JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 24, Number 12, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/lap.2014.0117
The Efficacy of Subcostal-Approach Laparoscopic Cholecystectomy in Patients with Previous Midline Incisions: Comparative Analysis with Conventional Laparoscopic Cholecystectomy Sae Byeol Choi, MD, PhD, Hyung Joon Han, MD, PhD, Wan Bae Kim, MD, PhD, Tae Jin Song, MD, PhD, and Sang Yong Choi, MD, PhD
Abstract
Background: In patients with previous abdominal surgery, difficulties in laparoscopic cholecystectomy (LC) are associated with adhesions from the previous surgery. We reported the efficacy of a subcostal-approach LC (SALC) in patients with previous midline incisions. Subjects and Methods: Thirty-five patients with previous upper midline incision who underwent SALC from 2009 to 2013 at Korea University Medical Center (Seoul, Korea) were included. In SALC, a subcostal incision instead of an umbilical one was used to avoid adhesion in the midline scar. We compared the clinical outcomes of SALC with those of conventional LC in patients with previous midline incisions. Results: In the SALC group, there were 25 men and 10 women. The mean age was 64 years. Median operative time was 60 minutes, and the median length of postoperative hospital stay was 2 days. Most of the patients underwent three-port cholecystectomy. Three patients underwent conversion to open surgery. The SALC group had a significantly shorter postoperative hospital stay and shorter operation time compared with the conventional LC (with supraumbilical incision) group. Conclusions: SALC is a safe and effective procedure for patients who have had a previous midline incision that can help prevent unnecessary adhesiolysis.
Introduction
T
he indications for laparoscopic surgery have been expanded because of the development of endoscopic instruments as well as an increase in surgical skill.1,2 Laparoscopic cholecystectomy (LC) is the gold standard in the surgical treatment of benign gallbladder disease. In the early days of laparoscopic surgery, a history of open abdominal surgery was considered a relative contraindication for the procedure due to adhesion.3,4 However, by virtue of recent surgical advancements, many surgeons have first attempted laparoscopic surgery in patients with a previous midline incision, and the outcomes were relatively satisfactory.1,5 The most difficult part of a laparoscopic operation in patients with previous abdominal surgery is usually related to insertion of the first trocar. Because adhesions are usually expected around the previous midline incision site, we selected a subcostal incision rather than a supraumbilical incision to avoid any adhesions formed by previous operations
as much as possible and reported our experience of subcostalapproach LC (SALC) in patients with previous midline incision.6 Since then, we have performed SALC for benign gallbladder disease in patients who had a history of operation, particularly those with midline incisions. The aim of this study was to investigate the surgical outcomes of SALC and also to evaluate the efficacy of SALC compared with conventional LC in patients with previous midline incisions. Subjects and Methods
We performed SALC in 35 patients with a history of previous operation for benign gallbladder diseases at Korea University Medical Center (Seoul, Korea) between May 2009 and March 2013. We investigated the surgical outcomes of SALC. In order to compare the efficacy of SALC with conventional LC or open cholecystectomy, we included 21 patients who underwent conventional LC for gallbladder disease between 2006 and 2010 at Korea University Medical
Department of Surgery, Korea University College of Medicine, Seoul, Korea.
842
EFFICACY OF SUBCOSTAL-APPROACH LC
Center who also had had a history of gastrectomy with a midline incision. Conventional LC is a three- or four-port technique using a supraumbilical incision for insertion of the trocar. In brief, SALC was performed using a three-port technique. A 1.5-cm subcostal incision was made 2 cm below the costal margin using an open method. Each layer of muscle and fascia was dissected bluntly using a Kelly clamp, and the peritoneum was opened under direct vision. A 30 right-up and head-up position was used, similar to conventional LC. Under camera guidance to avoid adhesions, two additional 5-mm incisions were made at the epigastric and right lateral areas crossing the anterior axillary and subcostal lines. The right lateral trocar is used for traction of the gallbladder. The main dissection is done using an epigastric trocar (Figs. 1 and 2). The following patient demographics and clinical information were retrospectively obtained from the medical records: age, gender, body mass index, comorbidities, American Society of Anesthesiologists class (www.asahq.org/clinical/physicalstatus .htm), time interval from cholecystectomy to previous operation, information about the previous surgery, operative time, conversion to open surgery, postoperative complications, length of hospital stay, and pathological results. Data were expressed as mean – standard deviation values or medians with 25th and 75th percentiles for continuous variables. Statistical calculations were performed using IBM (Armonk, NY) SPSS Statistics version 20 software. For categorical variables, comparisons between groups were tested using the Pearson chi-squared test. Comparing continuous variables for two groups, we used the independentsamples t test for variables that were normally distributed and the Mann–Whitney U test for variables that were not
843
normally distributed. A value of P < .05 was considered statistically significant. Results Clinical characteristics of the 35 patients who underwent SALC
There were 10 women and 25 men with a mean age of 64 years. Mean body mass index was 22.7 – 4.1 kg/m2. Twelve patients had comorbidities: hypertension (n = 8), myocardial infarction or angina (n = 2), arrhythmia (n = 2), diabetes mellitus (n = 3), chronic kidney disease (n = 2), and aplastic anemia (n = 1). The median interval from previous operation to SALC was 11 years, with a range of 1 to 50 years. The previous operative procedures included gastrectomy (n = 17), explorative laparotomy (n = 8), small bowel segmental resection (n = 3), small bowel primary repair (n = 3), colon anterior resection (n = 3), and right hemicolectomy (n = 1). Most of the SALC procedures were performed using three ports; however, 3 patients required an additional port for safe dissection, for a total of four ports. Comparisons of the clinical characteristics between the SALC and conventional LC groups
There was no statistically significant difference in age, sex, body mass index, American Society of Anesthesiologists class, conversion to open surgery, or presence of inflammation (combining cholecystitis) between the two groups. However, the conventional LC group had both a longer operative time (P = .075) and a longer postoperative hospital stay (P < .001) than the SALC group. There was no
FIG. 1. (A) Trocar position in subcostal-approach laparoscopic cholecystectomy. (B) Adhesion in the previous midline incision, seen from the camera through the subcostal trocar. (C and D) Operative view and dissection during subcostalapproach laparoscopic cholecystectomy.
844
CHOI ET AL.
Table 1. Comparative Analysis of the Subcostal-Approach Laparoscopic Cholecystectomy Group with the Conventional Laparoscopic Cholecystectomy Group Factor
FIG. 2. Postoperative scar in subcostal-approach laparoscopic cholecystectomy.
statistically significant difference in the occurrence of complications between the two groups (Table 1). Three patients in the SALC group required conversion to open surgery, compatible with a conversion rate of 9%, because of severe adhesion around the gallbladder (n = 2) and difficulties in dissecting the cystic duct and common bile duct junction due to fibrotic tissue. In the conventional LC group, 5 of the 21 patients required conversion to open surgery because of severe adhesion around the previous incision and gallbladder, consistent with a conversion rate of 24%. Postoperative complications developed in 2 patients in the SALC group and 2 in the conventional LC group. In the SALC group, cardiac angina and common bile duct stone after LC developed in 1 patient each. However, in the conventional LC group, 1 patient developed an intraabdominal abscess requiring percutaneous drainage, and another patient had a stricture in the common bile duct after operation, which required re-exploration with T-tube insertion. There was no postoperative mortality in either group. Discussion
We performed SALC with acceptable morbidity and conversion rates compared with conventional LC in patients with previous midline incisions. We used a subcostal incision rather than an umbilical one for insertion of the camera to avoid adhesions and adhesiolysis during LC. In the early laparoscopic era, severe adhesions around the operative scar often led to conversion to open surgery during LC.4,7 However, because of advances in surgical technique, adhesions may less frequently be a contraindication for laparoscopic surgery.1,5 During LC, the main reasons for conversion to open surgery were inflammation, adhesions, anatomical difficulty, and complications such as bleeding.8–10 The conversion rate for the conventional LC group in patients with a previous midline incision was reported to be 19% in a study published in the 1990s.1 In another study, the conversion rate of the
Age (years) Sex Female Male BMI (kg/m2) ASA class I II III Conversion to open surgery No Yes Cholecystitis No Yes Operative time (minutes) Hospital stay (days) Complication No Yes
Conventional SALC LC (n = 21) (n = 35) P value 63 – 12
64 – 12
8 13 22.8 – 2.5
10 25 22.7 – 4.1
8 11 2
7 26 2
.776 .460 .904 .244
.115 16 5 0 21 93 – 57 6 (3.5–8.5) 19 2
32 3 3 .168 32 72 – 34 .075 2 (2–5) < .001 33 2
.592
Data are mean – standard deviation values, number of patients, or median (range) as indicated. ASA, American Society of Anesthesiologists; BMI, body mass index; LC, laparoscopic cholecystectomy; SALC, subcostal-approach laparoscopic cholecystectomy.
previous abdominal surgery was 5.7% between 2004 and 2008.11 The conversion rate reported in the literature ranged from 2.2% to 5.2%8,10,11 in patients who underwent LC. In the current study, the conversion rates for SALC and conventional LC were 9% and 24%, respectively, although this difference did not reach statistical significance. In one study,12 the lateral-approach LC, in which patients were placed in a modified left lateral decubitus position and subcostal trocars were used, was reported to be safe and effective in patients with previous midline incisions. We placed the patient in a supine position and tilted the table similar to the procedure of conventional LC, which eliminates the inconvenience of changing the patient’s position. There were several efforts in the 1990s to detect the presence or degree of adhesion to the abdominal wall in patients with a history of previous laparotomy.13,14 Viscera slide is detected by ultrasonographic measurement of the movement of the abdominal viscera during deep respiration. A positive viscera slide sign means that viscera restricted by an adhesion to the abdominal wall are characterized by a shorter excursion of viscera (no movement or angular movement) during deep diaphragm respiration.13,14 Several authors reported the efficacy of the viscera slide sign in guiding trocar insertion in laparoscopic surgery, preventing injuries during the creation of the pneumoperitoneum.7,13 However, a recent lack of evidence shows that this measure is not used widely; initial trocar insertion avoiding the previous scars might be an alternative.
EFFICACY OF SUBCOSTAL-APPROACH LC
Access to the abdominal cavity by blind technique using a Veress needle has been reported to be safe1,15 in patients with previous incisions; however, our preference is the open (Hasson) technique in patients with a history of previous operation. Similarly, in the SALC group, the initial subcostal trocar site was established with an open method under direct vision and was not difficult or time consuming. Once safe access has been achieved, the other trocar sites were positioned to avoid adhesions and to provide an optimal dissection plane for the gallbladder under the laparoscopic view. Therefore, the need for adhesiolysis could be minimized, and time and effort were saved. The operative time tended to be shorter in the SALC group, although this did not reach statistical significance. A counterargument could be made regarding the efficacy of the SALC considering the surgeon’s ergonomic problems. The lateral trocar tended to be located more laterally in the SALC group than it was in the conventional LC group. This increased the surgeon’s range of motion, particularly in the upper arms, making dissection inconvenient when compared with conventional LC. Laparoscopic surgery typically requires wide movement of the left arm and shoulder, and one study reported that the left shoulder seemed to maintain a greater angle of flexion and abduction compared with the right in the laparoscopic surgery.16 In SALC, the lateral trocar site, usually used in traction of the gallbladder, could be placed at the surgeon’s discretion, considering the anatomy and avoidance of adhesions. SALC was undeterred by the conventional location of the trocars; therefore it is necessary for a surgeon to be experienced with LC. In conclusion, patients in the SALC group demonstrated significantly shorter postoperative hospital stays and shorter operation times compared with the conventional LC group. SALC is a safe and effective procedure for patients with previous midline incisions that helps prevent unnecessary adhesiolysis and provides relatively safe and easy introduction of trocars into the abdomen.
845
5. 6. 7. 8. 9. 10.
11.
12.
13.
14.
15.
Disclosure Statement
No competing financial interests exist. References
1. Karayiannakis AJ, Polychronidis A, Perente S, Botaitis S, Simopoulos C. Laparoscopic cholecystectomy in patients with previous upper or lower abdominal surgery. Surg Endosc 2004;18:97–101. 2. Suter M, Meyer A. A 10-year experience with the use of laparoscopic cholecystectomy for acute cholecystitis: Is it safe? Surg Endosc 2001;15:1187–1192. 3. Schirmer BD, Edge SB, Dix J, Hyser MJ, Hanks JB, Jones RS. Laparoscopic cholecystectomy. Treatment of choice for symptomatic cholelithiasis. Ann Surg 1991;213:665– 676; discussion 677. 4. Frazee RC, Roberts JW, Symmonds R, Snyder SK, Hendricks J, Smith R, Custer MD. What are the contraindica-
16.
tions for laparoscopic cholecystectomy? Am J Surg 1992;164:491–494; discussion 494–495. Sasaki A, Nakajima J, Nitta H, Obuchi T, Baba S, Wakabayashi G. Laparoscopic cholecystectomy in patients with a history of gastrectomy. Surg Today 2008;38:790–794. Choi SB, Han HJ, Kim WB, Song TJ, Choi SY. Subcostal approach laparoscopic cholecystectomy in patients with previous abdominal surgery. ANZ J Surg 2010;80:670. Borzellino G, De Manzoni G, Ricci F. Detection of abdominal adhesions in laparoscopic surgery. A controlled study of 130 cases. Surg Laparosc Endosc 1998;8:273–276. Le VH, Smith DE, Johnson BL. Conversion of laparoscopic to open cholecystectomy in the current era of laparoscopic surgery. Am Surg 2012;78:1392–1395. Lee NW, Collins J, Britt R, Britt LD. Evaluation of preoperative risk factors for converting laparoscopic to open cholecystectomy. Am Surg 2012;78:831–833. Bingener-Casey J, Richards ML, Strodel WE, Schwesinger WH, Sirinek KR. Reasons for conversion from laparoscopic to open cholecystectomy: A 10-year review. J Gastrointest Surg 2002;6:800–805. Robb WB, Falk GA, Larkin JO, Waldron R Jr, Waldron RP. A 10-step intraoperative surgical checklist (ISC) for laparoscopic cholecystectomy—Can it really reduce conversion rates to open cholecystectomy? J Gastrointest Surg 2012;16:1318–1323. Goldstein SL, Matthews BD, Sing RF, Kercher KW, Heniford BT. Lateral approach to laparoscopic cholecystectomy in the previously operated abdomen. J Laparoendosc Adv Surg Tech A 2001;11:183–186. Kolecki RV, Golub RM, Sigel B, Machi J, Kitamura H, Hosokawa T, Justin J, Schwartz J, Zaren HA. Accuracy of viscera slide detection of abdominal wall adhesions by ultrasound. Surg Endosc 1994;8:871–874. Sigel B, Golub RM, Loiacono LA, Parsons RE, Kodama I, Machi J, Justin J, Sachdeva AK, Zaren HA. Technique of ultrasonic detection and mapping of abdominal wall adhesions. Surg Endosc 1991;5:161–165. Sato Y, Ido K, Kumagai M, Isoda N, Hozumi M, Nagamine N, Ono K, Shibusawa H, Togashi K, Sugano K. Laparoscopic adhesiolysis for recurrent small bowel obstruction: Long-term follow-up. Gastrointest Endosc 2001;54:476–479. Szeto GP, Cheng SW, Poon JT, Ting AC, Tsang RC, Ho P. Surgeons’ static posture and movement repetitions in open and laparoscopic surgery. J Surg Res 2012;172:e19–e31.
Address correspondence to: Sae Byeol Choi, MD, PhD Department of Surgery Korea University College of Medicine Korea University Guro Hospital 80, Guro-dong Guro-gu, Seoul Korea E-mail: [email protected]
The Efficacy of Subcostal-Approach Laparoscopic Cholecystectomy in Patients with Previous Midline Incisions: Comparative Analysis with Conventional Laparoscopic Cholecystectomy Sae Byeol Choi, MD, PhD, Hyung Joon Han, MD, PhD, Wan Bae Kim, MD, PhD, Tae Jin Song, MD, PhD, and Sang Yong Choi, MD, PhD
Abstract
Background: In patients with previous abdominal surgery, difficulties in laparoscopic cholecystectomy (LC) are associated with adhesions from the previous surgery. We reported the efficacy of a subcostal-approach LC (SALC) in patients with previous midline incisions. Subjects and Methods: Thirty-five patients with previous upper midline incision who underwent SALC from 2009 to 2013 at Korea University Medical Center (Seoul, Korea) were included. In SALC, a subcostal incision instead of an umbilical one was used to avoid adhesion in the midline scar. We compared the clinical outcomes of SALC with those of conventional LC in patients with previous midline incisions. Results: In the SALC group, there were 25 men and 10 women. The mean age was 64 years. Median operative time was 60 minutes, and the median length of postoperative hospital stay was 2 days. Most of the patients underwent three-port cholecystectomy. Three patients underwent conversion to open surgery. The SALC group had a significantly shorter postoperative hospital stay and shorter operation time compared with the conventional LC (with supraumbilical incision) group. Conclusions: SALC is a safe and effective procedure for patients who have had a previous midline incision that can help prevent unnecessary adhesiolysis.
Introduction
T
he indications for laparoscopic surgery have been expanded because of the development of endoscopic instruments as well as an increase in surgical skill.1,2 Laparoscopic cholecystectomy (LC) is the gold standard in the surgical treatment of benign gallbladder disease. In the early days of laparoscopic surgery, a history of open abdominal surgery was considered a relative contraindication for the procedure due to adhesion.3,4 However, by virtue of recent surgical advancements, many surgeons have first attempted laparoscopic surgery in patients with a previous midline incision, and the outcomes were relatively satisfactory.1,5 The most difficult part of a laparoscopic operation in patients with previous abdominal surgery is usually related to insertion of the first trocar. Because adhesions are usually expected around the previous midline incision site, we selected a subcostal incision rather than a supraumbilical incision to avoid any adhesions formed by previous operations
as much as possible and reported our experience of subcostalapproach LC (SALC) in patients with previous midline incision.6 Since then, we have performed SALC for benign gallbladder disease in patients who had a history of operation, particularly those with midline incisions. The aim of this study was to investigate the surgical outcomes of SALC and also to evaluate the efficacy of SALC compared with conventional LC in patients with previous midline incisions. Subjects and Methods
We performed SALC in 35 patients with a history of previous operation for benign gallbladder diseases at Korea University Medical Center (Seoul, Korea) between May 2009 and March 2013. We investigated the surgical outcomes of SALC. In order to compare the efficacy of SALC with conventional LC or open cholecystectomy, we included 21 patients who underwent conventional LC for gallbladder disease between 2006 and 2010 at Korea University Medical
Department of Surgery, Korea University College of Medicine, Seoul, Korea.
842
EFFICACY OF SUBCOSTAL-APPROACH LC
Center who also had had a history of gastrectomy with a midline incision. Conventional LC is a three- or four-port technique using a supraumbilical incision for insertion of the trocar. In brief, SALC was performed using a three-port technique. A 1.5-cm subcostal incision was made 2 cm below the costal margin using an open method. Each layer of muscle and fascia was dissected bluntly using a Kelly clamp, and the peritoneum was opened under direct vision. A 30 right-up and head-up position was used, similar to conventional LC. Under camera guidance to avoid adhesions, two additional 5-mm incisions were made at the epigastric and right lateral areas crossing the anterior axillary and subcostal lines. The right lateral trocar is used for traction of the gallbladder. The main dissection is done using an epigastric trocar (Figs. 1 and 2). The following patient demographics and clinical information were retrospectively obtained from the medical records: age, gender, body mass index, comorbidities, American Society of Anesthesiologists class (www.asahq.org/clinical/physicalstatus .htm), time interval from cholecystectomy to previous operation, information about the previous surgery, operative time, conversion to open surgery, postoperative complications, length of hospital stay, and pathological results. Data were expressed as mean – standard deviation values or medians with 25th and 75th percentiles for continuous variables. Statistical calculations were performed using IBM (Armonk, NY) SPSS Statistics version 20 software. For categorical variables, comparisons between groups were tested using the Pearson chi-squared test. Comparing continuous variables for two groups, we used the independentsamples t test for variables that were normally distributed and the Mann–Whitney U test for variables that were not
843
normally distributed. A value of P < .05 was considered statistically significant. Results Clinical characteristics of the 35 patients who underwent SALC
There were 10 women and 25 men with a mean age of 64 years. Mean body mass index was 22.7 – 4.1 kg/m2. Twelve patients had comorbidities: hypertension (n = 8), myocardial infarction or angina (n = 2), arrhythmia (n = 2), diabetes mellitus (n = 3), chronic kidney disease (n = 2), and aplastic anemia (n = 1). The median interval from previous operation to SALC was 11 years, with a range of 1 to 50 years. The previous operative procedures included gastrectomy (n = 17), explorative laparotomy (n = 8), small bowel segmental resection (n = 3), small bowel primary repair (n = 3), colon anterior resection (n = 3), and right hemicolectomy (n = 1). Most of the SALC procedures were performed using three ports; however, 3 patients required an additional port for safe dissection, for a total of four ports. Comparisons of the clinical characteristics between the SALC and conventional LC groups
There was no statistically significant difference in age, sex, body mass index, American Society of Anesthesiologists class, conversion to open surgery, or presence of inflammation (combining cholecystitis) between the two groups. However, the conventional LC group had both a longer operative time (P = .075) and a longer postoperative hospital stay (P < .001) than the SALC group. There was no
FIG. 1. (A) Trocar position in subcostal-approach laparoscopic cholecystectomy. (B) Adhesion in the previous midline incision, seen from the camera through the subcostal trocar. (C and D) Operative view and dissection during subcostalapproach laparoscopic cholecystectomy.
844
CHOI ET AL.
Table 1. Comparative Analysis of the Subcostal-Approach Laparoscopic Cholecystectomy Group with the Conventional Laparoscopic Cholecystectomy Group Factor
FIG. 2. Postoperative scar in subcostal-approach laparoscopic cholecystectomy.
statistically significant difference in the occurrence of complications between the two groups (Table 1). Three patients in the SALC group required conversion to open surgery, compatible with a conversion rate of 9%, because of severe adhesion around the gallbladder (n = 2) and difficulties in dissecting the cystic duct and common bile duct junction due to fibrotic tissue. In the conventional LC group, 5 of the 21 patients required conversion to open surgery because of severe adhesion around the previous incision and gallbladder, consistent with a conversion rate of 24%. Postoperative complications developed in 2 patients in the SALC group and 2 in the conventional LC group. In the SALC group, cardiac angina and common bile duct stone after LC developed in 1 patient each. However, in the conventional LC group, 1 patient developed an intraabdominal abscess requiring percutaneous drainage, and another patient had a stricture in the common bile duct after operation, which required re-exploration with T-tube insertion. There was no postoperative mortality in either group. Discussion
We performed SALC with acceptable morbidity and conversion rates compared with conventional LC in patients with previous midline incisions. We used a subcostal incision rather than an umbilical one for insertion of the camera to avoid adhesions and adhesiolysis during LC. In the early laparoscopic era, severe adhesions around the operative scar often led to conversion to open surgery during LC.4,7 However, because of advances in surgical technique, adhesions may less frequently be a contraindication for laparoscopic surgery.1,5 During LC, the main reasons for conversion to open surgery were inflammation, adhesions, anatomical difficulty, and complications such as bleeding.8–10 The conversion rate for the conventional LC group in patients with a previous midline incision was reported to be 19% in a study published in the 1990s.1 In another study, the conversion rate of the
Age (years) Sex Female Male BMI (kg/m2) ASA class I II III Conversion to open surgery No Yes Cholecystitis No Yes Operative time (minutes) Hospital stay (days) Complication No Yes
Conventional SALC LC (n = 21) (n = 35) P value 63 – 12
64 – 12
8 13 22.8 – 2.5
10 25 22.7 – 4.1
8 11 2
7 26 2
.776 .460 .904 .244
.115 16 5 0 21 93 – 57 6 (3.5–8.5) 19 2
32 3 3 .168 32 72 – 34 .075 2 (2–5) < .001 33 2
.592
Data are mean – standard deviation values, number of patients, or median (range) as indicated. ASA, American Society of Anesthesiologists; BMI, body mass index; LC, laparoscopic cholecystectomy; SALC, subcostal-approach laparoscopic cholecystectomy.
previous abdominal surgery was 5.7% between 2004 and 2008.11 The conversion rate reported in the literature ranged from 2.2% to 5.2%8,10,11 in patients who underwent LC. In the current study, the conversion rates for SALC and conventional LC were 9% and 24%, respectively, although this difference did not reach statistical significance. In one study,12 the lateral-approach LC, in which patients were placed in a modified left lateral decubitus position and subcostal trocars were used, was reported to be safe and effective in patients with previous midline incisions. We placed the patient in a supine position and tilted the table similar to the procedure of conventional LC, which eliminates the inconvenience of changing the patient’s position. There were several efforts in the 1990s to detect the presence or degree of adhesion to the abdominal wall in patients with a history of previous laparotomy.13,14 Viscera slide is detected by ultrasonographic measurement of the movement of the abdominal viscera during deep respiration. A positive viscera slide sign means that viscera restricted by an adhesion to the abdominal wall are characterized by a shorter excursion of viscera (no movement or angular movement) during deep diaphragm respiration.13,14 Several authors reported the efficacy of the viscera slide sign in guiding trocar insertion in laparoscopic surgery, preventing injuries during the creation of the pneumoperitoneum.7,13 However, a recent lack of evidence shows that this measure is not used widely; initial trocar insertion avoiding the previous scars might be an alternative.
EFFICACY OF SUBCOSTAL-APPROACH LC
Access to the abdominal cavity by blind technique using a Veress needle has been reported to be safe1,15 in patients with previous incisions; however, our preference is the open (Hasson) technique in patients with a history of previous operation. Similarly, in the SALC group, the initial subcostal trocar site was established with an open method under direct vision and was not difficult or time consuming. Once safe access has been achieved, the other trocar sites were positioned to avoid adhesions and to provide an optimal dissection plane for the gallbladder under the laparoscopic view. Therefore, the need for adhesiolysis could be minimized, and time and effort were saved. The operative time tended to be shorter in the SALC group, although this did not reach statistical significance. A counterargument could be made regarding the efficacy of the SALC considering the surgeon’s ergonomic problems. The lateral trocar tended to be located more laterally in the SALC group than it was in the conventional LC group. This increased the surgeon’s range of motion, particularly in the upper arms, making dissection inconvenient when compared with conventional LC. Laparoscopic surgery typically requires wide movement of the left arm and shoulder, and one study reported that the left shoulder seemed to maintain a greater angle of flexion and abduction compared with the right in the laparoscopic surgery.16 In SALC, the lateral trocar site, usually used in traction of the gallbladder, could be placed at the surgeon’s discretion, considering the anatomy and avoidance of adhesions. SALC was undeterred by the conventional location of the trocars; therefore it is necessary for a surgeon to be experienced with LC. In conclusion, patients in the SALC group demonstrated significantly shorter postoperative hospital stays and shorter operation times compared with the conventional LC group. SALC is a safe and effective procedure for patients with previous midline incisions that helps prevent unnecessary adhesiolysis and provides relatively safe and easy introduction of trocars into the abdomen.
845
5. 6. 7. 8. 9. 10.
11.
12.
13.
14.
15.
Disclosure Statement
No competing financial interests exist. References
1. Karayiannakis AJ, Polychronidis A, Perente S, Botaitis S, Simopoulos C. Laparoscopic cholecystectomy in patients with previous upper or lower abdominal surgery. Surg Endosc 2004;18:97–101. 2. Suter M, Meyer A. A 10-year experience with the use of laparoscopic cholecystectomy for acute cholecystitis: Is it safe? Surg Endosc 2001;15:1187–1192. 3. Schirmer BD, Edge SB, Dix J, Hyser MJ, Hanks JB, Jones RS. Laparoscopic cholecystectomy. Treatment of choice for symptomatic cholelithiasis. Ann Surg 1991;213:665– 676; discussion 677. 4. Frazee RC, Roberts JW, Symmonds R, Snyder SK, Hendricks J, Smith R, Custer MD. What are the contraindica-
16.
tions for laparoscopic cholecystectomy? Am J Surg 1992;164:491–494; discussion 494–495. Sasaki A, Nakajima J, Nitta H, Obuchi T, Baba S, Wakabayashi G. Laparoscopic cholecystectomy in patients with a history of gastrectomy. Surg Today 2008;38:790–794. Choi SB, Han HJ, Kim WB, Song TJ, Choi SY. Subcostal approach laparoscopic cholecystectomy in patients with previous abdominal surgery. ANZ J Surg 2010;80:670. Borzellino G, De Manzoni G, Ricci F. Detection of abdominal adhesions in laparoscopic surgery. A controlled study of 130 cases. Surg Laparosc Endosc 1998;8:273–276. Le VH, Smith DE, Johnson BL. Conversion of laparoscopic to open cholecystectomy in the current era of laparoscopic surgery. Am Surg 2012;78:1392–1395. Lee NW, Collins J, Britt R, Britt LD. Evaluation of preoperative risk factors for converting laparoscopic to open cholecystectomy. Am Surg 2012;78:831–833. Bingener-Casey J, Richards ML, Strodel WE, Schwesinger WH, Sirinek KR. Reasons for conversion from laparoscopic to open cholecystectomy: A 10-year review. J Gastrointest Surg 2002;6:800–805. Robb WB, Falk GA, Larkin JO, Waldron R Jr, Waldron RP. A 10-step intraoperative surgical checklist (ISC) for laparoscopic cholecystectomy—Can it really reduce conversion rates to open cholecystectomy? J Gastrointest Surg 2012;16:1318–1323. Goldstein SL, Matthews BD, Sing RF, Kercher KW, Heniford BT. Lateral approach to laparoscopic cholecystectomy in the previously operated abdomen. J Laparoendosc Adv Surg Tech A 2001;11:183–186. Kolecki RV, Golub RM, Sigel B, Machi J, Kitamura H, Hosokawa T, Justin J, Schwartz J, Zaren HA. Accuracy of viscera slide detection of abdominal wall adhesions by ultrasound. Surg Endosc 1994;8:871–874. Sigel B, Golub RM, Loiacono LA, Parsons RE, Kodama I, Machi J, Justin J, Sachdeva AK, Zaren HA. Technique of ultrasonic detection and mapping of abdominal wall adhesions. Surg Endosc 1991;5:161–165. Sato Y, Ido K, Kumagai M, Isoda N, Hozumi M, Nagamine N, Ono K, Shibusawa H, Togashi K, Sugano K. Laparoscopic adhesiolysis for recurrent small bowel obstruction: Long-term follow-up. Gastrointest Endosc 2001;54:476–479. Szeto GP, Cheng SW, Poon JT, Ting AC, Tsang RC, Ho P. Surgeons’ static posture and movement repetitions in open and laparoscopic surgery. J Surg Res 2012;172:e19–e31.
Address correspondence to: Sae Byeol Choi, MD, PhD Department of Surgery Korea University College of Medicine Korea University Guro Hospital 80, Guro-dong Guro-gu, Seoul Korea E-mail: [email protected]
