystectomy (SSRC) versus single-incision laparoscopic cholecystectomy (SILC): comparison of learning curves. First European experience

BACKGROUND

Single-incision laparoscopic surgery is an emerging procedure developed to decrease parietal trauma and improve cosmetic results. However, many technical constraints, such as lack of triangulation, instrument collisions, and cross-handing, hamper this approach. Using a robotic platform may overcome these problems and enable more precise surgical actions by increasing freedom of movement and by restoring intuitive instrument control.

METHODS

We retrospectively collected, under institutional review board approval, data on the first 25 patients who underwent single-site robotic cholecystectomies (SSRC) at our center. Patients enrolled in this study underwent SSRC for symptomatic biliary gallstones or polyposis. Exclusion criteria were: BMI > 33; acute cholecystitis; previous upper abdominal surgery; ASA > II; and age >80 and <18 years. All procedures were performed with the da Vinci Si Surgical System and a dedicated SSRC kit (Intuitive). After discharge, patients were followed for 2 months. These SSRC cases were compared to our first 25 single-incision laparoscopic cholecystectomies (SILC) and with the literature.

RESULTS

There were no differences in patient characteristics between groups (gender, P = 0.4404; age, P = 0.7423; BMI, P = 0.5699), and there were no conversions or major complications in either cohort. Operative time was significantly longer for the SILC group compared with SSRC (83.2 vs. 62.7 min, P = 0.0006), and SSRC operative times did not change significantly along the series. The majority of patients in each group were discharged within 24 h, with an average length of hospital stay of 1.2 days for the SILC group and 1.1 days for the SSRC group (P = 0.2854). No wound complications (infection, incisional hernia) were observed in the SSRC group and in the SILC.

CONCLUSIONS

Our preliminary experience shows that SSRC is safe, can easily be learned, and performed in a reproducible manner and is faster than SILC.

Are natural orifice transluminal endoscopic surgery and single-incision surgery viable techniques for cholecystectomy?

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) and single-incision surgery (SIS) are less invasive alternatives to traditional laparoscopic techniques. Concerns exist over the safety of these new approaches, and randomized controlled trials have yet to confirm a net benefit. If NOTES and SIS techniques are to become standard practice, then they should be shown to be safe and hold clear benefits to patients. We aim at comparing the available results by using these techniques in a standard laparoscopic operation (cholecystectomy).

METHODS

A systematic review using available databases (MEDLINE, EMBASE, and the Cochrane Controlled Trials Register) and the published English language medical literature was performed. All the archived articles were cross-referenced. Outcome data obtained from a Cochrane review of laparoscopic cholecystectomy were used as the control group. All the operations performed via a single incision were grouped under SIS, and operations in which a natural orifice (alone or as a hybrid technique) was analyzed, under NOTES group. Mortality and complications were the primary outcome measures.

RESULTS

One hundred thirty-five papers including 4703 patients (714 NOTES, 3989 SIS) were selected for analysis. Overall complication rate was 4.2% in the NOTES group versus 4.3% in the SIS group, with a distinct complication profile. No mortality was reported in either group. NOTES procedures had a longer mean operative time than SIS techniques (107 versus 79 minutes). The conversion rate between NOTES and SILS was similar (3.4% versus 3.3%, respectively).

DISCUSSION

No difference in the incidence of complications was observed with the newer techniques. Adequately powered randomized control trials are needed to clarify whether SIS/NOTES cholecystectomy has a similar length of hospital stay to traditional laparoscopic cholecystectomy. The increased occurrence of specific types of complications and their use in acute pathology needs further investigation to warrant further use in routine surgical practice.