Alternative port site selection (APSS) for improved cosmesis in laparoscopic surgery

Cost-effective scarless cholecystectomy using a modified endoscopic minimally invasive reduced appliance technique (Emirate)

ABSTRACT

The current gold-standard surgical treatment for symptomatic gallstone disease is the conventional four-port laparoscopic cholecystectomy (CLC). In recent years, however, celebrities and social media have altered people's attitudes regarding surgery. Consequently, CLC has undergone several changes to reduce scarring and improve patient satisfaction. In this case-matched control study, the cost-effectiveness of a modified endoscopic minimally invasive reduced appliance technique (Emirate) that uses less equipment and three 5 mm reusable ports only at precisely specified anatomical sites was compared to CLC.

METHODS

Single-center retrospective matched cohort analysis including 140 consecutive patients treated with Emirate laparoscopic cholecystectomy ("ELC-group"), matched 1:1 by sex, indications for surgery, surgeon expertise, and preop bile duct imaging, with 140 patients receiving CLC in the same period of time ("CLC group").

RESULTS

We performed a retrospective case-matched review of 140 patients who had Emirate laparoscopic cholecystectomy for gallstones between January 2019 and December 2022. The groups included 108 females and 32 males with an equal ratio of surgical expertise-115 procedures were performed by consultants and 25 by trainees. In each group, 18 patients had preoperative MRCP or ERCP and 20 had acute cholecystitis as indications for surgery. Preoperative characteristics such as age (39 years in the Emirates group and 38.6 years in the CLC group), BMI (29.3 years in the Emirates group and 30 years in the CLC group), stone size, or liver enzymes showed no statistical difference between the two groups. In both groups, the average hospital stay was 1.5 days, and there was no conversion to open surgery, nor was there any bleeding requiring blood transfusion, bile leakage, stone slippage, bile duct injury, or invasive intervention postoperatively. When compared to the CLC group, the ELC group had significantly faster surgery times (t-test, p = 0.001), lower levels of the bile duct enzyme ALP (p = 0.003), and much lower costs (t-test, p = 0.0001).

CONCLUSION

The Emirate laparoscopic cholecystectomy method is a safe alternative to the traditional four-port laparoscopic cholecystectomy that is also much faster and less expensive.

Suprapubic Cholecystectomy Improves Cosmetic Outcome Compared to Classic Cholecystectomy

Currently, cholecystectomy is performed laparoscopically. While the conventional approach (CA) with four access ports persists, other methods seek to reduce trauma or to optimize cosmetic results. In this study, the safety and cosmetic outcome of a suprapubic approach (SA) were evaluated. Between 2015 and 2016, patients undergoing elective cholecystectomy either by CA or by a suprapubic approach (SA) at our institution were included. The cosmetic outcome, postoperative morbidity, operative time and length of stay were evaluated. Pictures of the site of intervention were taken 6−12 months postoperatively and rated on a scale from 1 (unsatisfying aesthetic result) to 5 (excellent aesthetic result). Five “non-medical” and five “medical” raters as well as one board-certified plastic surgeon performed the ratings. A total of 70 patients were included (n = 28 SA, n = 42 CA). The two groups did not differ in baseline characteristics (age, gender, BMI). The SA group showed a significantly better aesthetic outcome compared to the CA group 4.8 (4.8−4.9) vs. 4.2 (3.8−4.4), (p > 0.001). Medical raters: 4.0 (3.8−4.2) vs. 4.8 (4.6−5.0), (p < 0.001); non-medical raters: 4.2 (3.8−4.6) vs. 5.0 (4.8−5.0), (p < 0.001); plastic surgeon: 4.0 (4.0−4.0) vs. 5.0 (5.0−5.0), (p < 0.001). Fair interrater consistency was demonstrated with an ICC of 0.47 (95% CI = 0.38−0.57). No significant difference in the complication rate (1 (3.5%) in SA vs. 6 (14%) in CA, (p = 0.3)), or the operating time 66 (50−86) vs. 70 (65−82) min, (p = 0.3), were observed. Patients stayed for a median of three (3−3) days in the SA group and 3 (3−4) days in the CA group (p = 0.08). This study demonstrated that the suprapubic approach is an appropriate alternative to conventional laparoscopic cholecystectomy, presenting a better cosmetic outcome with a similar complication rate.

Bikini Line Approach for Cosmetic Laparoscopic Cholecystectomy

Four-port laparoscopic cholecystectomy (LC) is a standard procedure. Several alternative approaches have been described to make trocar scars invisible. This study describes and was successfully administered as a pilot for feasibility and safety of a bikini line port for better aesthetic results. In patients with symptomatic cholelithiasis undergoing LC between June 2021 and December 2021, bikini line ports were used in 67 patients. With the patient in the supine position, the first trocar (11 mm) was inserted into the abdomen through the umbilicus. The other three trocars were placed in the lower abdomen at the bikini line with the help of the camera. Standard instruments were used to perform the surgery. The mean operative time was 54.66 SD 14.1 min. No intraoperative or postoperative adverse events took place. The median follow-up for this cohort was 24 weeks. Cosmetic results were satisfactory for all patients. The use of one umbilical camera port and the other three ports in the bikini line in the lower abdomen completely hides the scars from the ports’ incision. The technique was quickly adopted by regular laparoscopic surgeons with usual instruments, much to the satisfaction of patients.

Laparoscopic cholecystectomy by the modified bikini line approach as a simple and safe technique

OBJECTIVE

The gold standard technique for laparoscopic cholecystectomy (LC) is using four ports in the upper abdomen. However, this operative approach may not provide aesthetic satisfaction for some patients because of visible incision marks. This study sought to demonstrate that these incision marks can be hidden by safely changing the port locations.

METHODS

For patients with symptomatic cholelithiasis undergoing LC between March 2019 and March 2020, the modified bikini line approach was used. With the patient in the supine position with open legs, the first trocar (10 mm) was inserted into the abdomen through an 11-mm incision in the umbilicus. The other three trocars were placed in the abdomen at the bikini line with the help of a camera. The standard equipment for LC was then used to perform the surgery.

RESULTS

The modified bikini line approach to LC was used for 38 patients. Average operative time was 28.65 min, and the average hospital stay was 1.07 days. No perioperative or postoperative complications occurred. Follow-up was at 1 week, 1 month, and 6 months. Cosmetic results were satisfactory for all patients.

CONCLUSIONS

As an alternative to the standard LC approach, the modified bikini line technique is safe and useful in patients for whom postoperative aesthetic appearance is important. The modified approach is simple to learn and use and is effective to hide the incision marks well.

Biliary Bypass with Laparoscopic Choledochoduodenostomy

Laparoscopic choledochoduodenostomy (LCDD) is employed to treat many benign biliary diseases when endoscopic or percutaneous techniques are not feasible. We describe our technique for LCDD, which utilizes common bile duct transection and an end-to-side biliary-enteric anastomosis. This procedure includes the following elements: isolation and transection of the common bile duct, mobilization of the duodenum (Kocher maneuver), inspection of the common bile duct, and end-to-side biliary-enteric anastomosis. Key details and pitfalls are discussed. Over a 5-year period, LCDD was performed on 18 patients. Indications included intractable abdominal pain (10) and choledocholithiasis (8). The majority of patients, 83%, tolerated the operation well with no complications. There was one postoperative intra-abdominal abscess and two anastomotic strictures, one in the immediate postoperative period and the other 9 months after the operation. The median length of stay was 4 days (IQR 3.0-5.3), and there was minimal blood loss. Based on our experience, LCDD with transection and end-to-side biliary-enteric anastomosis is a safe and effective biliary bypass technique.

Feasibility prospective study of laparoscopic cholecystectomy with suprapubic approach

BACKGROUND

Since the publication of laparoscopic cholecystectomy (LC) using three ports instead of four, no significant evolution has impacted on our clinical practice in order to improve length of stay, postoperative pain, time of recovery and cosmetic results. Recently, a renewed interest has been observed with the suprapubic approach, called occult scar laparoscopic cholecystectomy (OSLC). The aim of this prospective multicentric study was to evaluate the feasibility of OSLC in 2 French centers.

METHODS

From March to September 2014, 60 patients were prospectively included in this study. The operation incisions consisted of an umbilical incision for camera; an incision in the right groin for maneuvers of exposition and a suprapubic incision for instrumental dissection and clipping. Outcome was by operative time, operative complications, hospital length of stay, analgesia required after surgery, and cosmetic outcomes. The Patient Satisfaction Scale and Visual Analog Score (VAS) also were used to evaluate the level of cosmetic result and postoperative pain.

RESULTS

No laparoscopy was converted to an open procedure, the mean operative time was 53±20min. No patient had intraoperative bile duct injury or significant bleeding. The mean length of stay was 1.70±0.76 days. Two patients (3%) experienced postoperative complication (1 intra-abdominal abscess treated by antibiotics and 1 subcutaneous seroma of the 11-mm port wound treated successfully by needle aspiration).

CONCLUSION

The technique proved to be safe and feasible with no specific complication and without specific instrument. It offers satisfactory postoperative pain level and good cosmetic results.

Laparoscopic cholecystectomy with suprapubic approach

BACKGROUND

The laparoscopic cholecystectomies performed through single site surgery, despite undoubted aesthetic results, are costly and technically difficult to be performed. The suprapubic approach presents as a simpler and cheaper alternative with good aesthetic results.

AIM

To report the experience of Garavelo Hospital on laparoscopic cholecystectomy with suprapubic approach.

METHODS

Descriptive, crossectional study with retrospective data retrieval. The variables to be analyzed were success rate; occurrence of complications; surgical time and the length of stay.

RESULTS

The sample consisted of 42 patients, of which females were predominant (76.2%). The age ranged from 18 to 65 years with an average age of 36 years. The success rate was 95.3%. The average time for the procedure was 33.4 minutes. There were no intraoperative complications and all patients were discharged within 24 hours after surgery.

CONCLUSION

Laparoscopic cholecystectomy with suprapubic approach is safe and easy to domain. It can be performed in a time similar to traditional laparoscopy, without special instruments. It offers a good cosmetic result, and deserves more attention.