Dr Lam Shek Ming ShermanKwong Wah Hospital

Introduction Review of literature Conclusion

In 1882, first open cholecystectomy was performed by Carl Langenbach on a 42-year-old man with gallstones.

In 1985, the first laparoscopic cholecystectomy was performed by Prof Dr Med Erich Mühe

Since 1990s, laparoscopic cholecystectomy had been the gold standard for removal of gallbladder

Laparoscopic cholecystectomy. The new 'gold standard'? Soper NJ et. al. Arch Surg. 1992 Aug;127(8):917-21; discussion 921-3.

Laparoscopic cholecystectomy: an analysis of 777 cases. Perissat J et. al. Baillieres Clin Gastroenterol. 1992 Nov;6(4):727-42.

Laparoscopic cholecystectomy as standard intervention in symptomatic cholecystolithiasis. Experiences with 1,277 patients Faust H et. al. Chirurg. 1994 Mar;65(3):194-9.

Reduce size of incisions◦ Needlescopic surgery (2-3mm ports)

Reduce number of incisions◦ Single incision laparoscopic surgery

Single incision laparoscopic surgery Single port access surgery Laparoscopic endoscopic single-port

surgery

In 1997, Navarra G and his colleague performed the first single incision laparoscopic cholecystectomy

One-wound laparoscopic cholecystectomy. Navarra G et. al. Br J Surg. 1997 May; 84(5):695

3 methods◦ special, purpose-made access devices or ports for

introducing the laparoscope and instruments◦ passing three trocars side-by-side through the

fascia after exposing a wide area via a single umbilical incision

◦ using two trocars at the umbilicus along with suspension sutures to retract the gallbladder.

Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et. al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23.

3 methods◦ special, purpose-made access devices or ports for

introducing the laparoscope and instruments◦ passing three trocars side-by-side through the

fascia after exposing a wide area via a single umbilical incision

◦ using two trocars at the umbilicus along with suspension sutures to retract the gallbladder.

Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et. al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23.

3 methods◦ special, purpose-made access devices or ports for

introducing the laparoscope and instruments◦ passing three trocars side-by-side through the

fascia after exposing a wide area via a single umbilical incision

◦ using two trocars at the umbilicus along with suspension sutures to retract the gallbladder.

Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et. al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23.

3 methods◦ special, purpose-made access devices or ports for

introducing the laparoscope and instruments◦ passing three trocars side-by-side through the

fascia after exposing a wide area via a single umbilical incision

◦ using two trocars at the umbilicus along with suspension sutures to retract the gallbladder

Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et. al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23.

length of incision: 1.5-2 cm remaining steps are similar to the

conventional laparoscopic cholecystectomy

Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et. al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23.

The primary technical obstacles:◦ Collision of instruments both within and outside

the abdomen as a result of their common entry point (“sword fighting”)

◦ Inadequate triangulation◦ Compromised field of view due to obstruction by

instruments entering the common port◦ Inadequate exposure and retraction.

Single-incision laparoscopic cholecystectomy: lessons learned for success. Noam Shussman et. al. Surg Endosc. 2011 February; 25(2): 404–407.

Potential advantages:◦ Better cosmesis◦ Less pain

Potential disadvantages:◦ Steep learning curve◦ Compromised safety

◦ Single-incision laparoscopic cholecystectomy: a systematic review. Antoniou SA et. al. Surg Endosc. 2011 Feb;25(2):367-77. Epub 2010 Jul 7.

29 case series 1,166 patients many studies excluded acute cholecystitis conversion to conventional laparoscopic

cholecystectomy: 9.3%◦ obscure anatomy at Calot’s triangle (5.2%)◦ inadequate exposure of the Calot’s triangle due to insufficient

gallbladder retraction (2.6%)◦ inability to maintain pneumoperitoneum (1.4%)

conversion to open cholecystectomy 0.4% intraoperative complication rates: 0-20% (cumulative

rate: 2.7%)◦ gallbladder perforation/bile spillage (2.2%)◦ haemorrhage (0.3%)◦ bile duct injury (0.09%)

mortality: 0%

SILC [1] Needlescopic LC [2]

Conventional LC [3]

Conversion to open

0.4% 0.1% 5-7%

Complication rate

2.7% 2.08% 4%

Bile duct injury 0.09% 0.19% 0.3%

Gallbadder perforation

2.2% 0.5% 0.4%

[1] Single-incision laparoscopic cholecystectomy: a systematic review. Antoniou SA et. al. Surg Endosc. 2011 Feb;25(2):367-77. Epub 2010 Jul 7.

[2] Minilaparoscopic (needlescopic) cholecystectomy: a study of 1,011 cases. Lee PC et. al. Surg Endosc. 2004 Oct;18(10):1480-4. Epub 2004 Aug 24.

[3] Laparoscopic cholecystectomy: a review of 12,397 patients. Scott TR et. al. Surg Laparosc Endosc. 1992 Sep;2(3):191-8.

3 randomized control trials◦ Randomized clinical trial of single-incision laparoscopic

cholecystectomy versus minilaparoscopic cholecystectomy. Lee PC at. el. Br J Surg. 2010 Jul;97(7):1007-12.

◦ Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial. Tsimoyiannis EC et. al. Surg Endosc. 2010 Aug;24(8):1842-8. Epub 2010 Feb 20.

◦ Prospective randomized comparative study of single incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy. Lai EC et. al. Am J Surg. 2011 Sep;202(3):254-8.

70 patients 35 single-incision laparoscopic

cholecystectomy vs 35 minilaparoscopic cholecystectomy

70 patients 35 single-incision laparoscopic

cholecystectomy vs 35 minilaparoscopic cholecystectomy

70 patients 35 single-incision laparoscopic

cholecystectomy vs 35 minilaparoscopic cholecystectomy

40 patients 20 single-incision laparoscopic

cholecystectomy vs 20 minilaparoscopic cholecystectomy

51 patients 24 single incision laparoscopic cholecystectomy

vs 27 four-ports laparoscopic cholecystectomy

SILC 4-port LC P value

Hospital stay (days) 1.5 +/- .6 1.8 +/- 1.2 .20

Total wound length (cm)

1.76 +/- .29 2.25 +/- .05 .001

Time to return to usual physical activity (days)

5.6 +/- 1.6 5.0 +/- 1.6 .193

VAS pain score6 hours after surgery

4.5 (2-8) 4.0 (2-7) .203

7 days after surgery 1 (0-3) 0 (0-2) .048

Cosmetic score 3 months after surgery

7 (4-8) 6 (3-8) .023

51 patients 24 single incision laparoscopic cholecystectomy

vs 27 four-ports laparoscopic cholecystectomy

SILC 4-port LC P value

Hospital stay (days) 1.5 +/- .6 1.8 +/- 1.2 .20

Total wound length (cm)

1.76 +/- .29 2.25 +/- .05 .001

Time to return to usual physical activity (days)

5.6 +/- 1.6 5.0 +/- 1.6 .193

VAS pain score6 hours after surgery

4.5 (2-8) 4.0 (2-7) .203

7 days after surgery 1 (0-3) 0 (0-2) .048

Cosmetic score 3 months after surgery

7 (4-8) 6 (3-8) .023

The Learning Curve for Single-Port Laparoscopic Cholecystectomy by Experienced Laparoscopic Surgeon. Soon Hwa Youn et. al. J Korean Surg Soc 2011;80:119-124

Single-incision laparoscopic cholecystectomy: lessons learned for success. Noam Shussman et.al. Surg Endosc. 2011 February; 25(2): 404–407.

A specialized course of basic skills training for single-port laparoscopic surgery. Yang et. al. Surgery Volume 149, Number 6

A specialized course of basic skills training for single-port laparoscopic surgery. Yang et. al. Surgery Volume 149, Number 6

Single incision laparoscopic cholecystectomy is a safe option for treatment of symptomatic gallstone in early studies

Published RCTs so far support the advantage of better cosmesis, yet controversial in reduction of pain and shortening of hospital stay

It requires 20-30 to master the technique for experienced laparoscopic surgeons

Structured specialized training may be helpful in overcoming the learning curve