Single-incision laparoscopic cholecystectomy with an additional needle grasper: a novel technique

Laparoscopic surgery and robotic surgery for single-incision cholecystectomy: an updated systematic review

The role of single-incision laparoscopic cholecystectomy (SILC) and single-incision robotic cholecystectomy (SIRC) is still unclear. We update the summarization of the feasibility and safety of SILC and SIRC. A comprehensive search of SILC and SIRC of English literature published on PubMed database between January 2015 and November 2020 was performed. A total of 70 articles were included: 41 covering SILC alone, 21 showing SIRC alone, 7 reporting both, and 1 study not specified. In total, 7828 cases were recorded (SILC/SIRC/not specified, 6234/1544/50); and the gender of 7423 cases was definitively reported: the female rate was 64.0% (SILC/SIRC/not specified, 62.1%/71.5%/74.0%). The weighted mean for body mass index (BMI), operative time, blood loss and post-operative hospital stay was 25.5 kg/m2 (SILC/SIRC, 25.0/27.0 kg/m2), 73.8 min (SILC/SIRC, 68.2/88.8 min), 12.6 mL (SILC/SIRC, 12.1/14.8 mL) and 2.5 days (SILC/SIRC, 2.8/1.9 days), respectively. The pooled prevalence of an additional port, conversion to open surgery, post-operative complications, intraoperative biliary injury, and incisional hernia was 4.1% (SILC/SIRC, 4.7%/1.9%), 0.9% (SILC/SIRC, 0.7%/1.5%), 5.9% (SILC/SIRC, 6.2%/4.1%), 0.1% (SILC/SIRC, 0.2%/0.09%), and 2.1% (SILC/SIRC, 1.4%/4.8%), respectively. Compared with conventional laparoscopic cholecystectomy, SIRC has experienced more postoperative incisional hernias (risk difference = 0.05, 95% confidence interval 0.02-0.07; P < 0.0001). By far, SILC and SIRC have not been considered a standard procedure. With the innovation of medical devices and gradual accumulation of surgical experience, feasibility and safety of performing SILC and SIRC will improve.

Description and Initial Experience with the "LIFT" (Less Incisions but Four Trocars) Technique for Laparoscopic Cholecystectomy

Background: Modifications to conventional laparoscopic cholecystectomy (LC) aim to reduce trauma to the abdominal wall and improve cosmetic outcomes. Although single-incision laparoscopic surgery (SILS) provides excellent cosmetic results, the procedure is technically demanding. Herein, we describe the LIFT technique ("Less Incisions but Four Trocars"), with four trocars but only one 3-mm visible incision, using conventional instruments. Methods: Retrospective study with the LIFT technique for cholecystectomy during 2017. Access to the abdomen is obtained with two trocars (11 and 5 mm) through the same intraumbilical skin incision, and two extraumbilical 3-mm trocars for a correct triangulation (one of them concealed below the bikini line). The results are compared with a series of patients operated on with LC by the same surgical team during 2016. Results: During the study period, 90 procedures were performed. Both techniques showed similar results in terms of surgical time, conversion rate, complications, and hospital length of stay. The patients operated on with the LIFT technique reported better cosmetic evaluation and less postoperative pain at 3 months compared with LC. Conclusion: The LIFT technique is a safe and feasible alternative for cholecystectomy that can provide a significant improvement from the cosmetical point of view, mostly for those patients who are especially concerned with their body image.

A promising technique for easier single incision laparoscopic cholecystectomy: needle grasper traction of gallbladder

Introduction

Laparoscopic cholecystectomy (LC) is the primary treatment method for benign gallbladder diseases. Single incision laparoscopic cholecystectomy (SILC) was reported to be superior in terms of work return, cosmetic results, and post-operative pain, but limited maneuver capacity and overlapping of hand tools are technical difficulties associated with SILC that endanger patient safety.

Aim

To perform SILC using a needle grasper for gallbladder traction, thus simplifying the dissection of Calot's triangle.

Material and methods

The files of patients who underwent elective LC for gallbladder stone and polyps in general surgery clinics between December 2013 and December 2014 were analyzed retrospectively. The patients were divided into two groups: needle-grasper-assisted SILC (nSILC) and conventional laparoscopic cholecystectomy (CLC). Age, gender, height, weight, body mass index, visual analog scale (VAS) scores, ASA score, duration of operation, duration of post-operative hospital stay, complications, drain use, conversion to open and conventional technique, and oral feeding beginning time were analyzed.

Results

There were no per-operative or post-operative complications in either of the groups, and no significant differences were found between the groups in terms of complications. The mean duration of the operation was significantly longer in the nSILC group. There was no difference between the groups in terms of hospital stay. The mean visual analogue scale (VAS) scores in conventional nSILC were significantly lower for all hours. The patient satisfaction in terms of cosmetic results was better in the nSILC group.

Conclusions

Needle-grasper-assisted SILC reduces the number of tools that need to be held by surgeons; it also provides safe dissection, better cosmetic results, and less post-operative pain in elective cases.

Two-Incision Laparoscopic Cholecystectomy: Reducing Scars in a Simple Way

BACKGROUND

About 20% of the population has cholelithiasis and this is the main abdominal cause of hospitalization in developed countries. Considering that only in the United States about 700,000 cholecystectomies are done each year, it is possible to estimate the importance of the problem for public health.

OBJECTIVE

To describe a two-incision laparoscopic cholecystectomy (TILC) technique using only conventional material, without increasing complications or operative time.

MATERIALS AND METHODS

A consecutive and prospective case series compared to another historical operated by conventional laparoscopic cholecystectomy (LC). The TILC was performed with three trocars in two incisions, two trocars in umbilical incision, and one in epigastrium.

RESULTS

A total of 72 patients were operated on by the same surgeon (36 in each group). There were no significant differences between groups for gender, mean age, body mass index, or length of hospital stay. The procedures were classified by the surgeon according to surgical difficulty and 58.3% (n = 42) were considered low grade, 9.7% (n = 7) difficult, and the other were intermediaries, with no difference between the series (P < .05). There were minor complications in 6.94% (n = 5) procedures. There were no differences between mean operative time (P = .989), which was 49 (95% confidence interval [CI] 42-56) minutes in LC and 40 (95% CI 35-44) min in TILC. There was no need for additional trocars in any case or for conversion to open surgery.

CONCLUSIONS

TILC is feasible, safe, and with good aesthetic result, using the same instruments of LC, without increasing operative time.

New advantageous tool in single incision laparoscopic cholecystectomy: the needle grasper

INTRODUCTION

During single-incision laparoscopic cholecystectomy (SILC), the gallbladder is suspended with stitches, resulting in perforation risk and difficulty in exploration.

AIM

We used the needle grasper in SILC to hang and manipulate the gallbladder.

MATERIAL AND METHODS

Sixty-five patients (43 female, 22 male) who underwent SILC between December 2013 and December 2014 were analyzed retrospectively for patient demographics, duration of operation, laparotomy or conventional laparoscopy necessity, drain use, complications, and hospital stay periods. To place the SILC port (Covidien, Inc.), the needle grasper was inserted at the right upper abdominal quadrant without an incision to hang and manipulate the gall-bladder.

RESULTS

The mean age was 47.9 ±13.068 years; the mean body mass index (BMI) was 26.94 ±3.913 kg/m². ASA scores were 1, 2, and 3. Two patients with high BMI with additional trocar use were excluded. The operations were completed without any additional trocar in 59 patients. The mean operation time was 89 ±22.41 min. Eighteen patients required a drain; all were discharged after drain removal. One patient needed re-hospitalization and percutaneous drainage and was discharged on the 9^th day. Fifty-three patients were discharged on the 1^st post-operative day. Eleven patients with drains were discharged on the 2^nd day, and 1 was discharged on the 7^th day. The mean hospital stay period was 1.26 ±0.815 days.

CONCLUSIONS

The main difficulty of SILC is to manipulate hand tools because the triangulation principle of laparoscopy use is not possible in SILC. Inserting a needle grasper into the abdominal cavity at the right subcostal area to manipulate the gallbladder helps and does not leave a visible scar.