Quality of life after single-incision laparoscopic cholecystectomy: A randomized,clinical trial

Background

Controversy continues as to whether single-incision laparoscopic cholecystectomy, with the somewhat larger incision at the umbilicus, may lead to a worse postoperative quality of life and more pain compared with the more classic 4-port laparoscopic cholecystectomy. The aim of this study was to compare single-incision and 4-port laparoscopic cholecystectomy from the perspective of quality of life.

Single-Incision Laparoscopic Combined Cholecystectomy and Appendectomy

Background and Objectives:

Single-incision laparoscopic surgery is becoming more widely used, but few combined procedures have been reported. Herein we share our experience with single-incision laparoscopic combined cholecystectomy and appendectomy.

Methods:

We reviewed data from 26 patients who underwent single-incision laparoscopic combined cholecystectomy and appendectomy between May 1, 2009 and June 1, 2013 at Shengjing Hospital. All the procedures were performed with conventional laparoscopic instruments placed through a single operating portal of entry created within the umbilicus.

Results:

All the operations were successfully completed without conversion to conventional laparoscopic or open surgery. No intraoperative complications occurred. Patients were satisfied with the therapeutic and cosmetic outcomes.

Conclusions:

Single-incision laparoscopic combined cholecystectomy and appendectomy appear to be a technically feasible alternative to the standard laparoscopic procedure in simultaneous management of coexisting benign gallbladder and appendix pathologies. Larger studies are required to confirm these findings.     

The Learning Curve With Single-Port Cholecystectomy

Objectives:

Single-port surgery is a rapidly advancing technique in laparoscopic surgery. Currently, there is limited evidence on the learning curve and practicality of performing single-port laparoscopic cholecystectomy.

Methods:

Single-port cholecystectomy was performed on 20 consecutive patients for biliary dyskinesia, symptomatic cholelithiasis, or acute cholecystitis. The Tri-Port was placed in the umbilicus, and a combination of straight and articulating instruments were utilized. Patient characteristics and outcomes were reviewed, and a comparison was made with the prior 20 consecutive laparoscopic cholecystectomies performed using the 3-port technique.

Results:

Characteristics were similar in both groups. The 3-port cholecystectomy had a mean time of 65.7 minutes, and patients had an average body mass index of 28.16. The first single-port cholecystectomy took 160 minutes with sequential improvement to the sixth case of 66 minutes with a mean of 68.2 minutes for the last 15 single-port cases. The average patient body mass index was 30.24. No major complications occurred.

Conclusion:

The largest series to date of single-port cholecystectomy for multiple degrees of biliary disease is presented. This study validates that this technique can be applied effectively and performed in comparable operative times to traditional 3-port cholecystectomy with a learning curve of approximately 5 cases.     

Hybrid Single-Port Cholecystectomy in Children

Background and Objectives:

Multiple single-port or single-incision techniques have been successfully implemented for laparoscopic cholecystectomy in adults and children. These techniques require either a large multichannel port or a larger skin incision to accommodate multiple ports or instruments. Inspired by a first generation single-port instrument, we developed a safe and effective technique for a single-port laparoscopic cholecystectomy with virtually scarless results.

Methods:

Over a 14-mo period, 20 patients (19 females, 1 male) underwent the hybrid single-port cholecystectomy. A straight 10-mm Storz telescope with inbuilt 6-mm working channel in combination with 2 portless 2.3-mm percutaneous graspers was used. The dissection is carried out with 43-cm bariatric length instruments. The cystic artery and duct are sealed with WECK Hem-o-lok clips or the Harmonic scalpel.

Results:

Range (mean) age: 7.7 y to 19.5 y (15.5), BMI: 11.6kg/m² to 42.3kg/m² (27), operative duration 48 min to 120 min (79), postoperative length of stay: 5 h to 78 h (24). Diagnosis: 13 patients cholecystolithiasis, 7 patients biliary dyskinesia. Conversion to conventional 4-port cholecystectomy was required in 2 patients. No intra- or postoperative complications occurred.

Conclusion:

The hybrid single-port technique is easy to master. It provides traditional anatomical exposure and allows application of conventional laparoscopic principles.     

Single Port Access (SPA) Cholecystectomy: Two Year Follow-up

Introduction:

Laparoscopy is a constantly evolving field of surgery. New technology, applications, and benefits prompt continual improvement. We have developed a Single Port Access (SPA) surgical technique that allows for the entire cholecystectomy to be performed through a single incision within the umbilicus while maintaining safe standard dissection and retraction techniques of currently performed multi-port laparoscopic cholecystectomy.

Methods:

Fifteen consecutive patients underwent SPA cholecystectomy. Indications were cholelithiasis, cholecystitis, CBD stones, and biliary akinesia. The entire procedure was performed through a single umbilical incision measuring <1.8 cm within the umbilicus. Three trocars and a rigid grasper were inserted through separate fascial sites within the same skin incision. The cholecystectomy procedures are then performed in the standard fashion described in multi-port cholecystectomy.

Results:

Fifteen patients successfully underwent Single Port Access cholecystectomy. One patient required a second 5-mm port site secondary to difficulty with retraction of a large liver. Operative times averaged 107 minutes. Blood loss, patient recovery, and outcomes have been comparable to those of standard multi-port procedures. No umbilical hernias have been seen at 2 years of follow-up.

Conclusion:

We present the SPA cholecystectomy as an alternative to multi-port cholecystectomy. In the first 2 years, SPA surgery has evolved into a technique easily taught and performed without the restrictions of new equipment or added cost.     

SIMPLIFIED LAPAROSCOPIC CHOLECYSTECTOMY WITH TWO INCISIONS

Background

Laparoscopic cholecystectomy has traditionally been performed with four incisions to insert four trocars, in a simple, efficient and safe way.

Aim

To describe a simplified technique of laparoscopic cholecystectomy with two incisions, using basic conventional instrumental.

Technique

In one incision in the umbilicus are applied two trocars and in epigastrium one more. The use of two trocars on the same incision, working in "x" does not hinder the procedure and does not require special instruments.

Conclusion

Simplified laparoscopic cholecystectomy with two incisions is feasible and easy to perform, allowing to operate with ergonomy and safety, with good cosmetic result.     

Routine on-table cholangiography during cholecystectomy: a systematic review

INTRODUCTION

The aim of this review was to systemically analyse trials evaluating the efficacy of routine on-table cholangiography (R-OTC) versus no on-table cholangiography (N-OTC) in patients undergoing cholecystectomy.

METHODS

Randomised trials evaluating R-OTC versus N-OTC in patients undergoing cholecystectomy were selected and analysed.

RESULTS

Four trials (1 randomised controlled trial on open cholecystectomy and 3 on laparoscopic cholecystectomy) encompassing 860 patients undergoing cholecystectomy with and without R-OTC were retrieved. There were 427 patients in the R-OTC group and 433 patients in the N-OTC group. There was no significant heterogeneity among trials. Therefore, in the fixed effects model, N-OTC did not increase the risk (p=0.53) of common bile duct (CBD) injury, and it was associated with shorter operative time (p<0.00001) and fewer peri-operative complications (p<0.04). R-OTC was superior in terms of peri-operative CBD stone detection (p<0.006) and it reduced readmission (p<0.03) for retained CBD stones.

CONCLUSIONS

N-OTC is associated with shorter operative time and fewer peri-operative complications, and it is comparable to R-OTC in terms of CBD injury risk during cholecystectomy. R-OTC is helpful for peri-operative CBD stone detection and there is therefore reduced readmission for retained CBD stones. The N-OTC approach may be adopted routinely for patients undergoing laparoscopic cholecystectomy providing there are no clinical, biochemical or radiological features suggestive of CBD stones. However, a major multicentre randomised controlled trial is required to validate this conclusion.     

Laparoscopic Cholecystectomy and Newer Techniques of Gallbladder Removal

Objectives:

To describe the surgical complications associated with laparoscopic cholecystectomy, as performed by a single surgeon over an 8-year period and to discuss how this compares to newer methods of cholecystectomy, such as single-incision surgery and natural orifice transluminal endoscopic surgery.

Methods:

The charts of 1000 consecutive patients who underwent consecutive cholecystectomies were reviewed to gather the following information: age, sex, prior abdominal procedures, type of procedure performed (laparoscopic vs open, with or without cholangiography), pre and postoperative diagnosis, and complications directly related to surgical technique, such as biliary injury, bile leak, infection, trocar-related injury, and incisional hernia.

Results:

The laparoscopic approach was attempted in all but one patient and was successful in 94.1% of patients. The conversion rate was higher with acute cholecystitis than with other forms of biliary tract disease. Successful cholangiography was accomplished in over 97% of patients. Nineteen complications directly related to the surgical procedure were found, including one bile duct injury.

Conclusion:

Laparoscopic cholecystectomy continues to offer a safe and effective treatment for patients with symptomatic biliary tract disease. Although other forms of minimally invasive cholecystectomy are being studied, there is little data to suggest any additional benefit, other than a slight improvement in cosmesis. Until larger series demonstrate that these techniques have a complication rate similar to those cited in the surgical literature, traditional 4-port laparoscopic cholecystectomy should remain the standard of care.     

Operative timing of laparoscopic cholecystectomy for acute cholecystitis in a Japanese institute

Background and Objectives:

In patients with acute cholecystitis who cannot undergo early laparoscopic cholecystectomy (within 72 hours), 6 weeks to 12 weeks after onset is widely considered the optimal timing for delayed laparoscopic cholecystectomy. However, there has been no clear consensus about it. We aimed to determine optimal timing for delayed laparoscopic cholecystectomy for acute cholecystitis.

Methods:

Medical records of 100 patients who underwent standard laparoscopic cholecystectomy were reviewed retrospectively. Patients were divided into group 1, patients undergoing laparoscopic cholecystectomy within 72 hours of onset; group 2, between 4 days to 14 days; group 3, between 3 weeks to 6 weeks; group 4, >6 weeks.

Results:

No significant differences existed between groups in conversion rate to open surgery, operation time, blood loss, or postoperative morbidity, and hospital stay. However, total hospital stay in groups 1 and 2 was significantly shorter than that in groups 3 and 4 (P<.01). In addition, the total hospital stay in group 3 was also significantly shorter than that in group 4 (P<.01).

Conclusions:

Best timing of laparoscopic cholecystectomy for acute cholecystitis may be within 72 hours, and the delayed timing of laparoscopic cholecystectomy in patients who cannot undergo early laparoscopic cholecystectomy is probably as soon as possible after they can tolerate laparoscopic cholecystectomy.     

Laparoscopic Transumbilical Cholecystectomy: Surgical Technique

Background:

Laparoscopic cholecystectomy is generally performed using 4 ports by transperitoneal access. Recent developments regarding laparoscopic surgery have been directed toward reducing the size or number of ports to achieve the goal of minimally invasive surgery, by minilaparoscopy, natural orifice access, and the transumbilical approach. The aim of this article is to describe our laparoscopic transumbilical cholecystectomy technique using conventional laparoscopic instruments and ports.

Methods:

The Veress needle was placed through the umbilicus, which allowed carbon dioxide inflow. A 5-mm trocar was placed in the periumbilical site for the laparoscope followed by the placement of 2 additional 5-mm periumbilical trocars. The entire procedure was performed using conventional laparoscopic instruments. At the end of the surgery, trocars were removed, and all 3 periumbilical skin incisions were united for specimen retrieval.

Results:

Five transumbilical cholecystectomies were performed following this technique. The mean BMI was 26.6 kg/m². The mean operative time and blood loss were 46.2 minutes and 55 mL, respectively. No intraoperative complications occurred. Analgesia was performed using dipyrone (1g IV q6h) and ketoprofen (100 mg IV q12 h). Time to first oral intake was 8 hours. Mean hospital stay was 19.2 hours.

Conclusion:

Laparoscopic transumbilical cholecystectomy seems to be feasible even using conventional laparoscopic instruments and can be considered a potential alternative for traditional laparoscopic cholecystectomy.     

Large subcapsular liver hematoma following single-incision laparoscopic cholecystectomy

Background and Objectives:

Many laparoscopic surgeons are now transitioning from standard multiple-port laparoscopic cholecystectomy to single-incision laparoscopic surgery (SILS) in an attempt to improve cosmetic outcomes and decrease postoperative morbidity. However, little has been published regarding the potential complications of SILS operations.

Methods:

We report the case of a patient undergoing SILS cholecystectomy who developed the complication of a large hepatic hematoma, resulting in significant postoperative morbidity, blood transfusion requirement, and reoperation.

Results:

After an in-depth internal review of the postoperative morbidity of this case, it appears that the causative factor may be instrument shaft torque on the liver surface.

Conclusion:

Single-incision laparoscopic surgery may pose significant and unique risks that warrant additional operative caution. Quantitative comparison of SILS to the gold-standard laparoscopic cholecystectomy is needed to further elucidate definitive benefits and complications of this novel technique.     

How Managed Care May Choose Hospitals for Contracts for Laparoscopic Cholecystectomy

Background and Objectives:

Maricopa Medical Center (MMC) was found to have higher charges and length-of-stays than 16 other regional hospitals in an analysis of DRG categories for gallbladder disease. These comparative figures identified MMC as being inefficient and demanded review to determine the reasons for the inefficiencies.

Methods:

In an attempt to determine the reason for inefficiency of charges and length-of-stay for the laparoscopic portion of laparoscopic cholecystectomy, matched pairs of open cholecystectomy and converted laparoscopic cholecystectomy from a data base of 633 patients with cholecystectomies were reviewed. Thirty-five matches for age, sex and similar diagnosis were successful.

Results:

Matched pair evaluation disclosed a $6,880 difference in charges, which was attributed solely to the charge for laparoscopy. Subsequent chart analysis showed a high charge for instrumentation, prolonged anesthesia and operative times and longer preoperative delays before surgery. Moreover, no matter what the conversion rate is, open cholecystectomy was more cost effective. However, if there is a conversion rate of 5%, total hospital charges for laparoscopic cholecystectomy would have to be reduced to $12,679 (a reduction of $3,332 from $16,011) to make laparoscopic cholecystectomy cost-effective.

Conclusions:

Cost-effective decision tree analysis of matched pair comparisons and sensitivity analysis proves to be an effective technique in evaluating the cost-effectiveness of laparoscopic cholecystectomy in a hospital population.     

Single-Incision Versus Conventional Laparoscopic Adjustable Gastric Banding

Background and Objectives:

Laparoscopic adjustable gastric banding is an effective and popular bariatric surgery for weight loss in obese patients that traditionally involves up to 5 incisions. Recently, a more minimally invasive single-incision technique has been developed. In this retrospective study, we compare conventional and single-incision laparoscopic adjustable gastric banding with regard to weight loss and complication rates in a cohort of demographically similar patients.

Methods:

From February 2009 to February 2010, 59 patients underwent laparoscopic adjustable gastric banding by one surgeon at an outpatient surgery center. All patients were compared by age, sex, preoperative body mass index, 30-day complication rates, and excess weight loss. Thirty-seven operations were performed by a conventional, 5-incision technique, whereas 22 patients underwent the single-incision technique. The success of these techniques was determined by comparing complication rates and average percentage excess weight loss at 6-month follow-up intervals.

Results:

Patients who underwent conventional laparoscopic adjustable gastric banding had a mean age of 41.2 years and preoperative body mass index of 48.2 kg/m² compared with 43.9 years and 40.3 kg/m², respectively, for the single-incision patients. The mean operative time in the single-incision group was longer than that in the conventional group: 47.1 minutes versus 37.4 minutes (P = .0027). The overall percentage excess weight loss was not statistically different between the 2 groups for each follow-up period. There were no complications or deaths in either group.

Conclusion:

Although patients undergoing bariatric surgery may choose the single-incision technique for cosmetic purposes, this retrospective review comparing single-incision and conventional laparoscopic adjustable gastric banding shows longer operative times with equivalent weight loss and morbidity.     

Single-incision versus conventional laparoscopic appendectomy in 688 patients: a retrospective comparative analysis

Background

Laparoscopic surgery has become the standard for treating appendicitis. The cosmetic benefits of using single-incision laparoscopy are well known, but its duration, complications and time to recovery have not been well documented. We compared 2 laparoscopic approaches for treating appendicitis and evaluated postoperative pain, complications and time to full recovery.

Methods

We retrospectively reviewed the cases of consecutive patients with appendicitis and compared those who underwent conventional laparoscopic appendectomy (CLA) performed using 3 incisions and those who underwent single-incision laparoscopic appendectomy (SILA). During SILA, the single port was prepared to increase visibility of the operative site.

Results

Our analysis included 688 consecutive patients: 618 who underwent CLA and 70 who underwent SILA. Postsurgical complications occurred more frequently in the CLA than the SILA group (18.1% v. 7.1%, p = 0.018). Patients who underwent SILA returned to oral feeding sooner than those who underwent CLA (median 12 h v. 22 h, p < 0.001). These between-group differences remained significant after controlling for other factors. Direct comparison of only nonperforated cases, which was determined by pathological examination, revealed that SILA was significantly longer than CLA (60 min v. 50 min, p < 0.001). Patients who underwent SILA had longer in-hospital stays than those who underwent CLA (72 v. 55 h, p < 0.001); however, they had significantly fewer complications (3.0% v. 14.4%, p = 0.006).

Conclusion

In addition to its cosmetic advantages, SILA led to rapid recovery and no increase in postsurgical pain or complications.     

Alterations in respiratory mechanics after laparoscopic and open surgical procedures

Objective

To compare the effects of laparoscopic and open surgical procedures on postoperative strength and respiratory mechanics.

Design

Prospective cohort study.

Setting

Adult university hospital.

Participants

Fifty-one women aged 21 to 62 years scheduled to undergo elective cholecystectomy or hysterectomy (or related procedures), otherwise in good health.

Intervention

Open or laparoscopic cholecystectomy or hysterectomy (or related procedures).

Main Outcome Measures

Maximum voluntary handgrip strength (HGS), forced vital capacity (VC), forced expiratory volume in 1 second (FEV₁), and maximal inspiratory pressure (MIP) were each measured preoperatively and on the first postoperative morning. A visual analogue pain scale score was evaluated in relation to performance of the postoperative strength and respiratory measurements.

Results

VC, FEV₁ and MIP, but not HGS, were decreased after surgery. Postoperative VC, FEV₁ and MIP were lower after open procedures than after laparoscopic procedures and after cholecystectomy than after hysterectomy (all p < 0.001). Pain scores were lower after laparoscopic than after open procedures (p < 0.005) and could account in part for differences in postoperative respiratory mechanics.

Conclusions

Cholecystectomy and hysterectomy do not result in generalized muscle weakness, unlike more major abdominal procedures. Postoperative alterations in respiratory mechanics are related to the site of the surgery, the use of an open versus a laparoscopic approach and postoperative pain.     

Laparoscopic Cytoreduction for Primary Advanced Ovarian Cancer

Introduction:

We evaluated the feasibility of laparoscopic cytoreduction for primary advanced ovarian cancer.

Methods:

All patients with presumed stage 3/4 primary ovarian cancer underwent attempted laparoscopic cytoreduction. All patients had CT evidence of omental metastasis and ascites. A 5-port (5-mm) transperitoneal approach was used. A bilateral salpingo-oophorectomy, supracervical hysterectomy, and omentectomy were performed with PlasmaKinetic (PK) cutting forceps. A laparoscopic 5-mm Argon-Beam Coagulator was used to coagulate tumor in the pelvis, abdominal peritoneum, intestinal mesentery, and diaphragm.

Results:

Nine of 11 cases (82%) were successfully de-bulked laparoscopically without conversion to laparotomy. Median operative time was 2.5 hours, and median blood loss was 275 mL. All tumors were debulked to <2 cm and 45% had no residual disease. Stages were 1–3B, 7–3C, and 1–4. Median length of stay was one day. Median VAS pain score was 4 (discomforting). Two of 11 patients (18%) had postoperative complications.

Conclusion:

Laparoscopic cytoreduction was successful and resulted in minimal morbidity. Because of our small sample size, additional studies are needed.     

Indomethacin and ketorolac given preoperatively are equally effective in reducing early postoperative pain after laparoscopic cholecystectomy

Objective

To evaluate the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) on pain after laparoscopic cholecystectomy.

Design

A prospective, randomized, placebo-controlled, double-blind study.

Setting

A university hospital.

Patients

Fifty-two patients with cholelithiasis but without known allergy to one of the study drugs, history of bleeding, peptic ulcer disease, known cardiac, lung or renal disease, abnormal liver function or use of opiates or NSAIDs within 2 weeks before operation. Patients were assigned to one of three groups, and treatment was randomized by placing the drugs in sealed, numbered envelopes.

Intervention

Administration of the NSAIDs ketorolac, intramuscularly, or indomethacin, rectally, before laparoscopic cholecystectomy.

Main Outcome Measures

Postoperative pain scored on a visual analogue scale and by nurse assessment, total dose of fentanyl citrate given, and nausea or emesis.

Results

Patients in the placebo group reported significantly more pain than either NSAID group (p < 0.05) and were reported as having significantly more pain by the nurses (p < 0.05). These patients were subsequently treated with a higher mean postoperative dose of fentanyl citrate than either NSAID group (p < 0.05). Furthermore, the placebo group reported more nausea and emesis (p < 0.05). There was no significant difference in any of the parameters measured between the ketorolac or indomethacin group.

Conclusions

The data demonstrate that the NSAIDs ketolorac and indomethacin, administered preoperatively, decrease early postoperative pain and nausea after laparoscopic cholecystectomy and are equally efficacious in producing these results.     

Single-Site Nissen Fundoplication Versus Laparoscopic Nissen Fundoplication

Background:

Advances in minimally invasive surgery have led to the emergence of single-incision laparoscopic surgery (SILS). The purpose of this study is to assess the feasibility of SILS Nissen fundoplication and compare its outcomes with traditional laparoscopic Nissen fundoplication.

Methods:

This is a retrospective study of 33 patients who underwent Nissen fundoplication between January 2009 and September 2010.

Results:

There were 15 SILS and 18 traditional laparoscopic Nissen fundoplication procedures performed. The mean operative time was 129 and 182 minutes in the traditional laparoscopic and single-incision groups, respectively (P = .019). There were no conversions in the traditional laparoscopic group, whereas 6 of the 15 patients in the SILS group required conversion by insertion of 2 to 4 additional ports (P = .0004). At short-term follow-up, recurrence rates were similar between both groups. To date, there have been no reoperations.

Conclusions:

SILS Nissen fundoplication is both safe and feasible. Short-term outcomes are comparable with standard laparoscopic Nissen fundoplication. Challenges related to the single-incision Nissen fundoplication include overcoming the lengthy learning curve and decreasing the need for additional trocars.