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Laparoscopic cholecystectomy was first described and performed by Professor Erich Muhe on 12 September 1985 in Germany.1 This represented a major advancement in surgical technique where four or five much smaller incisions replaced the traditional Kockers incision.The advantages of laparoscopic surgery are well described and include shorter inpatient stay, less postoperative pain, earlier mobilisation, earlier return to work and daily activities and improved cosmesis.2 New techniques have evolved so a single small incision can be used, through which several instruments and the laparoscope, are passed.A number of devices are available to facilitate entry at one site. This incision is invariably hidden in the umbilicus, prompting the use of the term cscarless surgeryd. Initially one skin incision but multiple fascial incisions were used. Subsequently advances in product technology and design allowed one single skin and fascial incision to be madee.g. gelPoint 2122.Single incision laparoscopic cholecystectomy (SILC) surgery was first described in1997 by Navarra et al.3Variable nomenclature exists for this technique but all acronyms describe multiple ports inserted through one incision, often the umbilicus.4To date this technique has been introduced to gynaecological,5 urological, bariatric,6,7 and general surgical disciplines.8 General surgical procedures including appendicectomy,9 splenectomy,10 and hernia repair11 have all been treated successfully in this way. A surgical consortium in the United States has recently been established to coordinate and advance research and development of laparoendoscopic single site (LESS) surgery and to undertake it in a safe and responsible manner.12The unique property of gelPoint is that it creates a platform for a larger outer working surface area thereby enhancing triangulation (Figure 1 and 2). The platform is for incisions in the abdomen ranging from 1.5 to 7 centimetres (cm) and is essentially based on the size of the organ to be removed. The physical properties of the gelSeal platform allow for multiple exchanges without loss of the pneumoperitoneum.The disadvantages of SILC include a variable learning curve which often means, as a consequence a longer operating time. There may also be the need for certain new, disposable and expensive instruments i.e. 30 degree 5 mm scope, reticulating dissectors and/or graspers.13 Using the Alexis gelPoint system and ports alone, the additional cost is small.The next incremental step in improving the short-term cosmetic outcome of the procedure of laparoscopic cholecystectomy may be single incision laparoscopic cholecystectomy.We report the first three cases of this procedure in New Zealand using the gelPoint system and review the current literature on single incision laparoscopic cholecystectomy.Patients and Methods Patient 1A 58-year-old female and part time clerical worker, was listed for a laparoscopic cholecystectomy. Her symptoms were consistent with biliary colic and an ultrasound showed gallstones. Her liver function tests were normal. She had no significant past medical history of note and her medication consisted of paradex, a non steroidal and paroxetine for chronic back pain. Her body mass index (BMI) was 38.1. Patient 2A self-employed 43-year-old male was on the pooled waiting list with a diagnosis of biliary colic. He had radiological evidence of gall stones and a normal common bile duct on ultrasound. His liver function tests were normal. He had no comorbidities and was not on any medication. His BMI was 29.6. Patient 3A 54-year-old female with symptoms suggestive of biliary colic and radiological confirmation of gallstones was on the pooled waiting list for laparoscopic cholecystectomy. Her liver function tests were within normal limits and her common bile duct was of normal calibre. Her comorbidities included hypertension and gout. She had undergone previous surgery in the form of a laminectomy and sympathectomy for Raynauds disease. She was taking simple analgesics for chronic hip pain. She was not employed but was on a welfare benefit following recent back surgery. Her BMI was recorded at 24.7. Surgical Methods General anaesthesic agents and intraoperative analgesia was standardised for all patients. Informed consent was given to all patients for a laparoscopic cholecystectomy including the use of a modified technique, since only a minor modification in technique was being used specific ethical approval was not sought. According to our normal practice an intraoperative cholangiogram was not performed as all patients had normal liver function tests and normal sized common bile duct prior to surgery. All instruments used throughout the dissection were those present on a standard 4 port laparoscopic cholecystectomy tray routinely used in our hospital. The patients had 20 ml of 0.5% Marcaine with adrenaline infiltrated around the umbilicus prior to commencing the procedure. The umbilicus was everted and an incision was made in its centre for a maximum length of 2 cm. This allowed the sheath and peritoneum to be opened under direct vision14 and safe entry to the abdominal cavity. The Alexis 2122 wound retractor was then inserted (Figure 1) and the gelPoint secured to it, with a 10 mm camera trocar and three 5 mm trocars already in position. The trocars were initially placed as instructed (Figure 2) to give an optimal working fulcrum and to avoid clashing of instruments. The ports are inserted into the gel platform but not through the incision, this creates more space and range of movement at the critical point of the incision. If necessary the ports can be removed and repositioned throughout surgery without disturbing the pneumoperitoneum, or impairing working conditions. The view was from the umbilicus rather than the epigastrium but the standard approach to dissection was maintained. Once the gallbladder bed was found to be dry, the gelPoint was disconnected from the Alexis and the specimen was removed through the umbilical wound (Figure 3 and 4). Figures 1 & 2. The Alexis platform and trocars inserted into the gelPoint system (Figure 1 shows the wound retractor in place with a small incision) (Figure 2 shows the gelPoint device attached to the wound retractor) Figure 3 & 4. The gallbladder specimen and the final incision (Figure 3 shows the pathological specimen to be an 11cm large distended gallbladder) (Figure 4 is the final sutured two cm skin incision and the skin imprint of the Alexis retractor platform. This will fade in a couple of hours) Results The mean operating time was 108 minutes [range 703130 (Table 1)]. All patients were discharged 24 hours post procedure with paracetamol and ibuprofen to be taken if required, this was found to be adequate analgesia for each of the three patients. Each patient was telephoned on day-3 and day-10 post surgery and questioned regarding pain scores, activities of daily living and medication. The verbal rating pain scoring system was used where 1 is no pain and 10 represents the worst pain imaginable. Pain scores were generally low and by day 10, little or no pain was recorded in all patients. This mild pain or discomfort was managed with paracetamol only. There were no signs or symptoms suggestive of surgical complications and all patients reported normal gastrointestinal function 72 hours after surgery. Patient 3 required overnight catheterisation postoperatively for acute urinary retention. Finally, all patients were happy with their procedure and were keen to recommend it to a third party (Table 2). Table 1. Pain scores and analgesic requirements Variables Patient 1 Patient 2 Patient 3 Operating time (minutes) Blood loss Pain scores day 1 Pain scores day 3 Pain scores day 10 70 minimal 6/10 135/10 0/10 135 minimal 2/10 2/10 1/10 120 minimal 335/10 235/10 Table 2: General systemic concerns and patient satisfaction, as answered on day Variables Patient 1 Patient 2 Patient 3 Jaundice No No No Nausea No No No Pyrexia No No No Food intake Commenced night of surgery Commenced night of surgery Commenced night of surgery but bloated until day 3 Patient satisfaction with procedure Yes Yes Yes Recommend to third person Yes Yes Yes Discussion Although we initially used this technique in only three patients, our experience was that a laparoscopic cholecystectomy can be performed safely through one, small 2 cm skin and corresponding fascial incision. Operating times were longer through this single incision approach than would be expected for a standard four port technique. As with any new surgical technique there is a learning curve involved whereby the surgeon develops their technique and improves the efficiency of their movements. Internal clashing of instruments sometimes ensued but this was not found to significantly inhibit dissection. With further experience it is likely that this problem would occur less frequently and operating times would reduce accordingly. This assumption is supported by a study by Rivas et al. Which found that their mean operating time fell from 73 minutes for their first 50 patients who underwent a single incision laparoscopic cholecystectomy, compared with the second 50 patents which took a mean operating time of 45 minutes17. There are approximately 50 published articles describing single incision laparoscopic cholecystectomy. However the majority of these studies describe one skin incision and several fascial incisions. Only a small proportion of studies focus on a single skin and fascial incision. Despite the relatively large number of studies of SILC, to our knowledge there is only one randomised controlled trial.15 The remainder of the articles consist of published retrospective studies from specialist academic centres. This reflects the early experience with a new technique. The retrospective studies contain small numbers and easily measured end points such as hospital stay, but subjective endpoints e.g., postoperative pain are not consistently recorded. Not all reports are favourable and some authors believe that SILC does not represent much of an advantage over standard four port technique, particularly in obese patients or those with complications of biliary disease.16 In the randomised controlled trial by Tsimmoyannis et al,15 there was a significant reduction in lower abdominal and shoulder tip pain reported in the SILC group after 12 hours. At 24 hours post cholecystectomy the patients in the SILC group were noted to return to full daily activities. Rivas et al17 showed that scaring from previous abdominal surgery was not a barrier to this technique. There was no conversion to either 4-port laparoscopic or traditional cholecystectomy in over 100 cases and the morbidity rate was very low. In a small proportion of cases the patients had a diagnosis of acute cholecystitis or gallstone pancreatitis. Edwards et al18 retrospectively demonstrated the evolution of this surgical technique from dual incisions early on in the learning curve to a single fascial incision as the expertise of the surgeons grew. They used two transabdominal retraction sutures. These are sutures placed through the abdominal wall and tied extra corporeally to aid retraction of the fundus of the gall bladder. This adaptation, the need to convert and the complications they encountered led them to state that SILC is not necessarily safe and should initially be done only in thin patients with biliary colic. Cephalad retraction with sutures is limited and movement of the left hand is not as flexible as in the gold standard four port technique. They conclude that the view in single incision cholecystectomy is adequate but not necessarily optimal. One hundred consecutive cases from a general surgical unit where cholecystectomy is invariably done as a day case were reviewed by Erbella et al.16 These authors used two fascial incisions 2 cm apart within the umbilicus as well as transabdominal sutures. Single incision multi port laparoscopic (SIMPL) cholecystectomy using existing available equipment was found to be safe in the day case setting. They reported only two cases having to be converted to a traditional four port technique and also reported a very low morbidity rate. However their use of a 5 mm scope and a roticulating dissector may not be considered part of traditional laparoscopic sets in all hospitals. Romanelli reviewed 22 patients.4 These surgeons availed of several new devices from industry, SILS PORT 2122, TriPORT 2122 and the 12 mm Airseal trocar so that one skin and one fascial incision were made. One patient required conversion to the four port technique and one complication occurred. This was an early port site hernia which required further surgery including a bowel resection. Early on in this study several 5mm fascial incisions close together were used. They also used transabdominal retraction sutures to place traction on the gallbladder. The use of retraction sutures is a departure from the standard technique. The newer devices such as gelPointTMnegate the need for this, as several retractors can be passed through the port. Chamberlains comprehensive review of the literature to 2009 concludes that the clinical data is too preliminary to draw any real meaningful conclusions. They conclude that there remain significant ethical, procedural and technological questions with respect to SILC that require answering.19 A study by Varadarajulu et el comparing patients preference when given information about Natural Orifice Transabdominal Endoscopic Surgery (NOTES) Vs traditional four port technique laparoscopic cholecystectomy revealed that although little is known about patient preference, the majority of patients appear willing to undergo a more minimal surgery as long as the complication rate is similar. Those that preferred four port gold standard cholecystectomy stated that the lack of proven safety and efficacy and the unknown complication rate were reasons for not wishing to consider the newer procedure, and were not motivated by the expected advantages of reduction in acute postoperative pain and improved cosmesis.20 For a new technique to translate into surgical practice, in general it must be safe, reproducible, and cost effective and above all represent an improvement in patient care. For it to enter into the everyday surgical repertoire it must also be accepted and driven by both surgeons and patients alike. It must be equivalent or better than the gold standard laparoscopic cholecystectomy. So far there is no evidence in the literature that this is the case as SILC is still in need of a large randomised controlled study to answer this and many other questions. Routine four port laparoscopic cholecystectomy which can be done with reusable instruments in the day case setting has a morbidity of 8%,21 an average inpatient stay of less than 48 hours and an average return to work and daily activities within 2 weeks.22 SILC must at least match if not improve on these parameters. One major disadvantage of SILC is in-line viewing of the operative field. This does away with triangulation. Triangulation has been emphasised as important for four port laparoscopic cholecystectomy. In line viewing means that if one is to follow traditional movements of laparoscopic dissection of Calots trianglei.e. of using the right hand as a dissector and the left hand to manipulate Hartmanns pouch, then during SILC surgery, camera movement can dislodge adjacent instruments and necessitate alteration of the dissecting hand. This is clearly concerning as dissection towards the midline is not favoured in laparoscopic cholecystectomy. It is clear that the tradition of dissecting lateral to the gall bladder sulcus as described by Diamond et al and staying close to the gall bladder itself are safe and well founded.23 Due to restriction in movement and instrument clashing, SILC can potentially compromise basic well established principles of dissection that have been tried and tested in the traditional laparoscopic era. This is clearly a technical difficulty that some surgeons may not be able to overcome. Training, experience, skill and judgement of the operating surgeon, are needed to counteract these technical challenges. Above all, the safe basic principles of laparoscopic surgery that we strived to achieve in order to minimise serious complications should not be compromised. Conversion to four point laparoscopic cholecystectomy from a SILC is considered correct surgical judgement and should not to be deemed a failure. Merchant et al24 describe a standard, reliable and reproducible technique that avoids instrument clashing. This involves the use of the gelPort system. They argue that the ability to reinsert ports without losing the pneumoperitoneum is a clear advantage. This is similar to what we found when using this system. The main complaint from their patient group was of disproportionate post surgical umbilical pain. Conclusion SILC can be safely undertaken with the gelPoint (gelSeal and Alexis) device with a moderate cost increase (less than NZ$500) cost and minimal deviation from standard operating protocol. The extra cost is likely to reduce when more procedures are being performed by this technique. The gains of SILC is likely to be beneficial in terms of cosmesis and slightly better recovery. This may facilitate day case surgery. It would require a large randomised controlled trial to demonstrate an advantage and establish morbidity. The viewpoint of patients and short- and long-term outcomes also need to be evaluated. In the meantime its popularity is likely to be driven, or not, by patient preference. This was the case when laparoscopic cholecystectomy was introduced.

Summary

Abstract

We present the first three reported cases of single incision (through the umbilicus) laparoscopic cholecystectomy in New Zealand. The mean operating time was 108 minutes and all patients were discharged 24 hours after the procedure; they were all satisfied with their procedure and were keen to recommend it. We also provide a review of the international literature on this relatively new technique in New Zealand.

Aim

Method

Results

Conclusion

Author Information

Ian Lord, General Surgical Registrar; Blaithin Page, General Surgical Registrar, Magnus Thorn, General and Colorectal Surgeon; Mark Thompson-Fawcett, General and Colorectal Surgeon; Department of Surgery, Dunedin Hospital, Dunedin

Acknowledgements

Correspondence

Ian Lord, Department of Surgery, Dunedin Hospital, PO Box 1921 Dunedin, New Zealand.

Correspondence Email

lordyian@hotmail.com

Competing Interests

None.

Reynolds W, Jr. The first laparoscopic cholecystectomy. JSLS 2001;5:89-94.Velanovich V. Laparoscopic vs open surgery: a preliminary comparison of quality-of-life outcomes. Surg Endosc 2000;14:16-21.Navarra G, Pozza E, Occhionorelli S et al. One-wound laparoscopic cholecystectomy. Br J Surg 1997;84:695.Romanelli JR, Roshek TB, 3rd, Lynn DC, Earle DB. Single-port laparoscopic cholecystectomy: initial experience. Surg Endosc; 24:1374-9.Capar M, Balci O, Acar A, Colakoglu MC. Management of ovarian cysts by laparoscopic extracorporeal approach using single ancillary trocar. Taiwan J Obstet Gynecol 2009;48:380-4.Nguyen NT, Hinojosa MW, Smith BR, Reavis KM. Single laparoscopic incision transabdominal (SLIT) surgery-adjustable gastric banding: a novel minimally invasive surgical approach. Obes Surg 2008;18:1628-31.Huang CK, Tsai JC, Lo CH, et al. Preliminary Surgical Results of Single-Incision Transumbilical Laparoscopic Bariatric Surgery. Obes Surg.Kossi J, Luostarinen M. Initial experience of the feasibility of single-incision laparoscopic appendectomy in different clinical conditions. Diagn Ther Endosc 2010:240260.Chow A, Purkayastha S, Paraskeva P. Appendicectomy and cholecystectomy using single-incision laparoscopic surgery (SILS): the first UK experience. Surg Innov 2009;16:211-7.Targarona E M, Pallares J L, Balague C. Single incision approach for splenic diseases: a preliminary report on a series of 8 cases. Surg Endosc 2010;DOI 10.1007/s00464-010-0940-2.Danielson PD, Chandler NM. Single-port laparoscopic repair of a Morgagni diaphragmatic hernia in a paediatric patient: advancement in single-port technology allows effective intracorporeal suturing. J Pediatr Surg; 45:E21-4.Gill IS, Advincula AP, Aron M, et al. Consensus statement of the consortium for laparoendoscopic single-site surgery. Surg Endosc; 24:762-8.Pryor AD, Tushar JR, DiBernardo LR. Single-port cholecystectomy with the TransEnterix SPIDER: simple and safe. Surg Endosc; 24:917-23.Hasson HM. Open laparoscopy. Biomed Bull 1984; 5:1-6.1Tsimoyiannis EC, Tsimogiannis KE, Pappas-Gogos G, et al. Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial. Surg Endosc.Erbella J, Jr., Bunch GM. Single-incision laparoscopic cholecystectomy: the first 100 outpatients. Surg Endosc. 2010 Aug; 24:81958-61Rivas H, Varela E, Scott D. Single-incision laparoscopic cholecystectomy: initial evaluation of a large series of patients. Surg Endosc; 24:1403-12.Edwards C, Bradshaw A, Ahearne P, et al. Single-incision laparoscopic cholecystectomy is feasible: initial experience with 80 cases. Surg Endosc. 2010 Sept 24:9, 2241-2247Chamberlain RS, Sakpal SV. A comprehensive review of single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) techniques for cholecystectomy. J Gastrointest Surg 2009; 13:1733-40.Varadarajulu S, Tamhane A, Drelichman ER. Patient perception of natural orifice transluminal endoscopic surgery as a technique for cholecystectomy. Gastrointest Endosc 2008; 67:854-60.Wiseman JT, Sharuk MN, Singla A, et al. Surgical management of acute cholecystitis at a tertiary care centre in the modern era. Arch Surg; 145:439-44.Jensen AG, Prevedoros H, Kullman E, et al. Peroperative nitrous oxide does not influence recovery after laparoscopic cholecystectomy. Acta Anaesthesiol Scand 1993; 37:683-6.Diamond T, Mole DJ. Anatomical orientation and cross-checking-the key to safer laparoscopic cholecystectomy. Br J Surg 2005;92:663-4.Merchant AM, Cook MW, White BC et al. Transumbilical Gelport access technique for performing single incision laparoscopic surgery (SILS). J Gastrointest Surg 2009; 13:159-62.

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Laparoscopic cholecystectomy was first described and performed by Professor Erich Muhe on 12 September 1985 in Germany.1 This represented a major advancement in surgical technique where four or five much smaller incisions replaced the traditional Kockers incision.The advantages of laparoscopic surgery are well described and include shorter inpatient stay, less postoperative pain, earlier mobilisation, earlier return to work and daily activities and improved cosmesis.2 New techniques have evolved so a single small incision can be used, through which several instruments and the laparoscope, are passed.A number of devices are available to facilitate entry at one site. This incision is invariably hidden in the umbilicus, prompting the use of the term cscarless surgeryd. Initially one skin incision but multiple fascial incisions were used. Subsequently advances in product technology and design allowed one single skin and fascial incision to be madee.g. gelPoint 2122.Single incision laparoscopic cholecystectomy (SILC) surgery was first described in1997 by Navarra et al.3Variable nomenclature exists for this technique but all acronyms describe multiple ports inserted through one incision, often the umbilicus.4To date this technique has been introduced to gynaecological,5 urological, bariatric,6,7 and general surgical disciplines.8 General surgical procedures including appendicectomy,9 splenectomy,10 and hernia repair11 have all been treated successfully in this way. A surgical consortium in the United States has recently been established to coordinate and advance research and development of laparoendoscopic single site (LESS) surgery and to undertake it in a safe and responsible manner.12The unique property of gelPoint is that it creates a platform for a larger outer working surface area thereby enhancing triangulation (Figure 1 and 2). The platform is for incisions in the abdomen ranging from 1.5 to 7 centimetres (cm) and is essentially based on the size of the organ to be removed. The physical properties of the gelSeal platform allow for multiple exchanges without loss of the pneumoperitoneum.The disadvantages of SILC include a variable learning curve which often means, as a consequence a longer operating time. There may also be the need for certain new, disposable and expensive instruments i.e. 30 degree 5 mm scope, reticulating dissectors and/or graspers.13 Using the Alexis gelPoint system and ports alone, the additional cost is small.The next incremental step in improving the short-term cosmetic outcome of the procedure of laparoscopic cholecystectomy may be single incision laparoscopic cholecystectomy.We report the first three cases of this procedure in New Zealand using the gelPoint system and review the current literature on single incision laparoscopic cholecystectomy.Patients and Methods Patient 1A 58-year-old female and part time clerical worker, was listed for a laparoscopic cholecystectomy. Her symptoms were consistent with biliary colic and an ultrasound showed gallstones. Her liver function tests were normal. She had no significant past medical history of note and her medication consisted of paradex, a non steroidal and paroxetine for chronic back pain. Her body mass index (BMI) was 38.1. Patient 2A self-employed 43-year-old male was on the pooled waiting list with a diagnosis of biliary colic. He had radiological evidence of gall stones and a normal common bile duct on ultrasound. His liver function tests were normal. He had no comorbidities and was not on any medication. His BMI was 29.6. Patient 3A 54-year-old female with symptoms suggestive of biliary colic and radiological confirmation of gallstones was on the pooled waiting list for laparoscopic cholecystectomy. Her liver function tests were within normal limits and her common bile duct was of normal calibre. Her comorbidities included hypertension and gout. She had undergone previous surgery in the form of a laminectomy and sympathectomy for Raynauds disease. She was taking simple analgesics for chronic hip pain. She was not employed but was on a welfare benefit following recent back surgery. Her BMI was recorded at 24.7. Surgical Methods General anaesthesic agents and intraoperative analgesia was standardised for all patients. Informed consent was given to all patients for a laparoscopic cholecystectomy including the use of a modified technique, since only a minor modification in technique was being used specific ethical approval was not sought. According to our normal practice an intraoperative cholangiogram was not performed as all patients had normal liver function tests and normal sized common bile duct prior to surgery. All instruments used throughout the dissection were those present on a standard 4 port laparoscopic cholecystectomy tray routinely used in our hospital. The patients had 20 ml of 0.5% Marcaine with adrenaline infiltrated around the umbilicus prior to commencing the procedure. The umbilicus was everted and an incision was made in its centre for a maximum length of 2 cm. This allowed the sheath and peritoneum to be opened under direct vision14 and safe entry to the abdominal cavity. The Alexis 2122 wound retractor was then inserted (Figure 1) and the gelPoint secured to it, with a 10 mm camera trocar and three 5 mm trocars already in position. The trocars were initially placed as instructed (Figure 2) to give an optimal working fulcrum and to avoid clashing of instruments. The ports are inserted into the gel platform but not through the incision, this creates more space and range of movement at the critical point of the incision. If necessary the ports can be removed and repositioned throughout surgery without disturbing the pneumoperitoneum, or impairing working conditions. The view was from the umbilicus rather than the epigastrium but the standard approach to dissection was maintained. Once the gallbladder bed was found to be dry, the gelPoint was disconnected from the Alexis and the specimen was removed through the umbilical wound (Figure 3 and 4). Figures 1 & 2. The Alexis platform and trocars inserted into the gelPoint system (Figure 1 shows the wound retractor in place with a small incision) (Figure 2 shows the gelPoint device attached to the wound retractor) Figure 3 & 4. The gallbladder specimen and the final incision (Figure 3 shows the pathological specimen to be an 11cm large distended gallbladder) (Figure 4 is the final sutured two cm skin incision and the skin imprint of the Alexis retractor platform. This will fade in a couple of hours) Results The mean operating time was 108 minutes [range 703130 (Table 1)]. All patients were discharged 24 hours post procedure with paracetamol and ibuprofen to be taken if required, this was found to be adequate analgesia for each of the three patients. Each patient was telephoned on day-3 and day-10 post surgery and questioned regarding pain scores, activities of daily living and medication. The verbal rating pain scoring system was used where 1 is no pain and 10 represents the worst pain imaginable. Pain scores were generally low and by day 10, little or no pain was recorded in all patients. This mild pain or discomfort was managed with paracetamol only. There were no signs or symptoms suggestive of surgical complications and all patients reported normal gastrointestinal function 72 hours after surgery. Patient 3 required overnight catheterisation postoperatively for acute urinary retention. Finally, all patients were happy with their procedure and were keen to recommend it to a third party (Table 2). Table 1. Pain scores and analgesic requirements Variables Patient 1 Patient 2 Patient 3 Operating time (minutes) Blood loss Pain scores day 1 Pain scores day 3 Pain scores day 10 70 minimal 6/10 135/10 0/10 135 minimal 2/10 2/10 1/10 120 minimal 335/10 235/10 Table 2: General systemic concerns and patient satisfaction, as answered on day Variables Patient 1 Patient 2 Patient 3 Jaundice No No No Nausea No No No Pyrexia No No No Food intake Commenced night of surgery Commenced night of surgery Commenced night of surgery but bloated until day 3 Patient satisfaction with procedure Yes Yes Yes Recommend to third person Yes Yes Yes Discussion Although we initially used this technique in only three patients, our experience was that a laparoscopic cholecystectomy can be performed safely through one, small 2 cm skin and corresponding fascial incision. Operating times were longer through this single incision approach than would be expected for a standard four port technique. As with any new surgical technique there is a learning curve involved whereby the surgeon develops their technique and improves the efficiency of their movements. Internal clashing of instruments sometimes ensued but this was not found to significantly inhibit dissection. With further experience it is likely that this problem would occur less frequently and operating times would reduce accordingly. This assumption is supported by a study by Rivas et al. Which found that their mean operating time fell from 73 minutes for their first 50 patients who underwent a single incision laparoscopic cholecystectomy, compared with the second 50 patents which took a mean operating time of 45 minutes17. There are approximately 50 published articles describing single incision laparoscopic cholecystectomy. However the majority of these studies describe one skin incision and several fascial incisions. Only a small proportion of studies focus on a single skin and fascial incision. Despite the relatively large number of studies of SILC, to our knowledge there is only one randomised controlled trial.15 The remainder of the articles consist of published retrospective studies from specialist academic centres. This reflects the early experience with a new technique. The retrospective studies contain small numbers and easily measured end points such as hospital stay, but subjective endpoints e.g., postoperative pain are not consistently recorded. Not all reports are favourable and some authors believe that SILC does not represent much of an advantage over standard four port technique, particularly in obese patients or those with complications of biliary disease.16 In the randomised controlled trial by Tsimmoyannis et al,15 there was a significant reduction in lower abdominal and shoulder tip pain reported in the SILC group after 12 hours. At 24 hours post cholecystectomy the patients in the SILC group were noted to return to full daily activities. Rivas et al17 showed that scaring from previous abdominal surgery was not a barrier to this technique. There was no conversion to either 4-port laparoscopic or traditional cholecystectomy in over 100 cases and the morbidity rate was very low. In a small proportion of cases the patients had a diagnosis of acute cholecystitis or gallstone pancreatitis. Edwards et al18 retrospectively demonstrated the evolution of this surgical technique from dual incisions early on in the learning curve to a single fascial incision as the expertise of the surgeons grew. They used two transabdominal retraction sutures. These are sutures placed through the abdominal wall and tied extra corporeally to aid retraction of the fundus of the gall bladder. This adaptation, the need to convert and the complications they encountered led them to state that SILC is not necessarily safe and should initially be done only in thin patients with biliary colic. Cephalad retraction with sutures is limited and movement of the left hand is not as flexible as in the gold standard four port technique. They conclude that the view in single incision cholecystectomy is adequate but not necessarily optimal. One hundred consecutive cases from a general surgical unit where cholecystectomy is invariably done as a day case were reviewed by Erbella et al.16 These authors used two fascial incisions 2 cm apart within the umbilicus as well as transabdominal sutures. Single incision multi port laparoscopic (SIMPL) cholecystectomy using existing available equipment was found to be safe in the day case setting. They reported only two cases having to be converted to a traditional four port technique and also reported a very low morbidity rate. However their use of a 5 mm scope and a roticulating dissector may not be considered part of traditional laparoscopic sets in all hospitals. Romanelli reviewed 22 patients.4 These surgeons availed of several new devices from industry, SILS PORT 2122, TriPORT 2122 and the 12 mm Airseal trocar so that one skin and one fascial incision were made. One patient required conversion to the four port technique and one complication occurred. This was an early port site hernia which required further surgery including a bowel resection. Early on in this study several 5mm fascial incisions close together were used. They also used transabdominal retraction sutures to place traction on the gallbladder. The use of retraction sutures is a departure from the standard technique. The newer devices such as gelPointTMnegate the need for this, as several retractors can be passed through the port. Chamberlains comprehensive review of the literature to 2009 concludes that the clinical data is too preliminary to draw any real meaningful conclusions. They conclude that there remain significant ethical, procedural and technological questions with respect to SILC that require answering.19 A study by Varadarajulu et el comparing patients preference when given information about Natural Orifice Transabdominal Endoscopic Surgery (NOTES) Vs traditional four port technique laparoscopic cholecystectomy revealed that although little is known about patient preference, the majority of patients appear willing to undergo a more minimal surgery as long as the complication rate is similar. Those that preferred four port gold standard cholecystectomy stated that the lack of proven safety and efficacy and the unknown complication rate were reasons for not wishing to consider the newer procedure, and were not motivated by the expected advantages of reduction in acute postoperative pain and improved cosmesis.20 For a new technique to translate into surgical practice, in general it must be safe, reproducible, and cost effective and above all represent an improvement in patient care. For it to enter into the everyday surgical repertoire it must also be accepted and driven by both surgeons and patients alike. It must be equivalent or better than the gold standard laparoscopic cholecystectomy. So far there is no evidence in the literature that this is the case as SILC is still in need of a large randomised controlled study to answer this and many other questions. Routine four port laparoscopic cholecystectomy which can be done with reusable instruments in the day case setting has a morbidity of 8%,21 an average inpatient stay of less than 48 hours and an average return to work and daily activities within 2 weeks.22 SILC must at least match if not improve on these parameters. One major disadvantage of SILC is in-line viewing of the operative field. This does away with triangulation. Triangulation has been emphasised as important for four port laparoscopic cholecystectomy. In line viewing means that if one is to follow traditional movements of laparoscopic dissection of Calots trianglei.e. of using the right hand as a dissector and the left hand to manipulate Hartmanns pouch, then during SILC surgery, camera movement can dislodge adjacent instruments and necessitate alteration of the dissecting hand. This is clearly concerning as dissection towards the midline is not favoured in laparoscopic cholecystectomy. It is clear that the tradition of dissecting lateral to the gall bladder sulcus as described by Diamond et al and staying close to the gall bladder itself are safe and well founded.23 Due to restriction in movement and instrument clashing, SILC can potentially compromise basic well established principles of dissection that have been tried and tested in the traditional laparoscopic era. This is clearly a technical difficulty that some surgeons may not be able to overcome. Training, experience, skill and judgement of the operating surgeon, are needed to counteract these technical challenges. Above all, the safe basic principles of laparoscopic surgery that we strived to achieve in order to minimise serious complications should not be compromised. Conversion to four point laparoscopic cholecystectomy from a SILC is considered correct surgical judgement and should not to be deemed a failure. Merchant et al24 describe a standard, reliable and reproducible technique that avoids instrument clashing. This involves the use of the gelPort system. They argue that the ability to reinsert ports without losing the pneumoperitoneum is a clear advantage. This is similar to what we found when using this system. The main complaint from their patient group was of disproportionate post surgical umbilical pain. Conclusion SILC can be safely undertaken with the gelPoint (gelSeal and Alexis) device with a moderate cost increase (less than NZ$500) cost and minimal deviation from standard operating protocol. The extra cost is likely to reduce when more procedures are being performed by this technique. The gains of SILC is likely to be beneficial in terms of cosmesis and slightly better recovery. This may facilitate day case surgery. It would require a large randomised controlled trial to demonstrate an advantage and establish morbidity. The viewpoint of patients and short- and long-term outcomes also need to be evaluated. In the meantime its popularity is likely to be driven, or not, by patient preference. This was the case when laparoscopic cholecystectomy was introduced.

Summary

Abstract

We present the first three reported cases of single incision (through the umbilicus) laparoscopic cholecystectomy in New Zealand. The mean operating time was 108 minutes and all patients were discharged 24 hours after the procedure; they were all satisfied with their procedure and were keen to recommend it. We also provide a review of the international literature on this relatively new technique in New Zealand.

Aim

Method

Results

Conclusion

Author Information

Ian Lord, General Surgical Registrar; Blaithin Page, General Surgical Registrar, Magnus Thorn, General and Colorectal Surgeon; Mark Thompson-Fawcett, General and Colorectal Surgeon; Department of Surgery, Dunedin Hospital, Dunedin

Acknowledgements

Correspondence

Ian Lord, Department of Surgery, Dunedin Hospital, PO Box 1921 Dunedin, New Zealand.

Correspondence Email

lordyian@hotmail.com

Competing Interests

None.

Reynolds W, Jr. The first laparoscopic cholecystectomy. JSLS 2001;5:89-94.Velanovich V. Laparoscopic vs open surgery: a preliminary comparison of quality-of-life outcomes. Surg Endosc 2000;14:16-21.Navarra G, Pozza E, Occhionorelli S et al. One-wound laparoscopic cholecystectomy. Br J Surg 1997;84:695.Romanelli JR, Roshek TB, 3rd, Lynn DC, Earle DB. Single-port laparoscopic cholecystectomy: initial experience. Surg Endosc; 24:1374-9.Capar M, Balci O, Acar A, Colakoglu MC. Management of ovarian cysts by laparoscopic extracorporeal approach using single ancillary trocar. Taiwan J Obstet Gynecol 2009;48:380-4.Nguyen NT, Hinojosa MW, Smith BR, Reavis KM. Single laparoscopic incision transabdominal (SLIT) surgery-adjustable gastric banding: a novel minimally invasive surgical approach. Obes Surg 2008;18:1628-31.Huang CK, Tsai JC, Lo CH, et al. Preliminary Surgical Results of Single-Incision Transumbilical Laparoscopic Bariatric Surgery. Obes Surg.Kossi J, Luostarinen M. Initial experience of the feasibility of single-incision laparoscopic appendectomy in different clinical conditions. Diagn Ther Endosc 2010:240260.Chow A, Purkayastha S, Paraskeva P. Appendicectomy and cholecystectomy using single-incision laparoscopic surgery (SILS): the first UK experience. Surg Innov 2009;16:211-7.Targarona E M, Pallares J L, Balague C. Single incision approach for splenic diseases: a preliminary report on a series of 8 cases. Surg Endosc 2010;DOI 10.1007/s00464-010-0940-2.Danielson PD, Chandler NM. Single-port laparoscopic repair of a Morgagni diaphragmatic hernia in a paediatric patient: advancement in single-port technology allows effective intracorporeal suturing. J Pediatr Surg; 45:E21-4.Gill IS, Advincula AP, Aron M, et al. Consensus statement of the consortium for laparoendoscopic single-site surgery. Surg Endosc; 24:762-8.Pryor AD, Tushar JR, DiBernardo LR. Single-port cholecystectomy with the TransEnterix SPIDER: simple and safe. Surg Endosc; 24:917-23.Hasson HM. Open laparoscopy. Biomed Bull 1984; 5:1-6.1Tsimoyiannis EC, Tsimogiannis KE, Pappas-Gogos G, et al. Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial. Surg Endosc.Erbella J, Jr., Bunch GM. Single-incision laparoscopic cholecystectomy: the first 100 outpatients. Surg Endosc. 2010 Aug; 24:81958-61Rivas H, Varela E, Scott D. Single-incision laparoscopic cholecystectomy: initial evaluation of a large series of patients. Surg Endosc; 24:1403-12.Edwards C, Bradshaw A, Ahearne P, et al. Single-incision laparoscopic cholecystectomy is feasible: initial experience with 80 cases. Surg Endosc. 2010 Sept 24:9, 2241-2247Chamberlain RS, Sakpal SV. A comprehensive review of single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) techniques for cholecystectomy. J Gastrointest Surg 2009; 13:1733-40.Varadarajulu S, Tamhane A, Drelichman ER. Patient perception of natural orifice transluminal endoscopic surgery as a technique for cholecystectomy. Gastrointest Endosc 2008; 67:854-60.Wiseman JT, Sharuk MN, Singla A, et al. Surgical management of acute cholecystitis at a tertiary care centre in the modern era. Arch Surg; 145:439-44.Jensen AG, Prevedoros H, Kullman E, et al. Peroperative nitrous oxide does not influence recovery after laparoscopic cholecystectomy. Acta Anaesthesiol Scand 1993; 37:683-6.Diamond T, Mole DJ. Anatomical orientation and cross-checking-the key to safer laparoscopic cholecystectomy. Br J Surg 2005;92:663-4.Merchant AM, Cook MW, White BC et al. Transumbilical Gelport access technique for performing single incision laparoscopic surgery (SILS). J Gastrointest Surg 2009; 13:159-62.

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Laparoscopic cholecystectomy was first described and performed by Professor Erich Muhe on 12 September 1985 in Germany.1 This represented a major advancement in surgical technique where four or five much smaller incisions replaced the traditional Kockers incision.The advantages of laparoscopic surgery are well described and include shorter inpatient stay, less postoperative pain, earlier mobilisation, earlier return to work and daily activities and improved cosmesis.2 New techniques have evolved so a single small incision can be used, through which several instruments and the laparoscope, are passed.A number of devices are available to facilitate entry at one site. This incision is invariably hidden in the umbilicus, prompting the use of the term cscarless surgeryd. Initially one skin incision but multiple fascial incisions were used. Subsequently advances in product technology and design allowed one single skin and fascial incision to be madee.g. gelPoint 2122.Single incision laparoscopic cholecystectomy (SILC) surgery was first described in1997 by Navarra et al.3Variable nomenclature exists for this technique but all acronyms describe multiple ports inserted through one incision, often the umbilicus.4To date this technique has been introduced to gynaecological,5 urological, bariatric,6,7 and general surgical disciplines.8 General surgical procedures including appendicectomy,9 splenectomy,10 and hernia repair11 have all been treated successfully in this way. A surgical consortium in the United States has recently been established to coordinate and advance research and development of laparoendoscopic single site (LESS) surgery and to undertake it in a safe and responsible manner.12The unique property of gelPoint is that it creates a platform for a larger outer working surface area thereby enhancing triangulation (Figure 1 and 2). The platform is for incisions in the abdomen ranging from 1.5 to 7 centimetres (cm) and is essentially based on the size of the organ to be removed. The physical properties of the gelSeal platform allow for multiple exchanges without loss of the pneumoperitoneum.The disadvantages of SILC include a variable learning curve which often means, as a consequence a longer operating time. There may also be the need for certain new, disposable and expensive instruments i.e. 30 degree 5 mm scope, reticulating dissectors and/or graspers.13 Using the Alexis gelPoint system and ports alone, the additional cost is small.The next incremental step in improving the short-term cosmetic outcome of the procedure of laparoscopic cholecystectomy may be single incision laparoscopic cholecystectomy.We report the first three cases of this procedure in New Zealand using the gelPoint system and review the current literature on single incision laparoscopic cholecystectomy.Patients and Methods Patient 1A 58-year-old female and part time clerical worker, was listed for a laparoscopic cholecystectomy. Her symptoms were consistent with biliary colic and an ultrasound showed gallstones. Her liver function tests were normal. She had no significant past medical history of note and her medication consisted of paradex, a non steroidal and paroxetine for chronic back pain. Her body mass index (BMI) was 38.1. Patient 2A self-employed 43-year-old male was on the pooled waiting list with a diagnosis of biliary colic. He had radiological evidence of gall stones and a normal common bile duct on ultrasound. His liver function tests were normal. He had no comorbidities and was not on any medication. His BMI was 29.6. Patient 3A 54-year-old female with symptoms suggestive of biliary colic and radiological confirmation of gallstones was on the pooled waiting list for laparoscopic cholecystectomy. Her liver function tests were within normal limits and her common bile duct was of normal calibre. Her comorbidities included hypertension and gout. She had undergone previous surgery in the form of a laminectomy and sympathectomy for Raynauds disease. She was taking simple analgesics for chronic hip pain. She was not employed but was on a welfare benefit following recent back surgery. Her BMI was recorded at 24.7. Surgical Methods General anaesthesic agents and intraoperative analgesia was standardised for all patients. Informed consent was given to all patients for a laparoscopic cholecystectomy including the use of a modified technique, since only a minor modification in technique was being used specific ethical approval was not sought. According to our normal practice an intraoperative cholangiogram was not performed as all patients had normal liver function tests and normal sized common bile duct prior to surgery. All instruments used throughout the dissection were those present on a standard 4 port laparoscopic cholecystectomy tray routinely used in our hospital. The patients had 20 ml of 0.5% Marcaine with adrenaline infiltrated around the umbilicus prior to commencing the procedure. The umbilicus was everted and an incision was made in its centre for a maximum length of 2 cm. This allowed the sheath and peritoneum to be opened under direct vision14 and safe entry to the abdominal cavity. The Alexis 2122 wound retractor was then inserted (Figure 1) and the gelPoint secured to it, with a 10 mm camera trocar and three 5 mm trocars already in position. The trocars were initially placed as instructed (Figure 2) to give an optimal working fulcrum and to avoid clashing of instruments. The ports are inserted into the gel platform but not through the incision, this creates more space and range of movement at the critical point of the incision. If necessary the ports can be removed and repositioned throughout surgery without disturbing the pneumoperitoneum, or impairing working conditions. The view was from the umbilicus rather than the epigastrium but the standard approach to dissection was maintained. Once the gallbladder bed was found to be dry, the gelPoint was disconnected from the Alexis and the specimen was removed through the umbilical wound (Figure 3 and 4). Figures 1 & 2. The Alexis platform and trocars inserted into the gelPoint system (Figure 1 shows the wound retractor in place with a small incision) (Figure 2 shows the gelPoint device attached to the wound retractor) Figure 3 & 4. The gallbladder specimen and the final incision (Figure 3 shows the pathological specimen to be an 11cm large distended gallbladder) (Figure 4 is the final sutured two cm skin incision and the skin imprint of the Alexis retractor platform. This will fade in a couple of hours) Results The mean operating time was 108 minutes [range 703130 (Table 1)]. All patients were discharged 24 hours post procedure with paracetamol and ibuprofen to be taken if required, this was found to be adequate analgesia for each of the three patients. Each patient was telephoned on day-3 and day-10 post surgery and questioned regarding pain scores, activities of daily living and medication. The verbal rating pain scoring system was used where 1 is no pain and 10 represents the worst pain imaginable. Pain scores were generally low and by day 10, little or no pain was recorded in all patients. This mild pain or discomfort was managed with paracetamol only. There were no signs or symptoms suggestive of surgical complications and all patients reported normal gastrointestinal function 72 hours after surgery. Patient 3 required overnight catheterisation postoperatively for acute urinary retention. Finally, all patients were happy with their procedure and were keen to recommend it to a third party (Table 2). Table 1. Pain scores and analgesic requirements Variables Patient 1 Patient 2 Patient 3 Operating time (minutes) Blood loss Pain scores day 1 Pain scores day 3 Pain scores day 10 70 minimal 6/10 135/10 0/10 135 minimal 2/10 2/10 1/10 120 minimal 335/10 235/10 Table 2: General systemic concerns and patient satisfaction, as answered on day Variables Patient 1 Patient 2 Patient 3 Jaundice No No No Nausea No No No Pyrexia No No No Food intake Commenced night of surgery Commenced night of surgery Commenced night of surgery but bloated until day 3 Patient satisfaction with procedure Yes Yes Yes Recommend to third person Yes Yes Yes Discussion Although we initially used this technique in only three patients, our experience was that a laparoscopic cholecystectomy can be performed safely through one, small 2 cm skin and corresponding fascial incision. Operating times were longer through this single incision approach than would be expected for a standard four port technique. As with any new surgical technique there is a learning curve involved whereby the surgeon develops their technique and improves the efficiency of their movements. Internal clashing of instruments sometimes ensued but this was not found to significantly inhibit dissection. With further experience it is likely that this problem would occur less frequently and operating times would reduce accordingly. This assumption is supported by a study by Rivas et al. Which found that their mean operating time fell from 73 minutes for their first 50 patients who underwent a single incision laparoscopic cholecystectomy, compared with the second 50 patents which took a mean operating time of 45 minutes17. There are approximately 50 published articles describing single incision laparoscopic cholecystectomy. However the majority of these studies describe one skin incision and several fascial incisions. Only a small proportion of studies focus on a single skin and fascial incision. Despite the relatively large number of studies of SILC, to our knowledge there is only one randomised controlled trial.15 The remainder of the articles consist of published retrospective studies from specialist academic centres. This reflects the early experience with a new technique. The retrospective studies contain small numbers and easily measured end points such as hospital stay, but subjective endpoints e.g., postoperative pain are not consistently recorded. Not all reports are favourable and some authors believe that SILC does not represent much of an advantage over standard four port technique, particularly in obese patients or those with complications of biliary disease.16 In the randomised controlled trial by Tsimmoyannis et al,15 there was a significant reduction in lower abdominal and shoulder tip pain reported in the SILC group after 12 hours. At 24 hours post cholecystectomy the patients in the SILC group were noted to return to full daily activities. Rivas et al17 showed that scaring from previous abdominal surgery was not a barrier to this technique. There was no conversion to either 4-port laparoscopic or traditional cholecystectomy in over 100 cases and the morbidity rate was very low. In a small proportion of cases the patients had a diagnosis of acute cholecystitis or gallstone pancreatitis. Edwards et al18 retrospectively demonstrated the evolution of this surgical technique from dual incisions early on in the learning curve to a single fascial incision as the expertise of the surgeons grew. They used two transabdominal retraction sutures. These are sutures placed through the abdominal wall and tied extra corporeally to aid retraction of the fundus of the gall bladder. This adaptation, the need to convert and the complications they encountered led them to state that SILC is not necessarily safe and should initially be done only in thin patients with biliary colic. Cephalad retraction with sutures is limited and movement of the left hand is not as flexible as in the gold standard four port technique. They conclude that the view in single incision cholecystectomy is adequate but not necessarily optimal. One hundred consecutive cases from a general surgical unit where cholecystectomy is invariably done as a day case were reviewed by Erbella et al.16 These authors used two fascial incisions 2 cm apart within the umbilicus as well as transabdominal sutures. Single incision multi port laparoscopic (SIMPL) cholecystectomy using existing available equipment was found to be safe in the day case setting. They reported only two cases having to be converted to a traditional four port technique and also reported a very low morbidity rate. However their use of a 5 mm scope and a roticulating dissector may not be considered part of traditional laparoscopic sets in all hospitals. Romanelli reviewed 22 patients.4 These surgeons availed of several new devices from industry, SILS PORT 2122, TriPORT 2122 and the 12 mm Airseal trocar so that one skin and one fascial incision were made. One patient required conversion to the four port technique and one complication occurred. This was an early port site hernia which required further surgery including a bowel resection. Early on in this study several 5mm fascial incisions close together were used. They also used transabdominal retraction sutures to place traction on the gallbladder. The use of retraction sutures is a departure from the standard technique. The newer devices such as gelPointTMnegate the need for this, as several retractors can be passed through the port. Chamberlains comprehensive review of the literature to 2009 concludes that the clinical data is too preliminary to draw any real meaningful conclusions. They conclude that there remain significant ethical, procedural and technological questions with respect to SILC that require answering.19 A study by Varadarajulu et el comparing patients preference when given information about Natural Orifice Transabdominal Endoscopic Surgery (NOTES) Vs traditional four port technique laparoscopic cholecystectomy revealed that although little is known about patient preference, the majority of patients appear willing to undergo a more minimal surgery as long as the complication rate is similar. Those that preferred four port gold standard cholecystectomy stated that the lack of proven safety and efficacy and the unknown complication rate were reasons for not wishing to consider the newer procedure, and were not motivated by the expected advantages of reduction in acute postoperative pain and improved cosmesis.20 For a new technique to translate into surgical practice, in general it must be safe, reproducible, and cost effective and above all represent an improvement in patient care. For it to enter into the everyday surgical repertoire it must also be accepted and driven by both surgeons and patients alike. It must be equivalent or better than the gold standard laparoscopic cholecystectomy. So far there is no evidence in the literature that this is the case as SILC is still in need of a large randomised controlled study to answer this and many other questions. Routine four port laparoscopic cholecystectomy which can be done with reusable instruments in the day case setting has a morbidity of 8%,21 an average inpatient stay of less than 48 hours and an average return to work and daily activities within 2 weeks.22 SILC must at least match if not improve on these parameters. One major disadvantage of SILC is in-line viewing of the operative field. This does away with triangulation. Triangulation has been emphasised as important for four port laparoscopic cholecystectomy. In line viewing means that if one is to follow traditional movements of laparoscopic dissection of Calots trianglei.e. of using the right hand as a dissector and the left hand to manipulate Hartmanns pouch, then during SILC surgery, camera movement can dislodge adjacent instruments and necessitate alteration of the dissecting hand. This is clearly concerning as dissection towards the midline is not favoured in laparoscopic cholecystectomy. It is clear that the tradition of dissecting lateral to the gall bladder sulcus as described by Diamond et al and staying close to the gall bladder itself are safe and well founded.23 Due to restriction in movement and instrument clashing, SILC can potentially compromise basic well established principles of dissection that have been tried and tested in the traditional laparoscopic era. This is clearly a technical difficulty that some surgeons may not be able to overcome. Training, experience, skill and judgement of the operating surgeon, are needed to counteract these technical challenges. Above all, the safe basic principles of laparoscopic surgery that we strived to achieve in order to minimise serious complications should not be compromised. Conversion to four point laparoscopic cholecystectomy from a SILC is considered correct surgical judgement and should not to be deemed a failure. Merchant et al24 describe a standard, reliable and reproducible technique that avoids instrument clashing. This involves the use of the gelPort system. They argue that the ability to reinsert ports without losing the pneumoperitoneum is a clear advantage. This is similar to what we found when using this system. The main complaint from their patient group was of disproportionate post surgical umbilical pain. Conclusion SILC can be safely undertaken with the gelPoint (gelSeal and Alexis) device with a moderate cost increase (less than NZ$500) cost and minimal deviation from standard operating protocol. The extra cost is likely to reduce when more procedures are being performed by this technique. The gains of SILC is likely to be beneficial in terms of cosmesis and slightly better recovery. This may facilitate day case surgery. It would require a large randomised controlled trial to demonstrate an advantage and establish morbidity. The viewpoint of patients and short- and long-term outcomes also need to be evaluated. In the meantime its popularity is likely to be driven, or not, by patient preference. This was the case when laparoscopic cholecystectomy was introduced.

Summary

Abstract

We present the first three reported cases of single incision (through the umbilicus) laparoscopic cholecystectomy in New Zealand. The mean operating time was 108 minutes and all patients were discharged 24 hours after the procedure; they were all satisfied with their procedure and were keen to recommend it. We also provide a review of the international literature on this relatively new technique in New Zealand.

Aim

Method

Results

Conclusion

Author Information

Ian Lord, General Surgical Registrar; Blaithin Page, General Surgical Registrar, Magnus Thorn, General and Colorectal Surgeon; Mark Thompson-Fawcett, General and Colorectal Surgeon; Department of Surgery, Dunedin Hospital, Dunedin

Acknowledgements

Correspondence

Ian Lord, Department of Surgery, Dunedin Hospital, PO Box 1921 Dunedin, New Zealand.

Correspondence Email

lordyian@hotmail.com

Competing Interests

None.

Reynolds W, Jr. The first laparoscopic cholecystectomy. JSLS 2001;5:89-94.Velanovich V. Laparoscopic vs open surgery: a preliminary comparison of quality-of-life outcomes. Surg Endosc 2000;14:16-21.Navarra G, Pozza E, Occhionorelli S et al. One-wound laparoscopic cholecystectomy. Br J Surg 1997;84:695.Romanelli JR, Roshek TB, 3rd, Lynn DC, Earle DB. Single-port laparoscopic cholecystectomy: initial experience. Surg Endosc; 24:1374-9.Capar M, Balci O, Acar A, Colakoglu MC. Management of ovarian cysts by laparoscopic extracorporeal approach using single ancillary trocar. Taiwan J Obstet Gynecol 2009;48:380-4.Nguyen NT, Hinojosa MW, Smith BR, Reavis KM. Single laparoscopic incision transabdominal (SLIT) surgery-adjustable gastric banding: a novel minimally invasive surgical approach. Obes Surg 2008;18:1628-31.Huang CK, Tsai JC, Lo CH, et al. Preliminary Surgical Results of Single-Incision Transumbilical Laparoscopic Bariatric Surgery. Obes Surg.Kossi J, Luostarinen M. Initial experience of the feasibility of single-incision laparoscopic appendectomy in different clinical conditions. Diagn Ther Endosc 2010:240260.Chow A, Purkayastha S, Paraskeva P. Appendicectomy and cholecystectomy using single-incision laparoscopic surgery (SILS): the first UK experience. Surg Innov 2009;16:211-7.Targarona E M, Pallares J L, Balague C. Single incision approach for splenic diseases: a preliminary report on a series of 8 cases. Surg Endosc 2010;DOI 10.1007/s00464-010-0940-2.Danielson PD, Chandler NM. Single-port laparoscopic repair of a Morgagni diaphragmatic hernia in a paediatric patient: advancement in single-port technology allows effective intracorporeal suturing. J Pediatr Surg; 45:E21-4.Gill IS, Advincula AP, Aron M, et al. Consensus statement of the consortium for laparoendoscopic single-site surgery. Surg Endosc; 24:762-8.Pryor AD, Tushar JR, DiBernardo LR. Single-port cholecystectomy with the TransEnterix SPIDER: simple and safe. Surg Endosc; 24:917-23.Hasson HM. Open laparoscopy. Biomed Bull 1984; 5:1-6.1Tsimoyiannis EC, Tsimogiannis KE, Pappas-Gogos G, et al. Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial. Surg Endosc.Erbella J, Jr., Bunch GM. Single-incision laparoscopic cholecystectomy: the first 100 outpatients. Surg Endosc. 2010 Aug; 24:81958-61Rivas H, Varela E, Scott D. Single-incision laparoscopic cholecystectomy: initial evaluation of a large series of patients. Surg Endosc; 24:1403-12.Edwards C, Bradshaw A, Ahearne P, et al. Single-incision laparoscopic cholecystectomy is feasible: initial experience with 80 cases. Surg Endosc. 2010 Sept 24:9, 2241-2247Chamberlain RS, Sakpal SV. A comprehensive review of single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) techniques for cholecystectomy. J Gastrointest Surg 2009; 13:1733-40.Varadarajulu S, Tamhane A, Drelichman ER. Patient perception of natural orifice transluminal endoscopic surgery as a technique for cholecystectomy. Gastrointest Endosc 2008; 67:854-60.Wiseman JT, Sharuk MN, Singla A, et al. Surgical management of acute cholecystitis at a tertiary care centre in the modern era. Arch Surg; 145:439-44.Jensen AG, Prevedoros H, Kullman E, et al. Peroperative nitrous oxide does not influence recovery after laparoscopic cholecystectomy. Acta Anaesthesiol Scand 1993; 37:683-6.Diamond T, Mole DJ. Anatomical orientation and cross-checking-the key to safer laparoscopic cholecystectomy. Br J Surg 2005;92:663-4.Merchant AM, Cook MW, White BC et al. Transumbilical Gelport access technique for performing single incision laparoscopic surgery (SILS). J Gastrointest Surg 2009; 13:159-62.

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