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).

Laparoendoscopic single-site cholecystectomy vs three-port laparoscopic cholecystectomy: A large-scale retrospective study

AIM: To perform a large-scale retrospective comparison of laparoendoscopic single-site cholecystectomy (LESSC) and three-port laparoscopic cholecystectomy (TPLC) in a single institution. METHODS: Data were collected from 366 patients undergoing LESSC between January 2005 and July 2008 and were compared with the data from 355 patients undergoing TPLC between August 2008 and November 2011 in our department. Patients with body mass index greater than 35 kg/m2 , a history of major upper abdominal surgery, signs of acute cholecystitis, such as fever, right upper quadrant tenderness with or without Murphy's sign, elevated white blood cell count, imaging findings suggestive of pericholecystic fluid, gallbladder wall thickening > 4 mm, and gallstones > 3 cm, were excluded to avoid bias. RESULTS: Altogether, 298 LESSC and 315 TPLC patients met the inclusion criteria. The groups were well matched with regard to demographic data. There were no significant differences in terms of postoperative complications (contusion: 19 vs 25 and hematoma at incision: 11 vs 19), hospital stay (mean ± SD, 1.4 ± 0.2 d vs 1.4 ± 0.7 d) and visual analogue pain score (mean ± SD, 8 h after surgery: 2.3 ± 1.4 vs 2.3 ± 1.3 and at day 1: 1.2 ± 0.4 vs 1.3 ± 1.2) between the LESSC and TPLC patients. Four patients required the addition of extra ports and 2 patients were converted to open surgery in the LESSC group, which was not significantly different when compared with TPLC patients converted to laparotomy (2 vs 2). LESSC resulted in a longer operating time (mean ± SD, 54.8 ± 11.0 min vs 33.5 ± 9.0 min), a higher incidence of intraoperative gallbladder perforation (56 vs 6) and higher operating cost (mean ± SD, 1933.7 ± 64.4 USD vs 1874.7 ± 46.2 USD) than TPLC. No significant differences in operating time (mean ± SD, 34.3 ± 6.0 min vs 32.7 ± 8.7 min) and total cost (mean ± SD, 1881.3 ± 32.8 USD vs 1876.2 ± 33.4 USD) were found when the last 100 cases in the two groups were compared. A correlation was observed between reduced operating time of LESSC and increased experience (Spearman rank correlation coefficient, -0.28). More patients in the LESSC group expressed satisfaction with the cosmetic result (98% vs 85%). CONCLUSION: LESSC is a safe and feasible procedure in selected patients with benign gallbladder diseases, with the significant advantage of cosmesis.

Single port laparoscopic right hemicolectomy for ileocolic intussusception

A 36-year-old male was admitted with right lower abdominal pain and diarrhea for more than 3 mo. Colonoscopy and a barium enema study revealed a submucosal tumor over the cecum, but computed tomography showed an ileal lipoma. There was no definitive diagnosis preoperatively, but ileocolic intussusception was noted during surgery. Single port laparoscopic radical right hemicolectomy was performed because intra-operative reduction failed. The histological diagnosis of the resected tumor was lipoma. Single port laparoscopic surgery has recently been proven to be safe and feasible. There are advantages compared with conventional laparoscopic surgery, such as smaller incision wounds, fewer port site complications, and easier conversion. However, there are some drawbacks which need to be overcome, such as difficulties in triangulation and instrument clashing. If there are no contraindications to laparoscopy, single port laparoscopic surgery can be performed safely and should be considered for diagnosis and treatment of intussusception in adults. Here, we report the first case of ileocolic intussusception successfully treated by single port laparoscopic surgery.

Single port laparoscopy in gastroenterology and hepatology: A fine step forward

Single incision laparoscopy(SIL) has become an emerging technology aiming at a further reduction of abdominal wall trauma in minimally invasive surgery. Available data is encouraging for the safe application of standardized SIL in a wide range of procedures in gastroenterology and hepatology. Compared to technically simple SIL procedures, the merit of SIL in advanced surgeries, such as liver or colorectal interventions, compared to conventional laparsocopy is self-evident without any doubt. SIL has already passed the learning curve and is routinely utilized in expert centers. This minimized approach has allowed to enter a new era of surgical management that can not be acceded without a fruitful combination of prudent training, consistent day-to-day work and enthusiastic motivation for technical innovations. Both, basic and novel technical specifics as well as particular procedures are described herein. The focus is on the most important surgical interventions in gastroenterology and aims at reviewingthe current literature and shares our experience in a high volume center.

Single port laparoscopic right hemicolectomy with D3 dissection for advanced colon cancer

We report the first case of single port laparoscopic right hemicolectomy for advanced colon cancer.An abdominal 3 cm length incision was made via the umbilicus.A small wound retractor and a surgical glove were used as a single port.All soft tissue anterior to the superior mesenteric vein was completely removed and D3 lymph node dissection was achieved.The total operative time was 180 min with minimal blood loss (<50 mL).The size of the tumor was 5 cm×3 cm and its tumor stage was T3N0.Sixty-nine lymph nodes were harvested and none were positive.We believe that single port surgery for colon cancer is a feasible and safe procedure with surgical results comparable to conventional laparoscopic procedures.

Initial experience of single-incision plus one port left-side approach totally laparoscopic distal gastrectomy with uncut Roux-en-Y reconstruction

BACKGROUND Single incision plus one port left-side approach(SILS+1/L)totally laparoscopic distal gastrectomy(TLDG)is an emerging technique for the treatment of gastric cancer.Reduced port laparoscopic gastrectomy has a number of potential advantages for patients compared with conventional laparoscopic gastrectomy:relieving postoperative pain,shortening hospital stay and offering a better cosmetic outcome.Nevertheless,there are no previous reports on the use of SILS+1/L TLDG with uncut Roux-en-Y(uncut R-Y)reconstruction.AIM To investigate the initial feasibility of SILS+1/L TLDG with uncut Roux-en-Y digestive tract reconstruction(uncut R-Y reconstruction)to treat distal gastric cancer.METHODS A total of 21 patients who underwent SILS+1/L TLDG with uncut R-Y reconstruction for gastric cancer were enrolled.All patients were treated at The Second Hospital of Shandong University.Reconstructions were performed intracorporeally with 60 mm endoscopic linear stapler and 45 mm no-knife stapler.The clinicopathological characteristics,surgical details,postoperative short-term outcomes,postoperative follow-up upper gastrointestinal radiography findings and endoscopy results were analyzed retrospectively.RESULTS All SILS+1/L operations were performed by SILS+1/L TLDG successfully.The patient population included 13 men and 8 women with a mean age of 48.2 years(ranged from 40 years to 70 years)and median body mass index of 22.8 kg/m^2.There were no conversions to open laparotomy,and no other port was placed.The mean operation time was 146 min(ranged 130-180 min),and the estimated mean blood loss was 54 mL(ranged 20-110 mL).The mean duration to flatus and discharge was 2.3(ranged 1-3.5)and 7.3(ranged 6-9)d,respectively.The mean number of retrieved lymph nodes was 42(ranged 30-47).Two patients experienced mild postoperative complications,including surgical site infection(wound at the navel incision)and mild postoperative pancreatic fistula(grade A).Follow-up upper gastrointestinal radiography and endoscopy were carried out at 3 mo postoperatively.No patients experienced moderate or severe food stasis,alkaline gastritis or bile reflux during the follow-up period.No recanalization of the biliopancreatic limb was found.CONCLUSION SILS+1/L TLDG with uncut R-Y reconstruction could be safely performed as a reduced port surgery.

Single-port laparoscopic cholecystectomy vs standard laparoscopic cholecystectomy:A non-randomized,agematched single center trial

AIM: To compare the safety of single-port laparoscopic cholecystectomies with standard four-port cholecystectomies.METHODS: Between January 2011 and December 2012 datas were gathered from 100 consecutive patients who received a single-port cholecystectomy. Patient baseline characteristics of all 100 single-port cholecystectomies were collected(body mass index, age, etc.) in a database. This group was compared with 100 age-matched patients who underwent a conventional laparoscopic cholecystectomy in the same period. Retrospectively, per- and postoperative data were added. The two groups were compared to each other using independent t-tests and χ2-tests, P values below 0.05 were considered significantly different.RESULTS: No differences were found between both groups regarding baseline characteristics. Operating time was significantly shorter in the total single-port group(42 min vs 62 min, P < 0.05); in procedures performed by surgeons the same trend was seen(45 min vs 59 min, P < 0.05). Peroperative complications between both groups were equal(3 in the single-port group vs 5 in the multiport group; P = 0.42). Although not significant less postoperative complications were seen in the single-port group compared with the multiport group(3 vs 9; P = 0.07). No statistically significant differences were found between both groupswith regard to length of hospital stay, readmissions and mortality. CONCLUSION: Single-port laparoscopic cholecystectomy has the potential to be a safe technique with a low complication rate, short in-hospital stay and comparable operating time. Single-port cholecystectomy provides the patient an almost non-visible scar while preserving optimal quality of surgery. Further prospective studies are needed to prove the safety of the single-port technique.

Technical and instrumental prerequisites for single-port laparoscopic solo surgery:state of art

With the aid of advanced surgical techniques and instruments, single-port laparoscopic surgery(SPLS) can be accomplished with just two surgical members: an operator and a camera assistant. Under these circumstances, the reasonable replacement of a human camera assistant by a mechanical camera holder has resulted in a new surgical procedure termed singleport solo surgery(SPSS). In SPSS, the fixation and coordinated movement of a camera held by mechanicaldevices provides fixed and stable operative images that are under the control of the operator. Therefore, SPSS primarily benefits from the provision of the operator's eye-to-hand coordination. Because SPSS is an intuitive modification of SPLS, the indications for SPSS are the same as those for SPLS. Though SPSS necessitates more actions than the surgery with a human assistant, these difficulties seem to be easily overcome by the greater provision of static operative images and the need for less lens cleaning and repositioning of the camera. When the operation is expected to be difficult and demanding, the SPSS process could be assisted by the addition of another instrument holder besides the camera holder.

Single port laparoscopic liver surgery:A minireview

Nowadays,the trend is to perform surgeries with"scarless"incisions.In light of this,the single-port laparoscopic surgery(SPLS)technique is rapidly becoming widespread due to its lack of invasiveness and its cosmetic advantages,as the only entry point is usually hidden in the umbilicus.The interest in"scarless"liver resections did not grow as rapidly as the interest in other scarless surgeries.Hepatopancreatobiliary surgeons are reluctant to operate a malignant lesion through a narrowincision with limited exposure.There are concerns over adverse oncological outcomes for single-port laparoscopic liver resections(SPL-LR)for hepatocellular carcinoma or metastatic colorectal cancer.In addition,getting familiar with using the operating instruments through a narrow incision with limited exposure is very challenging.In this article,we reviewed the published literature to describe history,indications,contraindications,ideal patients for new beginners,technical difficulty,advantages,disadvantages,oncological concern and the future of SPL-LR.

A Prospective Study Comparing Quality of Life and Cosmetic Results between Single-Port and Conventional Laparoscopic Cholecystectomy

Background: Multiple studies from the last five years have demonstrated that single-incision laparoscopic surgery cholecystectomy (SILS) is not only feasible but also produces a result comparable with that of conventional laparoscopic cholecystectomy (CLC). Methods and results: In this bicentric study, we used the Short Form (36) (SF-36) and Nottingham Health Profile (NHP) surveys to estimate and compare the post-operative quality of life up to the 28th post-operative day for 66 patients who had undergone either CLC (n = 32) or SILS (n = 34). Additionally, we investigated patient satisfaction with the cosmetic results after one year. The curves summarizing the eight sections in the physical sum scale and in the mental sum scale (SF-36) were the same within the confidence interval with a confidence level of 95%. Thus, post-operative quality of life could be assumed to be equivalent for the two groups. Evaluation of the NHP survey produced similar results. The perceived cosmetic results were significantly better for the SILS group (1.3 on a scale of 1 - 5 with 1 being the best) than for the CLC group (1.9) (p = 0.016). Conclusions: This study did not demonstrate better quality of life for the single-port procedure as it had been expected. Instead, the single-port procedure produced subjectively better cosmetic results.

Single-port laparoscopic surgery for sigmoid volvulus

AIM:To report our experience with single-port laparoscopic surgery(SPLS)for sigmoid volvulus(SV).METHODS:Between October 2009 and April 2013,10patients underwent SPLS for SV.SPLS was performed transumbilically or through a predetermined stoma site.Conventional straight and rigid-type laparoscopic instruments were used.After intracorporeal,segmental resection of the affected sigmoid colon,the specimen was extracted through the single-incision site.Patientdemographics and perioperative data were analyzed.RESULTS:SPLS for SV was successful in all 10 patients(4,resection and primary anastomosis;6,Hartmann’s procedure).The median operative time and postoperative hospitalization period were 168(range,85-315)min and 6.5(range,4-29)d,respectively.No intraoperative complications were noted;there were 2 postoperative complications,including 1 anastomotic leak.CONCLUSION:SPLS was a safe and feasible therapeutic approach for SV,when performed by a surgeon experienced in conventional laparoscopic surgery.

Evaluation of the Single-Port Laparoscopic Right Hemicolectomy Learning Curve

Background: The use of single-port laparoscopy has gained popularity within recent years. Part of the appeal in learning this approach is that it draws heavily from concepts mastered through conventional laparoscopy. Various studies have shown the efficacy and feasibility of the single-port laparoscopic approach, but there are few that examine the learning curve in adopting this new technique. Objective: Our goal was to better define the learning curve in performing a single-port laparoscopic right hemicolectomy. Design: A review of prospectively gathered operative data was performed to analyze the results of single-port laparoscopic right hemicolectomies performed within our institution by experienced laparoscopic surgeons. The first 100 cases were divided into quintiles. Comparisons were made among the cohorts regarding patient demographics, operative time, length of stay, conversions, and complications. Results: There was no difference among quintiles with regard to age, sex, BMI, or ASA class. Operative time, conversions, length of stay, and number of complications did not significantly vary among each group of patients. There was a significant difference in estimated blood loss and length of stay between the fifth cohort and the others due to one patient’s poor outcome. Conclusions: The single-port laparoscopic right hemicolectomy learning curve for surgeons already skilled in laparoscopy is short. There are few differences in various outcome measures among groups at any stage in the learning curve. The skills utilized to perform conventional laparoscopic colorectal surgery readily translate to the single-port approach and result in proficiency from nearly the start.

Single port laparoscopic hysterectomy: Feasibility and safety

Objective: To evaluate the feasibility and safety of single-port laparoscopic hysterectomy comparing with multi-port laparoscopic hysterectomy in treatment of benign uterine diseases. Methods: Data were collected retrospectively by review of the medical records of 252 patients who underwent multi-port or single-port laparoscopic surgery for treatment of benign gynecologic diseases. Laparoscopy assisted vaginal hysterectomy (LAVH) was performed for single-port surgery and LAVH and total laparoscopic hysterectomy (TLH) were performed for multi-port surgery. Demographic variables were collected and analyzed by independent t-test and Pearson Chi-Square test. The primary outcome was analyzed by independent t-test and Fisher’s Exact test. Results: A longer operative time was observed in the multi-port surgery group compared with that of the single-port group (p < 0.05). No difference with respect to change of Hemoglobin between the preoperative level and that of the postoperative first day, the number of days from the operation to discharge, uterine weight, and the rate of laparotomy conversion and complications were observed between the two groups. Conclusion: Single-port laparoscopic hysterectomy for treatment of benign uterine diseases is a safe and feasible method.

Safety and efficacy of single-incision laparoscopic surgery for appendectomies: A meta-analysis

AIM: To compare single incision laparoscopic surgery for an appendectomy (SILS-A) with conventional laparoscopic appendectomy (C-LA) when implemented by experienced surgeons. METHODS: Studies and relevant literature regarding the performance of single-incision laparoscopic surgery vs conventional laparoscopic surgery for appendectomy were searched for in the Cochrane Central Register of Controlled Clinical Trials, MEDLINE, EMBASE and World Health Organization international trial register. The operation time (OR time), complications, wound infection and postoperative day using SILS-A or C-LAwere pooled and compared using a meta-analysis. The risk ratios and mean differences were calculated with 95%CIs to evaluate the effect of SILS-A. RESULTS: Sixteen recent studies including 1624 patients were included in this meta-analysis. These studies demonstrated that, compared with C-LA, SILS-A has a similar OR time in adults but needs a longer OR time in children. SILS-A has similar complications, wound infection and length of the postoperative day in adults and children, and required similar doses of narcotics in children, the pooled mean different of -0.14 [95%CI: -2.73-(-2.45), P > 0.05], the pooled mean different of 11.47 (95%CI: 10.84-12.09, P < 0.001), a pooled RR of 1.15 (95%CI: 0.72-1.83, P > 0.05), a pooled RR of 1.9 (95%CI: 0.92-3.91, P > 0.05), a pooled RR of 1.01 (95%CI: 0.51-2.0, P > 0.05) a pooled RR of 1.86 (95%CI: 0.77-4.48, P > 0.05), the pooled mean different of -0.25 (95%CI: -0.50-0, P = 0.05) the pooled mean different of -0.01 (95%CI: -0.05-0.04, P > 0.05) the pooled mean different of -0.13 (95%CI: -0.49-0.23, P > 0.05) respectively. CONCLUSION: SILS-A is a technically feasible and reliable approach with short-term results similar to those obtained with the C-LA procedure.

Therapeutic advances: Single incision laparoscopic hepatopancreatobiliary surgery

Single-port laparoscopic surgery(SPLS) is proposed to be a step towards minimizing the invasiveness of surgery, and has since gained popularity in several surgical sub-specialties including hepatopancreatobiliary surgery. SPLS has since been applied to cholecystectomy, liver resection as well as pancreatectomy for a multitude of pathologies. Benefits of SPLS over conventional multi-incision laparoscopic surgery include improved cosmesis and potentially post-operative pain at specific time periods and extra-umbilical sites. However, it is also associated with longer operating time, increased rate of complications, and increased rate of port-site hernia. There is no significant difference between length of hospital stay. SPLS has a significant learning curve that affects operating time, rate of conversion and rate of complications. In this article, we review the literature on SPLS in hepatobiliary surgery- cholecystectomy, hepatectomy and pancreatectomy, and offer tips on overcoming potential technical obstacles and minimizing the complications when performing SPLS- surgeon position, position of port and instruments, instrument crossing position, standard hand grip vs reverse hand grip, snooker cue guide position, prevention of incisional hernia. SPLS is a promising direction in laparoscopic surgery, and we recommend step-wise progression of applications of SPLS to various hepatopancreatobiliary surgeries to ensure safe adoption of the surgical technique.

Single access laparoscopic surgery:Complementary or alternative to NOTES?

In recent years,single access laparoscopic surgery(SALS) and natural orifice translumenal endoscopic surgery(NOTES) have gained interest from both clinical and industrial point of view,with the increased development of different laparoscopic instruments,production of various access ports,and improvement of operative endoscopes.The main advantages stimulating these two approaches are the cosmetic result,the rapid recovery of the patient,and the reduced need for pain killers.SALS and NOTES are in part complementary and in part alternative techniques.Currently,SALS is much simpler and technically easier than NOTES.

Evolving thoracic surgery: from open surgery to single port thoracoscopic surgery and future robotic

Thoracic Surgery is a continuous evolving specialty. In the past, thoracic surgeons had to make large incisions in order to operate any pathology inside the chest. This often meant big, painful and ugly scars and long recovery times after surgery. But he history of thoracic surgery changed since the begining of video-assisted thoracoscoDic surgery （VATg3

Single incision laparoscopic fundoplication: A systematic review of the literature

BACKGROUND Fundoplication, was first introduced as a surgical treatment method of gastroesophageal reflux disease. Consequently, several modifications of this method have been described, whereas laparoscopic fundoplication was recently introduced. Although single incision(SI) fundoplication was considered as an alternative to the conventional laparoscopic approach, several studies reported an increased operation duration, and high rates of multiport conversion and incisional hernia.AIM To provide a current overview of the technical variations and the postoperative outcomes of patients submitted to SI fundoplication.METHODS The present systematic review of the literature was designed and conducted on the basis of the PRISMA guidelines. A systematic screening of the electronic scholar databases(Medline, Scopus and Web of Science) was performed.RESULTS Literature search resulted in the identification of 19 studies. Overall, 266, 137 and110 SI Nissen, Dor and Toupet fundoplications were reported, respectively. In the majority of the trials, standard laparoscopic instruments were used. The left liver lobe was displayed through the use of forceps, graspers, retractors, drains or even glue. Both intra-corporeal and extracorporeal suturing was described. Mean operative time was 136.3 min. Overall complication rate was 5.2% and the rate of incisional hernia was 0.9%. No mortality was reported.CONCLUSIONDue to the methodological heterogeneity and the lack of high quality studies comparing multi to single access techniques and the several variations, we conclude that further well designed studies are necessary, in order to evaluate the role of SI fundoplication.

Novel and safer endoscopic cholecystectomy using only a flexible endoscope via single port

AIM: To apply the laparoscopic and endoscopic cooperative surgery concept, we investigated whether endoscopic cholecystectomy could be performed more safely and rapidly via only 1 port or not.METHODS: Two dogs(11 and 13-mo-old female Beagle) were used in this study. Only 1 blunt port was created, and a flexible endoscope with a tip attachment was inserted between the fundus of gallbladder and liver. After local injection of saline to the gallbladder bed, resection of the gallbladder bed from the liver was performed. After complete resection of the gallbladder bed, the gallbladder was pulled up to resect its neck using the Ring-shaped thread technique. The neck of the gallbladder was cut using scissor forceps. Resected gallbladder was retrieved using endoscopic net forceps via a port. RESULTS: The operation times from general anesthetizing with sevoflurane to finishing the closure of the blunt port site were about 50 min and 60 min respectively. The resection times of gallbladder bed were about 15 min and 13 min respectively without liver injury and bleeding at all. Feed were given just after next day of operation, and they had a good appetite. Two dogs are in good health now and no complications for 1 mo after endoscopic cholecystectomy using only a flexible endoscope via one port.CONCLUSION: We are sure of great feasibility of endoscopic cholecystectomy via single port for human.

Single access laparoscopic total colectomy for severe refractory ulcerative colitis

BACKGROUND Single port laparoscopic surgery allows total colectomy and end ileostomy for medically uncontrolled ulcerative colitis solely via the stoma site incision.While intuitively appealing,there is sparse evidence for its use beyond feasibility.AIM To examine the usefulness of single access laparoscopy(SAL)in a general series experience of patients sick with ulcerative colitis.METHODS All patients presenting electively,urgently or emergently over a three-year period under a colorectal specialist team were studied.SAL was performed via the stoma site on a near-consecutive basis by one surgical team using a“surgical glove port”allowing group-comparative and case-control analysis with a contemporary cohort undergoing conventional multiport surgery.Standard,straight rigid laparoscopic instrumentation were used without additional resource.RESULTS Of 46 consecutive patients requiring surgery,39(85%)had their procedure begun laparoscopically.27(69%)of these were commenced by single port access with an 89%completion rate thereafter(three were concluded by multi-trocar laparoscopy).SAL proved effective in comparison to multiport access regardless of disease severity providing significantly reduced operative access costs(>100€case)and postoperative hospital stay(median 5 d vs 7.5 d,P=0.045)without increasing operative time.It proved especially efficient in those with preoperative albumin>30 g/dL(n=20).Its comparative advantages were further confirmed in ten pairs case-matched for gender,body mass index and preoperative albumin.SAL outcomes proved durable in the intermediate term(median follow-up=20 mo).CONCLUSION Single port total colectomy proved useful in planned and acute settings for patients with medically refractory colitis.Assumptions regarding duration and cost should not be barriers to its implementation.