Our early experiences with single-incision laparoscopic surgery: the first 32 patients

Single-incision versus conventional multi-incision laparoscopic appendicectomy for suspected uncomplicated appendicitis

BACKGROUND

Appendicectomy is a well-established surgical procedure to manage acute appendicitis. The operation was historically performed as an open procedure and is currently performed using minimally invasive surgical techniques. A recent development in appendicectomy technique is the introduction of single-incision laparoscopic surgery. This incorporates all working ports (either one multi-luminal port or multiple mono-luminal ports) through a single skin incision; the procedure is known as single-incision laparoscopic appendicectomy or SILA. Unanswered questions remain regarding the efficacy of this novel technique, including its effects on patient benefit and satisfaction, complications, and long-term outcomes, when compared to multi-incision conventional laparoscopy (CLA). This is an update of a review published in 2011.

OBJECTIVES

To assess the effects of single-incision laparoscopic appendicectomy compared with multi-incision laparoscopic appendicectomy, on benefits, complications, and short-term outcomes, in patients with acute appendicitis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled trials (CENTRAL, the Cochrane Library 2018 Issue 2), Ovid MEDLINE (1983 to January 2024), Ovid Embase (1983 to January 2024), the WHO International Clinical Trial Register (January 2024), and Clinicaltrials.gov (January 2024). We also searched reference lists of relevant articles and reviews, conference proceedings, and ongoing trial databases. The searches were carried out on 20 January 2024.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared the single-incision procedure SILA against CLA for patients (male and female) over the age of 10 years, diagnosed with appendicitis, or symptoms of appendicitis, and undergoing laparoscopic appendicectomy.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data into a standardised form, and assessed the risk of bias in the studies. We extracted data relevant to the predetermined outcome measures. Where appropriate, we calculated a summary statistic: odds ratio (OR) with 95% confidence intervals (CIs) for dichotomous data and mean difference (MD) with 95% CI for continuous data. We used Review Manager Web for our statistical analysis.

MAIN RESULTS

This review was first published in 2011, when there was no RCT evidence available. For this update, we identified 11 RCTs involving 1373 participants (689 in the SILA groups and 684 in the CLA groups). The participants were similar at baseline in terms of age (mean 31.7 (SILA) versus 30.9 years (CLA)) and sex (female: 53.0% (SILA) versus 50.3% (CLA)). Diagnosis of appendicitis was based on clinical assessment; none of the studies used a diagnosis confirmed by imaging as part of their inclusion criteria. The certainty of the evidence was low to moderate, and the outcomes were predominately reported in the short term. Pain scores at 24 hours after surgery may be similar between the SILA and CLA groups (mean score SILA 2.53 versus CLA 2.65; mean difference (MD) in pain score -0.12, 95% CI -0.52 to 0.28; 294 participants, 4 RCTs; low-certainty evidence). SILA probably had superior cosmetic results as indicated by patients using the Body Image questionnaire (5 to 20) (mean score SILA 14.9 versus CLA 12.4; cosmesis score MD 1.97, 95% CI 1.60 to 2.33; 266 participants, 3 RCTs; moderate-certainty evidence). The rate of visceral and vascular injury was probably similar with both techniques (SILA 0/168 versus 4/169; OR 0.20, 95% CI 0.02 to 1.79; 337 participants, 3 RCTs; moderate-certainty evidence). The conversion rate to CLA or open surgery may be higher for SILA procedures than the conversion rate from CLA to open surgery (SILA 32/574 versus CLA 7/569; OR 2.95, 95% CI 1.36 to 6.42; 1143 participants, 9 RCTs; low-certainty evidence). Use of an additional port site was probably more likely with SILA compared to CLA (SILA 28/328 versus CLA 4/336; OR 3.80, 95% CI 1.13 to 12.72; 664 participants, 5 RCTs; moderate-certainty evidence). The recovery time was probably similar for both interventions for hospital stay (mean length of stay in hospital for SILA 2.25 days versus 2.29 days for CLA patients; MD -0.13, 95% CI -0.23 to 0.03; 1241 participants, 10 RCTs; moderate-certainty evidence) and time to return to normal activities (SILA 9.28 days versus CLA 10.0 days; MD -0.59, 95% CI -1.99 to 0.81; 451 participants, 4 RCTs; moderate-certainty evidence). We have low-to-moderate confidence in our findings due to differences in the measurement of certain outcomes, and lack of blinding in the studies, which makes them prone to performance bias.

AUTHORS' CONCLUSIONS

There is low-to-moderate certainty evidence that single-incision laparoscopic appendicectomy is comparable to conventional laparoscopic appendicectomy in terms of complications, length of hospital stay, return to normal activities, and postoperative pain in the first 24 hours. The disadvantage of SILA may be a higher conversion rate, but SILA is probably associated with better patient cosmetic satisfaction.

Feasibility of Solo Single-Incision Laparoscopic Surgery in Non-anatomical Minor Liver Resection: a Propensity Score-Matched Analysis

BACKGROUND

We introduced solo surgery using a laparoscopic scope holder to wide an operator's activity range and reduce instrument crowding and clashing in single incisional surgery. This study aimed to compare the surgical outcomes of solo single-incision laparoscopic surgery (SILS) and conventional multiport laparoscopic surgery (MULS) for hepatocellular carcinoma (HCC).

METHODS

Among 477 consecutive patients between January 2004 and December 2017, 214 patients were included. To overcome selection bias, we performed 1:1 match using propensity score matching between SILS and MULS. Baseline characteristics, operative outcomes, and postoperative complications were compared.

RESULTS

No significant differences in baseline characteristics and pathologic features were found between the two groups. Operation time, estimated blood loss, and postoperative major complication were not significantly different (119.0 min vs 141.6 min, p = 0.275; 200.0 mL min vs 373.3 min, p = 0.222; 0 vs 0, p = 1.000). However, postoperative hospital stay was significantly shorter in SILS (2.73 days vs 7.67 days, p = 0.005).

CONCLUSIONS

Solo SILS had comparable postoperative complications and feasibility in the aspect of operation time and hospital stay compared with conventional MULS for a favorable located single HCC.

Single incision laparoscopic abdominal surgeries: case series of 155 various procedures, an observational cohort study

Objectives

Over the last decade, surgeons have started to think of the ways in which to further reduce the trauma of surgery and improve cosmesis. Consequently, many surgeons have yielded to single incision laparoscopic surgeries (SILS) in order to maximize operative and postoperative outcomes. This study aimed to highlight the feasibility and challenges of different procedures by presenting our data about different fields of abdominal SILS practices with long term follow-up.

Material and Methods

We retrospectively analysed an observational cohort of 155 patients who underwent surgery for different indications using the SILS technique.

Results

Of the 155 SILS procedures: 75 (48.4%) were cholecystectomies; 22 (14.2%) were splenectomies; 17 (11%) were hernia repairs; 11 (7.1%) were appendectomies; 8 (5.2%) were partial colon resections; 8 (5.2%) were adrenalectomies; 6 (3.8%) were distal pancreatectomy & splenectomies; 3 (1.9%) were subtotal gastrectomies; 3 (1.9%) were partial liver resections; and 2 (1.3%) were Nissen fundoplications. Ten (6.5%) early and 3 (1.9%) late postoperative complications were detected. No mortality or late morbidity (> 30 days) was detected due to SILS procedures.

Conclusion

SILS is a feasible technique in experienced hands for specific procedures. Meticulous patient selection is also important for good cosmetic results and outcomes.

Application of stapling devices in liver surgery: Current status and future prospects

The liver is a vascular-rich solid organ. Safe and effective dissection of the vessels and liver parenchyma, and control of intraoperative bleeding are the main concerns when performing liver resection. Several studies have confirmed that intraoperative blood loss and postoperative transfusion are predictors of postoperative morbidity and mortality in liver surgery. Various methods and instruments have been developed during hepatectomy. Stapling devices are crucial for safe and rapid anastomosis. They are used to divide hepatic veins and portal branches, and to transect liver parenchyma in open liver resection. In recent years, laparoscopic liver surgery has developed rapidly, and is now preferred by many surgeons. Stapling devices have also been gradually introduced in laparoscopic liver surgery, from dividing vascular and biliary structures to parenchymal transection. This may be because staplers make manipulation more simple, rapid and safe. Even in single incision laparoscopic surgery, which is recognized as a new minimally invasive technique, staplers are also utilized, especially in left lateral hepatectomy. For safe application of stapling devices in liver surgery, more related designs and modifications, such as application of a suitable laparoscopic articulating liver tissue crushing device, a staple line reinforcement technique with the absorbable polymer membrane or radiofrequency ablation assistance, are still needed. More randomized studies are needed to demonstrate the benefits and find broader indications for the use of stapling devices, to help expand their application in liver surgery.

Single-incision laparoscopic splenectomy

Background and Objectives:

The single-incision approach in laparoscopic surgery is a relatively new concept. This systematic review of the literature was performed to appraise the existing clinical evidence concerning the use of the single-incision technique for spleen resection.

Methods:

We performed a systematic search of the PubMed and Scopus databases, and the studies retrieved were included in our review. The references of the included studies were also hand searched.

Results:

Thirty-one relevant studies were found in the field including 81 patients with an age range from 0.6 to 90 years and a body mass index range from 18 to 36.7 kg/m². Splenomegaly (44.6%), idiopathic thrombocytopenic purpura (31%), and immune thrombocytopenic purpura (6.8%) were the most common indications for the procedure. Concerning the applied port system, multiple single ports (5 to 12 mm) were used in 54.4% of patients, the SILS port (Covidien, Mansfield, Massachusetts) was used in 26.6%, the TriPort (Advanced Surgical Concepts, Wicklow, Ireland) was used in 7.6%, glove ports were used in 6.3%, and the GelPort (Applied Medical, Rancho Santa Margarita, California) was used in 5.1%. The median operative time was 125 minutes (range, 45–420 minutes), and the median quantity of blood loss was 50 mL (range, 10–450 mL). No conversion to open surgery and no transfusion were needed. The length of hospital stay was between 1 and 9 days. Low rates of complications and no patient deaths were found. The existing evidence on cosmesis is limited.

Conclusion:

Single-site/single-port laparoscopic surgery is a minimally invasive procedure that seems to be a challenging alternative in the management of spleen resection.

Comparison of single port and three port laparoscopic splenectomy in patients with immune thrombocytopenic purpura: Clinical comparative study

AIM

Single-port laparoscopic surgery (SILS) has become increasingly popular during the last decades. This prospective study was undertaken to evaluate the feasibility of single-port laparoscopic splenectomy compared with conventional multiport laparoscopic splenectomy.

MATERIALS AND METHODS

Between February 2, 2009 and August 29, 2011, a total of 40 patients with the diagnosis of immune thrombocytopenic purpura were included to study. Patients were alienated into two groups according to the procedure type including SILS and conventional multiport splenectomy.

RESULTS

There were 19 patients in group 1, and 21 in group 2. Operative time was significantly shorter in group 1 versus group 2 (112.4 ± 13.56 vs 71.2 ±18.1 minutes, respectively, P < 0.05). One patient in group 1 had converted to laparatomy due to preoperative bleeding. Postoperative pain analyses (VAS Score) revealed superiority of SILS in the early post-operative days (P < 0.05).

CONCLUSIONS

SILS splenectomy is a safe and effective alternative to standard laparoscopic splenectomy.

Transumbilical glove port: A cost-effective method for single-incision laparoscopic hepatectomy

Objectives:

Emerging concepts of “reduced port surgery” have gained considerable attention from laparoscopic surgeons, including the field of liver resection. To date, 86 cases of single-incision laparoscopic hepatectomy (SILH) have been reported, with commercially available access devices being used in most of these cases. We report herein a use of homemade transumbilical glove port for SILH.

Methods:

A 39-year-old woman represented giant hepatic hemangioma (9-cm in size) located at the left lateral segment (S2/3). Partial hepatectomy was performed by the glove method via single port access with conventional laparoscopic bipolar forceps, grasper and scissors without the need of any single-port specific devices.

Results:

The operative time was 77 minutes, and intraoperative blood loss was 50 mL. The postoperative course was uneventful.

Conclusions:

Glove method not only has significant advantages in terms of cost, but also is superior in its versatility, allowing wider range of movements compared to conventional access devices. Taking in consideration its cost effectiveness and versatility, glove method may be a good option for SILH.

Cholecystectomy for biliary dyskinesia: how did we get there?

BACKGROUND

The focus of biliary dyskinesia (BD) shifted within the last 30 years, moving from symptoms after cholecystectomy (CCY) to symptoms with morphological normal gallbladder, but low gallbladder ejection fraction.

METHODS

We searched the pubmed database to systematically review studies focusing on the diagnosis and treatment of gallbladder dysfunction.

RESULTS

Impaired gallbladder contraction can be found in about 20% of healthy controls and an even higher number of patients with various other disorders. Surgery for BD increased after introduction of laparoscopic CCY, with BD now accounting for >20% of CCY in adults and up to 60% in pediatric patients. The majority of cases reported were operated in the USA, which differs from surgical series for cholelithiasis. Postoperative outcomes do not differ between groups with abnormal or normal gallbladder function.

CONCLUSION

Functional gallbladder testing should not be seen as an indicator of relevant biliary tract disease or prognostic marker to identify patients who may benefit from operative intervention. Instead biliary dyskinesia should be considered as a part of a spectrum of functional disorders, which are generally managed conservatively. Small proof of concept studies have demonstrated effects of medical therapy on biliary dysfunction and should thus be never tested in appropriately designed trials.

Single incision laparoscopic hepatectomy: A systematic review

Single incision laparoscopic surgery is a rather innovative surgical technique. A systematic literature review was performed with the intention to evaluate the till now clinical evidence regarding the application of single incision technique on liver resections as a method of management in hepatic lesions. Twelve relative studies were found in the field including 30 patients with a age range from 29 to 90 years and a body mass index from 20.1 to 36.5 kg/m². Primary hepatic carcinoma (40%), metastatic nodules (26.7%), hepatic cysts (16.7%), hepatic haemangiomas (13.3%) and hepatic adenoma (3.3%) were the most common indications of the lesions resected. The types of hepatectomy performed included partial hepatectomy (43.3%), segmentectomy (30%) and lobectomy (26.7%). In the majority of the patients, left lateral segments (II-III-IV) (76.7%) were resected. The median operative time was 110 min (range: 55-235) while the median quantity of blood loss was 50 ml (range: 0-100). No conversion to open surgery and no transfusion were needed. The duration of hospital stay ranged between 2 and 11 days. No complications, no cases of disease recurrence or death of patients were reported. None of the studies included described data on the cosmesis of the application of single incision laparoscopic technique on hepatic resections. Moreover, the surgical technique, as well as the different type of ports used is also presented in this review. Single site port laparoscopic surgery is a promising minimally invasive procedure for liver resections.

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.

Feasibility and safety of single-incision laparoscopic splenectomy: a systematic review

OBJECTIVE

The aim of this review was to evaluate the feasibility, safety, and potential benefits of single-incision laparoscopic splenectomy (SILS-Sp).

METHODS

We conducted a systemic review of literature between 2009 and 2012 to retrieve all relevant articles.

RESULTS

A total of 29 studies with 105 patients undergoing SILS-Sp were reviewed. Fifteen studies used a commercially available single-port device. The range of body mass index was 14.7-41.4 kg/m(2). Six studies described combined operations including cholecystectomy (n = 8), mesh-pexy (n = 1), and pericardial devascularizaion (n = 1). The ranges of operative times and estimated blood losses were 28-420 min and 0-350 mL, respectively. Of 105 patients, three patients (2.9%) required additional ports, two patients (1.9%) were converted to open, and three patients (2.9%) to conventional multiport laparoscopic splenectomy (overall conversion rate, 4.8%). Postoperative bleeding occurred in two patients (1.9%) who both required reoperation. Overall mortality was 0% (0/105). The length of postoperative stay varied across reports (1-11 d). Among four comparative studies, one showed greater estimated blood loss and lower numeric pain rating scale score in the SILS-Sp group than in the multiport laparoscopic splenectomy group (206.25 ± 142.45 versus 111.11 ± 99.58 mL) and (3.81 ± 0.91 versus 4.56 ± 1.29), respectively. Another comparative study showed that SILS-Sp was associated with a shorter operative time (92.5 versus 172 min; P = 0.003), lower conversion rate, equivalent length of hospital stay, reduced mortality, similar morbidity, and comparable postoperative narcotic requirements.

CONCLUSIONS

In early series of highly selected patients, SILS-Sp appears to be feasible and safe when performed by experienced laparoscopic surgeons. However, as an emerging operation, publication bias is a factor that should be considered before we can draw an objective conclusion.

Single-incision vs three-incision laparoscopic cholecystectomy for complicated and uncomplicated acute cholecystitis

AIM

To compare the clinical outcome of single-incision laparoscopic cholecystectomy (SILC) and three-incision laparoscopic cholecystectomy (3ILC) for acute cholecystitis.

METHODS

From July 2009 to September 2012, 136 patients underwent SILC or 3ILC for acute cholecystitis at a tertiary referral hospital. One experienced surgeon performed every procedure using 5 or 10 mm 30-degree laparoscopes, straight instruments, and conventional ports. Five patients with perforated gallbladder and diffuse peritonitis and 23 patients with mild acute cholecystitis were excluded. The remaining 108 patients were divided into complicated and uncomplicated groups according to pathologic findings. Patient demography, clinical data, operative results and complications were recorded and analyzed.

RESULTS

Fifty patients with gangrenous cholecystitis, gallbladder empyema, or hydrops were classified as the complicated group, and 58 patients with acute cholecystitis were classified as the uncomplicated group. Twenty-three (46.0%) of the patients in the complicated group (n = 50) and 39 (67.2%) of the patients in the uncomplicated group (n = 58) underwent SILC; all others underwent 3ILC. The postoperative length of hospital stay (PLOS) was significantly shorter in the SILC subgroups than the 3ILC subgroups (3.5 ± 1.1 d vs 4.6 ± 1.3 d, P < 0.01 in the complicated group; 2.9 ± 1.1 d vs 3.7 ± 1.4 d, P < 0.05 in the uncomplicated group). The maximum body temperature recorded at day 1 and at day 2 following the procedure was lower in the SILC subgroups, but the difference reached statistical significance only in the uncomplicated group (37.41 ± 0.56 °C vs 37.80 ± 0.72 °C, P < 0.05 on postoperative day 1; 37.10 ± 0.43 °C vs 37.57 ± 0.54 °C, P < 0.01 on postoperative day 2). The operative time, estimated blood loss, postoperative narcotic use, total length of hospital stay, conversion rates, and complication rates were similar in both SILC and 3ILC subgroups. The complicated group had longer operative time (122.2 ± 35.0 min vs 106.6 ± 43.6 min, P < 0.05), longer PLOS (4.1 ± 1.3 d vs 3.2 ± 1.2 d, P < 0.001), and higher conversion rates (36.0% vs 19.0%, P < 0.05) compared with the uncomplicated group.

CONCLUSION

SILC is safe and efficacious for patients with acute cholecystitis. The main benefit is a faster recovery than that achieved with 3ILC.

Single-access transumbilical laparoscopic unroofing of a giant hepatic cyst using reusable instruments

INTRODUCTION

Single-access laparoscopy has garnered growing interest in recent years in an attempt to improve cosmesis, reduce postoperative pain, and minimize abdominal wall trauma.

CASE DESCRIPTION

A female patient suffering from a symptomatic giant biliary cyst of the liver segments 4-7-8 was admitted for transumbilical single-access laparoscopic cyst unroofing. The procedure was performed using a standard 11-mm reusable trocar for a 10-mm, 30 degree-angled, rigid scope and curved reusable instruments inserted transumbilically without trocars. Operative time was 90 minutes, and the final incision length was 14 mm. The use of minimal pain medication permitted discharge on the third postoperative day, and after 25 months, the patient remains asymptomatic with a no visible umbilical scar.

CONCLUSIONS

Giant biliary cysts can be removed by single-access laparoscopy. Because of this technique, surgeons work in ergonomic positions, and the cost of the procedure remains similar to that of the multitrocar technique. The incision length and the use of pain medication are kept minimal as well.

A review of minimally invasive single-port/incision laparoscopic appendectomy

INTRODUCTION

Single-port/incision laparoscopic appendectomy (SPILA) is a modern advancement toward stealth surgery, using a single point of entry. Despite the paucity of clinical data, it is increasingly being used to minimize scarring and, potentially, pain associated with the multiple entry points. We aimed to summarize and present available data on this new approach.

METHODOLOGY

All available databases until December 2010 including the Cochrane Controlled Trials Register, MEDLINE, and EMBASE were searched and cross-referenced for studies describing single-incision laparoscopic appendectomy. Case and experimental reports, series with fewer than 5 patients, and non-English articles were excluded. Outcome measures were operative time, postoperative hospital stay, pain scores, complications, conversion, and mortality, stratified according to type of SPILA approach. SPSS version 18.0.0 software was used for data collection.

RESULTS

Database query yielded 79 articles; 45 were included (1 randomized controlled trial, 44 case series). Total cases were 2806, with mean patient age for studies ranging from 7.0 to 37.5 years. No mortality was reported. The overall complication rate was 4.13%. The overall weighted mean operating time was 41.3 minutes (range, 15.0-95.9 minutes). The weighted mean hospital stay was 2.79 days (range, 1.0-6.6 days).

CONCLUSIONS

Although the incidence of complications with SPILA remains low and operating times between new and traditional approaches are comparable in case-based literature, adequately powered randomized trials are required to assess its effectiveness. Occurrence of long-term complication types remains unexplored.

Single-incision vs three-port laparoscopic cholecystectomy: Prospective randomized study

AIM: To compare the clinical outcome of single-incision laparoscopic cholecystectomy (SILC) with three-port laparoscopic cholecystectomy (TPLC).

METHODS: Between 2009 and 2011, one hundred and two patients with symptomatic benign gallbladder diseases were randomized to SILC (n = 49) or TPLC (n = 53). The primary end point was post operative pain score (at 6 h and 7 d). Secondary end points were blood loss, operation duration, overall complications, postoperative analgesic requirements, length of hospital stay, cosmetic result and total cost. Surgical techniques were standardized and all operations were performed by one experienced surgeon, who had performed more than 500 laparoscopic cholecystectomies.

RESULTS: One patient in the SILC group required conversion to two-port LC. There were no open conversions or major complications in either treatment groups. There were no differences in terms of estimated blood loss (mean ± SD, 14 ± 6.0 mL vs 15 ± 4.0 mL), operation duration (mean ± SD, 41.8 ± 17.0 min vs 38.5 ± 22.0 min), port-site complications (contusion at incision: 5 cases vs 4 cases and hematoma at incision: 2 cases vs 1 case), total cost (mean ± SD, 12 075 ± 1047 RMB vs 11 982 ± 1153 RMB) and hospital stay (mean ± SD, 1.0 ± 0.5 d vs 1.0 ± 0.2 d) , respectively. TPLC had a significantly worse visual analogue pain score at 8 h after surgery (mean ± SD, 3.5 ± 1.6 vs 2.0 ± 1.5), however, the scores were similar on day 7 (mean ± SD, 2.5 ± 1.4 vs 2.0 ± 1.3). Cosmetic satisfaction, as determined by a survey at 2 mo follow-up favored SILC (mean ± SD, 8 ± 0.4 vs 6 ± 0.2).

CONCLUSION: SILC is a safe and feasible approach in selected patients. The main advantages are a better cosmetic result and less pain.

Adopting Gayet's Techniques of Totally Laparoscopic Liver Surgery in the United States

Professor Brice Gayet of the Institut Mutualiste Montsouris in Paris, France, has developed totally laparoscopic techniques for all segments of the liver. As a pioneer in the field of minimally invasive hepato-pancreato-biliary surgery, he started a Minimally Invasive Hepato-Pancreato-Biliary Fellowship in 2006. A retrospective review of all hepatic cases performed by a single surgeon since completing this Fellowship was undertaken. From November 2007 to October 2012, a total of 80 liver resections were done, of which 73 were begun with the intention of completing the case laparoscopically. Of these, more than 90% were completed laparoscopically and 88% were for malignant disease. One of the foundations of Professor Gayet's techniques is the low lithotomy or 'French' position and the utilization of a small robotically controlled laparoscope holder that is sterilizeable and considerably more economic than complete surgical systems. Prototypes exist of robotically controlled hand-held laparoscopic instruments that, unlike the complete surgical system, enable surgeons to maintain a sense of touch (haptics). Proper training in minimally invasive hepato-pancreato-biliary techniques can be obtained with surgeons able to independently perform laparoscopic major hepatectomies without senior minimally invasive backup. Furthermore, miniature and more affordable robotics may enable more surgeons to enjoy the benefits of minimally invasive surgery while maintaining patient safety and minimizing the rising burden of health-care costs worldwide.

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 versus laparoscopic cholecystectomy: a prospective randomized study

This prospective randomized study compared single-incision laparoscopic cholecystectomy (SILC) and laparoscopic cholecystectomy (LC) with respect to estimated blood loss, operative time, postoperative pain levels, and complications. Thirty-four study patients were divided into 2 groups: 17 patients underwent SILC and 17 underwent LC. Operative time was longer for SILC than for LC, and the difference was statistically significant (P<0.001). There was no statistically significant difference in the relationship of body mass index with operative time between SILC and LC (P=0.613, P=0.983, respectively). The 2 groups had no statistically significant differences with respect to visual analog scale scores, estimated blood loss, shoulder pain, or complications (P>0.05). SILC can be the treatment of choice for gallbladder disease. Although the surgeon's first several attempts at SILC require a longer operative time compared with LC, there are no differences in hospital length of stay, blood loss, complication rates, or pain scores between SILC and LC.

Single-incision laparoscopic splenectomy versus conventional multiport laparoscopic splenectomy: a retrospective comparison of outcomes

BACKGROUND

The authors report their experience with single-incision laparoscopic splenectomy (SLS) and compare postoperative outcomes of conventional multiport laparoscopic splenectomy (MLS) with SLS in patients with spleen sizes ≤15 cm.

METHODS

Demographic, intraoperative, and postoperative data were analyzed retrospectively and compared between patients who underwent MLS from June 20, 2006, to July 9, 2009 (MLS group, 18 patients) and those who underwent SLS from July 28, 2009, to November 2, 2010 (SLS group, 16 patients).

RESULTS

Blood loss was significantly greater in the SLS group than in the MLS group (206.25 ± 142.45 vs 111.11 ± 99.58 mL, respectively; P = .047). The Numeric Pain Rating Scale in the SLS group was significantly lower than in the MLS group (3.81 ± 0.91 vs 4.56 ± 1.29, respectively; P = .041). There were no significant differences between the groups for other variables.

CONCLUSIONS

SLS is a feasible method with good cosmetic benefit and equivalent clinical outcomes as compared with MLS.

Single-site umbilical laparoscopic splenectomy

Laparoscopic splenectomy was first described in children in 1993. Since then, it has become a commonly performed procedure in children because of reduced discomfort and hospitalization and significantly improved cosmesis compared with the open approach. With the advent of single-site laparoscopic surgery, it is only natural that this approach be used for splenectomy. This article will describe the reasons that the single-site approach might be useful for splenectomy and also the technique used at the author's institution. Moreover, a brief review of the current literature in children will be presented.

Single port laparoscopic appendectomy: are we pursuing real advantages?

Single port appendectomy, due to its cosmetic appeal and to a technique similar to classic laparoscopic appendectomy, is provoking an increasing number of publications and case series to explore its feasibility and effective improvements for patients with acute appendicitis. The margins for improvement are not so large, as laparoscopic appendectomy is, after 20 years from its beginning, still debated. A literature search has been accomplished to investigate the outcomes of the operation. 23 case series or retrospective comparisons with classic laparoscopy have been found. The numbers and low quality of the published data do not permit to draw evidence based conclusions. Still, trends seem to evidence an increase in complications especially in complicated appendicitis, which suggests caution in its dissemination outside clinical trials.

Single incision versus conventional multi-incision appendicectomy for suspected appendicitis

BACKGROUND

Appendicectomy is a well established surgical procedure used in the management of acute appendicitis.  The operation can be performed with minimally invasive surgery (laparoscopic) or as an open procedure. A recent development in appendicectomy has been the introduction of less invasive single incision laparoscopic surgery, using a single multi-luminal port or multiple mono-luminal ports, through a single skin incision. There are yet unanswered questions regarding the efficacy of this new and novel technique including: patient benefit and satisfaction, complications, long-term outcomes, and survival.

OBJECTIVES

The aim of this review is to perform meta-analysis using data from available trials comparing single incision with conventional multi-incision laparoscopic appendicectomy for appendicitis, in order to ascertain any differences in outcome.

SEARCH STRATEGY

We searched the electronic databases including MEDLINE/PubMed (from 1980 to December 2010), EMBASE/Ovid (from 1980 to December 2010) and CENTRAL (The Cochrane Library 2010, Issue 11) with pre-specified terms. We also searched reference lists of relevant articles and reviews, conference proceedings and ongoing trial databases.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of patients with appendicitis, or symptoms of appendicitis, undergoing laparoscopic appendicectomy, in which at least one arm involves single incision procedures and another multi-incision procedures.

DATA COLLECTION AND ANALYSIS

There were no RCTs or prospectively controlled trials found that met the inclusion criteria.

MAIN RESULTS

Three authors performed study selection independently.No studies that met the inclusion criteria of this review were identified. Current evidence exists only the form of case-series.This review has been authored as 'empty' pending the results of 5 ongoing trials.

AUTHORS' CONCLUSIONS

No RCTs comparing single incision laparoscopic appendectomy with multi-incision surgery could be identified. No definitive conclusions can be made at this time. Well designed prospective RCTs are required in order to evaluate benefit or harm from laparoscopic surgical approaches for appendicectomy. Until appropriate data has been reported, the institutional polices of healthcare providers must be based on the clinical judgement of experts in the field.

da Vinci robotic single-incision cholecystectomy and hepatectomy using single-channel GelPort access

BACKGROUND/PURPOSE

Minimally invasive surgery including laparoscopic and robotic surgery was recently approved for clinical use in hepatobiliary surgery. The purpose of this article is to evaluate the feasibility and technical aspects of robotic single incision for hepatobiliary surgery using the GelPort laparoscopic system in a preliminary animal study.

METHODS

We performed eight robotic single-incision laparoscopic surgery (SILS) procedures, including four cholecystectomies and four lateral segmentectomy of the liver, in a porcine study using the da Vinci S-HD Surgical System. A single-channel GelPort access was placed through a 2.5-cm single incision for robotic access. A 12-mm camera port, two 8-mm ports for the robotic arms and one 5-mm port for the patient-side assistant were inserted. A Mini Loop Retractor was applied to retract the fundus of the gallbladder. The EndoWrist dissector and grasping forceps was introduced to fine-dissect Calot's triangle. The instruments were crossed to avoid "sword fighting" and clashing of instruments in the abdomen. The cystic duct was divided after double ligation and the gallbladder was removed. Hepatic transection was performed with bipolar Harmonic shears and LigaSure for vascular pedicles.

RESULTS

All robotic SILS procedures were completed (8/8, 100%). The cholecystectomies and hepatectomies were safely performed in average operating times of 70 min (±15) and 60 min (±20), respectively, with minimal blood loss. There were no conversions, re-interventions or extension of the skin incision.

CONCLUSIONS

Robotic hepatobiliary SILS is technically feasible and safe using GelPort as a single-incision access platform. Robotic SILS is becoming established and is enormously advantageous to the patient.

Single port laparoscopic liver resection for hepatocellular carcinoma: a preliminary report

Single port laparoscopic surgery is an emerging technique, now commonly used in cholecystectomy. The experience of using this technique in liver resection for hepatocellular carcinoma is described in a series of 3 cases with single port laparoscopic liver resection performed during 2010. All patients were male aged 61 to 70 years, with several comorbidities. There were no complications in this early series. The length of hospital stay was 3-5 days. The blood loss was 200-450 mL, with operating time between 142 and 171 minutes. We conclude that this technique is feasible and safe to perform in experienced centers.