Current development in single‐incision laparoscopic surgery

This article reviews current developments in single‐incision laparoscopic surgery, with a focus on reported experiences in cholecystectomy. Difficulties and likely future developments in single‐incision laparoscopic surgery are also discussed.     

经脐单切口腹腔镜在子宫肌瘤剔除术中的应用

目的探讨经脐单孔腹腔镜技术在子宫肌瘤剔除术中的安全性及可行性。方法 2012年3月~2013年1月实施经脐单孔腹腔镜子宫肌瘤剔除术15例,记录手术时间、术中出血量、术后患者疼痛情况和术后引流量,并与同期常规腹腔镜子宫肌瘤剔除术组对比。结果完成单孔手术15例,其中1例肌瘤直径7.0 cm,因与黏膜关系密切,剔除后改行常规多孔腹腔镜手术,顺利完成。其余14例均无副损伤和并发症发生。结论经脐单孔腹腔镜技术在子宫肌瘤剔除术的应用是完全安全可行的,且其更微创美观,值得推广。     

Single‐incision laparoscopic cholecystectomy for porcelain gallbladder: A case report

Single‐incision laparoscopic cholecystectomy (SILC) has been performed in patients with gallbladder stones without inflammation. Porcelain gallbladder is a rare finding of chronic cholecystitis that is characterized by extensive calcification of the gallbladder wall. Herein we describe our experience with SILC for porcelain gallbladder with a successful outcome. A 67‐old‐year woman was diagnosed with porcelain gallbladder. We performed SILC using a SILS Port and a 5‐mm forceps through the umbilical incision. Because a small amount of the omentum around the gallbladder was left to facilitate grasping the fundus, a view of both the cystic artery and the cystic duct was easily obtained. The operative time and the intraoperative blood loss were 66 min and less than 1 mL, respectively. The patient was discharged 3 days after surgery and was satisfied with the cosmetic results. Our procedure may represent an alternative to conventional laparoscopic cholecystectomy in patients with porcelain gallbladder.     

Single‐port laparoscopic splenectomy: The first three cases

In the past two decades, laparoscopic surgery has replaced open surgery in most abdominal surgeries, including splenectomies for which it has become the standard. Single‐port laparoscopic surgery is a newly emerging surgical technique that decreases postoperative scarring and parietal trauma. Herein we report on three cases of splenectomy in which single‐port laparoscopic surgery technique was applied. Between October 2008 and January 2009, a 13‐year‐old male suffering from grade‐III splenic trauma and two females, aged 33 and 61, respectively, and both diagnosed with immune thrombocytopenic purpura, underwent single‐port laparoscopic splenectomies. Preoperative and postoperative management, including vaccination, was performed in a routine manner. A 3.5 cm transverse incision at the anterior axillary line at umbilicus level was used as a single‐port entry point. The entire procedure took 195, 125 and 133 minutes, respectively. All patients recovered and were discharged without any complications.     

Single‐incision laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor arising from the duodenum

We report a case involving a minimally invasive single‐incision laparoscopic and endoscopic cooperative local excision of a duodenal gastrointestinal stromal tumor. A 59‐year‐old man presented with a 35‐mm lesion located in the second portion of the duodenum. A local resection was performed via single‐incision laparoscopic and endoscopic cooperative surgery. Intraluminal endoscopic dissection of the duodenal mucosa and submucosa was performed circumferentially around the tumor. The resection was then completed by laparoscopic dissection of the seromuscular layer around the tumor. The tumor was retrieved laparoscopically. After confirming that the resection achieved clear surgical margins, we closed the duodenal wall with a laparoscopic stapling device. There were no postoperative complications, including stenosis. Single‐incision laparoscopic and endoscopic cooperative surgery can be safely and effectively performed for a duodenal submucosal tumor.     

Single‐port endo‐laparoscopic surgery in combined abdominal procedures

Single‐port endo‐laparoscopic surgery has gained support in the surgical community because it is perceived to offer a better postoperative outcome as it requires only a single incision. We write this prospective observational study to ascertain the feasibility and safety of this technique in patients otherwise requiring two operations. Five patients who underwent double procedures with a single‐port device were reviewed: Case 1, a transabdominal preperitoneal hernia repair and gastric wedge resection; Case 2, cholecystectomy and diaphragmatic hernia repair; Case 3, oophorectomy and incisional hernia repair; Case 4, anterior resection of the rectum and hepatic segmentectomy; and Case 5, left adrenalectomy and cholecystectomy. Patient demographics, type of port used, operative time, complications and incision length were collected. Mean operative time for the cases ranged from 100 to 315 min. Incision length for the single‐port device was 2 cm. In Case 2, an additional 5‐mm port was used and an intraoperative complication involving a laceration of the liver occurred during the suturing of the gallbladder fundus. An additional 8‐cm lower abdominal incision (Pfannenstiel) was required in Case 4 to complete the colonic anastomosis and for specimen retrieval. Single‐port endo‐laparoscopic surgery is a feasible and safe technique for approaching double procedures. It drastically reduces the number of scars that a double procedure creates, and if difficulty arises, another port can always be added to ease the operation. It can also potentially reduce the number of admissions and anesthesia that a patient undergoes.     

Single port surgery: Review of the literature and our initial experience

This review summarizes the published data regarding single port surgery (SPS) in order to evaluate the current status of SPS. SPS is a rapidly evolving technique in minimally invasive surgery. A wide variety of SPS have been performed since 1992, including appendectomy, cholecystectomy, colectomy, inguinal hernia repair, liver cyst fenestration, and bariatric surgery, and the technical feasibility has been demonstrated. Further advancements in technology and technique may allow the broad acceptance of this new method. Prospective randomized trials comparing SPS to laparoscopic surgery are essential to further determine the advantages and disadvantages of SPS.     

Natural orifice surgery: applications in colonic surgery

Natural orifice transluminal endoscopic abdominal surgery, or NOTES, allows invasive operations to be performed through a single or multiple natural‐orifice approach either in isolation (“pure”) or in combination with a transparietal (”hybrid”) access format. Therefore, to facilitate a colonic or rectal resection, the transgastric, transrectal or transcolonic routes, as well as the transvaginal route in women, can all be used either alone or in combination. We are now performing resectional colonic techniques on our patients that have been inspired by this revolutionary concept, carefully planned with storyboarding and validated in porcine models with survival analysis. Adaptation of existing equipment along with the use of new instruments and some simple ideas, such as magnetic fields to retract and mobilize the colon, have allowed us to simplify and standardize the operative technique (the first steps to ensuring procedural reproducibility). Initial potential applications can easily be imagined for partial colonic resections for voluminous benign polyps and for small early cancers, but these applications may extend to incorporate inflammatory bowel diseases such as diverticular disease of the sigmoid colon. For these techniques to further improve and the concept to become a concrete reality, a change in current surgical practice is required, and conventional laparoscopic techniques must be understood to represent a point along the evolutional development of surgery and not considered the final destination. However, as important as technical capacity is, due consideration and assurance of oncological and immunological propriety is essential, as is the issue of clarifying precise patient harm:benefit risk ratios.     

Single‐port laparoscopic surgery,the new evolution of endoscopic surgery

Introduction: Laparoscopic surgery through a single port is gaining great interest throughout the world. Our group has pioneered and been a leader on these novel techniques. Here we describe our experience based on a model of single‐port laparoscopic cholecystectomy. Materials and Methods: From January 2008 until August 2009, over 200 patients have undergone single‐port laparoscopic surgery at our institution. Here, we analyze a cohort of the initial 100 cholecystectomies in order to evaluate a proposed technique, common challenges, the learning curve and potential solutions. Results: Single‐port laparoscopic surgery was feasible in all patients from this cohort. Patients were strictly selected. Operating times similar to those of conventional laparoscopy were only achieved after completing 50 cases. Common technical challenges included clashing instruments, deflection of laparoscope due to conflict with light source, and organ retraction. Acceptance by surgeons and lack of patience and time may become significant obstacles that prevent the procedure's widespread adoption. The excellent aesthetic results are superior to laparoscopy. Other benefits of laparoscopy are preserved and may prove to be superior on clinical trials. Discussion: Single‐port laparoscopic surgery is becoming popular worldwide. Safe and successful adoption requires learning the basic concepts of this method, identifying challenges, and implementing solutions. Once these essentials are mastered, the learning curve may be shortened, especially for experienced laparoscopic surgeons, and this technique may then be used to replicate many abdominal operations. Transparency with patients and team building are essential requirements for a successful adoption. Clinical trials are ideal before universal adoption.     

Novel procedure, SILSOID colectomy, is a bridge between conventional and single-incisional laparoscopic colectomy

Introduction: Laparoscopic colectomy (LC) is a widely accepted treatment for various diseases of the colon. Transumbilical single‐incisional laparoscopic surgery (SILS) offers excellent cosmetic results compared with standard multi‐port laparoscopic surgery. We describe a new hybrid laparoscopic procedure, SILSOID colectomy, which combines conventional LC with SILS. Methods: We performed SILSOID colectomy to treat four patients with colorectal disease. Three ports were inserted through the single transumbilical incision, and an additional port was inserted in the flank at a site that depended on the location of the lesion. Division and anastomosis of the colon were performed extracorporeally. Results: SILSOID colectomy was carried out uneventfully in all four cases. The median operation time was 220 minutes (range, 179–320 min), and the median blood loss was negligible (range, negligible–285 mL), respectively. Although one patient experienced a postoperative wound infection, no other postoperative complications occurred. Conclusion: SILSOID colectomy is safe and feasible and it can be used as an alternative to conventional LC. We consider this procedure to be a bridge between conventional LC and more advanced laparoscopic procedures, such as SILS.     

Single‐incision laparoscopic cholecystectomy for gallbladder torsion: A case report and literature review

We present a case of preoperatively diagnosed gallbladder torsion (GT) that was successfully treated by single‐incision laparoscopic cholecystectomy. An 80‐year‐old woman presented with sudden pain and a palpable mass in the right upper quadrant. Contrast‐enhanced CT revealed ischemic changes, a swollen gallbladder with a V‐shaped distortion of the extrahepatic ducts, and the gallbladder in an abnormal anatomical position; clinical findings indicated GT. We performed single‐incision laparoscopic cholecystectomy and intraoperatively found that the floating gallbladder was twisted counterclockwise by 180° around the cystic duct. After an uneventful postoperative course, the patient was discharged on postoperative day 7. Laparoscopic cholecystectomy for a GT was first performed in 1994, and since then, 28 cases, including ours, have been treated laparoscopically. Laparoscopic cholecystectomy for GT could be the standard treatment for this condition, and single‐incision laparoscopic cholecystectomy may be a good surgical option for patients with GT because of its anatomical characteristics.     

Single‐incision totally extraperitoneal inguinal hernia repair is safe and feasible in elderly patients: A single‐center experience of 365 procedures

The aim of this study was to evaluate the feasibility and safety of SILS for totally extraperitoneal inguinal hernia repair in elderly patients. A retrospective analysis of 365 patients who underwent of SILS for totally extraperitoneal inguinal hernia repair from January 2012 to November 2015 at Osaka Police Hospital was performed, and the outcomes of patients aged <80 years and those aged ≥80 years were compared. There was a greater proportion of patients with an ASA score ≥3 among those ≥80 years than among those <80 years. The mean operative time for unilateral inguinal hernia was 94 min in patients <80 years and 98 min in patients ≥80 years. The mean operative time for bilateral inguinal hernia was 133 min in patients <80 years and 130 min in patients ≥80. Intraoperative bleeding was minimal in all patients. Conversion to a different operative procedure occurred in 3% (10/322) of patients <80 years and in 5% (2/43) of patients ≥80 years (P = 0.6). The mean postoperative hospital stay was 2.2 days for patients <80 years and 2.2 days for patients ≥80 years. The mean follow‐up period 21 ± 14 months (range, 3–50 months) for patients <80 years and 17 ± 14 months (range, 3–50 months) for patients ≥80 years (P = 0.3). Postoperative complications were seen in 12% (38/322) of patients <80 years and in 14% (6/43) of patients ≥80 years (P = 0.7). A seroma was seen in 9% (28/322) of patients <80 years and in 12% (5/43) of patients ≥80 years (P = 0.6). A wound infection occurred in 2% (8/322) of patients <80 years. These seromas and wound infections were managed conservatively. Pulmonary embolism was seen in one patient <80 years (0.3%). There was no mortality or recurrence in either group. SILS for totally extraperitoneal inguinal hernia repair has good cosmesis and can be performed in elderly patients with acceptable morbidity and mortality.     

Reduced port laparoscopic gastrectomy: A review,techniques, and perspective

Reduced port laparoscopic surgery has been used increasingly. It is a concept that has grown out of the various efforts aimed at minimally invasive surgery, with SILS being the ultimate reduced port technique. Reduced port laparoscopic surgery has been used to perform sleeve gastrectomy in bariatric surgery and excision of benign gastric submucosal tumor, applications that generally do not require lymph node dissection or complicated reconstruction. It can be done safely, result in a permanent cure, and offer good cosmetic outcomes. Reduced port laparoscopic surgery for gastric cancer has a short history, and its usefulness has not yet been fully established. This review describes the present situation and challenges faced as well as standardized procedures and the future prospects of reduced port laparoscopic gastrectomy for gastric cancer, which my team performs almost daily. These aspects of reduced port laparoscopic surgery are presented in light of the literature.