Transcript Single incision laparoscopic cholecystectomy

Dr Lam Shek Ming Sherman
Kwong Wah Hospital
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Introduction
Review of literature
Conclusion
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In 1882, first open cholecystectomy was
performed by Carl Langenbach on a 42-yearold man with gallstones.
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In 1985, the first laparoscopic
cholecystectomy was performed by Prof Dr
Med Erich Mühe
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Since 1990s, laparoscopic cholecystectomy
had been the gold standard for removal of
gallbladder
Laparoscopic cholecystectomy. The new 'gold standard'? Soper NJ et. al. Arch Surg.
1992 Aug;127(8):917-21; discussion 921-3.
Laparoscopic cholecystectomy: an analysis of 777 cases. Perissat J et. al. Baillieres
Clin Gastroenterol. 1992 Nov;6(4):727-42.
Laparoscopic cholecystectomy as standard intervention in symptomatic
cholecystolithiasis. Experiences with 1,277 patients Faust H et. al. Chirurg. 1994
Mar;65(3):194-9.
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Reduce size of incisions
◦ Needlescopic surgery (2-3mm ports)
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Reduce number of incisions
◦ Single incision laparoscopic surgery
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Single incision laparoscopic surgery
Single port access surgery
Laparoscopic endoscopic single-port surgery
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In 1997, Navarra G and his colleague
performed the first single incision
laparoscopic cholecystectomy
One-wound laparoscopic cholecystectomy. Navarra G et. al. Br J Surg. 1997
May; 84(5):695
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3 methods
◦ special, purpose-made access devices or ports for
introducing the laparoscope and instruments
◦ passing three trocars side-by-side through the
fascia after exposing a wide area via a single
umbilical incision
◦ using two trocars at the umbilicus along with
suspension sutures to retract the gallbladder.
Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et.
al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23.
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3 methods
◦ special, purpose-made access devices or ports for
introducing the laparoscope and instruments
◦ passing three trocars side-by-side through the
fascia after exposing a wide area via a single
umbilical incision
◦ using two trocars at the umbilicus along with
suspension sutures to retract the gallbladder.
Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et.
al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23.

3 methods
◦ special, purpose-made access devices or ports for
introducing the laparoscope and instruments
◦ passing three trocars side-by-side through the
fascia after exposing a wide area via a single
umbilical incision
◦ using two trocars at the umbilicus along with
suspension sutures to retract the gallbladder.
Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et.
al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23.

3 methods
◦ special, purpose-made access devices or ports for
introducing the laparoscope and instruments
◦ passing three trocars side-by-side through the
fascia after exposing a wide area via a single
umbilical incision
◦ using two trocars at the umbilicus along with
suspension sutures to retract the gallbladder
Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et.
al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23.
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length of incision: 1.5-2 cm
remaining steps are similar to the
conventional laparoscopic cholecystectomy
Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et.
al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23.
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The primary technical obstacles:
◦ Collision of instruments both within and outside the
abdomen as a result of their common entry point
(“sword fighting”)
◦ Inadequate triangulation
◦ Compromised field of view due to obstruction by
instruments entering the common port
◦ Inadequate exposure and retraction.
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Single-incision laparoscopic cholecystectomy: lessons learned for success. Noam
Shussman et. al. Surg Endosc. 2011 February; 25(2): 404–407.
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Potential advantages:
◦ Better cosmesis
◦ Less pain
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Potential disadvantages:
◦ Steep learning curve
◦ Compromised safety
◦ Single-incision laparoscopic cholecystectomy: a
systematic review. Antoniou SA et. al. Surg Endosc.
2011 Feb;25(2):367-77. Epub 2010 Jul 7.
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29 case series
1,166 patients
many studies excluded acute cholecystitis
conversion to conventional laparoscopic cholecystectomy:
9.3%
◦ obscure anatomy at Calot’s triangle (5.2%)
◦ inadequate exposure of the Calot’s triangle due to insufficient
gallbladder retraction (2.6%)
◦ inability to maintain pneumoperitoneum (1.4%)
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conversion to open cholecystectomy 0.4%
intraoperative complication rates: 0-20% (cumulative rate:
2.7%)
◦ gallbladder perforation/bile spillage (2.2%)
◦ haemorrhage (0.3%)
◦ bile duct injury (0.09%)
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mortality: 0%
SILC [1]
Needlescopic LC
[2]
Conventional LC
[3]
Conversion to
open
0.4%
0.1%
5-7%
Complication
rate
2.7%
2.08%
4%
Bile duct injury
0.09%
0.19%
0.3%
Gallbadder
perforation
2.2%
0.5%
0.4%
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[1] Single-incision laparoscopic cholecystectomy: a systematic review. Antoniou SA
et. al. Surg Endosc. 2011 Feb;25(2):367-77. Epub 2010 Jul 7.
[2] Minilaparoscopic (needlescopic) cholecystectomy: a study of 1,011 cases. Lee
PC et. al. Surg Endosc. 2004 Oct;18(10):1480-4. Epub 2004 Aug 24.
[3] Laparoscopic cholecystectomy: a review of 12,397 patients. Scott TR et. al.
Surg Laparosc Endosc. 1992 Sep;2(3):191-8.
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3 randomized control trials
◦ Randomized clinical trial of single-incision laparoscopic
cholecystectomy versus minilaparoscopic
cholecystectomy. Lee PC at. el. Br J Surg. 2010
Jul;97(7):1007-12.
◦ Different pain scores in single transumbilical incision
laparoscopic cholecystectomy versus classic
laparoscopic cholecystectomy: a randomized controlled
trial. Tsimoyiannis EC et. al. Surg Endosc. 2010
Aug;24(8):1842-8. Epub 2010 Feb 20.
◦ Prospective randomized comparative study of single
incision laparoscopic cholecystectomy versus
conventional four-port laparoscopic cholecystectomy.
Lai EC et. al. Am J Surg. 2011 Sep;202(3):254-8.
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70 patients
35 single-incision laparoscopic
cholecystectomy vs 35 minilaparoscopic
cholecystectomy
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70 patients
35 single-incision laparoscopic
cholecystectomy vs 35 minilaparoscopic
cholecystectomy
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70 patients
35 single-incision laparoscopic
cholecystectomy vs 35 minilaparoscopic
cholecystectomy
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40 patients
20 single-incision laparoscopic
cholecystectomy vs 20 minilaparoscopic
cholecystectomy
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51 patients
24 single incision laparoscopic cholecystectomy vs
27 four-ports laparoscopic cholecystectomy
SILC
4-port LC
P value
1.5 +/- .6
1.8 +/- 1.2
.20
Total wound length (cm) 1.76 +/- .29
2.25 +/- .05
.001
Time to return to usual
physical activity (days)
5.6 +/- 1.6
5.0 +/- 1.6
.193
VAS pain score
6 hours after surgery
4.5 (2-8)
4.0 (2-7)
.203
7 days after surgery
1 (0-3)
0 (0-2)
.048
Cosmetic score
3 months after surgery
7 (4-8)
6 (3-8)
.023
Hospital stay (days)
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51 patients
24 single incision laparoscopic cholecystectomy vs
27 four-ports laparoscopic cholecystectomy
SILC
4-port LC
P value
1.5 +/- .6
1.8 +/- 1.2
.20
Total wound length (cm) 1.76 +/- .29
2.25 +/- .05
.001
Time to return to usual
physical activity (days)
5.6 +/- 1.6
5.0 +/- 1.6
.193
VAS pain score
6 hours after surgery
4.5 (2-8)
4.0 (2-7)
.203
7 days after surgery
1 (0-3)
0 (0-2)
.048
Cosmetic score
3 months after surgery
7 (4-8)
6 (3-8)
.023
Hospital stay (days)
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The Learning Curve for Single-Port Laparoscopic
Cholecystectomy by Experienced Laparoscopic
Surgeon. Soon Hwa Youn et. al. J Korean Surg Soc
2011;80:119-124
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Single-incision laparoscopic cholecystectomy:
lessons learned for success. Noam Shussman et.al.
Surg Endosc. 2011 February; 25(2): 404–407.
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A specialized course of basic skills training for single-port
laparoscopic surgery. Yang et. al. Surgery Volume 149,
Number 6
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A specialized course of basic skills training for single-port
laparoscopic surgery. Yang et. al. Surgery Volume 149,
Number 6
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Single incision laparoscopic cholecystectomy
is a safe option for treatment of symptomatic
gallstone in early studies
Published RCTs so far support the advantage
of better cosmesis, yet controversial in
reduction of pain and shortening of hospital
stay
It requires 20-30 to master the technique for
experienced laparoscopic surgeons
Structured specialized training may be helpful
in overcoming the learning curve