Real-time near-infrared fluorescent cholangiography could shorten operative time during robotic single-site cholecystectomy

Background

With the introduction of a new platform, robotic single-site cholecystectomy (RSSC) has been reported as feasible and safe for selected cases. In parallel, the development of real-time near-infrared fluorescent cholangiography using indocyanine green (ICG) has been seen as a help during the dissection, even if the data are still preliminary. The study purpose is to report our experience with ICG RSSC and compare the outcomes to standard RSSC.

Methods

From February 2011 to December 2011, 44 selected patients underwent RSSC for symptomatic cholelithiasis. Among them, 23 (52.3 %) were included in an experimental protocol using the ICG, and the remainder (47.7 %) underwent standard RSSC. There was no randomization. The endpoints were the perioperative outcomes. This is a prospective study, approved by our local Ethics Committee.

Results

There were no differences in terms of patients’ characteristics, except that there were more male patients in the ICG group (47.8 vs. 9.5 %; p = 0.008). Regarding the surgical data, the overall operative time was shorter for the ICG group, especially for patients with a body mass index (BMI) ≤25 (?24 min) but without reaching statistical significance (p = 0.06). For BMI >25, no differences were observed. Otherwise, there were no differences in terms of conversion, complications, or length of stay between both groups.

Conclusions

A RSSC with a real-time near-infrared fluorescent cholangiography can be performed safely. In addition, for selected patients with a low BMI, ICG could shorten the operative time during RSSC. Larger studies are still required before drawing definitive conclusions.     

Incisional hernia after robotic single-site cholecystectomy: a pilot study

Purpose

Robotic LaparoEndoscopic Single-Site Surgery Cholecystectomy has been performed for 5 years using a dedicated platform (da Vinci^® Single-Site^®) with the da Vinci^® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). While short-term feasibility has been described, long-term assessment of this method is currently outstanding. The aim of this study was to assess long-term parietal complications of this technique.

Methods

In this retrospective study, patients operated between 2011 and 2013 were evaluated. Parietal incision was assessed with ultrasonography and patients screened for residual pain from scar tissue. Demographic and perioperative data were also collected.

Results

We evaluated 48 patients [38 female, 79.2%; median age 49 years (range: 24–81 years)]; mean BMI 25.9 kg/m² [±SD 4.1 kg/m²]. After a median follow-up of 39 months (range: 25–46 months), six incisional hernias (two patients had a positive echography but a negative clinical examination) were found (12.5%, 95% CI 7.5–30.2), and two patients had a surgical repair. The overall rate of incisional hernia was 16.7% (95% CI 7.5–30.2). Residual pain was observed in 5 of 48 patients.

Conclusion

This preliminary study suggests that a clinically significant rate of incisional hernias can occur after R-LESS-C. Larger studies comparing R-LESS-C to alternative methods with long-term follow-up are necessary.

     

Single-site robotic cholecystectomy (SSRC) versus single-incision laparoscopic cholecystectomy (SILC): comparison of learning curves. First European experience

Background

Single-incision laparoscopic surgery is an emerging procedure developed to decrease parietal trauma and improve cosmetic results. However, many technical constraints, such as lack of triangulation, instrument collisions, and cross-handing, hamper this approach. Using a robotic platform may overcome these problems and enable more precise surgical actions by increasing freedom of movement and by restoring intuitive instrument control.

Methods

We retrospectively collected, under institutional review board approval, data on the first 25 patients who underwent single-site robotic cholecystectomies (SSRC) at our center. Patients enrolled in this study underwent SSRC for symptomatic biliary gallstones or polyposis. Exclusion criteria were: BMI?>?33; acute cholecystitis; previous upper abdominal surgery; ASA?>?II; and age?>80 and?<18?years. All procedures were performed with the da Vinci Si Surgical System^? and a dedicated SSRC kit (Intuitive^?). After discharge, patients were followed for 2?months. These SSRC cases were compared to our first 25 single-incision laparoscopic cholecystectomies (SILC) and with the literature.

Results

There were no differences in patient characteristics between groups (gender, P?=?0.4404; age, P?=?0.7423; BMI, P?=?0.5699), and there were no conversions or major complications in either cohort. Operative time was significantly longer for the SILC group compared with SSRC (83.2 vs. 62.7?min, P?=?0.0006), and SSRC operative times did not change significantly along the series. The majority of patients in each group were discharged within 24?h, with an average length of hospital stay of 1.2?days for the SILC group and 1.1?days for the SSRC group (P?=?0.2854). No wound complications (infection, incisional hernia) were observed in the SSRC group and in the SILC.

Conclusions

Our preliminary experience shows that SSRC is safe, can easily be learned, and performed in a reproducible manner and is faster than SILC.     

Routine near infra-red indocyanine green fluorescent cholangiography versus intraoperative cholangiography during laparoscopic cholecystectomy: a case-matched comparison

The aim is to evaluate safety and efficacy of near infra-red (NIR) indocyanine green (ICG) fluorescence structural imaging during laparoscopic cholecystectomy (LC) (Group A) and to compare perioperative data, including operative time, with a series of patients who underwent LC with routine traditional intraoperative cholangiography (IOC) (Group B). Forty-four patients with acute or chronic cholecystitis underwent NIR-ICG fluorescent cholangiography during LC. ICG was administered intravenously at different time intervals or by direct gallbladder injection during surgery. Fluorescence intensity and anatomy identification were scored according to a visual analogue scale between 1 (least accurate) and 5 (most accurate). Group B patients (n = 44) were chosen from a prospectively maintained database of patients who underwent LC with routine IOC, matched for age, sex, body mass index, and diagnosis with group A patients. No adverse reactions were recorded. In group A, mean time between intravenous administration of ICG and surgery was 10.7 ± 8.2 (range 2–52) h. Administered doses ranged from 3.5 to 13.5 mg. Fluorescence was present in all cases, scoring ≥ 3 in 41 patients. Mean operative time was 86.9 ± 36.9 (30–180) min in group A and 117.9 ± 43.4 (40–220) min in group B (p = 0.0006). No conversion to open surgery nor bile duct injuries were observed in either group. LC with NIR-ICG fluorescent cholangiography is safe and effective for early recognition of anatomical landmarks, reducing operative time as compared to LC with IOC, even when residents were the main operator. NIR-ICG fluorescent cholangiography was effective in patients with acute cholecystitis and in the obese. Data collection into large registries on the results of NIR-ICG fluorescent cholangiography during LC should be encouraged to establish whether this technique might set a new safety standard for LC.     

Intraoperative cholangiography can be safely omitted during laparoscopic cholecystectomy: a prospective study of 413 consecutive patients.

BACKGROUND AND AIMS: The aim of the study was to show that laparoscopic cholecystectomy (LC) can be performed safely without intraoperative cholangiography (IOC). MATERIAL AND METHODS: We conducted a prospective study of 413 consecutive patients with symptomatic gallstone disease, who underwent LC. According to the preoperative clinical, laboratory and ultrasound criteria, 38 patients (9.2%) were selected for preoperative endoscopic retrograde cholangiography (ERC). All patients were followed postoperatively for symptoms and signs of common bile duct (CBD) stones. RESULTS: Preoperative ERC allowed to make a diagnosis of choledocholithiasis in 22 (58%) of the 38 selected patients. Stone clearance was achieved with endoscopic sphincterotomy (ES) in all cases. Three patients (7.9%) had an episode of mild self-limited pancreatitis after the procedure. Eight patients (1.9%) of 413 required conversion from LC to open cholecystectomy. There were no CBD injuries and no death cases. Of the postoperative complications, 1.5% were recorded during hospital stay. During the follow-up period, for at least 2 years after surgery, retained CBD stones were verified in 6 patients (1.5%); however, the supposed rate of residual stones was 2.4%. CONCLUSIONS: This study demonstrates that performance of selective preoperative ERC with ES when necessary, followed by LC, is an appropriate and safe approach to the treatment of patients with cholecystolithiasis and unsuspected choledocholithiasis. This approach allows to omit IOC and to perform LC safely without biliary duct injuries, ensuring low rate of retained CBD stones in the late follow-up period.     

Consequences of routine peroperative cholangiography during cholecystectomy for gallstone disease: A prospective,randomized study

To assess the value of routine peroperative cholangiography (PC), 457 patients undergoing cholecystectomy for gallstone disease were prospectively screened for the presence of 11 predefined criteria indicating possible choledocholithiasis. Two hundred and eighty patients who had no positive criteria and in whom preoperative endoscopic retrograde cholangiography (ERC) had not been performed were randomized to PC or no PC. The patients were followed up 12 months postoperatively, and those who had signs or symptoms of possible retained common bile duct calculi were referred to ERC. The difference in mean operative time between the 2 treatment groups was 23.3 minutes. Four patients (2.8%) in the PC group had unsuspected common bile duct calculi, and in 3 patients (2.1%), the PC was false-positive. On follow-up, no case of retained common bile duct calculi was found in either group. The rate of postoperative complications was significantly higher in the PC group than in the non-PC group. It is concluded that PC should be performed only in patients with indications of common bile duct disease or in whom clarification of the anatomy is necessary.

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Resumen Con el objeto de determinar el valor de la colangiografía peroperatoria (CP), 457 pacientes programados para colecistectomía por enfermedad litiásica biliar fueron preoperatoriamente tamizados para establecer la presencia de 11 criterios predefinidos indicando posible coledocolitiasis. Doscientos ochenta pacientes que no presentaban criterios positivos y en quienes la colangiografía retrógrada endoscópica (CRE) no había sido practicada fueron asignados al azar a CP o a no CP. Los pacientes fueron seguidos por 12 meses después de la operación, y aquellos con signos o síntomas de posibles cálculos retenidos en el colédoco fueron referidos para CRE. La diferencia en el tiempo operatorio promedio entre los 2 grupos fue de 23.3 minutos. Cuatro pacientes (2.8%) en el grupo con CP presentaron cálculos inesperados en el colédoco, y en 3 casos (2.1%), la CP resultó falsapositiva. En el curso del seguimiento, ningÚn caso de cálculos retenidos en el colédoco fue hallado en uno u otro grupo. La tasa de complicaciones postoperatorias fue significativamente mayor en el grupo con CP que en el grupo sin CP. Se concluye que la CP debe ser practicada sólo en pacientes con criterios de patología coledociana o en quienes sea necesario clarificar la anatomía.

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Résumé Pour apprécier la valeur de la cholangiographie opératoire de routine, 457 sujets subissant une cholécystectomie pour lithiase vésiculaire ont été étudiés prospectivement en fonction de 11 critères de présomption de lithiase cholédocienne. Deux cent quatre-vingts d'entre eux qui ne présentaient pas un critère de présomption et chez qui n'avait pas été pratiquée une cholangiographie rétrograde endoscopique ont été soumis à une cholangiographie opératoire à la suite d'un choix par tirage au sort. Ils furent ensuite suivis pendant une période de 12 mois au décours de l'intervention de manière que ceux qui présentaient des symptômes et des signes en faveur de la présence de calculs oubliés dans le cholédoque fussent soumis à une cholangiographie rétrograde endoscopique. Premier élément, la durée de l'intervention fut augmentée en moyenne de 23.3 minutes lorsque fut pratiquée la cholangiographie opératoire. Quatre malades (2.8%) ainsi explorés présentaient des calculs cholédociens. Trois cas de faux positifs (2.1%) furent enregistrés. Aucun cas de lithiase résiduelle n'a été découvert dans les 2 groupes. Le taux des complications postopératoires fut plus élevée lorsque la cholangiographie opératoire fut pratiquée. On peut conclure de ces faits, que cette exploration doit Être proposée seulement lorsque la présence de calculs dans la voie biliare principale est à envisager ou quand il est nécessaire de préciser l'anastomie des voies biliares.

     

Transvaginal cholecystectomy versus single-incision laparoscopic cholecystectomy versus four-port laparoscopic cholecystectomy: a prospective cohort study

Objective

This report describes the first prospective cohort study comparing transvaginal cholecystectomies (TVC) with single incision laparoscopic cholecystectomies (SILC) and four-port laparoscopic cholecystectomies (4PLC).

Methods

Between May 2009 and August 2010, 14 patients underwent a TVC. These patients were compared with patients who underwent SILC (22 patients) or 4PLC (11 patients) in a concurrent, randomized, controlled trial. Demographic data, operative time, numerical pain scales, complications, and return to work were recorded.

Results

Mean age (TVC: 33.5?±?3.0?year; SILC: 38.4?±?3.3?year; 4PLC: 35.5?±?4.1?year; p?=?0.58) and mean BMI (TVC: 28.8?±?1.5?kg/m²; SILC: 31.8?±?1?kg/m²; 4PLC: 31.4?±?2.2?kg/m²; p?=?0.35) were not statistically significant. However, mean operative time (TVC: 67?±?3.9?min; SILC: 48.9?±?2.6?min; 4PLC: 42.3?±?3.9?min; p?p?=?0.02) with equilibration of pain scores by days 14 and 30. Return to work (TVC: 6.4?±?1.5?days; SILC: 13.1?±?1.3?days; 4PLC: 14.1?±?1.4?days; p?Conclusions Transvaginal cholecystectomy is a safe and well-tolerated procedure with statistically significantly less pain at 1 and 3?days after surgery, with a faster return to work but longer operative times compared with single incision and four-port laparoscopic cholecystectomy.     

Advantages of the glove port docking technique in robotic single-site cholecystectomy: comparison with the conventional silicone port

Although the da Vinci Single-Site^® silicone port allows exact alignment and effective triangulation of instruments, it also has drawbacks. We introduce an alternative docking technique using the Glove port^®. From April 2014 to December 2016, respective 50 patients of the conventional silicone port and the glove port group were compared. The mean docking time was 16.6 ± 6.6 min in the silicone port group and 10.6 ± 3.6 min in the glove port group. Re-docking during the operation was needed in three patients in the silicone port group and readjustment of cannulae without re-docking could be simply performed in five patients in the glove port group. Skin injury was observed in 17 patients in the silicone port group and 0 patients in the glove port group without significant complications. Some limitations of the conventional silicone port were improved by the glove port.     

Hydro-Jet-assisted laparoscopic cholecystectomy: a prospective randomized clinical study

BACKGROUND: A new dissection technique with high-pressure water stream (Hydro-Jet) has recently been applied for selective dissection during various surgical procedures. The aim of this study was to compare Hydro-Jet with the conventional technique for laparoscopic cholecystectomy. METHODS: Eighty patients were randomized to undergo laparoscopic cholecystectomy with standard (n = 40) or Hydro-Jet-assisted (n = 40) dissection techniques. The rates of intraoperative complications, including blood loss and injury to the adjacent organs, were compared between the groups. The versatility of this technique and the features of surgical dissection were also evaluated and compared. RESULTS: Laparoscopic cholecystectomy was successfully completed in all subjects. The mean operative times were 78 minutes (range, 52-120 minutes) and 81 minutes (range, 45-135 minutes) for Hydro-Jet versus conventional dissection, respectively (P = not significant). Complications included gallbladder perforation in 15% and 30% (P <.1) and liver laceration in 0% and 10% (P <.04) with Hydro-Jet and conventional techniques, respectively. Increased hemorrhage from the gallbladder bed that necessitated fulguration occurred in 12 patients with the conventional technique as compared with none in the Hydro-Jet group (P <.001). Hydro-Jet resulted in a selective dissection of connective tissue preserving blood vessels and the cystic duct. The continuous water flow allowed a clear view for the operator, and the dissection was performed in a relatively bloodless field. The ease of blunt dissection with the bent-tip dissector represents another advantage. CONCLUSION: This study shows that Hydro-Jet dissection represents an excellent alternative to the conventional technique for laparoscopic cholecystectomy. The improved anatomic dissection combined with an almost bloodless operating field as the result of continuous water flow decreased the rate of dissection-related complications.     

Fluorescence cholangiography during laparoscopic cholecystectomy: a feasibility study on early biliary tract delineation

Background

Laparoscopic cholecystectomy (LC) is one of the most commonly performed laparoscopic procedures. Bile duct injury is a rare but serious complication during this procedure, mostly caused by misidentification of the extrahepatic bile duct anatomy. Intraoperative cholangiography may be helpful to reduce the risk of bile duct injury; however, this is not a common procedure worldwide. Near-infrared fluorescence cholangiography (NIRFC) using indocyanine green (ICG) is a promising alternative for the identification of the biliary tree. This prospective observational study was designed to assess the feasibility and image quality of intermittent NIRFC during LC, using a newly developed laparoscopic fluorescence system.

Methods

Consecutive patients undergoing elective LC were included and received a single intravenous injection of ICG directly after induction of anesthesia. During dissection of the base of the gallbladder and the cystic duct, the extrahepatic bile ducts were visualized by using a dedicated laparoscope, which offers both conventional state-of-the-art imaging and fluorescence imaging. Intraoperative recognition of the biliary structures was registered at set time points, as well as the establishment of the critical view of safety.

Results

Fifteen patients were included between December 2011 and May 2012. ICG was visible in the liver and bile ducts within 20 min after intravenous administration and remained for approximately 2 h, using the fluorescence mode of the laparoscope. The common bile duct and cystic duct could be clearly identified at an early stage of the operation and, more important, significantly earlier than with the conventional camera mode. No per- or postoperative complications occurred as a consequence of ICG use.

Conclusions

Intermittent fluorescence imaging using a newly developed laparoscope and preoperative administration of ICG seems a useful aid in accelerating visualization of the extrahepatic bile ducts during laparoscopic cholecystectomy.     

Early cholecystectomy for acute cholecystitis: a prospective randomized study

A randomized clinical trial was undertaken to compare early and delayed cholecystectomy for acute cholecystitis. Patients entering early (n = 83) or delayed (n = 82) surgery groups were comparable with regard to prerandomization data. One patient in the early group and five in the delayed group refused surgery (p < 0.1) and two misdiagnoses occurred in each group. (2.4%). There was no difference in the incidence of technical difficulty measured by operative complications and duration of operations between the two groups. The same number of patients with common duct stones and perforations of the gallbladder were in each group. There was one death in the delayed group and none in the early group. Postoperative morbidity was 13.8% in the early group and 17.3% in the delayed surgery group (p > 0.1). Wound complications were slightly more common in the early surgery group (p > 0.1). In the delayed surgery group 13% of the patients had to be operated on before the planned date of surgery because conservative management failed. In addition, 15% of the patients had clear recurrent symptoms. Early surgery reduced total hospital stay by a mean of 7.5 days and the period of the patient's incapacity for work by 14.4 days. The data suggest that in acute cholecystitis early surgery is preferable when performed by an experienced surgeon with adequate pre- and intraoperative aids. Besides lower costs it offers the advantage of avoiding recurrent attacks and emergency operations without increasing mortality or morbidity.