Single incision laparoscopic cholecystectomy Dr Lam Shek Ming

Outline Introduction Review of literature Conclusion

Introduction In 1882, first open cholecystectomy was performed by Carl Langenbach on a 42

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

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

Ways to minimize surgical access trauma Reduce size of incisions ◦ Needlescopic surgery (2

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

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

Single incision laparoscopic cholecystectomy 3 methods ◦ special, purpose-made access devices or ports for

Method 3: Two trocars and suspension sutures

Single incision laparoscopic cholecystectomy length of incision: 1. 5 -2 cm remaining steps are

Single incision laparoscopic cholecystectomy The primary technical obstacles: ◦ Collision of instruments both within

Single incision laparoscopic cholecystectomy Potential advantages: ◦ Better cosmesis ◦ Less pain Potential disadvantages:

Systematic review ◦ Single-incision laparoscopic cholecystectomy: a systematic review. Antoniou SA et. al. Surg

Antoniou SA et. al. 2011 29 case series 1, 166 patients many studies excluded

SILC [1] Needlescopic LC [2] Conventional LC [3] Conversion to open 0. 4% 0.

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

Lee PC at. el. 2010 70 patients 35 single-incision laparoscopic cholecystectomy vs 35 minilaparoscopic

Tsimoyiannis EC et. al. 2010 40 patients 20 single-incision laparoscopic cholecystectomy vs 20 minilaparoscopic

Lai EC et. 2011 51 patients 24 single incision laparoscopic cholecystectomy vs 27 four-ports

Learning curve The Learning Curve for Single-Port Laparoscopic Cholecystectomy by Experienced Laparoscopic Surgeon. Soon

Learning curve Single-incision laparoscopic cholecystectomy: lessons learned for success. Noam Shussman et. al. Surg

Structured specialized training A specialized course of basic skills training for single-port laparoscopic surgery.

Conclusion Single incision laparoscopic cholecystectomy is a safe option for treatment of symptomatic gallstone

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Single incision laparoscopic cholecystectomy Dr Lam Shek Ming Sherman Kwong Wah Hospital

Outline Introduction Review of literature Conclusion

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

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

Introduction Since 1990 s, 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.

Ways to minimize surgical access trauma Reduce size of incisions ◦ Needlescopic surgery (2 -3 mm ports) Reduce number of incisions ◦ Single incision laparoscopic surgery

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

Single incision laparoscopic cholecystectomy 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

Single incision laparoscopic cholecystectomy 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.

Method 1: Special devices

Method 2 : Three trocars side-by-side

Single incision laparoscopic cholecystectomy 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.

Method 3: Two trocars and suspension sutures

Single incision laparoscopic cholecystectomy 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.

Single incision laparoscopic cholecystectomy 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.

Single incision laparoscopic cholecystectomy Potential advantages: ◦ Better cosmesis ◦ Less pain Potential disadvantages: ◦ Steep learning curve ◦ Compromised safety

Review of the literature

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

Antoniou SA et. al. 2011 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.

Randomized control trials 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.

Lee PC at. el. 2010 70 patients 35 single-incision laparoscopic cholecystectomy vs 35 minilaparoscopic cholecystectomy

Tsimoyiannis EC et. al. 2010 40 patients 20 single-incision laparoscopic cholecystectomy vs 20 minilaparoscopic cholecystectomy

Tsimoyiannis EC et. al. 2010

Lai EC et. 2011 51 patients 24 single incision laparoscopic cholecystectomy vs 27 four-ports laparoscopic cholecystectomy SILC 4 -port LC P value 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 score 6 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 Hospital stay (days)

Learning curve 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

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

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

Conclusion 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

Thank you

Structured specialized training