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

A Comprehensive Analysis of Single-Incision Laparoscopic Cholecystectomy: Trends, Challenges, and Future Directions

Single-incision laparoscopic cholecystectomy (SILC) is a minimally invasive surgical technique introduced as an advancement to laparoscopic cholecystectomy (LC). This narrative review delves into the emergence of SILC, emphasizing its distinct advantages such as improved cosmesis, reduced postoperative pain, and potentially faster recovery compared to traditional LC. The study meticulously examines current trends and challenges in SILC, including variations in techniques and their impact on patient outcomes. Furthermore, the article sheds light on the technical intricacies and longer operative times associated with SILC. It aims to contribute valuable insights to the medical community by synthesizing existing literature and recent research findings, fostering a deeper understanding of SILC, and guiding future advancements in minimally invasive surgical approaches. The discussion extends to the learning curve, complications, and a comparative analysis between SILC and traditional LC, offering a nuanced understanding of their respective strengths and limitations. The article concludes with a forward-looking perspective, exploring future directions and innovations in SILC, including advancements in surgical techniques and the integration of innovative technologies, such as robotic assistance and in vivo robots, to enhance precision and efficacy. The call for continued research into the long-term outcomes, safety, and refined patient selection criteria emphasizes the evolving landscape of SILC and its potential to shape the future of minimally invasive abdominal surgeries.

Single-incision versus conventional multiport laparoscopic cholecystectomy in acute cholecystitis according to disease severity: single center retrospective study in Korea

Purpose

The safety of single-incision laparoscopic cholecystectomy (SILC) for acute cholecystitis (AC) has not yet been confirmed.

Methods

This single-center retrospective study included patients who underwent laparoscopic cholecystectomy (LC) for AC between April 2010 and December 2020. Propensity scores were used to match patients who underwent SILC with those who underwent conventional multiport LC (CMLC) in the entire cohort and in the two subgroups.

Results

A total of 1,876 patients underwent LC for AC, and 427 (22.8%) underwent SILC. In the propensity score-matched analysis of the entire cohort (404 patients in each group), the length of hospital stay (2.9 days vs. 3.5 days, p = 0.029) was shorter in the SILC group than in the CMLC group. No significant differences were observed in other surgical outcomes. In grade I AC (336 patients in each group), the SILC group showed poorer surgical outcomes than the CMLC group, regarding operation time (57.6 minutes vs. 52.4 minutes, p = 0.001) and estimated blood loss (22.9 mL vs. 13.1 mL, p = 0.006). In grade II/III AC (58 patients in each group), there were no significant differences in surgical outcomes between the two groups. Postoperative pain outcomes were also not significantly different in the two groups, regardless of severity.

Conclusion

This study demonstrated that SILC had similar surgical and pain outcomes to CMLC in patients with AC; however, subgroup analysis showed that SILC was associated with poor surgical outcomes than CMLC in grade I AC. Therefore, SILC should be carefully performed in patients with AC by experienced hepatobiliary surgeons.

Outcome of single-incision laparoscopic cholecystectomy compared to three-incision laparoscopic cholecystectomy for acute cholecystitis

BACKGROUNDS/AIMS

While single-incision laparoscopic cholecystectomy (SILC) has advantages in cosmesis and postoperative pain, its utilization has been limited. This study raises the possibility of expanding its indication to acute cholecystitis with the novel method of solo surgery under retrospective analysis.

METHODS

We compared the outcomes of SILC (n = 58) to those of three-incision laparoscopic cholecystectomy (TILC; n = 117) for acute cholecystitis, being performed from March 2014 to December 2015.

RESULTS

Intraoperative results, including the operation time, did not differ significantly, except for drain catheter insertion (p = 0.004). Each group had 1 case of open conversion due to common bile duct injury. There was no significant difference in the length of hospital stay. Either group by itself was not a risk factor for complications, but in preoperative drainage for intraoperative perforation, 3 factors of intraoperative perforation, biliary complication, and history of upper abdominal operation for additional port, only American Society of Anesthesiology (ASA) scores for postoperative complication of Clavien-Dindo grades III and IV were significant risk factors.

CONCLUSIONS

Our study findings showed comparative outcomes between both groups, providing evidence for the safety and feasibility of SILC for acute cholecystitis.

Optimal indication of single-incision laparoscopic cholecystectomy using Konyang Standard Method in benign gallbladder diseases

Purpose

The optimal indications for single-incision laparoscopic cholecystectomy (SILC) have not yet been established.

Methods

This single-center retrospective study included consecutive patients who underwent SILC between April 2010 and June 2020. Difficult surgery (DS) (conversion to multiport or open cholecystectomy, adjacent organ injury, operation time of ≥90 minutes, or estimated blood loss of ≥100 mL) and poor postoperative outcome (PPO) (postoperative hospital stay ≥ 7 days or Clavien-Dindo grade ≥ II postoperative complications) were defined to comprehensively evaluate surgical difficulty and postoperative outcomes, respectively.

Results

Of 1,405 patients (mean age, 51.2 years; 802 female [57.1%]), 427 (grade I, n = 358; grade II/III, n = 69) underwent SILC for acute cholecystitis (AC), 34 (2.4%) needed conversion to multiport (n = 33) or open cholecystectomy (n = 1), 7 (0.5%) had adjacent organ injury during surgery, and 49 (3.5%) developed postoperative complications. Of the patients, 89 and 52 had DS and PPO, respectively. In the multivariate analysis, grade I AC, grade II/III AC, and body mass index of ≥30 kg/m² were significant predictors of DS. Age of ≥70 years and DS were significant predictors of PPO. In a subgroup analysis of patients with AC, DS (9.5% vs. 27.5%, p < 0.001) and PPO (5.0% vs. 15.9%, p = 0.001) were more frequent in patients with grade II/III AC than in those with grade I AC.

Conclusion

SILC is not recommended in patients with grade II/III AC and should be carefully performed by experienced and well-trained surgeons.

Single-Port Cholecystectomy for Cholecystitis Versus Non-Cholecystitis

BACKGROUND AND OBJECTIVES

To assess the safety and efficacy of single-port laparoscopic cholecystectomy (SPLC) for the treatment of symptomatic cholelithiasis in different gallbladder pathologic conditions.

METHODS

All patients who underwent SPLC in our department between October 1, 2017 and March 31, 2020 were registered consecutively in a prospective database. Patients' charts were retrospectively divided according to histological diagnosis: normal gallbladder (NG) (n = 13), chronic cholecystitis (CC) (n =47), and acute cholecystitis (AC) (n = 10). The parameters for assessing the procedure outcome included operative time, blood loss, use of additional trocars, conversion to laparotomy, intraoperative and postoperative complications, and length of hospital stay. Patient groups were statistically compared.

RESULTS

Seventy patients underwent SPLC. Duration of surgery increased from NG (55 ± 22.7 min) to CC (70 ± 33.5 min), and to AC patients (110.5 ± 50.5 min), which is statistically significant (P = .001). Postoperative complication rates were 7.6% in NG patients, 17% in CC, and 30% in AC (P = .442). Length of hospitalization was shorter for NG patients (1.0 ± 0.6 days) versus CC (2.0 ± 1.1 days) and AC patients (2.0 ± 4.7 days), with statistical significance (P = .020). Multivariate analysis found that pathology type and the occurrence of postoperative complications were independent predictors for prolonged operative times and prolonged hospital stay, respectively.

CONCLUSION

SPLC is feasible for acute and chronic cholecystitis with good procedural outcomes. Since SPLC technique itself can be sometimes challenging with the existing technology, its application, especially in cases of acute cholecystitis, should be done with caution. Only prospective randomized studies on this approach for acute and chronic gallbladder diseases will assess the complete reliability of this technique.

Completion of single-incision laparoscopic cholecystectomy using the modified Konyang standard method

BACKGROUND

To date, a surgical method for single-incision laparoscopic cholecystectomy (SILC) has not been standardized. Therefore, this study aimed to introduce a standardized surgical method for SILC, in addition to reporting our experience over 10 years.

METHODS

Patients who underwent SILC at a single institution between April 2010 and December 2019 were included in this study. We analyzed the patient demographics and surgical outcomes according to the surgical method used: phase 1 (Konyang standard method, KSM) comprising initial 3-channel SILC, phase 2 (modified KSM, mKSM) comprising 4-channel SILC with a snake retractor, and phase 3 (commercial mKSM, C-mKSM) using a commercial 4-channel port.

RESULTS

Of 1372 patients (mean age, 51.3 years; 781 [56.9%] women), 418 (30.5%) surgeries were performed for acute cholecystitis (AC), 33 (2.4%) were converted to multiport or open cholecystectomy, and 49 (3.6%) developed postoperative complications. The mean operation time (OT) and length of postoperative hospital stay (LOS) were 51.9 min and 2.6 days, respectively. Overall, 325 patients underwent SILC with the KSM, 660 with the mKSM, and 387 with the C-mKSM. In the C-mKSM group, the number of patients with AC was the lowest (26.8% vs. 38.2% vs. 20.4%, p < 0.001) and the OT (51.7 min vs. 55.4 min vs. 46.1 min, p < 0.001), estimated blood loss (24.5 mL vs. 15.5 mL vs. 6.1 mL, p < 0.001), and LOS (2.8 days vs. 2.5 days vs. 2.3 days, p = 0.001) were significantly improved. The surgical outcomes were better in the non-AC group than in the AC group.

CONCLUSION

Based on our 10 year experience, C-mKSM is a safe and feasible method of SILC in selected patients, although there were lower percentage of patients with AC compared to other groups.

Emergency single-incision laparoscopic cholecystectomy for acute cholecystitis: A multi-center study

Single-incision laparoscopy is accepted as a safe alternative to multiple port laparoscopy for elective cholecystectomy; however, there are limited data on its use in patients with acute cholecystitis. The present multi-center study evaluated the outcomes of emergency single-incision surgeries for acute cholecystitis in hospitals in Belgium, Jamaica, and Trinidad and Tobago over a 5-year period. Standardized definitions of uncomplicated and complicated acute cholecystitis were used and the data were compared using SPSS software. The results revealed that over the 5-year period, 108 patients with a mean age of 48±15 years and a mean body mass index of 27±4.2 kg/m² underwent emergency single-incision cholecystectomies. The surgeries were successful in 92.1% of cases without supplemental trocars being used. The overall morbidity rates (9.3%) were also comparable to the historic controls with multiple port cholecystectomy. As was expected, the complicated cholecystitis group required a significantly longer operating time (86.11±30.16 vs. 66.79±16.8; P<0.00194), as well as supplemental trocars (7.9%) vs. 0; P=0.0413). On the whole, the present study demonstrates that emergency single-incision cholecystectomy is a technically feasible and safe procedure for patients with acute cholecystitis. These findings advocate a low threshold to place additional ports to assist with dissection and exposure.

Single Incision Cholecystectomies for Acute Cholecystitis: A Single Surgeon Series from the Caribbean

INTRODUCTION

Single incision laparoscopic surgery (SILS) is accepted as a safe alternative to conventional multiport laparoscopic (MPL) cholecystectomy for benign gallbladder disease. Since many surgeons carefully select patients without inflammation, there are limited data on SILS for acute cholecystitis. We report a single surgeon experience with SILS cholecystectomy for patients with acute cholecystitis.

MATERIALS AND METHODS

After securing ethical approval, we performed an audit of all SILS cholecystectomies for acute cholecystitis by a single surgeon from January 1, 2009, to December 31, 2019. The following data were extracted: patient demographics, intraoperative details, surgical techniques, specialized equipment utilized, conversions (additional port placement), morbidity, and mortality. Data were analyzed using SPSS 12.0.

RESULTS

SILS cholecystectomy was performed in 25 females at a mean age of 35 ± 4.1 (SD) years and a mean BMI of 31.9 ± 3.8 (SD) using a direct fascial puncture technique without access platforms. The operations were completed in 83 ± 29.4 minutes (mean ± SD) with an estimated blood loss of 76.9 ± 105 (mean + SD). Three (12%) patients required additional 5 mm port placement (conversions), but no open operations were performed. The patients were hospitalized for 1.96 ± 0.9 days (mean ± SD). There were 2 complications: postoperative superficial SSI (grade I) and a diaphragmatic laceration (grade III). No bile duct injuries were reported. There were 9 patients with complicated acute cholecystitis, and this sub-group had longer mean operating times (109.2 ± 27.3 minutes) and mean postoperative hospital stay (1.3 ± 0.87 days).

CONCLUSION

The SILS technique is a feasible and safe approach to perform cholecystectomy for acute cholecystitis. We advocate a low threshold to place additional ports to assist with difficult dissections for patient safety.

The chronological change of indications and outcomes for single-incision laparoscopic cholecystectomy: a Korean multicenter study

BACKGROUND

Although single-incision laparoscopic cholecystectomy (SILC) is a common procedure, the change in its surgical indications and perioperative outcomes has not been analyzed.

METHODS

We collected the clinical data of patients who underwent pure SILC in 9 centers between 2009 and 2018 and compared the perioperative outcomes.

RESULTS

In this period, 6497 patients underwent SILC. Of these, 2583 were for gallbladder (GB) stone (39.7%), 774 were for GB polyp (11.9%), 994 were for chronic cholecystitis (15.3%), and 1492 were for acute cholecystitis (AC) (23%). 162 patients (2.5%) experienced complication, including 20 patients (0.2%) suffering from biliary leakage. The number of patients who underwent SILC for AC increased over time (p = 0.028), leading to an accumulation of experience (27.4 vs 23.7%, p = 0.002). The patients in late period were more likely to have undergone a previous laparotomy (29.5 vs 20.2%, p = 0.006), and to have a shorter operation time (47.0 vs 58.8 min, p < 0.001). Male (odds ratio [OR]; 1.673, 95% confidence interval [CI] 1.090-2.569, p = 0.019) and moderate or severe acute cholecystitis (OR; 2.602, 95% CI 1.677-4.037, p < 0.001) were independent predictive factors for gallbladder perforation during surgery, and open conversion (OR; 5.793, 95% CI 3.130-10.721, p < 0.001) and pathologically proven acute cholecystitis or empyema (OR; 4.107, 95% CI 2.461-6.854, p < 0.001) were related with intraoperative gallbladder perforation CONCLUSION: SILC has expanded indication in late period. In this period, the patients had shorter operation times and a similar rate of severe complications, despite there being more numerous patients with AC.

Long-term and short-term surgical outcomes of single-incision laparoscopic hepatectomy on anterolateral liver segments

BACKGROUND

Laparoscopic liver resection yields improved short-term surgical outcomes, whereas the reports about clinical benefits of single-incision laparoscopic hepatectomy (SILH) are scarce. This retrospective study is to compare the surgical outcomes of SILH with those of multi-incision laparoscopic hepatectomy (MILH).

METHODS

The study included 54 patients who had undergone SILH and 184 patients who had undergone MILH between January 2010 and December 2017. Short-term outcomes were compared in those of patients who underwent left lateral sectionectomy and partial hepatectomy of segment 5-6. A subgroup analysis of hepatocellular carcinoma (HCC) was also performed for long-term outcome comparisons.

RESULTS

In those of patients who underwent left lateral sectionectomy, SILH group had less chronic hepatitis B (15.2 vs. 45.8%; p = 0.004), less liver cirrhosis (12.1 vs. 50.0%; p = 0.002), less tumor proximal to major vessel (6.1 vs. 29.2%; p = 0.018), shorter surgical time (113.2 ± 37.9 vs. 146.0 ± 50.5 min; p = 0.007), and shorter postoperative hospital stays (4.4 ± 1.1 vs. 5.4 ± 1.3 days; p = 0.002) compared with MILH group. In those of patients with tumor located at segment 5-6, no significant differences were observed in surgical time, blood loss, complications, and mortality. Single-incision laparoscopic partial hepatectomy was only associated with wider surgical margins (11.8 ± 7.0 vs. 5.3 ± 5.2 mm; p = 0.003). In the HCC subgroup, SILH had similar 1-, 3-, and 5-year overall survival and 1-, 3-, and 5-year recurrence-free survival rates compared with patients who had undergone MILH.

CONCLUSIONS

The study demonstrates the safety and feasibility of single-incision laparoscopic liver resection for left lateral sectionectomy and partial hepatectomy for segment 5-6. In selected patients within the group and by experienced surgical team, the SILH technique results in comparable short-term surgical outcomes and long-term oncological outcomes.

The First Additional Port During Single-Incision Laparoscopic Cholecystectomy

BACKGROUND AND OBJECTIVES

Single-incision laparoscopic cholecystectomy (SILC) has become increasingly popular. Regarding the difficulties of SILC in acute cholecystitis, additional port insertion is sometimes required. However, appropriate locations for additional port insertion have not been well studied. In the present study, the safety and effectiveness of the first additional port insertion in the epigastric region during SILC was assessed.

METHODS

Additional port insertions were needed in 52 of 113 patients who underwent SILC for acute cholecystitis. The first port was inserted in the epigastric region and the second (if required) was inserted in the right lateral subcostal area. A drainage catheter was positioned through the epigastric port.

RESULTS

One additional port was inserted in 43 patients and two additional ports were inserted in 9 patients. Mean operation time was 45.0 minutes in the Pure SILC group and 83.3 minutes in Additional Port group. Mean hospital stay was 3.7 days in the Pure SILC group and 5.9 days in Additional Port group. There was no open conversion. Intra-operative (n = 5) and postoperative bile leakages (n = 2) were identified in six patients. Timing of operation after onset of symptoms was significantly greater in the group with bile duct injury than in those without bile duct injury in patients who required additional ports.

CONCLUSIONS

The first additional port in the epigastric area during SILC for acute cholecystitis helps to complete the operation without open conversion. However, the procedure can be performed safely in selective patients with relatively short duration of symptoms.

Higher cost of single incision laparoscopic cholecystectomy due to longer operating time. A study of opportunity cost based on meta-analysis

BACKGROUND

We aimed to calculate the opportunity cost of the operating time to demonstrate that single incision laparoscopic cholecystectomy (SILC) is more expensive than classic laparoscopic cholecystectomy (CLC).

METHODS

We identified studies comparing use of both techniques during the period 2008-2016, and to calculate the opportunity cost, we performed another search in the same period of time with an economic evaluation of classic laparoscopy. We performed a meta-analysis of the items selected in the first review considering the cost of surgery and surgical time, and we analyzed their differences. We subsequently calculated the opportunity cost of these time differences based on the design of a cost/time variable using the data from the second literature review.

RESULTS

Twenty-seven articles were selected from the first review: 26 for operating time (3.138 patients) and 3 for the cost of surgery (831 patients), and 3 articles from the second review. Both echniques have similar operating costs. Single incision laparoscopy surgery takes longer (16.90min) to perform (p <0.00001) and this difference represents an opportunity cost of 755.97 € (cost/time unit factor of 44.73 €/min).

CONCLUSIONS

SILC costs the same as CLC, but the surgery takes longer to perform, and this difference involves an opportunity cost that increases the total cost of SILC. The value of the opportunity cost of the operating time can vary the total cost of a surgical technique and it should be included in the economic evaluation to support the decision to adopt a new surgical technique.

Prevention and acute management of biliary injuries during laparoscopic cholecystectomy: Expert consensus statement

Gallstone disease is very common and laparoscopic cholecystectomy is one of the most common surgical procedures all over the world. Parallel to the increase in the number of laparoscopic cholecystectomies, bile duct injuries also increased. The reported incidence of bile duct injuries ranges from 0.3% to 1.4%. Many of the bile duct injuries during laparoscopic cholecystectomy are not due to inexperience, but are the result of basic technical failures and misinterpretations. A working group of expert hepatopancreatobiliary surgeons, an endoscopist, and a specialist of forensic medicine study searched and analyzed the publications on safe cholecystectomy and biliary injuries complicating laparoscopic cholecystectomy under the organization of Turkish Hepatopancreatobiliary Surgery Association. After a series of e-mail communications and two conferences, the expert panel developed consensus statements for safe cholecystectomy, management of biliary injuries and medicolegal issues. The panel concluded that iatrogenic biliary injury is an overwhelming complication of laparoscopic cholecystectomy and an important issue in malpractice claims. Misidentification of the biliary system is the major cause of biliary injuries. To avoid this, the "critical view of safety" technique should be employed in all the cases. If biliary injury is identified intraoperatively, reconstruction should only be performed by experienced hepatobiliary surgeons. In the postoperative period, any deviation from the expected clinical course of recovery should alert the surgeon about the possibility of biliary injury.

Laparoscopic transfistulous bile duct exploration for Mirizzi syndrome type II: a simplified standardized technique

BACKGROUND

Laparoscopic treatment is a viable option for Mirizzi syndrome (MS) type I, but it is not recommended for MS type II (McSherry classification). We introduce laparoscopic transfistulous bile duct exploration (LTBDE) as a simplified standardized technique for MS type II.

METHODS

Eleven consecutive LTBDEs performed by a surgeon for MS type II were analyzed retrospectively, including three successful single-incision LTBDEs (SILTBDEs). Transfistulous stone removal followed by primary closure of gallbladder remnant and partial cholecystectomy was performed. An additional choledochotomy was required in one patient.

RESULTS

Preoperative endoscopic retrograde cholangiopancreatography and operative findings confirmed the diagnosis of MS in five and five patients, respectively. Preoperative ultrasound implied the remaining diagnosis. The operative time was 270.5 ± 65.5 min. The stone clearance rate was 100 %. The postoperative length of hospital stay was 5.1 ± 2.2 days. There was no open conversion. Overall complications comprised two postoperative transient hyperamylasemia (18.2 %) and one superficial wound infection (9.1 %). Compared with the other group of 92 patients who underwent laparoscopic bile duct exploration, the MS type II group had a significantly younger age, a higher jaundice rate, a lower single-incision laparoscopic approach rate, a lower choledochotomy rate, longer operative time, a lower postoperative pethidine dose, and a longer total length of hospital stay. The average follow-up period was 12.1 months.

CONCLUSIONS

LTBDE is safe and efficacious for MS type II including Csendes type IV. A high suspicion of MS is critical. SILTBDE is feasible in selected cases. Long-term follow-up is mandatory.

Risk factors for conversion to conventional laparoscopic cholecystectomy in single incision laparoscopic cholecystectomy

PURPOSE

The aim of this study was to investigate the risk factors for conversion to conventional laparoscopic cholecystectomy (CLC) in single incision laparoscopic cholecystectomy (SILC) along with the proposal for procedure selection guidelines in treating patients with benign gallbladder (GB) diseases.

METHODS

SILC was performed in 697 cases between April 2010 and July 2014. Seventeen cases (2.4%) underwent conversion to conventional LC. We compared these 2 groups and analyzed the risk factors for conversion to CLC.

RESULTS

In univariate analysis, American Society of Anesthesiologist score > 3, preoperative percutaneous transhepatic GB drainage status and pathology (acute cholecystitis or GB empyema) were significant risk factors for conversion (P = 0.010, P = 0.019 and P < 0.001). In multivariate analysis, pathology (acute cholecystitis or GB empyema) was significant risk factors for conversion to CLC in SILC (P < 0.001).

CONCLUSION

Although SILC is a feasible method for most patients with benign GB disease, CLC has to be considered in patients with acute cholecystitis or GB empyema because it is likely to result in inadequate visualization of the Calot's triangle and greater bleeding risk.

Single-incision laparoscopic surgery for biliary tract disease

Single-incision laparoscopic surgery (SILS), or laparoendoscopic single-site surgery, has been employed in various fields to minimize traumatic effects over the last two decades. Single-incision laparoscopic cholecystectomy (SILC) has been the most frequently studied SILS to date. Hundreds of studies on SILC have failed to present conclusive results. Most randomized controlled trials (RCTs) have been small in scale and have been conducted under ideal operative conditions. The role of SILC in complicated scenarios remains uncertain. As common bile duct exploration (CBDE) methods have been used for more than one hundred years, laparoscopic CBDE (LCBDE) has emerged as an effective, demanding, and infrequent technique employed during the laparoscopic era. Likewise, laparoscopic biliary-enteric anastomosis is difficult to carry out, with only a few studies have been published on the approach. The application of SILS to CBDE and biliary-enteric anastomosis is extremely rare, and such innovative procedures are only carried out by a number of specialized groups across the globe. Herein we present a thorough and detailed analysis of SILC in terms of operative techniques, training and learning curves, safety and efficacy levels, recovery trends, and costs by reviewing RCTs conducted over the past three years and two recently updated meta-analyses. All existing literature on single-incision LCBDE and single-incision laparoscopic hepaticojejunostomy has been reviewed to describe these two demanding techniques.

Do height and weight affect the feasibility of single-incision laparoscopic cholecystectomy?

BACKGROUND

Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common laparoscopic procedure worldwide. Single-incision laparoscopic surgery has recently emerged as a less invasive potential alternative to conventional three- or four-port laparoscopy. However, the feasibility of single-incision laparoscopic cholecystectomy (SILC) remains unclear, and there are no rigorous criteria in the literature. Identifying patients at risk of failure of this new technique is essential. The aim of our study was to determine risk factors that may predict failure of the procedure.

METHODS

From May 2010 to March 2012, 110 consecutive patients underwent SILC and were reviewed retrospectively. The main feasibility criterion was the procedure failure rate, defined as addition of supplementary port(s) and prolonged (>60 min) operative time. The factors evaluated were age, gender, height, weight, body mass index, previous abdominal surgery, indication for surgery and gallbladder suspension.

RESULTS

There was conversion in 16 patients (14.5%), and the operative time exceeded 60 min for 20 patients (30.9%). Univariate analysis showed a significant independent association between additional port requirement and each of weight as a continuous value, weight ≥80 kg, BMI >26.5 kg/m(2) and height >172 cm. Univariate analysis also showed a significant independent association between prolonged operative duration (>60 min) and each of height and weight as continuous values, height >172 cm and previous abdominal surgery. In the multivariate analysis, only weight remained independently associated with additional port requirement, and height remained independently associated with prolonged operative duration.

CONCLUSION

Preoperative identification of the factors increasing the risk of conversion may assist surgeons in making decisions concerning the management of patients, including appropriate use of SILC.

Is routine single-incision laparoscopic cholecystectomy feasible? A retrospective observational study

BACKGROUND

Single-incision laparoscopic cholecystectomy (SILC) has been shown to be safe for uncomplicated gallbladder diseases. Routinely applying SILC is debatable.

METHODS

Two hundred SILCs were performed with single-incision multiple-port longitudinal-array and self-camera techniques.

RESULTS

Eighty-eight (44%) procedures were scheduled for complicated diseases. The routine group had a higher comorbidity rate, a lower preoperative endoscopic retrograde cholangiopancreatography rate, a higher intraoperative cholangiography rate, a higher proportion of complicated gallbladder diseases, shorter operative time, more intraoperative blood loss, and lower postoperative pethidine dose than the selective group (the first 73 patients). The conversion and complication rates showed no statistical difference. It took fewer cases but longer time to pass the learning phase of SILC for complicated gallbladder diseases. The multivariate analysis showed that male sex and complicated gallbladder diseases were associated with a higher procedure conversion rate, and increased patient age was related to a higher complication rate.

CONCLUSIONS

Routine SILC for benign gallbladder diseases is feasible in the experienced phase. Practicing SILC for uncomplicated gallbladder diseases helps to achieve competence in this technique for complicated diseases.

Single-incision laparoscopic cholecystectomy for acute cholecystitis: A retrospective cohort study of 52 consecutive patients

BACKGROUND

Single-incision laparoscopic cholecystectomy (SILC) has become increasingly popular but its role in acute cholecystitis remains controversial.

METHODS

We compared the clinical features and outcomes of SILC procedures between 52 patients with acute cholecystitis (the AC group) and 308 patients without acute cholecystitis (the NAC group). We also analyzed clinical variables to identify factors affecting difficulties associated with SILC for acute cholecystitis.

RESULTS

The patients in the AC group were significantly older than those in the NAC group (72 vs. 61 years, median, P = 0.0005). The preoperative levels of white blood cell counts were significantly higher in the AC group than in the NAC group (6600 vs. 5500/μL, P = 0.0004). The operative time was significantly longer in the AC group than in the NAC group (188 vs. 135 min, P < 0.0001). The volume of intraoperative blood loss was significantly larger in the AC group than in the NAC group (20 vs. 5 mL, P < 0.001). Furthermore, additional trocar insertion was required in 12% in the NAC group, whereas it was required in 60% in the AC group (P < 0.0001). Regarding the difficulties of SILC for acute cholecystitis, delayed operation (after 72 h from the onset) was significantly associated with a prolonged operative time, while a higher grade of acute cholecystitis (grade II or III) was significantly associated with an increased blood loss during surgery.

CONCLUSIONS

These findings suggest that when compared to SILC for gallbladder diseases without acute inflammation, SILC for acute cholecystitis was associated with a longer operative time, increased blood loss, higher rate of additional trocar requirement, higher rate of postoperative complications, and longer hospital stay. The difficulties associated with SILC for acute cholecystitis were affected by the timing of surgery and the grade of inflammation.

Application of laparoscopy in the combined surgical procedures of gynecological and digestive disorders in obese women: a retrospective cohort study

BACKGROUND

Laparoscopy surgery has been widely used for many decades and combined laparoscopic procedures have become favorable choices for concomitant pathologies in the abdomen. However, the type of combination procedures and their safety in obese women have not been well elucidated in obese women.

METHODS

Here we retrospectively reported 147 obese women underwent combined laparoscopic gynecological surgery and cholecystectomy/appendicectomy in our hospital from January 2003 to December 2011. Of the total number of patients (n = 147), various laparoscopic gynecological surgeries were combined with laparoscopic cholecystectomy in 93 patients, and were combined with laparoscopic appendectomy in the rest 54 patients. Patients' ages ranged from 24 to 55 years with an average of 33 years.

RESULTS

Our results showed that combined procedures caused various operative time and blood loss, with no difference considering the time to resume oral intake and length of hospital stay. Intraoperative complications occurred in a total of 7 patients (4.8%). None of the patients suffered from major complications after laparoscopic surgery, and minor postoperative complications occurred in 30 patients (20.4%). The follow-up period ranged from 6 to 24 months (average, 18.5 months). None of the patients developed complications during follow-up, except that one patient suffered from colporrhagia.

CONCLUSIONS

Our results further suggest that the combined abdominal laparoscopic procedures of gynecologic and general surgery are safe and economic choices for obese women, and benefit patients in many ways including lesser pain, shorter hospital stays and earlier recovery.

Evolution of SILS Cholecystectomy in the Caribbean: The Direct Transfascial Puncture Technique Using Conventional Instruments without Working Ports

Introduction. Single incision laparoscopic cholecystectomy (SILC) has become accepted as an alternative to conventional multiport cholecystectomy. However, SILC is still limited in applicability in low resource centres due to the expense associated with specialized access platforms, curved instruments, and flexible scopes. Presentation of Case. We present three cases where a modified SILC technique was used with conventional instruments and no working ports. The evolution of this technique is described. Discussion. In order to contain cost, we used conventional instruments and three transfascial ports placed in an umbilical incision, but we noted significant instrument clashes that originated at the port platforms. Therefore, we modified our technique by omitting ports for the working instruments. The technique allowed us to exchange instruments as necessary, maximized ergonomics, and prevented collisions from the bulky port platforms. Finally, the puncture left by the instrument alone did not require fascial closure at the termination of the procedure. Conclusion. The direct transfascial puncture using conventional laparoscopic instruments without working ports is a feasible option that minimizes cost and increases ergonomics.