Single-incision laparoscopic cholecystectomy: initial evaluation of a large series of patients

Abstract

Background: Findings have shown that single-incision laparoscopic cholecystectomy (SILC) is feasible and reproducible. The authors have pioneered a two-trocar SILC technique at the University of Texas Southwestern. Their results for 100 patients are presented.

Methods: From January 2008 to March 2009, 100 patients with symptomatic gallbladder disease underwent SILC through a 1.5- to 2-cm umbilical incision using a two-port (5-mm) technique. For nearly all the patients, a 30 degrees angled scope was used. The gallbladder was retracted, with two or three sutures placed along the gallbladder. These sutures were either fixated internally or placed through the abdominal wall to obtain a critical view of Calot's triangle. The SILC procedure was performed using standard technique with 5-mm reticulating or conventional laparoscopic instruments. The cystic duct and artery were well visualized, clipped, and divided. Cholecystectomy was completed with electrocautery, and the specimen was retrieved through the umbilical incision.

Results: In this series, 80 women (85%) and 15 men (15%) with an average age of 33.8 years (range, 17-66 years) underwent SILC. Their mean BMI was 29.8 kg/m(2) (range, 17-42.5 kg/m(2)), and 39% of these patients had undergone previous abdominal surgery. The mean operative time was 50.8 min (range, 23-120 min). The mean estimated blood loss was 22.3 ml (range, 5-125 ml), and 5% of the patients had an intraoperative cholangiogram. There were no conversions of the SILC technique. A two-trocar technique was feasible for 87% of the patients. For the remaining patients, either a three-channel port or three individual trocars were required. A SILC technique was used for 5% of the patients to manage acute cholecystitis or gallstone pancreatitis.

Conclusion: The SILC technique with a two-trocar technique is safe, feasible, and reproducible. The operating times are reasonable and can be lessened with experience. Even complex cases can be managed with this technique. Excellent exposure of the critical view was obtained in all cases. The SILC procedure is becoming the standard of care for most of the authors' elective patients with gallbladder disease. Clinical trials are warranted before the SILC technique is adopted universally.

Fig. 1

Eversion of the umbilicus and transumbilical incision within the umbilical folds giving adequate access and excellent aesthetic results. Copyright © 2009 Covidien. All rights reserved. Used with the permission of Covidien

Fig. 2

Open abdominal entry through the umbilical stalk. Copyright © 2009 Covidien. All rights reserved. Used with the permission of Covidien

Fig. 3

Adequate entry into the abdomen confirmed with placement of a blunt instrument through the incised umbilical stalk. Copyright © 2009 Covidien. All rights reserved. Used with the permission of Covidien

Fig. 4

Two to three sutures used to retract the gallbladder. Modified with permission from Dávila F: Surgery without a trace. UNAM/AMCE Ed, 2002, First edition, México

Fig. 5

Cephalad suture retraction at the dome of the gallbladder

Fig. 6

Lateral suture retraction at the level of the neck of the gallbladder

Fig. 7

Critical view of structures at the triangle of Calot

Fig. 8

View of distended gallbladder hanging by retracting sutures from the abdominal wall

Fig. 9

Excellent aesthetic results 3 weeks after single-incision laparoscopic cholecystectomy

Fig. 10

Excellent aesthetic results 6 months after single-incision laparoscopic cholecystectomy