Evaluation of the role of single incision laparoscopic cholecystectomy (SILC) for the management of chronic calculous cholecystitis

Evaluation of the role of single incision laparoscopic cholecystectomy (SILC) for the management of chronic calculous cholecystitis

Abdel Hamid Ghazal, MD

GIT Surgical Unit, General Surgery Department, University of Alexandria, Egypt.

Background:     Laparoscopic     cholecystectomy     has     become    the   gold     standard     for cholecystectomy.  Single-incision  laparoscopic  operations  have  recently  emerged  as  a less invasive alternative to conventionallaparoscopy as the tendency of minimizing surgical trauma encourages the use of new approaches in laparoscopic surgery which has the potential of further reducing the trauma  of surgical access. This  may  lead to reduced  post operative  pain and improved patient cosmesis.  Single-incision  laparoscopic  surgery (SILS) is a rapidly evolving field as a bridge between  traditional  laparoscopic  surgery and natural  orifice transluminal endoscopic surgery (NOTES). The aim of this work was to evaluate the role of SILC  for the management of chronic calculous cholecystitis as regards its feasibility and outcome.

Patients   and  methods:  Between  January  2010  and  January  2014,  120  patients  were subjected to SILC. A single 2.5cm long semicircular supraumbilical skin incision was used. Pneumoperitoneum was  established  with the Veress access  needle.  Abdominal  cavity  was entered through three trocars: 10-mm trocar for camera and two 5-mm trocars, each placed

1-2cm laterally and cranially from the 10-mm trocar, with carefully placed sutures to puppeteer the gall bladder and thus aid retraction.

Results: In this series, out of 120 patients, 90 patients (75%) were females, and the remaining

30 patients (25%) were males, with an average age of 32.8 years (range, 23-60 years), and 36 female patients had undergone previous lower abdominal  surgery (Cesarean  section or other gynecological procedures). Mean operative time was 58.6 min (range 40-120 min). Out of 120 patients, 106 patients (88.3%) successfully underwent SILC. In 10 patients (8.3%) an additional epigastric port was used, in 3 patients (2.5%) conversion to the traditional4-port laparoscopic technique was done, and conversion to open surgery was done in one patient.

Conclusions:  SILC  using   conventional   laparoscopic   instrumentation   is  an  effective alternative to standard four-incision  laparoscopic  cholecystectomy  in selected patients,  it is safe, feasible, and reproducible. The operating times are reasonable and can be lessened with experience.

Key words:  Laparoscopic  cholecystectomy;  single-incision  laparoscopic  surgery;  single­

incision laparoscopic cholecystectomy;  natural orifice transluminal endoscopic surgery.

Introduction:

Chronic calculus cholecystitis has been encountered as a common health problem, at first it was treated by open procedure but really this procedure has a lot of disadvantages like ugly  scar, possibility  of  developing  hernia, post operative pain, and long stay in hospital.l With the advent of laparoscopy, laparoscopic surgical techniques  have transformed  much of surgery over recent decades, this minimal access techniques allow extensive operations to be performed with little trauma.l  Thus enabled  this  procedure  to  gain  rapid worldwide acceptance as a result of better cosmetic  results,  less  post  operative  pain, and shorter recovery time than with open procedures.2

Since  the  introduction   of  laparoscopic cholecystectomy  as the gold standard procedure to remove the gallbladder, many surgeons  have  attempted  to  reduce  the number and size of ports in laparoscopic cholecystectomy to decrease parietal trauma and  improve  cosmetic  results.These  efforts are some of the fundamentals  of the natural orifice trans-luminal  endoscopic surgery (NOTES) approach,3-6 which removes trans­ abdominal incisions completely, but NOTES is technically challenging and current instruments  needed to be further  improved. As a bridge between traditionallaparoscopic surgery  and  NOTES,  the  recent  focus  has been on the development of single-incision laparoscopic surgery (SILS) to further minimize the invasiveness of laparoscopic surgery by reducing the number of incisions.7

Single  mc1s1on laparoscopic   surgery (SILS)   was   developed   with   the   aim   of reducing the invasiveness of traditional laparoscopy. It can be performed  using the same instruments used for conventional laparoscopic  procedures,   surgeons  can perform SILS without any new instruments, SILS may offer the advantages of reduced postoperative    pain   and   more   cosmesis.l SILC  appears  to  provide  outcomes  similar to standard laparoscopic cholecystectomy, technically feasible alternative, but it is more difficult.2

First experience  with SILC  was reported by Navarra et al8 and with a different approach by Piskun and Rajpai.9 Technical limitations postponed  the full  extent  of  its application until recently, when articulating and bent laparoscopic instruments and modified ports have become commercially available.lO

We reported a series of 120 single-incision laparoscopic cholecystectomies utilizing a single umbilical incision to evaluate its role in management of chronic calculus cholecystitis. Primary   end   points   were   feasibility   and safety. We described the challenges that we faced and the evolution of our techniques.

Patients and methods:

Patient selection:  Between  January  2010 and January 2014, 120 patients with chronic calculus cholecystitis (proved by ultrasound) were admitted to the Upper Gastrointestinal Surgery Unit, Alexandria Main University Hospital. They underwent single-incision laparoscopic cholecystectomy. Patients who underwent   this   procedure   were   informed about the procedure, and an informed consent was obtained  from every patient  before carrying the procedure.

Operative technique: Patients were positioned on the operating table in a reverse Trendelenburg,  right  side  up  pos1t10n. Patients  were  draped  in a standard  manner. A single semicircular supraumbilical skin incision 2.5 em long was made. The incision should not breach the umbilical ring. After exposing  the  fascia,  a  Veress  needle  was placed  into  the  peritoneum  and  insufflated up to 15 mm Hg with C0 . Three ports were placed within the umbilical incision in a triangular    configuration    (single   incision), one  10-mm  trocar  through  which  a 10-mm 30-degree  camera  was then  introduced  and the  abdominal   cavity   was  explored.   Two 5-mm trocars each placed 1-2cm laterally and cranially from the 10-mm trocar  Figure (1), or single port technique that allows insertion of two hand instruments and an optic through the same port Figure (2). The first operator should now stand between the patient's legs with the assistant holding the laparoscope on the patient's  left hand side.

Retraction     and    manipulation     of    the gallbladder were achieved with the use of (2/0 prolene; Ehicon) on a straight cutting needle introduced through the abdominal wall. These sutures were passed through the gallbladder before being pushed out of the abdominal cavity again. Careful suture placement allows the  operator  to "puppeteer" the  gallbladder thus replicating the movement that would normally   be  performed   by  the   surgeon's left hand in a traditional  laparoscopic cholecystectomy.

We  choose  to  place  our  sutures  in  the following manner. The fundus of the gallbladder  was grasped  and elevated  to the anterior abdominal wall. The fundus was pushed cranially to demonstrate the desired exposure ofthe undersides ofthe gallbladder and   liver.  Simultaneous   palpation   of  the abdominal  wall  demonstrates  the  optimum site for insertion of the first suture, which was placed  as high  as  possible  while  avoiding the pleura. A 2/0 prolene suture on a straight cutting  needle  was  pushed  vertically  down into the abdomen under direct laparoscopic surveillance, the needle was taken by a laparoscopic  needle-holder   and  passed through the fundus of the gallbladder  before being passed back up through the abdominal wall  as  close  as  possible  to  the  point  of entry. The second  suture  was introduced  in the epigastric region under direct vision. A laparoscopic needle holder was used to pass the suture needle through the Hartmann's pouch,   the   needle   was   then   passed   out through   the   lateral   right   abdominal   wall (when needed). Intra-abdominally, titanium clips were placed  on the suture at the entry and exit points from Hartmann's  pouch using a clip applicator.

Dissection ofthe Calot's'triangle now can proceed. The goal of operative procedure was the same as with the conventionallaparoscopy, i.e., dissection of the gall bladder until the critical view of safety was obtained, followed by transection of cystic duct and artery and removal of the gallbladder. The critical view of safety was obtained when the triangle of Calot was dissected free of all tissues, except for the  cystic  duct and artery, and the  base of the liver was exposed. This was done by dissection of the gallbladder hilum with a Maryland dissector to expose the cystic duct and artery which were clipped using a 5-mm clip applier, and then divided with scissors, or by using 5-mm 30 degree camera and 10-mm clip applier, or by using the Harmonic Scalpel (Ethicon Endo Surgery) which is known as clipless laparoscopic cholecystectomy.

Dissection   of   the   gallbladder   off   the liver bed was performed with the Maryland dissector  and  hook  electrocautery.  At  this point, the  1Omm camera  was exchanged  by 5mm  camera,  and the  gallbladder  was then extracted from the abdominal cavity through the 10-mm port.  

Results:

Operative     Results:      One-hundred     and twenty   patients  were  selected  to  undergo single-incision laparoscopic cholecystectomy between  January  2010  and  January  2014. Out of 120 patients, 90 patients (75%) were females, and the remaining 30 patients (25%) were males, with an average age of32.8years (range, 23-60 years), and 36 out of90 female patients (40%) had undergone previous lower abdominal surgery (Cesarean section or other gynecological procedures). Mean operative time was 58.6 min (range 40-120 min).

Out of 120 patients, 106 patients (88.3%) successfully underwent single-incision laparoscopic cholecystectomy  either through a three-channel  device or three individual trocars. The three-port technique, with placement  of the  camera  inferiorly  and  the two working ports at 2 and 10 o'clock,  was the most consistently successful arrangement in  our   series.   This   arrangement   allowed for ergonomics similar to conventional laparoscopy, with the surgeon using two hands to control inline, un-crossed  instruments. Using this technique, we rarely required more than one retraction suture of the remaining patients,  an  additional  epigastric  5mm working trocar was used in 10 patients (8.3%) due  to  failure  to  progress  in  a  reasonable time, and difficulty to obtain safe dissection of  the  cystic  duct  and  artery   particularly in  the  early  learning  curve.  In  3  patients (2.5%), conversion to the standard four-port laparoscopic cholecystectomy due to dense adhesion  as a results  of acute cholecystitis, and therefore difficult to identify anatomic landmarks through the single-incision technique. In one patient (0.83%) conversion to  open  cholecystectomy   was required  due to suspected  common bile duct injury at the time of dissection of the cystic duct, after conversion;  with  careful  dissection  of  the cystic duct, the tear was found in the cystic duct near its junction  with the common  bile duct, but it was still safe to close the cystic duct with running suture without encroaching on the  common  bile  duct  with the  help  of intra-operative cholangiogram.

Early      complications:      Three     patients suffered  from  early  complications,  one female  patient  had asymptomatic  seroma  at the port-site, and she was treated by aspiration and prophylactic antibiotic. The other two patients had port-site wound infections, requiring a course of antibiotic  and frequent daily dressings. All patients returned to their preoperative activity level.

Delayed      complications:      Follow       up information from the clinic visits one month up  to  six months  post-operatively  was available for the majority of patients (112 patients). Four   patients   had   late   complications.

One  female  patient  who  was a  40-year  old returned back to the Emergency Department three weeks post- operative with right upper quadrant  pain  and  fever.  The  white  blood cell   count   was   elevated   to   24,000/cmm. Computed tomography  demonstrated  3x2cm fluid collection within the gall bladder fossa. She was treated empirically with intravenous antibiotic after performing ERCP that showed no leakage and the patient was discharged to her home on hospital day 3 on oral antibiotic.

Two  patients  presented  with  right  upper quadrant    pain    associated    with    nausea and    vomiting    with    mild    elevation    of serum bilirubin and alkaline phosphatase. Ultrasonography     showed     no     abnormal signs in the two patients, however magnetic resonance   cholangiopancreatography (MRCP) showed a retained common bile duct stone; ERCP with sphincterotomy and stone retrieval was performed and the two patients were discharged from the hospital.

The  last  patient   returned   back  after  6 months with an incisional hernia at the port­ site, she was treated by mesh repair.

Discussion:

SILC  is  a  new  step  in  minimally invasive surgery. The fact that laparoscopic cholecystectomy is currently the gold standard and is performed literally at almost every hospital worldwide, being considered safe and cost effective, should not prevent its further technical  evolution. The benefit of transition from standard laparoscopic approach to SILC will not be as visible as it was for the transition from open to laparoscopic cholecystectomy. However,  as  stated  in  a  study  performed by Bisgaard  et al, 11 further  minimization  is justified. It cannot be over stated that every incision  and  trocar  placement  poses  a  risk of bleeding, organ damage and incisional hernia. Moreover, since cosmetic effect is increasingly important to patients, we should not neglect cosmetic improvement with SILS, especially when SILS is performed within the umbilicus. 12·13

Single-incision transumbilicallaparoscopic cholecystectomy  was first described in Italian literature in 1995.8 In 1997, Navarra et al8 published the first case series of 30 patients who underwent what they described as "one­ wound   laparoscopic   surgery".   In  the   last several  years,  there  has  been  a  resurgence of popularity of SILS. Gumbs et ai14 Cuesta et  al15 and  the  most  recently  Tacchino  et ai2  have   reported   their   experience   with single incision transumbilical laparoscopic cholecystectomies. Although NOTES was introduced  as  a  new  surgical  concept  that would share the same benefits conferred by conventional minimally invasive surgery but without scars and perhaps with considerable minimal  pain  to  none  at  all.16-20 But  all these theoretical advantages have spurred widespread  research  and investigation forward, with extensive financial and scientific investment  allocated to  NOTES. In contrast to NOTES, SILS does not require the opening of hollow organ, such as stomach,  colon, or vagina. Thus, complication related to visceral closure, such as gastrotomy or colostomy leakage,   are  avoided.   Moreover;  in  SILS access  to the  abdominal  cavity  is obtained by one small incision, which is concealed perfectly  when  placed transumbilical. Through  this  one  port,  several  instruments can be inserted and changed without loss of pressure of the pneumoperitoneum. 21,22

Performing  laparoscopic  surgery through SILS  seems  more  intuitive  than  NOTES, especially  for  the  surgeons  who  routinely perform  laparoscopic  surgery  and  may  not have   the   sophisticated   infrastructure   that NOTES may require. This surgical concept of laparoscopy  through a single  incision seems itself a bridge to NOTES because it promises the  absence  of  visible  scar  and  potentially

Figure (1): Single incision laparoscopic cholecystectomy

Figure (2): Single port laparoscopic cholecystectomy.

less pain than conventionallaparoscopy.23,24

The   major   difficulty  with  SILS  stems fi:om the need for the surgeon to adapt to the new method of instmmentation. The SILS technique is not naturallyergonomic technique because the traditionallaparoscopic principles of t:Iiangulation are lost, because both the operating  inst:Iuments and laparoscope  are inn·oduced tluough  the  same  incision,  and on the same axis, the operator  and assistant often impede  the movements  of each other. This is not helped by cunent insn·umentation, which has not been designed with the single­ incision approach in mind. Inst:Iuments often interfere with each other not only within the abdomen but also extra-abdominally, where attachments  such  as  the  camera  light  lead often impede movements.25 And that we had faced at the beginning of our work, and at the use of the tluee-channel  device. This makes clear  and  accurate  communication  between the surgeon and assistant essential.

In our series, the use of 2- to 3-cm periumbilical  incision  consistently  allowed for the placement  of up to tluee  n·ocars in a  single  skin  incision,  with  approximately 3-cm  distance  between  n·ocars. The  tluee­ pmt technique, with the placement of the camera infetiorly  and the two working ports at 2 and 10 o'clock, was the most consistently successful anangements in our series. This anangement allowed for ergonomics similar to conventionallaparoscopy, with the surgeon using two hands to conn·ol inline, uncrossed inst:Iuments. We experienced some difficulties in obtaining a satisfactmy exposure, when several adhesions between the duodenum, the infetior aspect of the liver and the gallbladder particularly in the presence of acute or sub­ acute inflammation or distended n·ansverse colon  covered  the  infundibulum,  therefore in cettain cases we needed to add additional n·ocar in the epigast:Iium in 10 patients, or we used the miginal  four n·ocars technique in 3 patients.

At the end of the procedure, a careful reconst:Iuction of the umbilicus  will allow it to be replaced to its miginal position, thus achieving a completely invisible scar. The percutaneous stitches used for gallbladder suspension  leave  no scar  in  the abdominal wall, and thus we can claim  a "non  visible scar" procedure.

Our results are similar to those previously presented in the literature,15,21,24 we used the conventionallaparoscopic inst:Iuments, we did not perform inn·a-operative cholangiograms (IOC)  during  the procedure  of SILC.  Over the course of this series, our operative time improved from  an  average  120  minutes  for the  first  quarter   of  cases,  to  an  average   80 minutes  for  the  second  quarter   of  cases,  to an  average  55  minutes  in the  third  quarter, and  to just  40 minutes  for  the  final  quarter. We experimented in the beginning with different  techniques including retraction with two stay suture, then retraction with only one stay  suture  placed  at the  fundus,  the  use  of the  three-channel device,  Harmonic scalpel and the use of 5mm clip applier. However  it quickly became obvious that the use of single retraction suture,  three  port  SILS,  and  the use of Harmonic scalpel facilitate the ease of dissection and removal  of the gallbladder. We have also adopted the use of an extracorporeal stay  suture  to  assist  in  cephalad retraction, and  there  was  a minimal  bile  spillage  from the placement  ofthis stitch.

In our experience good haemostasis is essential for  SILC  till  the  critical   view  of safety  is obtained  at the  time  of  removal  of the  gallbladder from  its  bed.  If haemostasis is  difficult  to  control   with  SILS  approach, we advocate the insertion of additional laparoscopic trocars,  with conversion to an open  procedure  if deemed  necessary.

To conclude, SILS should  be done  by surgeons  experienced in laparoscopy. Proper patient selection is also of great importance to reduce  the rate of conversion until acquiring adequate experience as a result of the conflict between the operative  instruments, and the camera and the smaller degree of instrument triangulation compared to that of conventional laparoscopic surgery.

Despite    this    limitation,   single-incision laparoscopic      cholecystectomy      1s    safe, feasible, and quite reproducible in experienced hands.   This  technique  can  be  applied   for the   management  of   patients   in  outpatient surgery  centers  because  most  of  them  may not  have   a  complex  disease.   Furthermore, with  progressive experience, more  complex patients  may  be suitable  candidates for  this technique. The  outcomes  seem  comparable with   those    of   conventional   laparoscopic techniques, with  similar  minimal   morbidity and no mortality  in our series.

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