|Year : 2019 | Volume
| Issue : 4 | Page : 133-138
Mini-single-incision laparoscopic cholecystectomy: Pursuing the least invasive procedure
Department of Surgery, Division of General Surgery, Hsinchu MacKay Memorial Hospital, Hsin-Chu; Department of Health Food, College of Health, Chung Chou University of Science and Technology, Changhua, Taiwan
|Date of Submission||11-Dec-2018|
|Date of Decision||25-Dec-2018|
|Date of Acceptance||02-Apr-2019|
|Date of Web Publication||27-Aug-2019|
Dr. Shu-Hung Chuang
Department of Surgery, Division of General Surgery, Hsinchu MacKay Memorial Hospital, No. 690, Sec. 2, Guangfu Road, Hsin-Chu 30071
Source of Support: None, Conflict of Interest: None
Background: Both mini-laparoscopic surgery and single-incision laparoscopic surgery are feasible and safe alternatives to conventional multi-incision laparoscopic surgery.
Materials and Methods: Fifty-one conventional single-incision laparoscopic cholecystectomies (CSILCs) and 34 mini-single-incision laparoscopic cholecystectomies (MSILCs) were performed by a single surgeon for uncomplicated diseases. Compared with a 2-cm paraumbilical incision in CSILC, the incision in MSILC was 1.2 cm in length.
Results: In the CSILC period, all the procedures were performed successfully except one (2.2%). In the MSILC period, 6 (15%) CSILCs and 34 (85%) MSILCs were scheduled. All the former procedures were successful, whereas three MSILCs were converted to CSILCs. Fewer patients needed more than two pethidine doses, and the accumulated dosage was lower in the MSILC period compared with the CSILC period (2 [5.0%] vs. 11 [24.4%] and 0.595 ± 0.505 mg/kg vs. 0.936 ± 0.912 mg/kg, P < 0.05). The complication rates were 2.2% and 2.5% in the CSILC and MSILC periods, respectively (Clavien–Dindo Grade I).
Conclusion: MSILC can be performed safely for uncomplicated diseases. Compared with CSILC, MSILC has advantages of reduced postoperative pain and faster recovery but potentially increases operative time. Careful patient selection with a low threshold of conversion is obligatory.
Keywords: Laparoendoscopic single-site surgery, laparoscopic cholecystectomy, mini-laparoscopic surgery, single-incision laparoscopic surgery, uncomplicated gallbladder disease
|How to cite this article:|
Chuang SH. Mini-single-incision laparoscopic cholecystectomy: Pursuing the least invasive procedure. Formos J Surg 2019;52:133-8
| Introduction|| |
Both mini-laparoscopic surgery (MLS) and single-incision laparoscopic surgery (SILS) are feasible and safe alternatives to conventional multi-incision laparoscopic surgery (MILS).,,,, Despite their multiple potential benefits of reduced postoperative pain, faster recovery, fewer incisional complications, and better cosmesis, the prevalence of these techniques is not as high as expected. Several important issues of instrumental problems, technical demands, and a low cost-effectiveness ratio still persist. Increased incidence rates of incisional hernia and bile duct injury for SILS were reported in some studies, but not in others.,, It is generally believed that following the success of conventional MILS, making substantial improvements to this well-established procedure is nearly impossible. However, the pursuit of the least invasive surgery never stops, as evidenced by the development of Natural Orifice Transluminal Endoscopic Surgery (NOTES).,,,
The application of MLS and SILS to cholecystectomy, one of the most popular intra-abdominal surgeries, has been introduced for more than two decades.,,, Herein, we report a pilot study of combining MLS and SILS for uncomplicated gallbladder (GB) disease. The surgical technique is described in detail, and its effect on patient outcomes is analyzed retrospectively.
| Materials and Methods|| |
We started to apply single-incision multiple-port longitudinal array (SIMPLY) and self-camera (with a laparoscope controlled by the surgeon rather than the assistant) techniques for single-incision laparoscopic cholecystectomy (SILC) with a 5-mm rigid laparoscope and straight instruments beginning in March 2010. During an SILC procedure, a 2-cm left paraumbilical skin incision and three small separate fasciotomies were created in a vertical arrangement for the insertion of three 5-mm ports [Figure 1]a and [Figure 1]b. In March 2015, when >400 SILCs had been performed with low conversion and complication rates, we developed an innovative procedure called “mini-SILC” (MSILC). The technical principle is the same as our previous conventional SILC (CSILC) with the exception that 3-mm mini-laparoscopic instruments replaced 5-mm instruments. The 2-cm left paraumbilical skin incision was reduced to 1.2 cm, which is adequate to fit two 3-mm working ports and a 5-mm optic port [Figure 1]c and [Figure 1]d. A critical view of safety was routinely obtained and documented after dissecting Calot's triangle [Figure 2]a and [Figure 2]b. For selective intraoperative cholangiography (IOC), a 5-French feeding tube shared the same fasciotomy with the upper 3-mm working port to access the transcystic route [[Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d and Video 1]. As a 3-mm endoclip applier is not available in our facility, the upper 3-mm port was upgraded to a 5-mm port during the clipping of the cystic duct (CD) and vessels. Then, the 5-mm port was switched back to a 3-mm port as soon as possible to prevent overcompression on the incisional margin. Mild air leakage following this step could occur and could be addressed by simple gauze packing. At the end of the procedure, the three small fasciotomies were fused for extracting the specimen in a retrieval bag. In cases of marked subhepatic adhesions or GB wall thickening, the procedure could be easily converted to a CSILC during an early stage. In such an instance, the 1.2-cm left paraumbilical incision was enlarged to a 2-cm incision to fit three 5-mm ports. A subhepatic drain brought out from an additional abdominal incision rather than the paraumbilical one could be placed at surgeon's discretion and removed within 48 h in case of no bile leakage or bleeding.
|Figure 1: Port arrangement of single-incision multiple-port longitudinal-array and self-camera techniques during a conventional single-incision laparoscopic cholecystectomy (a) and a mini-single-incision laparoscopic cholecystectomy (c). (b) The 2-cm closed incision after a conventional single-incision laparoscopic cholecystectomy. (d) The 1.2-cm closed incision after a mini-single-incision laparoscopic cholecystectomy|
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|Figure 2: Critical view of safety during a mini-single-incision laparoscopic cholecystectomy. Both anterior (a) and posterior (b) views were obtained. CA: Cystic artery, CBD: Common bile duct, CD: Cystic duct, CP: Cystic plate, GB: Gallbladder|
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|Figure 3: Intraoperative cholangiography during a mini-single-incision laparoscopic cholecystectomy. (a and b) A 5-French feeding tube shared the same fasciotomy with the upper 3-mm working port to access the transcystic route for intraoperative cholangiography. (c and d) The cholangiogram showed no evidence of choledocholithiasis|
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During the recovery period, postoperative pain was relieved by routine oral acetaminophen tablet (500 mg four times daily), and intramuscular pethidine injection every 4 h based on patient's request. The pethidine dosage scale was 30 mg for a body weight (BW) <50 kg, 40 mg for a BW between 50 kg and 90 kg, and 50 mg for a BW >90 kg. Any patient tolerating oral feeding well, having a body temperature under 37.5° for > 24 h, and needing no pethidine injection would be discharged in case of no complication.
From May 2014 to December 2015, 85 consecutive SILCs, including 51 CSILCs and 34 MSILCs, were performed by a single surgeon for uncomplicated GB diseases. The exclusion criteria included acute cholecystitis, jaundice, pancreatitis, and concomitant choledocholithiasis. The diagnosis of acute cholecystitis was based on the preoperative impression, intraoperative finding, or pathologic examination. Presence of concomitant bile duct stones was confirmed by preoperative imaging or IOC. A female patient with an extremely rare bile duct anomaly (right hepatic duct joining the CD) was also excluded. Patient characteristics and operative results were recorded by medical chart review. The preoperative prognostic prediction was based on the American Society of Anesthesiologists classification. Comorbidity referred to coexisting major systemic and organ diseases. Previous abdominal surgery was a history of undergoing any type of intra-abdominal operations. The operative time was defined as the interval from skin incision to skin closure. Postoperative narcotic administration was recorded as the total dose number (based on patient's request) and the accumulated dosage (mg) of intramuscular pethidine per kilogram of patient's BW. The postoperative length of hospital stay (PLOS) was recorded as the duration between the day of surgery and the day of discharge. Any procedure that failed to be accomplished as scheduled was considered as converted. Complications were categorized according to the Clavien–Dindo classification. We defined the duration before the first MSILC as the CSILC period (from May 2014 to February 2015), whereas the remaining was MSILC period (from March 2015 to December 2015). This study was approved by the MacKay Memorial Hospital Institutional Review Board in March 2016 (IRB Number: 15MMHIS226e). A signed informed consent document was obtained from every patient before surgery.
The above data were analyzed with Pearson's Chi-square test and Student's t-test. P < 0.05 was considered statistically significant.
| Results|| |
No significant differences in patient characteristics were noted between the two groups [Table 1].
In the CSILC period, all the 45 CSILC procedures were performed successfully except one (2.2%), which was converted to a three-incision laparoscopic cholecystectomy [Table 2]. In the MSILC period, 6 (15%) CSILCs and 34 (85%) MSILCs were scheduled. All of the former procedures were accomplished as planned, whereas three MSILCs were converted to CSILCs. As a result, the successful rate of scheduled MSILC was 91.1% (31/34). Regarding the operative modifications and results, fewer patients needed more than two pethidine doses, and the pethidine accumulated dosage was significantly lower in the MSILC period compared with the CSILC period (2 [5.0%] vs. 11 [24.4%], P < 0.05 and 0.595 ± 0.505 mg/kg vs. 0.936 ± 0.912 mg/kg, P < 0.05), whereas other parameters were similar [Figure 4] and [Table 2]. One complication occurred in each period of this study. The former was pulmonary atelectasis, and the latter was transient left vocal cord palsy following intubation. Both complications were classified as Clavien–Dindo Grade I and were successfully managed with conservative treatment. Accordingly, the complication rate was 2.2% (1/45) and 2.5% (1/40) in the CSILC and MSILC periods, respectively. The average follow-up period was 4.3 ± 5.3 (range: 0.5–18) months.
|Figure 4: The dose number distribution (percentage) of postoperative pethidine administration during the conventional single-incision laparoscopic cholecystectomy and mini-single-incision laparoscopic cholecystectomy periods|
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| Discussion|| |
MLS and SILS were introduced as the next-generation laparoscopic surgery for less traumatic effects of abdominal incision. The application of these two new techniques to cholecystectomy, mini-laparoscopic cholecystectomy (MLC), and SILC has been reported in hundreds of studies for more than two decades.,,,,,,,, Compared with multi-incision laparoscopic cholecystectomy (MILC), the shortened incisions in MLC provide some benefits in terms of reduced postoperative pain, faster recovery, and better cosmesis at the cost of longer operative time.,,, However, instrumental problems, which were reported in more than half of the MLC procedures in one study, and the inherent higher conversion rate to MILC are the drawbacks. In contrast, the paraumbilical incision is enlarged to eliminate other incisions in SILC. High technical demands, longer operative time, and additional instrumental costs are several major disadvantages., In addition to the well-known, excellent cosmetic outcome, other potential advantages, such as reduced postoperative pain and faster recovery, seem to be marginal and clinically insignificant.,, Furthermore, increased incidence rates of bile duct injury and local wound complications are related to SILC in some studies;,, however, others failed to demonstrate the correlation., A mandatory registration system of a national or international database with a safety checklist has been strongly recommended to ensure the critical view of safety achieved rather than to measure the incidence of bile duct injury. In summary, the clinical value of MLC and SILC tends to be “cost-ineffective.”
Nevertheless, the pursuit of the least invasive surgery never stops. Systematic reviews regarding transvaginal hybrid NOTES cholecystectomy revealed its advantages of reduced postoperative pain, faster recovery, excellent cosmesis, and patient satisfaction at the cost of specialized endoscopic expertise, longer operative time, and some access-related complications (e.g., injuries of the bowel, urinary bladder, and vagina) compared with traditional laparoscopic cholecystectomy.,,, Although this novel technique is still in the developmental stage, it points to an answer to a persisting controversy in laparoscopic procedures: incision number and size matter. By combining the advantages of MLC (no change in paraumbilical incision size) and SILC (elimination of incisions other than the paraumbilical one), our innovative MSILC technique exhibits great potential for markedly reduced postoperative pain without inducing undesirable local wound complications. This expectation is consistent with our finding. On average, the patients in the MSILC period had a 36.4% lower postoperative pethidine use compared with those in the CSILC period [Table 2]. Another important finding was that only 5% of the patients needed more than two postoperative pethidine doses in the MSILC period [Figure 4] and [Table 2], and this small percentage fell within an expected admission rate of 10% following an outpatient laparoscopic cholecystectomy. This finding implies that MSILC could be an ideal daycare surgery. In contrast, approximately one-fourth (24.4%) of the patients in the CSILC period required the third pethidine injection, which was administered >8 h after surgery (the pethidine dosing interval was 4 h in our hospital), and this duration was far beyond the recommended postoperative observation in a daycare surgery. In addition, only five of the patients who underwent an MSILC had a chief complaint of umbilical wound pain the next day following surgery, whereas greater than half of those who underwent a CSILC did so (data not shown).
Our study failed to demonstrate a difference in PLOS between CSILC and MSILC periods [Table 2], but this simply reflects our current discharge policy: any patient tolerating oral feeding well, having a body temperature under 37.5° for >24 h, and needing no pethidine injection should be discharged. Given that only patients with uncomplicated GB diseases were enrolled in this study, postoperative fever was a rare event and had minimal impact on the PLOS. In addition, almost all the patients asked for pethidine injection within 24 h after surgery. As a result, the timing of oral feeding determined the PLOS. In this study, most patients resumed a liquid or soft diet the morning after the operation, and approximately 1 day was required to achieve the normal feeding amount. Therefore, the average PLOS was approximately 2 days in both CSILC and MSILC periods.
Patient selection bias from a retrospective study is a weak point of this study. Thus, we compared two periods of 10 months (CSILC period vs. MSILC period) instead of two procedures. The distributions of patient characteristics and GB pathology were similar, as anticipated [Table 1] and [Table 2]. Since March 2012, we routinely adopted SILC for all kinds of benign GB diseases. Furthermore, we developed single-incision laparoscopic common bile duct exploration as the standard procedure for choledocholithiasis in July 2012., Thus, the learning curve effects could be reduced to a minimum as >300 SILCs have been performed with low conversion and complication rates (no any bile duct injury except a transient minor bile leak from a subvesical accessory bile duct, duct of Luschka) before this study. In addition, the small difference of wound appearance between CSILC and MSILC could further diminish the cognitive biases from patients [Figure 1]b and [Figure 1]d. Since the operative incisions were all within the navel rim, a comparison of cosmetic appearance was not performed. We believe that patients subjected to MSILC truly benefit from minimal traumatic impact rather than cosmetic improvement. Nevertheless, we will conduct randomized controlled clinical trials to investigate the substantial benefits and drawbacks of MSILC compared with those of MILC, MLC, and CSILC in the future, and critical view of safety will be routinely obtained for patient safety.
In the MSILC period, 34 (85%) patients underwent an MSILC, and the success rate was 91.1% (31/34). Thus, 77.5% (31/40) of patients with uncomplicated GB diseases in this period could benefit from this innovative procedure. We strongly recommend that a clinical impression of acute cholecystitis, a preoperative image of GB shrinkage, GB wall thickening of >5 mm, gallstones >2 cm in the long axis, patients with a body mass index of 30 kg/m2 or greater, and patients with a xipho-umbilical distance of 20 cm or longer should be considered as contraindications of MSILC. It is very difficult to achieve an adequate retraction of an inflamed or fibrotic GB or to dissect dense adhesions with mini-laparoscopic instruments. Extracting a GB containing large stones through a 1.2-cm incision is extremely time-consuming with a considerable risk of wound contamination. In addition, it is nearly impossible to access the GB fossa with mini-laparoscopic instruments on obese patients or those with a 20-cm xipho-umbilical distance. Nevertheless, the previous abdominal surgery is not an indicator of procedure failure for MSILC (data not shown). Proper patient selection for this novel procedure is crucial to lower the conversion and complication rates.
Although the operative time did not show a significant difference in this study, the IOC rate in the CSILC period is higher than that in the MSILC period (26.7% vs. 15.0%). When using a portable C-arm, an IOC takes approximately 15–20 min in our facility and has a substantial impact on operative duration accordingly. In general, in our experience, an MSILC requires approximately 20 more minutes than a CSILC, even though we failed to show this difference in [Table 2].
| Conclusion|| |
MSILC can be performed safely and efficaciously for most uncomplicated GB diseases by experienced laparoscopic surgeons. It combines the advantages of MLC (no change in([para-] umbilical incision size) and SILC (elimination of incisions other than the ([para-] umbilical incisions) and avoids the undesirable access-related complications of transvaginal hybrid NOTES cholecystectomy. Compared with CSILC, MSILC has an advantage of reduced postoperative pain and faster recovery but may potentially increase operative time. Careful patient selection with a low threshold of procedure conversion is obligatory for safety concerns. Further randomized controlled clinical trials are anticipated to investigate this innovative technique.
The author gratefully acknowledge the work of Ms. Yi-Chun Liao and Ms. Pei-Yi Wang in assisting with the data collection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]