Single Incision Cholecystectomies for Acute Cholecystitis: A Single Surgeon Series from the Caribbean

Abstract

Introduction: Single incision laparoscopic surgery (SILS) is accepted as a safe alternative to conventional multiport laparoscopic (MPL) cholecystectomy for benign gallbladder disease. Since many surgeons carefully select patients without inflammation, there are limited data on SILS for acute cholecystitis. We report a single surgeon experience with SILS cholecystectomy for patients with acute cholecystitis.

Materials and methods: After securing ethical approval, we performed an audit of all SILS cholecystectomies for acute cholecystitis by a single surgeon from January 1, 2009, to December 31, 2019. The following data were extracted: patient demographics, intraoperative details, surgical techniques, specialized equipment utilized, conversions (additional port placement), morbidity, and mortality. Data were analyzed using SPSS 12.0.

Results: SILS cholecystectomy was performed in 25 females at a mean age of 35 ± 4.1 (SD) years and a mean BMI of 31.9 ± 3.8 (SD) using a direct fascial puncture technique without access platforms. The operations were completed in 83 ± 29.4 minutes (mean ± SD) with an estimated blood loss of 76.9 ± 105 (mean + SD). Three (12%) patients required additional 5 mm port placement (conversions), but no open operations were performed. The patients were hospitalized for 1.96 ± 0.9 days (mean ± SD). There were 2 complications: postoperative superficial SSI (grade I) and a diaphragmatic laceration (grade III). No bile duct injuries were reported. There were 9 patients with complicated acute cholecystitis, and this sub-group had longer mean operating times (109.2 ± 27.3 minutes) and mean postoperative hospital stay (1.3 ± 0.87 days).

Conclusion: The SILS technique is a feasible and safe approach to perform cholecystectomy for acute cholecystitis. We advocate a low threshold to place additional ports to assist with difficult dissections for patient safety.

Figure 1

A comparison of the intraoperative views during SILS cholecystectomy in a patient without acute inflammation (a) and one with acute cholecystitis (b). The mural erythema and oedema in the patient with acute cholecystitis make grasping the gallbladder difficult and limit exposure of Calot's triangle (arrows).

Figure 2

(a) Intraoperative views of structures in Calot's triangle during SILS cholecystectomy in a patient without inflammation and (b) one with acute cholecystitis. In (a), the cystic artery (red arrow), cystic duct (green arrow), and Rouviere's sulcus (white arrow) are visible across the thin, uninflamed peritoneum even before dissection, but the structures are not readily visible in the patient with acute cholecystitis.