J Hepatobiliary Pancreat Sci (2014) 21:E48–E52 DOI: 10.1002/jhbp.106
TECHNICAL VIEW
Tips for single-port laparoscopic cholecystectomy Noriaki Kameyama · Ryohei Miyata · Masato Tomita · Hiroaki Mitsuhashi · Shigeaki Baba · Shunichi Imai
Published online: 15 April 2014 © 2014 Japanese Society of Hepato-Biliary-Pancreatic Surgery
Abstract Single-port laparoscopic cholecystectomy (SPLC) is an emerging technique and gaining increased attention by its superiority in cosmesis. A 1.5-cm vertical transumbilical incision is used for the single port, followed by the glove method. Indications for SPLC are the same as those for standard 4-port laparoscopic cholecystectomy, including patients with morbid obesity, previous upper abdominal surgery, severe acute cholecystitis, or suspected presence of common bile duct stones. Some randomized controlled trials have shown negative results of SPLC regarding operative time, wound-related complications, and postoperative pain. However, our retrospective analysis shows equivalent clinical outcomes among the two approaches in terms of postoperative pain and complications. In this context, SPLC can be a good option for gallbladder pathologies. Keywords Cholecystectomy · Laparoscopic surgery · Single port Introduction Standard 4-port laparoscopic cholecystectomy (LC) has been recognized as a well-established technique for the treatment of gallbladder pathologies. Within the context of recent rapid dissemination of single-port laparoscopic cholecystectomy (SPLC), the “gold standard” treatment is now facing a turning point. More recently, a growing body of clinical evidence has been introduced in order to compare these two techniques, standard 4-port vs. single port. Some clinical trials have led to a heightened concern about the potential negative effects of SPLC on operative time, post-
N. Kameyama (*) · R. Miyata · M. Tomita · H. Mitsuhashi · S. Baba · S. Imai International Goodwill Hospital, 1-28-1 Nishigaoka, Izumi-ku, Yokohama, Kanagawa 245-0006, Japan e-mail: [email protected]
operative pain, wound complication, and incisional hernia, which might outweigh their superiority in cosmesis [1]. This article provides step-by-step description and tips of our SPLC using glove-port technique, a brief review on current randomized controlled trials (RCT), and retrospective analysis of our experience. Materials and methods Patient selection Indications for SPLC are the same as those for standard 4-port LC, including symptomatic cholelithiasis, chronic biliary colic, biliary dyskinesia, or gallstone pancreatitis. We have expanded our indications for patients with morbid obesity (body mass index [BMI] > 35), previous upper abdominal surgery, severe acute cholecystitis, or suspected presence of common bile duct stones. Exclusion criteria include pregnancy, American Society of Anesthesiologists (ASA) classification 3/4, liver cirrhosis, and gallbladder malignancy. Surgical technique Patient position and room setup Operation room is set up and the patient is placed in the supine position with the legs split apart and strapped to the leg boards. We routinely use both anti-embolic stockings and an intermittent calf compression device. Both arms are placed on arm boards at 60 degrees to the torso. The surgeon stands between the legs and the camera assistant stands on the left of the patient facing the monitor at the patient’s right arm. The operating table is tilted in reverse Trendelenburg position with the right side up for 15 to 20 degrees, when needed to clear abdominal organs from the gallbladder. The insulation of electrocautery devices are checked in advance to prevent unexpected intraoperative thermal injury.
J Hepatobiliary Pancreat Sci (2014) 21:E48–E52
Umbilical access (glove method) After local anesthetic infiltration (1% xylocaine), the umbilicus is inverted by two-toothed forceps and a 1.5 cm vertical transumbilical incision is made for Alexis wound retractor (XXS size: Applied Medical, Rancho Santa Margarita, CA, USA), which is inserted by an open access method and a surgical glove (size 5.5) is attached. Two low-profile laparoscopic ports (5-mm trocars) are inserted through the holes of the surgical glove with cut fingertips and Roticulator Endo Dissect (Covidien, Mansfield, MA, USA) is inserted directly through the hole of cut fingertip (Fig. 1).
Dissection of the gallbladder Roticulator Endo Dissect is used to manipulate the gallbladder and no transparietal traction suture is required. In cases for complicated cholecystitis, an additional miniport at the right lumber region can be helpful to establish triangulation or in cases of bleeding. The surgeon’s right hand manipulates bipolar forceps (POWERGRIP, Bissinger, Germany), which can dissect, coagulate and cut.Amonopolar suction irrigation spatula can be helpful for cases with intraoperative arterial bleeding or bile leakage. However, we have found that most SPLC can be achieved by using the abovementioned three laparoscopic instruments (Roticulator Endo Dissect, POWERGRIPT, and a laparoscope). First, the neck of the gallbladder is grasped by Roticulator in the direction perpendicular to the longitudinal axis of gallbladder, with the surgeon’s left hand push
E49
forward to retract the gallbladder to the cephalad (slightly to the left of the screen) direction. The direction of the common bile duct can be recognizable at this point for less-inflamed gallbladders. The gallbladder is approached from the Hartmann’s pouch and the gallbladder peritoneum is cut to partially expose the cystic duct-infundibular junction. Roticulator is then pushed medially and the lateral peritoneal wall is divided toward the fundus. Next, the body of the gallbladder is grasped in the parallel direction to the longitudinal axis of the gallbladder, with the surgeon’s left hand rotating anti-clockwise to expose the medial side of the gallbladder. The medial peritoneal wall is divided toward the fundus. The convex curvature of Roticulator pushes the liver bed to the cephalad direction, providing a good view of the medial side of the gall bladder. Cholecystectomy can be either normograde or retrograde depending on the visibility of the Calot’s triangle. Mobilization of the gallbladder is not a mandatory procedure before transection of the cystic duct. However, we recommend “fundus-first” dissection for patients with complicated cholecystitis, which minimizes the possibility of bile duct injury. The cystic duct and artery are exposed using the curved part of Maryland dissecting forceps. Blunt dissection is used for the exposure of both vessels whenever possible for the utmost safety. Transection of the cystic artery can be preceded, which helps create a wider window of the “critical view of safety”, further assuring even more accurate identification of the biliary anatomy. Both the cystic duct and artery are double-clipped (5-mm Endoclip III, Covidien) and divided with laparoscopic scissors. For thickened or dilated cystic ducts, a 2/0 polyglactin suture is delivered and the duct is ligated with a fishermen’s knot tied extracorporeally. Alternatively, the surgeon can use commercially available endoscopic ligation devices such as Endoloop Ligature (Ethicon, Somerville, NJ, USA) or Surgitie Loop (Covidien). Specimen extraction The gallbladder can be extracted through the umbilical port and a retrieval bag is not routinely needed, as Alexis wound retractor acts as a wound protector that prevents port-site contamination. However, the gallbladder with bile contamination is extracted using an inexpensive plastic bag. In cases for large stones or enlarged gallbladders, the wound may need to extend to 20 mm or more. Closure of the incision
Fig. 1 External view of single-port access through the umbilicus. A surgical glove (size 5.5) is attached to Alexis wound retractor (XXS size). Two 5-mm trocars are inserted through the holes of the surgical glove with cut 1st and 3rd fingertips and Roticulator Endo Dissect is inserted directly through the holes of cut 5th fingertip
The fascial defects are closed with interrupted 2-0 polysorb sutures (four stitches). The subcuticular layers are closed with interrupted 4-0 polydioxanone suture (Fig. 2). The umbilical incision is compressed with a cotton ball with a Tegadarm placed over the umbilicus.
E50
J Hepatobiliary Pancreat Sci (2014) 21:E48–E52
retrospectively and compared with an unpaired t-test. All the P-values listed were SPLC vs. LC. Personal data of an expert surgeon
Fig. 2 Postoperative appearance of the umbilicus. The fascial defects are closed with 2-0 polysorb sutures. The subcuticular layers is closed with 4-0 polydioxanone suture
Tips and tricks (which render this technique different from multitrocar laparoscopy) Laparoscope A 5-mm flexible scope (5 mm EndoEYE flex; Olympus, Tokyo, Japan) is preferred for SPLC. A co-axial, not perpendicular, light cable is mandatory to avoid crowding. As most conventional coagulation devices are straight, the laparoscope and the grasper should be flexible or articulated to avoid instrument crowding and interference. Cross-hand technique A cross-hand technique is required to perform SPLC. The grasper (Roticulator Endo Dissect) of the left hand comes in from the right side of the screen and the bipolar forceps (POWERGRIP) of the right hand comes in from the left side of the screen. Retrospective analysis of our experience Between May 2011 and August 2013, we performed 246 cholecystectomies (SPLC, n = 141; LC, n = 105) at our institute. Five patients with gallbladder cancer or pairing cholecystectomy with other intra-abdominal surgery were excluded and 241 cases (SPLC, n = 138; LC, n = 103) were analyzed. The surgical approach was selected by patients’ preferences. More patients selected SPLC (141 vs. 105) with the higher levels of preference evident among female patients (selected SPLC: male, 48%; female, 66%). SPLC were performed by five surgeons including two residents, who performed four cases (2.9%). LC were performed by 12 surgeons including four residents who performed 24 cases (23.3%). Parametric values of the two groups were analyzed
Between May 2009 and November 2013, we performed 285 SPLC, of which an expert surgeon performed 247 (87%) cases. He performed 134 LC before starting SPLC at our institute. Eleven patients with gallbladder cancer or pairing cholecystectomy with other intra-abdominal surgery were excluded, and 370 cases (SPLC, n = 244; LC, n = 126) were analyzed. The indication of SPLC was identical with LC after August 2009, he performed SPLS for all the cholecystectomies including patients with severe cholecystitis or history of upper abdominal operation. Parametric values of the two groups were analyzed retrospectively and compared with an unpaired t-test. All of the P-values listed were SPLC vs. LC. Results Institutional surgical outcomes There were no differences in patient characteristics. Operative time was significantly shorter with SPLC (Table 1). Significant differences were observed for lengths of hospital stay and total doses of analgesics. Postoperative complications were significantly less in SPLC. No hernias were observed during the follow-up period (1 to 12 months; Table 1). A supplemental miniport was required for only four cases (4/138, 2.9%) in SPLC. LC was converted to open surgery in five cases (5/103, 4.9%) while no SPLC was converted to open surgery (Table 1). Personal surgical outcomes of an expert surgeon There were no differences in patient characteristics. There were no statistical differences in operative time (SPLC vs. LC; 69 min vs. 70 min), lengths of hospital stay (3.8 days vs. 4.4 days), and postoperative complications [12/244 (4.9%) vs. 9/126 (7.1%); Table 2]. Conversion to laparotomy was significantly less in SPLC [1/244 (0.4%) vs. 3/126 (2.4%)]. In the SPLC group, a supplemental miniport was required for 21 cases (8.6%). Discussion On the basis of currently published randomized controlled trials (RCTs) and meta-analyses comparing SPLC and LC, one can hypothesize that SPLC is favored over LC in terms of cosmesis and patient satisfaction [2], which may be overshadowed by negative consequences including longer
J Hepatobiliary Pancreat Sci (2014) 21:E48–E52
E51
Table 1 Surgical outcomes of single-port laparoscopic cholecystectomy (SPLC) and laparoscopic cholecystectomy (LC)
Operative time (min) Hospital stay (days) Total doses of analgesics Postoperative complications Fat lysis Wound infection Biloma Common bile duct injury Large bowel injury Small-bowel obstruction Incisional hernia Supplemental miniport 5-mm port 3-mm port Conversion to open surgery
SPLC
LC
P-value
n = 138
n = 103
65 (range 29–160) 4.0 1.5 8 (5.8%) 6 1 1 0 0 0 0 4 (2.9%) 3 1 0 (0%)
118 (range 51–207) 5.5 2.6 11 (10.7%) 4 3 1 1 1 1 0
TECHNICAL VIEW
Tips for single-port laparoscopic cholecystectomy Noriaki Kameyama · Ryohei Miyata · Masato Tomita · Hiroaki Mitsuhashi · Shigeaki Baba · Shunichi Imai
Published online: 15 April 2014 © 2014 Japanese Society of Hepato-Biliary-Pancreatic Surgery
Abstract Single-port laparoscopic cholecystectomy (SPLC) is an emerging technique and gaining increased attention by its superiority in cosmesis. A 1.5-cm vertical transumbilical incision is used for the single port, followed by the glove method. Indications for SPLC are the same as those for standard 4-port laparoscopic cholecystectomy, including patients with morbid obesity, previous upper abdominal surgery, severe acute cholecystitis, or suspected presence of common bile duct stones. Some randomized controlled trials have shown negative results of SPLC regarding operative time, wound-related complications, and postoperative pain. However, our retrospective analysis shows equivalent clinical outcomes among the two approaches in terms of postoperative pain and complications. In this context, SPLC can be a good option for gallbladder pathologies. Keywords Cholecystectomy · Laparoscopic surgery · Single port Introduction Standard 4-port laparoscopic cholecystectomy (LC) has been recognized as a well-established technique for the treatment of gallbladder pathologies. Within the context of recent rapid dissemination of single-port laparoscopic cholecystectomy (SPLC), the “gold standard” treatment is now facing a turning point. More recently, a growing body of clinical evidence has been introduced in order to compare these two techniques, standard 4-port vs. single port. Some clinical trials have led to a heightened concern about the potential negative effects of SPLC on operative time, post-
N. Kameyama (*) · R. Miyata · M. Tomita · H. Mitsuhashi · S. Baba · S. Imai International Goodwill Hospital, 1-28-1 Nishigaoka, Izumi-ku, Yokohama, Kanagawa 245-0006, Japan e-mail: [email protected]
operative pain, wound complication, and incisional hernia, which might outweigh their superiority in cosmesis [1]. This article provides step-by-step description and tips of our SPLC using glove-port technique, a brief review on current randomized controlled trials (RCT), and retrospective analysis of our experience. Materials and methods Patient selection Indications for SPLC are the same as those for standard 4-port LC, including symptomatic cholelithiasis, chronic biliary colic, biliary dyskinesia, or gallstone pancreatitis. We have expanded our indications for patients with morbid obesity (body mass index [BMI] > 35), previous upper abdominal surgery, severe acute cholecystitis, or suspected presence of common bile duct stones. Exclusion criteria include pregnancy, American Society of Anesthesiologists (ASA) classification 3/4, liver cirrhosis, and gallbladder malignancy. Surgical technique Patient position and room setup Operation room is set up and the patient is placed in the supine position with the legs split apart and strapped to the leg boards. We routinely use both anti-embolic stockings and an intermittent calf compression device. Both arms are placed on arm boards at 60 degrees to the torso. The surgeon stands between the legs and the camera assistant stands on the left of the patient facing the monitor at the patient’s right arm. The operating table is tilted in reverse Trendelenburg position with the right side up for 15 to 20 degrees, when needed to clear abdominal organs from the gallbladder. The insulation of electrocautery devices are checked in advance to prevent unexpected intraoperative thermal injury.
J Hepatobiliary Pancreat Sci (2014) 21:E48–E52
Umbilical access (glove method) After local anesthetic infiltration (1% xylocaine), the umbilicus is inverted by two-toothed forceps and a 1.5 cm vertical transumbilical incision is made for Alexis wound retractor (XXS size: Applied Medical, Rancho Santa Margarita, CA, USA), which is inserted by an open access method and a surgical glove (size 5.5) is attached. Two low-profile laparoscopic ports (5-mm trocars) are inserted through the holes of the surgical glove with cut fingertips and Roticulator Endo Dissect (Covidien, Mansfield, MA, USA) is inserted directly through the hole of cut fingertip (Fig. 1).
Dissection of the gallbladder Roticulator Endo Dissect is used to manipulate the gallbladder and no transparietal traction suture is required. In cases for complicated cholecystitis, an additional miniport at the right lumber region can be helpful to establish triangulation or in cases of bleeding. The surgeon’s right hand manipulates bipolar forceps (POWERGRIP, Bissinger, Germany), which can dissect, coagulate and cut.Amonopolar suction irrigation spatula can be helpful for cases with intraoperative arterial bleeding or bile leakage. However, we have found that most SPLC can be achieved by using the abovementioned three laparoscopic instruments (Roticulator Endo Dissect, POWERGRIPT, and a laparoscope). First, the neck of the gallbladder is grasped by Roticulator in the direction perpendicular to the longitudinal axis of gallbladder, with the surgeon’s left hand push
E49
forward to retract the gallbladder to the cephalad (slightly to the left of the screen) direction. The direction of the common bile duct can be recognizable at this point for less-inflamed gallbladders. The gallbladder is approached from the Hartmann’s pouch and the gallbladder peritoneum is cut to partially expose the cystic duct-infundibular junction. Roticulator is then pushed medially and the lateral peritoneal wall is divided toward the fundus. Next, the body of the gallbladder is grasped in the parallel direction to the longitudinal axis of the gallbladder, with the surgeon’s left hand rotating anti-clockwise to expose the medial side of the gallbladder. The medial peritoneal wall is divided toward the fundus. The convex curvature of Roticulator pushes the liver bed to the cephalad direction, providing a good view of the medial side of the gall bladder. Cholecystectomy can be either normograde or retrograde depending on the visibility of the Calot’s triangle. Mobilization of the gallbladder is not a mandatory procedure before transection of the cystic duct. However, we recommend “fundus-first” dissection for patients with complicated cholecystitis, which minimizes the possibility of bile duct injury. The cystic duct and artery are exposed using the curved part of Maryland dissecting forceps. Blunt dissection is used for the exposure of both vessels whenever possible for the utmost safety. Transection of the cystic artery can be preceded, which helps create a wider window of the “critical view of safety”, further assuring even more accurate identification of the biliary anatomy. Both the cystic duct and artery are double-clipped (5-mm Endoclip III, Covidien) and divided with laparoscopic scissors. For thickened or dilated cystic ducts, a 2/0 polyglactin suture is delivered and the duct is ligated with a fishermen’s knot tied extracorporeally. Alternatively, the surgeon can use commercially available endoscopic ligation devices such as Endoloop Ligature (Ethicon, Somerville, NJ, USA) or Surgitie Loop (Covidien). Specimen extraction The gallbladder can be extracted through the umbilical port and a retrieval bag is not routinely needed, as Alexis wound retractor acts as a wound protector that prevents port-site contamination. However, the gallbladder with bile contamination is extracted using an inexpensive plastic bag. In cases for large stones or enlarged gallbladders, the wound may need to extend to 20 mm or more. Closure of the incision
Fig. 1 External view of single-port access through the umbilicus. A surgical glove (size 5.5) is attached to Alexis wound retractor (XXS size). Two 5-mm trocars are inserted through the holes of the surgical glove with cut 1st and 3rd fingertips and Roticulator Endo Dissect is inserted directly through the holes of cut 5th fingertip
The fascial defects are closed with interrupted 2-0 polysorb sutures (four stitches). The subcuticular layers are closed with interrupted 4-0 polydioxanone suture (Fig. 2). The umbilical incision is compressed with a cotton ball with a Tegadarm placed over the umbilicus.
E50
J Hepatobiliary Pancreat Sci (2014) 21:E48–E52
retrospectively and compared with an unpaired t-test. All the P-values listed were SPLC vs. LC. Personal data of an expert surgeon
Fig. 2 Postoperative appearance of the umbilicus. The fascial defects are closed with 2-0 polysorb sutures. The subcuticular layers is closed with 4-0 polydioxanone suture
Tips and tricks (which render this technique different from multitrocar laparoscopy) Laparoscope A 5-mm flexible scope (5 mm EndoEYE flex; Olympus, Tokyo, Japan) is preferred for SPLC. A co-axial, not perpendicular, light cable is mandatory to avoid crowding. As most conventional coagulation devices are straight, the laparoscope and the grasper should be flexible or articulated to avoid instrument crowding and interference. Cross-hand technique A cross-hand technique is required to perform SPLC. The grasper (Roticulator Endo Dissect) of the left hand comes in from the right side of the screen and the bipolar forceps (POWERGRIP) of the right hand comes in from the left side of the screen. Retrospective analysis of our experience Between May 2011 and August 2013, we performed 246 cholecystectomies (SPLC, n = 141; LC, n = 105) at our institute. Five patients with gallbladder cancer or pairing cholecystectomy with other intra-abdominal surgery were excluded and 241 cases (SPLC, n = 138; LC, n = 103) were analyzed. The surgical approach was selected by patients’ preferences. More patients selected SPLC (141 vs. 105) with the higher levels of preference evident among female patients (selected SPLC: male, 48%; female, 66%). SPLC were performed by five surgeons including two residents, who performed four cases (2.9%). LC were performed by 12 surgeons including four residents who performed 24 cases (23.3%). Parametric values of the two groups were analyzed
Between May 2009 and November 2013, we performed 285 SPLC, of which an expert surgeon performed 247 (87%) cases. He performed 134 LC before starting SPLC at our institute. Eleven patients with gallbladder cancer or pairing cholecystectomy with other intra-abdominal surgery were excluded, and 370 cases (SPLC, n = 244; LC, n = 126) were analyzed. The indication of SPLC was identical with LC after August 2009, he performed SPLS for all the cholecystectomies including patients with severe cholecystitis or history of upper abdominal operation. Parametric values of the two groups were analyzed retrospectively and compared with an unpaired t-test. All of the P-values listed were SPLC vs. LC. Results Institutional surgical outcomes There were no differences in patient characteristics. Operative time was significantly shorter with SPLC (Table 1). Significant differences were observed for lengths of hospital stay and total doses of analgesics. Postoperative complications were significantly less in SPLC. No hernias were observed during the follow-up period (1 to 12 months; Table 1). A supplemental miniport was required for only four cases (4/138, 2.9%) in SPLC. LC was converted to open surgery in five cases (5/103, 4.9%) while no SPLC was converted to open surgery (Table 1). Personal surgical outcomes of an expert surgeon There were no differences in patient characteristics. There were no statistical differences in operative time (SPLC vs. LC; 69 min vs. 70 min), lengths of hospital stay (3.8 days vs. 4.4 days), and postoperative complications [12/244 (4.9%) vs. 9/126 (7.1%); Table 2]. Conversion to laparotomy was significantly less in SPLC [1/244 (0.4%) vs. 3/126 (2.4%)]. In the SPLC group, a supplemental miniport was required for 21 cases (8.6%). Discussion On the basis of currently published randomized controlled trials (RCTs) and meta-analyses comparing SPLC and LC, one can hypothesize that SPLC is favored over LC in terms of cosmesis and patient satisfaction [2], which may be overshadowed by negative consequences including longer
J Hepatobiliary Pancreat Sci (2014) 21:E48–E52
E51
Table 1 Surgical outcomes of single-port laparoscopic cholecystectomy (SPLC) and laparoscopic cholecystectomy (LC)
Operative time (min) Hospital stay (days) Total doses of analgesics Postoperative complications Fat lysis Wound infection Biloma Common bile duct injury Large bowel injury Small-bowel obstruction Incisional hernia Supplemental miniport 5-mm port 3-mm port Conversion to open surgery
SPLC
LC
P-value
n = 138
n = 103
65 (range 29–160) 4.0 1.5 8 (5.8%) 6 1 1 0 0 0 0 4 (2.9%) 3 1 0 (0%)
118 (range 51–207) 5.5 2.6 11 (10.7%) 4 3 1 1 1 1 0
