Surg Endosc DOI 10.1007/s00464-016-4802-4
and Other Interventional Techniques
Tips and tricks to avoid bile duct injury in SILC: an experience of 500 cases Tony Li1 • Guowei Kim2 • Stephen Chang3
Received: 5 November 2015 / Accepted: 3 February 2016 Ó Springer Science+Business Media New York 2016
Abstract Introduction Conventional laparoscopic cholecystectomy is the gold standard surgical treatment for symptomatic gallstones. Surgeons have attempted to minimize the number of incisions via single-incision laparoscopic cholecystectomy (SILC), which offers benefits including improved cosmesis, possibly less postoperative pain, and improved patient satisfaction. However, studies show that there is an increased risk of operative complications—in particular bile duct injuries. We report 500 consecutive cases of SILC performed without bile duct injury. Methods A retrospective study of 500 continuous cases of SILC performed by the same surgeon at a single institution was conducted. Data on patient demographics, operative details, and postoperative outcomes were collected and evaluated. Detailed analysis of surgical techniques specifically to reduce bile duct injury was performed and described in this study. Results In total, 500 patients underwent SILC during the study period. Eight patients needed additional ports to complete the surgery, while one was converted to an open surgery. No serious intraoperative complications, such as bile duct injury, were encountered.
& Stephen Chang [email protected] 1
Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
2
Department of Surgery, National University Hospital, Singapore, Singapore
3
Division of Hepatobiliary and Pancreatic Surgery and Liver Transplant Program, University Surgical Cluster, National University Hospital, 1E Kent Ridge Road, Singapore 119228, Singapore
Conclusion Our experience shows that with due care and caution during SILC, with particular attention towards achieving the critical view of safety and a standardized technique, bile duct injury in SILC can be avoided. Keywords Single-incision laparoscopic surgery Cholecystectomy Bile duct injury Since laparoscopic cholecystectomy was first described in 1985, the development of laparoscopic technology and technique has revolutionized surgery. Laparoscopic procedures have been shown to result in less postoperative pain, faster recovery, and better cosmesis as compared to open surgery [1]. Today, novel methods are being pioneered to further capitalize upon these advantages by reducing the number of incisions, such as in single-incision laparoscopic surgeries [2, 3]. Single-incision laparoscopic cholecystectomy (SILC) is usually performed through a single incision at the umbilicus, which heals into a scar similar to its original appearance [4, 5]. Such a technique offers advantages including better cosmesis, and possibly less postoperative pain, faster recovery, and improved patient satisfaction [6]. While SILC remains a relatively new technique, there has been strong enthusiasm among surgeons for its application. Reports of SILC have shown it to be feasible and associated with outcomes similar to conventional laparoscopic cholecystectomy (CLC) [7, 8]. However, as with any new technique, it is crucial to critically evaluate the safety profile of SILC. For cholecystectomy, bile duct injury is one of the most feared complications and is associated with significant perioperative morbidity, mortality, reduced long-term survival, and quality of life [9, 10]. Despite the excellent functional and
123
Surg Endosc
anatomical results that can be achieved by early identification and appropriate primary repair, prevention is ultimately preferable to remediation [11, 12]. During the transition from open to laparoscopic cholecystectomy, there was a sharp increase in the incidence of bile duct injuries from 0.2 to 2.8 % [13]. A similar trend is seen in the early adoption of SILC with the incidence of bile duct injury reportedly as high as 0.72 % [14, 15]. This has led to some apprehension towards SILC in the surgical community due to fear for patient safety. This study presents a series of 500 consecutive SILCs performed by a single surgeon at a single institution of which there was no incidence of bile duct injury. This demonstrates that SILC can be performed safely using modified techniques that minimize the risk of bile duct injury.
Materials and methods A retrospective review of prospectively collected data was carried out for patients who had underwent SILC at the National University Hospital (NUH), Singapore, since its first introduction in April 2009 to August 2015. All procedures were performed by the same surgeon. Data analysed included patient demographics (i.e. age, gender, and body mass index), operative findings, and complications (Table 1). Surgical method The patient was placed in a French position. The surgeon stands between the legs of the patient, while the assistant sits on the left side. The assistant would be seated while operating the camera to offer maximum space to the surgeon for instrument manipulation (see Fig. 1). The abdomen is entered via a transumbilical incision of 15 mm, and a multiport device is utilized to introduce the various instruments. The OlympusÒ 5 mm 30° Laparoscope Endoeye is used in our experience. The telescope should be placed in the most dependent position, with the instruments Table 1 Patient demographics for SILC General Number of procedures
500
Average age (years)
49.71 ± 14.06
Average height (cm)
(20 - 87) 160.9 ± 8.2
Average weight (kg)
65.03 ± 13.53
(136 - 182) (35 - 130) Average body mass index (kg/m2)
25.23 ± 4.62 (15.14 - 46.81)
123
Fig. 1 Photographs showing the position of surgeon and assistant in SILC
superior to the camera and introduced at varying depths to avoid clashing. In the first 50 patients, the Covidien SILSTM Port was utilized. Subsequently, so as to reduce the cost of the procedure for the patient, a self-made glove-in-port device was utilized to introduce the multiple instruments. The posterior–lateral peritoneum of the gallbladder is first judiciously dissected with hook cautery to free the gallbladder on the lateral aspect. This allows for subsequent lateral retraction of the gallbladder more liberally to better expose the Calot’s triangle anterior-medially. When manipulating the instruments, they should be crossed inside the abdomen, ensuring that the distance between the crossing point and surgeon’s hand is greater than the distance between the crossing point and the effector end (see Fig. 2). This is to reduce the chance of hand clashing and allow for finer control of the effector ends of the dissecting instruments. To expose the anterior–medial aspect of the Calot’s triangle, the assistant sitting in front of the surgeon then holds the grasping forceps to grasp the infundibulum of the gallbladder and swings it lateral. The surgeon then proceeds to dissect the cystic duct and artery free of the underlying fat and connective tissue. During dissection, the surgeon should operate both the camera and dissecting instrument in a ‘‘snooker cue guide technique’’ to allow him to maintain the field of vision as he requires (see Fig. 3A). Furthermore, instruments are held in a reverse grip with the handles pointing upwards so as to reduce
Surg Endosc
Fig. 2 Diagram showing instrument crossing in SILC. In A, crossing of instruments occurs outside the abdomen and the effector ends are further from the fulcrum, leading to more drastic movements at the effector ends. In B which is the technique adopted in SILC, the instruments cross only in the abdomen such that the effector ends are closer to the fulcrum allowing for finer control of their movements
clashing with the other hand and instrument (see Fig. 3B). Similarly, the assistant should hold instruments with the handles pointing laterally to avoid clashing with the surgeon (see Fig. 3C). After isolation, the cystic duct and artery are clipped using 5-mm Hem-o-lok clip (Weck Closure Systems, Research Triangle Park, NC) and the cystic duct and artery are divided using scissors. The gallbladder is then dissected free of the liver bed with hook cautery. Haemostasis is ensured, and the surgical field was washed out and all fluids aspirated. The gallbladder is finally removed via the umbilical port in a retrieval bag, and the abdomen is closed with two figure-of-eight knots.
Results During the study period, 500 consecutive SILCs were successfully performed, consisting of 195 male and 305 female patients. All patients who required a cholecystectomy were
offered the option of SILC. Exclusion criteria included suspicions of a perforated gallbladder. The mean age was 49.7 ± 14.1 years old, and mean body mass index (BMI) was 25.2 ± 4.6 kg/m2. The final histological diagnoses were also recorded where 92.0 % of the patients had a diagnoses of chronic cholecystitis, 6.6 % of the patients had acute cholecystitis, while the remaining 1.4 % had other histological findings such as malignancy. The average length of surgery was 50.16 min. Nine cases (1.80 %) required additional ports or conversion to open surgery. The reasons for conversion are presented in Table 2. No significant postoperative complications were reported by the patients, and most were discharged well and ambulant on the same day as surgery with an average admission period of 1.65 days (range 1–6). There was no incidence of bile duct injury in all 500 cases of SILC performed. On follow-up, of all the SILC cases performed, 4 (0.8 %) developed incisional hernia necessitating further surgical repair. These 4 cases occurred in the early part of the series where only 1 figure-of-eight knot was used in closing the wound. Subsequently, two figure-of-eight knots were used and there were no further occurrences of incisional hernia.
Discussion When laparoscopic cholecystectomy was first introduced in the 1990s, it was accompanied by an increase in the rate of iatrogenic bile duct injuries. While SILC and CLC are not as drastically different as compared to the shift from open to laparoscopic cholecystectomy, SILC does involve techniques that differ from the classical approaches in conventional laparoscopic surgery. The majority of bile duct injuries in laparoscopic cholecystectomy can be attributed to two main causes (1) misidentification of the local anatomy or (2) technical errors leading to inadvertent injury [16]. The technical challenges in SILC can complicate the procedure and lead to bile duct injury on both counts. Firstly, there is loss of
Fig. 3 Photographs show A snooker cue guide technique, B reverse handle grip position for the surgeon, C lateral handle grip for the assistant
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Surg Endosc Table 2 SILC cases requiring conversion
1
Reason for conversion
Mode of conversion
Acute cholecystitis
Previous abdominal surgery
BMI
Bile leak at the cystic duct stump due to incomplete occlusion by Hem-o-lok
2 9 additional 5 mm port
No
Yes
32.3
2
Dense adhesions at Calot’s triangle
2 9 additional 5 mm port
No
No
28.7
3
Dense adhesions to the omentum
3 9 additional 5 mm port
Yes
No
21.5
4
Gallbladder densely adherent to liver
2 9 additional 5 mm port
No
No
30.2
5
Wide cystic duct requiring retrograde gallbladder dissection for ligation of cystic duct with suture loop
1 9 additional 5 mm port
No
No
24.2
6
Bile leak at the cystic duct stump due to incomplete occlusion by Hem-o-lok
Converted to open cholecystectomy
No
Yes
24.8
7
Thickened inflamed gallbladder with dense adhesions
2 9 additional 5 mm port
Yes
No
26.8
8
Dense adhesions at Calot’s triangle
1 9 additional 5 mm port
No
No
26.8
9
Cystic duct is short and difficult to skeletonize due to adhesions
3 9 additional 5 mm port
Yes
No
34.0
triangulation between the camera and the surgical instruments as the instruments and the camera enter parallel to each other via the same umbilical incision. This parallel instrument alignment means that the operating field can only be approached from one angle which limits the range of dissecting angles. Furthermore, having all the instruments enter through the same incision places all the instruments in close proximity and can cause clashing of the hands holding them. This leads to greater technical difficulty in manoeuvring the instruments which can lead to inadvertent bile duct injury such as in thermal injury by energy devices. The current reported rate of biliary injury in SILC is around 0.7 %, which would mean that an expected 3–4 cases of bile duct injury should have been observed thus far. However, we have not observed any incidence of bile duct injury in our experience. This is achieved by making efforts to overcome the technical challenges faced in SILC and mitigate the risk of bile duct injury. While there have been many reports of the techniques by which SILC can be performed, there have thus far been no reports of the techniques to avoid bile duct injury and improve the safety of the procedure. Firstly efforts are made to reduce the technical challenge of manoeuvring the instruments within the confined space caused by the single port. Firstly, the telescope and laparoscopic instruments are introduced at varying depths and from different angles so as to reduce collision of the hands outside the abdomen during manipulation. In order to maximize working space for the surgeon, the assistant also sits down in front of the surgeon while holding his instrument. This position is comfortable for both surgeon and assistant and allows both an unobstructed view to a single monitor.
123
Crossing of the inserted instruments is also inevitable in SILC, but where and how the instruments are crossed affects the surgery greatly. Crossing the instruments inside the abdomen on the other hand renders the tips of the instruments closer to the fulcrum and allows for much finer control of the instruments at the effector tissue end, especially important for fine dissection at the Calot’s triangle. At the same time, this also allows for the surgeon’s hands controlling the instruments to be further from the abdomen and each other, providing greater manoeuvrability. While crossing the instruments may be difficult in obese patients, this was not experienced in our study as we managed to apply our techniques even in obese patients with a maximum BMI of 45.6. Another key challenge in SILC is the ‘‘in-line’’ view of the instruments towards the field of dissection as both the instrument and the telescope are inserted via the same incision. This ‘‘in-line’’ view is very different from that observed in conventional laparoscopic cholecystectomy. Furthermore, in such a scenario, if the telescope is to be held by the assistant, a lot of coordination will be required between the surgeon and the assistant to ensure minimal hand clashing and yet adequate visualization of the field of dissection. To overcome this, the surgeon can handle both the laparoscopic camera and the dissecting instrument in a ‘‘snooker cue guide technique’’. This will enable the surgeon to better maintain the field of vision just as he requires it. In addition, the handling of the instrument is also different from conventional situations. The instruments are held in a reverse grip with the handles pointing upwards so as to reduce the clashing with the other hand and instrument. This reverse handle grip can be applied to most instruments that are held by the surgeon such as the Hem-
Surg Endosc
Fig. 4 Intraoperative photographs showing A an instrument approaching from superolaterally via the epigastric port to dissect the Calot’s triangle in CLC, B in SILC, the gallbladder is retracted to the left to expose the posterior peritoneum which is dissected to free
the gallbladder from the liver bed (arrow points to the dissection plane). C The gallbladder is retracted to the right to expose the Calot’s triangle for dissection anteriorly by the instrument approaching from the umbilical port
Fig. 5 Intraoperative photographs showing A the skeletonized Calot’s triangle with the exposed cystic artery and duct (indicated by arrows), B the distal end of the Hem-o-lok is not clearly visualized, and it is unclear whether the clip covers the full width of
the cystic duct (arrow points to the distal tip of the Hem-o-lok). C On pulling back the Hem-o-lok, the distal edge of the clip is now visualized and it is sure that the full width of the cystic duct has been occluded (arrow points to the distal tip of the Hem-o-lok)
o-lok applicator and scissors. Similarly, the assistant should hold instruments with the handles pointing laterally to avoid clashing with the surgeon. Misidentification of the local anatomy is the most common reason that can lead to accidental biliary injury. As such, it is crucial to dissect the Calot’s triangle and identify the relevant structures accurately. In CLC, the presence of an epigastric port allows for an instrument approaching superiorly from the left side to dissect the Calot’s triangle anteriorly (see Fig. 4A). In SILC where all the instruments approach the operating field via an inferior umbilical port, this dissecting angle is lost; thus, the Calot’s triangle cannot be effectively dissected. To address this shortcoming, the posterior peritoneum is judiciously dissected to free the gallbladder to allow greater room for lateral retraction to better expose the Calot’s triangle anteriorly for safer dissection (see Fig. 4B, C). In our experience, a common cause for conversion or the need for additional ports is bile leak at the cystic duct
stump, which is commonly due to incomplete occlusion by the Hem-o-lok clip. This is because the clip has not actually fully occluded the width of the cystic duct. This can potentially not be picked up, as the distal end of the clip is difficult to properly visualize in the ‘‘in-line’’ view in SILC. As such, we suggest pulling back on the Hem-o-lok applicator at each application and zooming into better visualize the distal end of the clip before releasing it so as to ensure occlusion of the full width of the cystic duct (see Fig. 5A, B). This helps to avoid subsequent bile leak from the cystic duct stump after dissection. Similar to CLC, it remains important to apply the tenets of the SAGES Safe Cholecystectomy Taskforce [17] so as to avoid the low but real risk of bile duct injury in SILC. It remains crucial to attain the critical view of safety by dissecting Calot’s triangle to expose the cystic duct and artery, with the liver bed exposed to avoid any anatomical misidentification and accidental injury of the bile duct [18]. Although SILC may have technical challenges in terms of
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Surg Endosc
the restricted movements, difficulty achieving triangulation, and inability to change the camera angle, this same standard should still apply. If one is unable to attain the critical view of safety, the surgeon should consider alternatives such as using additional ports or converting to an open procedure. Caution is also taken not to injure the common bile duct during the dissection; for example, the cystic duct is dissected as close to the neck of the gallbladder as possible and away from the hepatic and common bile ducts. The use of cautery is also minimized around these structures. While the surgical techniques presented helped to avoid bile duct injury in our experience, the surgeon’s skill and experience are also important. When laparoscopic cholecystectomy was first adopted, there was a noted spike in the rates of bile duct injury that many attributed to the learning curve [19]. In the current landscape where SILC remains a new procedure requiring training different from conventional laparoscopic procedures, the spike in bile duct injuries can possibly be attributed to a similar effect [20, 21]. Thus, it remains crucial that the surgeon is well trained and experienced in laparoscopic procedures before attempting SILC. Other centres have also suggested the use of articulating instruments or angled cameras to increase the ease of the procedure. It should be noted that the current series presented include all the cases of SILC that have been performed since the procedure was first introduced in our centre in 2009.
Conclusion Our experience shows that with the modified techniques as described above, bile duct injury can be avoided in SILC. Compliance with ethical standards Disclosure Covidien provided the SILSTM Port which was used for the first 50 SILS cases. Mr. Li, Dr. Kim, and Dr. Chang have no conflicts of interest or financial ties to disclose.
References 1. Keus F, de Jong JA, Gooszen HG et al (2006) Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev 4(4):CD006231 2. Markar SR, Karthikesalingam A, Thrumurthy S, Muirhead L, Kinross J, Paraskeva P (2012) Single-incision laparoscopic surgery (SILS) versus conventional multiport cholecystectomy: systematic review and meta-analysis. Surg Endosc 26(5):1205–1213
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3. Allemann P, Schafer M, Demartines N (2010) Critical appraisal of single port access cholecystectomy. Br J Surg 97(10):1476–1480 4. Chang SK, Tan SS, Kok YO (2012) Early experience in singlesite laparoscopic cholecystectomy. Singap Med J 53(6):377–380 5. Bhandarkar D, Mittal G, Shah R, Katara A, Udwadia TE (2011) Single-incision laparoscopic cholecystectomy: How I do it? J Minim Access Surg 7(1):17–23 6. Sajid MS, Ladwa N, Kalra L, Hutson KK, Singh KK, Sayegh M (2012) Single-incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy: meta-analysis and systematic review of randomized controlled trials. World J Surg 36(11):2644–2653 7. Chang SK, Tay CW, Bicol RA, Lee YY, Madhavan K (2011) A case-control study of single-incision versus standard laparoscopic cholecystectomy. World J Surg 35(2):289–293 8. Antoniou SA, Pointner R, Granderath FA (2010) Single-incision laparoscopic cholecystectomy: a systematic review. SurgEndosc 25(2):367–377 9. Connor S (2009) Single-port-access cholecystectomy: history should not be allowed to repeat. World J Surg 33(5):1020–1021 10. Nuzzo G, Giuliante F, Giovannini I et al (2005) Bile duct injury during laparoscopic cholecystectomy: results of an Italian national survey on 56 591 cholecystectomies. Arch Surg 140(10): 986–992 11. Moore DE, Feurer ID, Holzman MD, Wudel LJ, Strickland C, Gorden DL et al (2004) Long–term detrimental effect of bile duct injury on health-related quality of life. Arch Surg 139(5):476–482 12. Connor S, Garden OJ (2006) Bile duct injury in the era of laparoscopic cholecystectomy. Br J Surg 93(2):158–168 13. Richardson MC, Bell G, Fullarton GM (1996) Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: an audit of 5913 cases: West of Scotland Laparoscopic Cholecystectomy Audit Group. Br J Surg 83(10):1356–1360 14. Joseph M, Phillips MR, Farrell TM, Rupp CC (2012) Single incision laparoscopic cholecystectomy is associated with a higher bile duct injury rate: a review and a word of caution. Ann Surg 256(1):1–6 15. Allemann P, Demartines N, Schafer M (2014) Remains of the day: biliary complications related to single-port laparoscopic cholecystectomy. World J Gastroenterol 20(3):843–851 16. Malla S (2012) Prevention of Common Bile Duct injuries in laparoscopic cholecystectomy. World J Lap Surg 5(1):27–32 17. Pucher PH, Brunt LM, Fanelli RD, Asbun HJ, Aggarwal R (2015) SAGES expert Delphi consensus: critical factors for safe surgical practice in laparoscopic cholecystectomy. Surg Endosc 29(11): 3074–3085 18. Strasberg SM (2002) Avoidance of biliary injury during laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg 9(5): 543–547 19. Russell JC, Walsh SJ, Mattie AS, Lynch JT (1996) Bile duct injuries, 1989–1993: a statewide experience: Connecticut Laparoscopic Cholecystectomy Registry. Arch Surg 131(4):382–388 20. Lau KN, Sindram D, Agee N, Martinie JB, Iannitti DA (2010) Bile duct injury after single incision laparoscopic cholecystectomy. JSLS 14(4):587–591 21. Kameyama N, Miyata R, Tomita M, Mitsuhashi H, Baba S, Imai S (2014) Tips for single-port laparoscopic cholecystectomy. J Hepatobiliary Pancreat Sci 21(7):E48–E52
and Other Interventional Techniques
Tips and tricks to avoid bile duct injury in SILC: an experience of 500 cases Tony Li1 • Guowei Kim2 • Stephen Chang3
Received: 5 November 2015 / Accepted: 3 February 2016 Ó Springer Science+Business Media New York 2016
Abstract Introduction Conventional laparoscopic cholecystectomy is the gold standard surgical treatment for symptomatic gallstones. Surgeons have attempted to minimize the number of incisions via single-incision laparoscopic cholecystectomy (SILC), which offers benefits including improved cosmesis, possibly less postoperative pain, and improved patient satisfaction. However, studies show that there is an increased risk of operative complications—in particular bile duct injuries. We report 500 consecutive cases of SILC performed without bile duct injury. Methods A retrospective study of 500 continuous cases of SILC performed by the same surgeon at a single institution was conducted. Data on patient demographics, operative details, and postoperative outcomes were collected and evaluated. Detailed analysis of surgical techniques specifically to reduce bile duct injury was performed and described in this study. Results In total, 500 patients underwent SILC during the study period. Eight patients needed additional ports to complete the surgery, while one was converted to an open surgery. No serious intraoperative complications, such as bile duct injury, were encountered.
& Stephen Chang [email protected] 1
Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
2
Department of Surgery, National University Hospital, Singapore, Singapore
3
Division of Hepatobiliary and Pancreatic Surgery and Liver Transplant Program, University Surgical Cluster, National University Hospital, 1E Kent Ridge Road, Singapore 119228, Singapore
Conclusion Our experience shows that with due care and caution during SILC, with particular attention towards achieving the critical view of safety and a standardized technique, bile duct injury in SILC can be avoided. Keywords Single-incision laparoscopic surgery Cholecystectomy Bile duct injury Since laparoscopic cholecystectomy was first described in 1985, the development of laparoscopic technology and technique has revolutionized surgery. Laparoscopic procedures have been shown to result in less postoperative pain, faster recovery, and better cosmesis as compared to open surgery [1]. Today, novel methods are being pioneered to further capitalize upon these advantages by reducing the number of incisions, such as in single-incision laparoscopic surgeries [2, 3]. Single-incision laparoscopic cholecystectomy (SILC) is usually performed through a single incision at the umbilicus, which heals into a scar similar to its original appearance [4, 5]. Such a technique offers advantages including better cosmesis, and possibly less postoperative pain, faster recovery, and improved patient satisfaction [6]. While SILC remains a relatively new technique, there has been strong enthusiasm among surgeons for its application. Reports of SILC have shown it to be feasible and associated with outcomes similar to conventional laparoscopic cholecystectomy (CLC) [7, 8]. However, as with any new technique, it is crucial to critically evaluate the safety profile of SILC. For cholecystectomy, bile duct injury is one of the most feared complications and is associated with significant perioperative morbidity, mortality, reduced long-term survival, and quality of life [9, 10]. Despite the excellent functional and
123
Surg Endosc
anatomical results that can be achieved by early identification and appropriate primary repair, prevention is ultimately preferable to remediation [11, 12]. During the transition from open to laparoscopic cholecystectomy, there was a sharp increase in the incidence of bile duct injuries from 0.2 to 2.8 % [13]. A similar trend is seen in the early adoption of SILC with the incidence of bile duct injury reportedly as high as 0.72 % [14, 15]. This has led to some apprehension towards SILC in the surgical community due to fear for patient safety. This study presents a series of 500 consecutive SILCs performed by a single surgeon at a single institution of which there was no incidence of bile duct injury. This demonstrates that SILC can be performed safely using modified techniques that minimize the risk of bile duct injury.
Materials and methods A retrospective review of prospectively collected data was carried out for patients who had underwent SILC at the National University Hospital (NUH), Singapore, since its first introduction in April 2009 to August 2015. All procedures were performed by the same surgeon. Data analysed included patient demographics (i.e. age, gender, and body mass index), operative findings, and complications (Table 1). Surgical method The patient was placed in a French position. The surgeon stands between the legs of the patient, while the assistant sits on the left side. The assistant would be seated while operating the camera to offer maximum space to the surgeon for instrument manipulation (see Fig. 1). The abdomen is entered via a transumbilical incision of 15 mm, and a multiport device is utilized to introduce the various instruments. The OlympusÒ 5 mm 30° Laparoscope Endoeye is used in our experience. The telescope should be placed in the most dependent position, with the instruments Table 1 Patient demographics for SILC General Number of procedures
500
Average age (years)
49.71 ± 14.06
Average height (cm)
(20 - 87) 160.9 ± 8.2
Average weight (kg)
65.03 ± 13.53
(136 - 182) (35 - 130) Average body mass index (kg/m2)
25.23 ± 4.62 (15.14 - 46.81)
123
Fig. 1 Photographs showing the position of surgeon and assistant in SILC
superior to the camera and introduced at varying depths to avoid clashing. In the first 50 patients, the Covidien SILSTM Port was utilized. Subsequently, so as to reduce the cost of the procedure for the patient, a self-made glove-in-port device was utilized to introduce the multiple instruments. The posterior–lateral peritoneum of the gallbladder is first judiciously dissected with hook cautery to free the gallbladder on the lateral aspect. This allows for subsequent lateral retraction of the gallbladder more liberally to better expose the Calot’s triangle anterior-medially. When manipulating the instruments, they should be crossed inside the abdomen, ensuring that the distance between the crossing point and surgeon’s hand is greater than the distance between the crossing point and the effector end (see Fig. 2). This is to reduce the chance of hand clashing and allow for finer control of the effector ends of the dissecting instruments. To expose the anterior–medial aspect of the Calot’s triangle, the assistant sitting in front of the surgeon then holds the grasping forceps to grasp the infundibulum of the gallbladder and swings it lateral. The surgeon then proceeds to dissect the cystic duct and artery free of the underlying fat and connective tissue. During dissection, the surgeon should operate both the camera and dissecting instrument in a ‘‘snooker cue guide technique’’ to allow him to maintain the field of vision as he requires (see Fig. 3A). Furthermore, instruments are held in a reverse grip with the handles pointing upwards so as to reduce
Surg Endosc
Fig. 2 Diagram showing instrument crossing in SILC. In A, crossing of instruments occurs outside the abdomen and the effector ends are further from the fulcrum, leading to more drastic movements at the effector ends. In B which is the technique adopted in SILC, the instruments cross only in the abdomen such that the effector ends are closer to the fulcrum allowing for finer control of their movements
clashing with the other hand and instrument (see Fig. 3B). Similarly, the assistant should hold instruments with the handles pointing laterally to avoid clashing with the surgeon (see Fig. 3C). After isolation, the cystic duct and artery are clipped using 5-mm Hem-o-lok clip (Weck Closure Systems, Research Triangle Park, NC) and the cystic duct and artery are divided using scissors. The gallbladder is then dissected free of the liver bed with hook cautery. Haemostasis is ensured, and the surgical field was washed out and all fluids aspirated. The gallbladder is finally removed via the umbilical port in a retrieval bag, and the abdomen is closed with two figure-of-eight knots.
Results During the study period, 500 consecutive SILCs were successfully performed, consisting of 195 male and 305 female patients. All patients who required a cholecystectomy were
offered the option of SILC. Exclusion criteria included suspicions of a perforated gallbladder. The mean age was 49.7 ± 14.1 years old, and mean body mass index (BMI) was 25.2 ± 4.6 kg/m2. The final histological diagnoses were also recorded where 92.0 % of the patients had a diagnoses of chronic cholecystitis, 6.6 % of the patients had acute cholecystitis, while the remaining 1.4 % had other histological findings such as malignancy. The average length of surgery was 50.16 min. Nine cases (1.80 %) required additional ports or conversion to open surgery. The reasons for conversion are presented in Table 2. No significant postoperative complications were reported by the patients, and most were discharged well and ambulant on the same day as surgery with an average admission period of 1.65 days (range 1–6). There was no incidence of bile duct injury in all 500 cases of SILC performed. On follow-up, of all the SILC cases performed, 4 (0.8 %) developed incisional hernia necessitating further surgical repair. These 4 cases occurred in the early part of the series where only 1 figure-of-eight knot was used in closing the wound. Subsequently, two figure-of-eight knots were used and there were no further occurrences of incisional hernia.
Discussion When laparoscopic cholecystectomy was first introduced in the 1990s, it was accompanied by an increase in the rate of iatrogenic bile duct injuries. While SILC and CLC are not as drastically different as compared to the shift from open to laparoscopic cholecystectomy, SILC does involve techniques that differ from the classical approaches in conventional laparoscopic surgery. The majority of bile duct injuries in laparoscopic cholecystectomy can be attributed to two main causes (1) misidentification of the local anatomy or (2) technical errors leading to inadvertent injury [16]. The technical challenges in SILC can complicate the procedure and lead to bile duct injury on both counts. Firstly, there is loss of
Fig. 3 Photographs show A snooker cue guide technique, B reverse handle grip position for the surgeon, C lateral handle grip for the assistant
123
Surg Endosc Table 2 SILC cases requiring conversion
1
Reason for conversion
Mode of conversion
Acute cholecystitis
Previous abdominal surgery
BMI
Bile leak at the cystic duct stump due to incomplete occlusion by Hem-o-lok
2 9 additional 5 mm port
No
Yes
32.3
2
Dense adhesions at Calot’s triangle
2 9 additional 5 mm port
No
No
28.7
3
Dense adhesions to the omentum
3 9 additional 5 mm port
Yes
No
21.5
4
Gallbladder densely adherent to liver
2 9 additional 5 mm port
No
No
30.2
5
Wide cystic duct requiring retrograde gallbladder dissection for ligation of cystic duct with suture loop
1 9 additional 5 mm port
No
No
24.2
6
Bile leak at the cystic duct stump due to incomplete occlusion by Hem-o-lok
Converted to open cholecystectomy
No
Yes
24.8
7
Thickened inflamed gallbladder with dense adhesions
2 9 additional 5 mm port
Yes
No
26.8
8
Dense adhesions at Calot’s triangle
1 9 additional 5 mm port
No
No
26.8
9
Cystic duct is short and difficult to skeletonize due to adhesions
3 9 additional 5 mm port
Yes
No
34.0
triangulation between the camera and the surgical instruments as the instruments and the camera enter parallel to each other via the same umbilical incision. This parallel instrument alignment means that the operating field can only be approached from one angle which limits the range of dissecting angles. Furthermore, having all the instruments enter through the same incision places all the instruments in close proximity and can cause clashing of the hands holding them. This leads to greater technical difficulty in manoeuvring the instruments which can lead to inadvertent bile duct injury such as in thermal injury by energy devices. The current reported rate of biliary injury in SILC is around 0.7 %, which would mean that an expected 3–4 cases of bile duct injury should have been observed thus far. However, we have not observed any incidence of bile duct injury in our experience. This is achieved by making efforts to overcome the technical challenges faced in SILC and mitigate the risk of bile duct injury. While there have been many reports of the techniques by which SILC can be performed, there have thus far been no reports of the techniques to avoid bile duct injury and improve the safety of the procedure. Firstly efforts are made to reduce the technical challenge of manoeuvring the instruments within the confined space caused by the single port. Firstly, the telescope and laparoscopic instruments are introduced at varying depths and from different angles so as to reduce collision of the hands outside the abdomen during manipulation. In order to maximize working space for the surgeon, the assistant also sits down in front of the surgeon while holding his instrument. This position is comfortable for both surgeon and assistant and allows both an unobstructed view to a single monitor.
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Crossing of the inserted instruments is also inevitable in SILC, but where and how the instruments are crossed affects the surgery greatly. Crossing the instruments inside the abdomen on the other hand renders the tips of the instruments closer to the fulcrum and allows for much finer control of the instruments at the effector tissue end, especially important for fine dissection at the Calot’s triangle. At the same time, this also allows for the surgeon’s hands controlling the instruments to be further from the abdomen and each other, providing greater manoeuvrability. While crossing the instruments may be difficult in obese patients, this was not experienced in our study as we managed to apply our techniques even in obese patients with a maximum BMI of 45.6. Another key challenge in SILC is the ‘‘in-line’’ view of the instruments towards the field of dissection as both the instrument and the telescope are inserted via the same incision. This ‘‘in-line’’ view is very different from that observed in conventional laparoscopic cholecystectomy. Furthermore, in such a scenario, if the telescope is to be held by the assistant, a lot of coordination will be required between the surgeon and the assistant to ensure minimal hand clashing and yet adequate visualization of the field of dissection. To overcome this, the surgeon can handle both the laparoscopic camera and the dissecting instrument in a ‘‘snooker cue guide technique’’. This will enable the surgeon to better maintain the field of vision just as he requires it. In addition, the handling of the instrument is also different from conventional situations. The instruments are held in a reverse grip with the handles pointing upwards so as to reduce the clashing with the other hand and instrument. This reverse handle grip can be applied to most instruments that are held by the surgeon such as the Hem-
Surg Endosc
Fig. 4 Intraoperative photographs showing A an instrument approaching from superolaterally via the epigastric port to dissect the Calot’s triangle in CLC, B in SILC, the gallbladder is retracted to the left to expose the posterior peritoneum which is dissected to free
the gallbladder from the liver bed (arrow points to the dissection plane). C The gallbladder is retracted to the right to expose the Calot’s triangle for dissection anteriorly by the instrument approaching from the umbilical port
Fig. 5 Intraoperative photographs showing A the skeletonized Calot’s triangle with the exposed cystic artery and duct (indicated by arrows), B the distal end of the Hem-o-lok is not clearly visualized, and it is unclear whether the clip covers the full width of
the cystic duct (arrow points to the distal tip of the Hem-o-lok). C On pulling back the Hem-o-lok, the distal edge of the clip is now visualized and it is sure that the full width of the cystic duct has been occluded (arrow points to the distal tip of the Hem-o-lok)
o-lok applicator and scissors. Similarly, the assistant should hold instruments with the handles pointing laterally to avoid clashing with the surgeon. Misidentification of the local anatomy is the most common reason that can lead to accidental biliary injury. As such, it is crucial to dissect the Calot’s triangle and identify the relevant structures accurately. In CLC, the presence of an epigastric port allows for an instrument approaching superiorly from the left side to dissect the Calot’s triangle anteriorly (see Fig. 4A). In SILC where all the instruments approach the operating field via an inferior umbilical port, this dissecting angle is lost; thus, the Calot’s triangle cannot be effectively dissected. To address this shortcoming, the posterior peritoneum is judiciously dissected to free the gallbladder to allow greater room for lateral retraction to better expose the Calot’s triangle anteriorly for safer dissection (see Fig. 4B, C). In our experience, a common cause for conversion or the need for additional ports is bile leak at the cystic duct
stump, which is commonly due to incomplete occlusion by the Hem-o-lok clip. This is because the clip has not actually fully occluded the width of the cystic duct. This can potentially not be picked up, as the distal end of the clip is difficult to properly visualize in the ‘‘in-line’’ view in SILC. As such, we suggest pulling back on the Hem-o-lok applicator at each application and zooming into better visualize the distal end of the clip before releasing it so as to ensure occlusion of the full width of the cystic duct (see Fig. 5A, B). This helps to avoid subsequent bile leak from the cystic duct stump after dissection. Similar to CLC, it remains important to apply the tenets of the SAGES Safe Cholecystectomy Taskforce [17] so as to avoid the low but real risk of bile duct injury in SILC. It remains crucial to attain the critical view of safety by dissecting Calot’s triangle to expose the cystic duct and artery, with the liver bed exposed to avoid any anatomical misidentification and accidental injury of the bile duct [18]. Although SILC may have technical challenges in terms of
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the restricted movements, difficulty achieving triangulation, and inability to change the camera angle, this same standard should still apply. If one is unable to attain the critical view of safety, the surgeon should consider alternatives such as using additional ports or converting to an open procedure. Caution is also taken not to injure the common bile duct during the dissection; for example, the cystic duct is dissected as close to the neck of the gallbladder as possible and away from the hepatic and common bile ducts. The use of cautery is also minimized around these structures. While the surgical techniques presented helped to avoid bile duct injury in our experience, the surgeon’s skill and experience are also important. When laparoscopic cholecystectomy was first adopted, there was a noted spike in the rates of bile duct injury that many attributed to the learning curve [19]. In the current landscape where SILC remains a new procedure requiring training different from conventional laparoscopic procedures, the spike in bile duct injuries can possibly be attributed to a similar effect [20, 21]. Thus, it remains crucial that the surgeon is well trained and experienced in laparoscopic procedures before attempting SILC. Other centres have also suggested the use of articulating instruments or angled cameras to increase the ease of the procedure. It should be noted that the current series presented include all the cases of SILC that have been performed since the procedure was first introduced in our centre in 2009.
Conclusion Our experience shows that with the modified techniques as described above, bile duct injury can be avoided in SILC. Compliance with ethical standards Disclosure Covidien provided the SILSTM Port which was used for the first 50 SILS cases. Mr. Li, Dr. Kim, and Dr. Chang have no conflicts of interest or financial ties to disclose.
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