Transcript MICROPUNCTURE (NEEDLESCOPIC) LAP CHOLE IN ACUTE …

MINILAP CHOLECYSTECTOMY
PROF. H. KABIR CHOWDHURY
Department of Surgery
Ibrahim Medical College &
BIRDEM Hospital
DHAKA, BANGLADESH
• Mico-Laparoscopic Cholecystectomy
• Mini Laparoscopic Cholecystectomy
• Needlescopic Cholecystectomy
GUSTAVO L CARVALHO MD, PhD,
MARCELO P LOUREIRO, MD, PhD and
EDUARDO A BONIN, MD, MSc.
Oswaldo Cruz University Hospital and
UNIPECLIN, Faculty of Medical Sciences,
University of Pernambuco - Recife and
Positivo University - Curitiba, Brazil.
A general availability with few access
limitations, easy applicability with a short
learning curve and a superior benefit to
cost ratio ensures whether a technique
survives for posterity. Lastly, without direct
and substantial benefit to the patient, any
new technique or technology would
ultimately be consigned to the flames of
history. The final decider obviously is the
end consumer or the patient for whose
benefit all this is necessitated.
• Unlike other new access methods like NOTES
and Single port, MINI reigns for its simplicity,
offering increased dexterity, delicacy, and
precision, without significantly adding extra
costs and at the same time, maintains the
triangulation that is deemed essential in
standard laparoscopy. Surgical precision has
been always dear to our hearts. One wonders
whether one should risk losing this for the
sake of cosmesis.
• Minilaparoscopy stands out because it uses
various diminutive accesses. Consequently, the
potential benefits of MINI would be less volume
of parietal injury, less total area of tension at the
incision and less somatic pain.15, 16 At the
present time, Mini instruments are the only
ubiquitous instruments that can be used in all
current endoscopic techniques, including NOTES
and single port hybrid techniques. Many hybrid
techniques are indeed Minilaparoscopy
• Leonardo Da Vinci’s quote: “Simplicity is the
ultimate sophistication.”
Surg Endosc. 2010 Jul;24(7):1746-51. Epub 2010 Jan 7.
Incisions do not simply sum.
Blinman T.
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METHODS:
Wounds of various sizes are compared using a simple mathematical model. The closing tension perpendicular to any linear incision is a function of
the incision's length, varying symmetrically together with a maximum at the midpoint of length. If tension rises linearly across an incision, integration
of the tension relationship demonstrates that the total wound tension actually is proportional to the square of the length. In this report, incisions of
various lengths are modeled, and plausible alternative incision scenarios for various procedures (e.g., Nissen, appendectomy) are compared.
RESULTS:
Total tension rises nonlinearly with increasing wound length. Thus, total tension across multiple incisions is always less than the total tension for an
incision of the same total length. For example, an open appendectomy creates 2.7-fold more wound tension than a laparoscopic appendectomy.
Similarly, two 3-mm trocars create less total tension than a single 5-mm trocar.
CONCLUSION:
Conventional incisions are subject to more total tension than any combination of trocar incisions of equal total length. This inequality yields three
clinically relevant corollaries. First, it supports the practice of using the smallest effective trocars (or even no-trocar methods) to minimize pain and
scar. Second, addition of a trocar in difficult cases adds relatively little morbidity. Finally, using two small trocars is better than using a single larger
trocar.
Diagn Ther Endosc. 2010;2010:759431. Epub 2010 Feb 14.
Current Limitations and Perspectives in Single Port Surgery: Pros and Cons Laparo-Endoscopic Single-Site
Surgery (LESS) for Renal Surgery.
Weibl P, Klingler HC, Klatte T, Remzi M.
Source
Department of Urology, Medical University of Vienna, AKH, Währinger Gürtel 18-20, 1090 Wien, Austria
• Single port surgery is considered minimally
invasive laparoscopy; on the other hand,
when using additional ports, it is no more
single port, but hybrid traditional laparoscopy.
Whether LESS is a superior or equally
technique compared to traditional
laparoscopy has to be proven by future
prospective randomized trials.
• Like any other new surgical technique, MISS surgery
will have to pass through two important
developmental phases, first is the clinical feasibility and
safety and the other is suitable technology to perform
this technique.
• While media attention may persuade patients to seek
out this procedure for an enhanced cosmetic result, we
must ensure a safe result. Although industry will be
liked to the development of new procedures and
instrumentation, surgeons should be the driving force
in the development of necessary technology and not
vice versa
GI SURGERY Year : 2011 | Volume : 7 | Issue : 1 | Page : 40-51 Minimally invasive single-site surgery for the
digestive system: A technological review
Parag W Dhumane, Michele Diana, Joel Leroy, Jacques Marescaux
IRCAD/EITS, Hôpitaux Universitaires, 1 Place de l'Hôpital, 67091 Strasbourg Cedex, France
• we believe that the "Ultimate form of
Minimally Invasive Surgery" will be a hybrid
form of MISS surgery and Natural Orifice
Transluminal Endoscopic Surgery,
complimented by technological innovations
from the fields of robotics and computerassisted surgery.
NC itself is not associated with a higher risk of conversion to
open surgery. Technical limitations encountered during NC due
to the fine instruments can usually be resolved by early
conversion to a LC approach rather than struggling with
inadequate retraction or exposure. In our experience,
replacement of one or two ports is usually sufficient to complete
the operation with little impairment to the postoperative
outcome.
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M. LOOK, S.P. CHEW, Y.C. TAN, S.E. LIEW, D.M.O. CHEONG, J.C.H. TAN, S.B. WEE,
C.H. TEH and C.H. LOW
Department of Surgery, Tan Tock Seng Hospital, Singapore
Two of the three randomised studies, from Singapore and
Copenhagen, found a significant reduction in postoperative
pain after needlescopic surgery.
However, all three trials failed to demonstrate any difference in other
objective parameters, including operating time, hospital stay
The only distinct advantage of adopting needlescopic cholecystectomy is,
perhaps, the better cosmetic results possible and, as a result, better
patient acceptance.
M. LOOK, S.P. CHEW, Y.C. TAN, S.E. LIEW, D.M.O. CHEONG, J.C.H. TAN,
S.B. WEE, C.H. TEH and C.H. LOW
Department of Surgery, Tan Tock Seng Hospital, Singapore
Needlescopic Cholecystectomy (NC)/
Mini Laparoscopic Cholecystectomy
Patients in the needlescopic group:
– Had less pain (mean visual analogue score 2.2 versus 3.6; P < 0.003)
and
– Had smaller scars (median length 17.0 versus 25.0 mm; P < 0.001). In
addition, patients in the needlescopic group tended to require
– Fewer intramuscular pethidine injections (P = 0.05). However,
– Oral analgesic requirements in the two groups were similar.
– There were no complications in either group.
– Needlescopic cholecystectomy resulted in less postoperative pain and
a smaller surgical scar than laparoscopic cholecystectomy in patients
with chronic cholecystitis.
Cheah WK
Department of Surgery, National University Hospital
Needlescopic Cholecystectomy (NC)/
Mini Laparoscopic Cholecystectomy
 Mini-laparoscopic cholecystectomy was performed in 1,009 of 1,011 patients
 The total operative time was 68.8 ± 31.9 min.
 The total hospital stay was 2.5 ± 2 days.
 One patient (0.10%) underwent conversion, hepatic duct laceration.
 Ten patients (0.99%) major complications including intra-abdominal abscess (1
patient), bile leakage (5 patients), major bile duct injury (2 patients), bowel injury (1
patient), and postoperative hemorrhage (1 patient).
 Eleven patients (1.09%) had minor complications including wound infection,
incisional herniation, postoperative ileus, and acute urine retention.
 Minilaparoscopic cholecystectomy is a technically demanding approach. Our results
indicate that this procedure could be performed successfully and safely by
experienced surgical teams.
P.-C. Lee, I.-R. Lai and S.-C. Yu Department of General Surgery, National Taiwan
University Hospital and National, Taiwan University College of Medicine
Needlescopic Cholecystectomy (NC)/
Mini Laparoscopic Cholecystectomy
Sixty cholecystectomies were performed using mini-laparoscopy, out of a total of 203
video-laparo-cholecystectomies
The benefits of mini-cholecystectomy are potential advantages in improved
appearance, reduced pain, better respiratory function, fewer wall complications.
Therefore, the authors believe that mini-laparoscopy should not be assessed in terms
of percentage of use or success, but rather considered as a part of the
laparoscopic method to be used in selected cases.
FAGGIONI A. et al, Hepato-gastroenterology 1998, vol. 45, no22, pp. 1014-1015
Needlescopic Cholecystectomy (NC)/
Mini Laparoscopic Cholecystectomy
The operative time ranged from 30 to 256 minutes for the mini-LC group and
25 to 255 minutes for the C-LC group, with means of 89 and 82 minutes,
respectively (P > 0.05).
Postoperative length of stay ranged from 0 to 18 days for the mini-LC group
and 0 to 21 days for the C-LC group, with means of 1.5 and 1.9 days,
respectively (P > 0.05).
There were no conversions to open cholecystectomy.
These data suggest that a more minimalist approach to laparoscopic
cholecystectomy can be accomplished safely and effectively.
Reardon PR, et al, J Laparoendosc Adv Surg Tech A. 1999 Aug;9(4):373.
Needlescopic Cholecystectomy (NC)/
Mini Laparoscopic Cholecystectomy
The level of postoperative pain was lower in the MLC group (p < 0.001).
More patients in the MLC group expressed satisfaction with the cosmetic result (p <
0.05).
MLC was shown to be feasible in uncomplicated situations.
Randomized studies are still needed to confirm these findings.
Surgical Endoscopy Volume 15, Number 6/ / June, 2001, 614-618L. Sarli, R.
Costi, G. Sansebastiano
Journal of Minimal Access Surgery
Single-incision laparoscopic surgery
Alfred Cuschieri
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However, there are a number of important issues which need to be addressed
before we can confirm with good evidence that this variant laparoscopic approach
does indeed benefit the patient. Thus aside from reduction of visible scars, the jury
remains out on whether SILS does indeed reduce postoperative pain and adhesion
formation. Likewise the contraindications to SILS have yet to be clarified and
defined. There is one potential area of concern and this relates to an increased risk
of incisional periumbilical hernia formation. The extent of this perceived
complication will only be established by prospective cohort or randomised studies
and longer follow-up. Meantime, we need to ensure that these umbilical wounds
are closed with a meticulous technique using non-absorbable material.
Even with the best instrumentation currently available, the SILS approach imposes
restrictions on instrument manipulation, retraction and limits triangulation.
Michel Gagner
Mount Senai Medical center, Florida
Journal of Gastrointest Surgery
July 2010
• Needlescopic instruments are often added to complement
the surgical task during SILS
• Needlescopic instruments permits triangulation in surgical
complex task during SILS procedure
• The scar after needlescopic surgery is very negligible and
non-existent after 12 months achieving similar cosmetic
result to SILS, even better.
• Due to higher trauma to the periumbilical are the pain may
be more in SILS
• Long term herniation risk in the peri umbilical area is more
n SILS
• Mesh repair of this hernia will prevent another SILS for the
same patient
ANZ J Surg. 2009 Jun;79(6):437-42.
Needlescopic versus laparoscopic cholecystectomy: a meta-analysis.
Sajid MS, Khan MA, Ray K, Cheek E, Baig MK.
Department of Colorectal Surgery, Worthing Hospital, Worthing, West Sussex, UK.
• Sixteen trials on NC versus LC encompassing
1549 patients were retrieved from electronic
databases.
• NC was superior to LC in terms of less postoperative pain and better cosmetic outcomes.
Single-incision laparoscopic surgery for cholecystectomy: a retrospective comparison with 4port laparoscopic cholecystectomy.
Chow A, Purkayastha S, Aziz O, Pefanis D, Paraskeva P.
Source
Department of Biosurgery and Surgical Technology, Imperial College London, England.
• Operative time was longer with SILS for cholecystectomy
compared with conventional laparoscopic cholecystectomy
(P < .001). A correlation was seen between reducing SILS
operative time and increasing experience (Spearman rank
correlation coefficient, -0.29). Three patients in the SILS for
cholecystectomy group required the addition of extra
laparoscopic ports. No patients in the SILS for
cholecystectomy group required conversion to open
surgery compared with 4 patients in the standard
laparoscopic cholecystectomy group. Patients stayed an
average of 0.76 days following SILS for cholecystectomy
and 1.53 days following conventional laparoscopic
cholecystectomy. One patient in each group had a
postoperative biliary leak.
Laparoscopic versus single-incision cholecystectomy.
Khambaty F, Brody F, Vaziri K, Edwards C.
Source
Department of Surgery, The George Washington University Medical Center, 2150 Pennsylvania
Avenue, NW, Suite 6B, Washington, DC 20037, USA.
• The data suggests that individuals with a BMI
over 33 may not be candidates for singleincision cholecystectomy. Those patients that
undergo a successful single-incision
laparoscopic cholecystectomy require fewer
narcotics postoperatively and have a shorter
LOS. Although this data is intriguing, the
overall utility of single-incision procedures
requires more analysis and potentially
randomized trials.
Source
From the Hepatobiliary and Pancreatic
Surgery Program, Providence Portland
Medical Center, Portland, OR.
• : SPLC procedure time was longer and incurred
more complications than CLC without significant
benefits in patient satisfaction, postoperative
pain and QOL. SPLC may be offered in carefully
selected patients. Larger randomized trials
performed later in the learning curve with SPLC
may identify more subtle advantages of one
method over another.
• World J Surg. 2011 May;35(5):967-72.
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Towards (Virtually)
Incisionless Surgery
Andrei
Nadu
1,*
• Needlescopic surgery, performed with 2- and
•Department
3-mm instruments represents
a further refinement
of Urology,
Sheba Medical
• of laparoscopic surgery. Several authors have
Center, the
Tel-Hashomer
Israel
• demonstrated
feasibility and safety of52621,
various
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needlescopic procedures
The 2- and 3-mm ports are virtually incisionless and
do not necessitate suturing (adhesive tape is sufficient),
and the consequent scars are almost invisible,
understandably encouraging surgeons at selected
centers to consider needlescopy or minilaparoscopy
as the next logical step in the evolution ofminimally
invasive surgery
Surgeons Philoshophy
• Advancements in laparoscopic surgery : is it properly
directed?
• Only 15% of the world population live in developed
countries
• Advancements requiring high skill, intensive training and
expensive facilities are for whom?
• Medical education and training of a surgeon in the
developing and under developed countries needs to be
addressed
• Surgical techniques, supply and delivery needs to be cost
effective
• Should only the poor should think about cost effectiveness
and developed countries go on wasting the resources?
• We should not run for innovations which do
not help the majority.
• Surgeon while working should be comfortable,
and enjoy what he is doing.
• If only increased noise can increase SSI then a
diffifult procedure may cause many problems
which need to be addressed.
Needlescopic Cholecystectomy (NC)/
Mini Laparoscopic Cholecystectomy
• Since the beginning of lap chole, making it more comfortable and more
cosmetic never stopped.
• With a little addition to the standard instruments we started mini lap
chole in 1995 by making 5 mm port in place of 10 mm epigastric port
Needlescopic Cholecystectomy (NC)/
Mini Laparoscopic Cholecystectomy
Technique
• Since 1998 we are doing modified Needlescopic Cholecystectomy,
where umbilical port is 10 mm and three other ports are 3 mm.
• Clips are used through the umbilical port under the vision of a 2
mm scope from the epigastric port.
• Gallbladder is delivered through the umbilical port
Needlescopic Cholecystectomy (NC)/
Mini Laparoscopic Cholecystectomy
Since 1993 till Sept 2006 about 14000 cases of Laparoscopic
Cholecystectomy was done by the author. Among which 5600 cases
are Needlescopic .
Conversion
• to 5 mm port was done in 5.5% cases.
• to standard lap chole was 1.5%
• to open chole was less then 1%
Needlescopic Cholecystectomy (NC)/
Mini Laparoscopic Cholecystectomy
• In this series Acute Cholecyatitis was 12%
• NC was possible in 65% of the acute cases.
• One patient died due to MI 24 hours after surgery.
• Minor umbilical wound infection was reported in 1.5% cases
• Minor Bile duct injury
1 case
( Repaired Laparoscopically)
Needlescopic Cholecystectomy (NC)/
Mini Laparoscopic Cholecystectomy
Mean operation time
25 min
Needlescopic Cholecystectomy (NC)/
Mini Laparoscopic Cholecystectomy
• Analgesics
• Pre-op NSAID Suppository only
•+
Post –op NSAID Inj
• + Phthedine
35%
60%
5%
Needlescopic Cholecystectomy (NC)/
Mini Laparoscopic Cholecystectomy
• Hospital stay
• <24 hours
( Average 20 hours, where NC completed)
98%
Needlescopic Cholecystectomy (NC)/
Mini Laparoscopic Cholecystectomy
• Cosmetic
– All patients expressed high satisfaction
Needlescopic Cholecystectomy (NC)/
Mini Laparoscopic Cholecystectomy
• Difficulties
– Grasping thick wall with thin instruments.
– Aspiration of thick pus and debris is difficult.
– Thin instruments are not good enough for transmitting required force.
– In inexperienced hands chances of injury may be more
Needlescopic Cholecystectomy (NC)/
Mini Laparoscopic Cholecystectomy
• Our policy was to try all cases except acute cases after 72 hours
• This helped to gain more experience with acute cases.
• A 10 mm umbilical port allowed to introduce rolled gauze for
dissection and haemostasis.
Needlescopic Cholecystectomy (NC)/
Mini Laparoscopic Cholecystectomy
Advantages :
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More cosmetic
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Slow dissection
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More careful dissection
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Needs a clean field
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Less complications
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Patient satisfaction is high
Needlescopic Cholecystectomy (NC)/
Mini Laparoscopic Cholecystectomy
So why not offer the best.
7th Post Operative day