Remains of the day:Biliary complications related to single-port laparoscopic cholecystectomy

AIM:To assesse the rate of bile duct injuries(BDI)and overall biliary complications during single-port laparoscopic cholecystectomy(SPLC)compared to conventional laparoscopic cholecystectomy(CLC).METHODS:SPLC has recently been proposed as an innovative surgical approach for gallbladder surgery.So far,its safety with respect to bile duct injuries has not been specifically evaluated.A systematic review of the literature published between January 1990 and November 2012 was performed.Randomized controlled trials(RCT)comparing SPLC versus CLC reporting BDI rate and overall biliary complications were included.The quality of RCT was assessed using the Jadad score.Analysis was made by performing a meta-analysis,using Review Manager 5.2.This study was based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.A retrospective study including all retrospective reports on SPLC was also performed alongside.RESULTS:From 496 publications,11 RCT including 898patients were selected for meta-analysis.No studies were rated as high quality(Jadad score≥4).Operative indications included benign gallbladder disease operated in an elective setting in all studies,excluding all emergency cases and acute cholecystitis.The median follow-up was 1 mo(range 0.03-18 mo).The incidence of BDI was 0.4%for SPLC and 0%for CLC;the difference was not statistically different(P=0.36).The incidence of overall biliary complication was 1.6%for SPLC and 0.5%for CLC,the difference did not reached statistically significance(P=0.21,95%CI:0.66-15).Sixty non-randomized trials including 3599 patients were also analysed.The incidence of BDI reported then was 0.7%.CONCLUSION:The safety of SPLC cannot be assumed,based on the current evidence.Hence,this new technology cannot be recommended as standard technique for laparoscopic cholecystectomy.

NOTES new frontier:Natural orifice approach to retroperitoneal disease

AIM: To develop a pure transvaginal access to the retroperitoneum, that is simple, reproducible and uses endoscopic material available on the market. METHODS: From February 2008 to April 2009, 31 pigs were operated on, with 17 as an acute experiment and 14 with a survival protocol. The animals were placed in a supine position and a 12-mm double-channel endoscope (Karl StorzTM, Tuttlingen) was used for vision and dissection. During the same time period, the access experiment was reproduced on 3 human cadavers using material similar to that used in the animal model. RESULTS: In the animal model, 37 interventions were done on the kidney, adrenal gland and pancreas. The mean time to fashion the access was 10 min (range 5 to 20 min). No intraoperative death was observed. Two major (5%) intraoperative complications occurred: one hemorrhage on the aorta and one tearing of the right renal vein. Peritoneal laceration was encountered in 5 cases without impairing the planned task. In the survival group, good clinical outcome was observed at a mean follow-up of 3 wk (range 2 to 6 wk). In the 3 cadavers, access was performed correctly. The mean time to fashion the access was 52 min (range 40 to 60 min). All the anatomical landmarks described in the pig model were clearly identified in the same sequence. CONCLUSION: A retroperitoneal natural orifice translumenal surgical transvaginal approach is feasible in both animal and human models and allows performance of a large panel of interventions.

Transgastric cholecystectomy:From the laboratory to clinical implementation

After the first report by Kalloo et al on transgastric peritoneoscopy in pigs,it rapidly became apparent that there was no room for an under-evaluated concept and blind adoption of an appealing(r)evolution in minimal access surgery.Systematic experimental work became mandatory before any trans lation to the clinical setting.Choice and management of the access site,techniques of dissection,exposure,retraction and tissue approximationsealing were the basics that needed to be evaluated before considering any surgical procedure or study of the relevance of natural orifice transluminal endoscopic surgery(NOTES).After several years of testing in experimental labs,the revolutionary concept of NOTES,is now progressively being experimented on in clinical settings.In this paper the authors analyse the challenges,limitations and solutions to assess how to move from the lab to clinical implementation of transg astric endoscopic cholecystectomy.