SILC for SILC: Single Institution Learning Curve for Single-Incision Laparoscopic Cholecystectomy

A Systematic Review and Meta-Analysis of Single-Incision Laparoscopic Cholecystectomy Versus Conventional Four-Port Laparoscopic Cholecystectomy

The present systematic review compares single-incision laparoscopic cholecystectomy (SILC) with conventional laparoscopic cholecystectomy (CLC) with the aim of assessing early postoperative pain and morbidity. The secondary outcomes assessed were the duration of surgery, length of hospital stay, and conversion to open surgery. A systematic search for medical records was conducted on PubMed, Embase, Medline, and the Cochrane Library. Meta-analysis was conducted using Review Manager 5.4. A total of 14 randomized control trials met the eligibility criteria, involving a total of 1762 patients. Early postoperative pain (four to six hours) (mean difference (MD): -0.86; 95%; confidence interval (CI): -1.16 to -0.55) showed significantly better results in the SILC group but showed no difference on the first or second postoperative day. There were significantly fewer complications (relative risk (RR): 1.7; 95%; CI: 1.16-2.50) recorded in the CLC group as compared to the SILC group. Operative time (MD: 19.66; 95% CI: 13.21-26.11) was significantly longer in the SILC group, while the duration of hospital stay (MD: -0.01; 95% CI: -0.28-0.26) and conversion to open surgery (RR: 0.99; 95% CI: 0.20-4.82) showed no significant difference. SILC had a significantly longer operative time and more complications as compared to CLC. However, it was associated with significantly lower early post-operative pain.

[The trend towards full-endoscopic decompression : Current possibilities and limitations in disc herniation and spinal stenosis]

BACKGROUND

The most frequent causes of degenerative constrictions of the spinal canal are disk herniations and spinal stenoses. The lumbar and cervical spine is the most affected.

SURGICAL PROCEDURES

After conservative treatments have been exhausted, surgical intervention may be necessary. Today, microsurgical decompression is regarded as the standard procedure in the lumbar region, while in the cervical spine, microsurgical anterior decompression and fusion are standard. Full-endoscopic techniques for decompression are becoming increasingly widespread worldwide. The development of various surgically created approaches and appropriate instrument sets have made the full-endoscopic operation of disk herniations and spinal stenosis possible. This development has also permitted resection of soft disk herniations in the cervical spine. The use of the approaches depends on anatomical and pathological inclusion and exclusion criteria.

RESULTS

The clinical results of standard procedures have been achieved, which must be regarded as a minimum criterion for the introduction of new technologies. On the basis of EBM criteria, it can be established that using the full-endoscopic techniques developed, adequate decompression is achieved in the defined indications with reduced traumatization, improved visibility conditions, and positive cost benefits. Today, full-endoscopic operations may be regarded as an expansion and alternative within the overall concept of spinal surgery.

An ergonomics study on wrist posture when using laparoscopic tools in four techniques in minimally invasive surgery

PURPOSE

With reference to four minimally invasive surgery (MIS) cholecystectomies, the aims were (a) to recognize the factors influencing dominant wrist postures manifested by the surgeon; (b) to detect risk factors involved in maintaining deviated wrist postures; (c) to compare the wrist postures of surgeons while using laparoscopic tools.

METHODS

Video films were recorded during live surgeries. The films were synchronized with wrist joint angles obtained from wireless electrogoniometers placed on the surgeon's hand. The analysis was conducted for five laparoscopic tools used during all surgical techniques.

RESULTS

The most common wrist posture was extension. In the case of one laparoscopic tool, the mean values defining extended wrist posture were distinct in all four surgical techniques. For one type of surgical technique, considered the most beneficial for patients, more extreme postures were noticed regarding all laparoscopic tools. We recognized a new factor, apart from the tool's handle design, that influences extreme and deviated wrist postures. It involves three areas of task specification including the type of action, type of motion patterns and motion dynamism.

CONCLUSIONS

The outcomes proved that the surgical technique which is best for the patient imposes the greatest strain on the surgeon's wrist. .

Learning curve of radiology residents during training in fluoroscopy-guided facet joint injections

OBJECTIVE

To develop a simulator for training in fluoroscopy-guided facet joint injections and to evaluate the learning curve for this procedure among radiology residents.

MATERIALS AND METHODS

Using a human lumbar spine as a model, we manufactured five lumbar vertebrae made of methacrylate and plaster. These vertebrae were assembled in order to create an anatomical model of the lumbar spine. We used a silicon casing to simulate the paravertebral muscles. The model was placed into the trunk of a plastic mannequin. From a group of radiology residents, we recruited 12 volunteers. During simulation-based training sessions, each student carried out 16 lumbar facet injections. We used three parameters to assess the learning curves: procedure time; fluoroscopy time; and quality of the procedure, as defined by the positioning of the needle.

RESULTS

During the training, the learning curves of all the students showed improvement in terms of the procedure and fluoroscopy times. The quality of the procedure parameter also showed improvement, as evidenced by a decrease in the number of inappropriate injections.

CONCLUSION

We present a simple, inexpensive simulation model for training in facet joint injections. The learning curves of our trainees using the simulator showed improvement in all of the parameters assessed.

Advantages and Disadvantages of 1-Incision, 2-Incision, 3-Incision, and 4-Incision Laparoscopic Cholecystectomy: A Workflow Comparison Study

A comparison of 1-port, 2-port, 3-port, and 4-port laparoscopic cholecystectomy techniques from the point of view of workflow criteria was made to both identify specific workflow components that can cause surgical disturbances and indicate good and bad practices. As a case study, laparoscopic cholecystectomies, including manual tasks and interactions within teamwork members, were video-recorded and analyzed on the basis of specially encoded workflow information. The parameters for comparison were defined as follows: surgery time, tool and hand activeness, operator's passive work, collisions, and operator interventions. It was found that 1-port cholecystectomy is the worst technique because of nonergonomic body position, technical complexity, organizational anomalies, and operational dynamism. The differences between laparoscopic techniques are closely linked to the costs of the medical procedures. Hence, knowledge about the surgical workflow can be used for both planning surgical procedures and balancing the expenses associated with surgery.

Use of a multi-instrument access device in abdominoperineal resections

BACKGROUND

Laparoscopic colorectal surgery results in less post-operative pain, faster recovery, shorter length of stay and reduced morbidity compared with open procedures. Less or minimally invasive techniques have been developed to further minimise surgical trauma and to decrease the size and number of incisions. This study describes the safety and feasibility of using an umbilical multi-instrument access (MIA) port (Olympus TriPort+) device with the placement of just one 12-mm suprapubic trocar in laparoscopic (double-port) abdominoperineal resections (APRs) in rectal cancer patients.

PATIENTS AND METHODS

The study included 20 patients undergoing double-port APRs for rectal cancer between June 2011 and August 2013. Preoperative data were gathered in a prospective database, and post-operative data were collected retrospectively.

RESULTS

The 20 patients (30% female) had a median age of 67 years (range 46-80 years), and their median body mass index (BMI) was 26 kg/m2 (range 20-31 kg/m2). An additional third trocar was placed in 2 patients. No laparoscopic procedures were converted to an open procedure. Median operating time was 195 min (range 115-306 min). A radical resection (R0 resection) was achieved in all patients, with a median of 14 lymph nodes harvested. Median length of stay was 8 days (range 5-43 days).

CONCLUSION

Laparoscopic APR using a MIA trocar is a feasible and safe procedure. A MIA port might be of benefit as an extra option in the toolbox of the laparoscopic surgeon to further minimise surgical trauma.

One-year experience with single incision laparoscopic cholecystectomy in a single center: without the use of inverse triangulation

PURPOSE

Single incision laparoscopic cholecystectomy (SILC) is generally performed with the use of inverse triangulation. In this study, we performed 3-channel or 4-channel SILC without the use of inverse triangulation. We evaluated the adequacy and feasibility of SILC using our surgical method.

METHODS

We retrospectively reviewed our series of 309 SILCs performed between March 2014 and February 2015.

RESULTS

Among 309 SILCs, male were 148 and female were 161 patients, mean age was 48.7 ± 15.3 years old and mean body mass index was 24.8 ± 3.8 kg/m(2). Forty patients had previously undergone abdominal surgery including 6 cases of upper abdominal surgery. SILC after percutaneous transhepatic gallbladder (GB) drainage was completed in 8.7% of cases. There were 10 cases of emergency SILC. SILC was performed for noncomplicated GB including symptomatic GB stone and polyp in 66.7% of cases, acute cholecystitis in 33.3%. Overall, 96.8% of procedures were successfully completed without additional port. The reason for addition of an extra port or open conversion included technical difficulties due to severe adhesion and bleeding. The mean operating time was 60.7 ± 22.3 minutes. The overall complication rate was 4.8%: 9 patients of wound seroma, 1 case of bile leakage from GB bed, 4 cases of intra-abdominal abscess or fluid collection, and 1 case of incisional hernia were developed. There was no case of common bile duct injury.

CONCLUSION

Our surgical method of SILC without the use of inverse triangulation is safe, feasible and effective technique.

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.

Risk factors for prolonged operative time in single-incision laparoscopic cholecystectomy

Purpose

We performed 3-channel single incision laparoscopic cholecystectomy (SILC) in earlier period of this study and modified our method to 4-channel SILC using a snake retractor for better operative field in later period. This study has been designed to evaluate the risk factors for prolonged operative time in SILC.

Methods

From April 2010 to August 2014, 323 cases of 3-channel SILC (Konyang standard method [KSM] group) and 399 cases of 4-channel SILC (modified KSM [mKSM] group) using a snake retractor were performed.

Results

The clinical characteristics were not significantly different between KSM and mKSM group except preoperative percutaneous transhepatic gallbladder drainage (PTGBD) treatment (9.6% vs. 16.5%, P < 0.007). The mean operation time was longer in mKSM group than KSM group (55.8 ± 19.7 minutes vs. 51.7 ± 20.1 minutes, P = 0.006). The estimated blood loss of KSM group was more than mKSM group (24.6 ± 54.1 mL vs. 16.9 ± 27.0 mL, P = 0.013). According to the histopathologic findings, acute cholecystitis or empyema were confirmed more in mKSM group as compared with KSM group (28% vs. 14.0%, P = 0.025). In multivariate analysis, the risk factors for prolonged operation time were drainage insertion, histopathologic findings (acute cholecystitis or empyema), surgeons' technical expertise, body mass index > 30 kg/m² as well as the 4-channel SILC.

Conclusion

Among patients with these risk factors, conventional laparoscopic cholecystectomy could be considered as well although SILC might be safe and feasible modality for benign gallbladder disease.

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.

A comparison of single-port laparoscopic cholecystectomy and an alternative technique without a suspension suture

OBJECTIVE

Many surgeons face difficulties during single-incision laparoscopic cholecystectomy (SILC) surgery and are forced to use an additional port. We compared the results of a technique that we developed with SILC.

MATERIAL AND METHODS

Fifty-four patients who were diagnosed with chronic cholelithiasis were prospectively randomized and divided into two groups. An additional 5-mm port (MCAP: with an additional port using a multi-channel device through the umbilicus) was placed in the subxiphoid area instead of a transabdominal suspension suture in one group of patients. The other group was operated on with the SILC technique. The demographic and surgical data of the patients were compared.

RESULTS

The MCAP technique shortened the surgery duration by more than half (MCAP: 35.0±12.3, SILC: 79.1±27.7 min) (p<0.05). No difference was found between the two methods in terms of estimated blood loss, length of hospitalization, postoperative day 1 and 7 visual analog scale scores, need for analgesia in the postoperative period, and rate of changing to another technique due to inadequacy of the surgical technique.

CONCLUSION

MCAP is as safe as SILC for cholecystectomy and is easier for the surgeon to perform.