Internal retraction in single-port laparoscopic cholecystectomy: Initial experience and learning curve

Abstract

Introduction: We report our experience and learning curve in single-port laparoscopic cholecystectomy (SPLC) using an internal anchored retraction system. Methods: Usefulness of the retraction system was analysed in 18 SPLC. The first eight, the following ten SPLC and 20 consecutive four-port laparoscopic cholecystectomies (4PLC) were compared. Duration of operation, burns on nontarget tissue and gallbladder perforations were assessed by reviewing videotapes recorded during the procedures. Results: Use of the retraction system failed in three out of five patients (60%) with intraoperative signs of chronic inflammation and in one out of 13 (7.1%) without such signs (p = 0.0441). Median operation time was 90 (45–120) in the first eight and 55 (40–180) minutes in the following ten SPLC (p = 0.0361). Whereas the first eight SPLC lasted longer compared to 4PLC (70 (40–140) minutes, p = 0.0435) the difference disappeared after eight procedures (p = 0.2076). Median number of burns to nontarget tissue was seven (1–16) in the first eight and one (0–8) in the following ten SPLC (p = 0.0049). There was no difference in perforation of the gallbladder. Discussion: Internal retraction enables a safe exposure of the Calot triangle avoiding bile spillage in cholecystectomies without intraoperative signs of inflammation. Familiarisation with SPLC was rapidly achieved. Operation time and dexterity were equal to 4PLC after eight SPLC.     

Enlargement of umbilical incision in standard laparoscopic cholecystectomy is frequently necessary: An argument for the single incision approach?

Objective: Cosmetic result after cholecystectomy is up for debate. The aim of this study was to investigate the incidence and extent of enlargement of initial skin and fascia incision in standard laparoscopic cholecystectomy and to detect predictive factors for such an enlargement. Material and methods: The size of the umbilical incision was measured before and after standard laparoscopic gallbladder removal in 391 patients from August 2009 to October 2012. Predisposing factors for the need of enlargement of the umbilical incision were analysed. Results: Additional enlargement of the umbilical incision for gallbladder removal was required in 35.8% of the patients at skin level, and in 40.4% at fascia level. The median enlargement of the umbilical skin incision was 11 mm, from 25 mm to 36 mm. Gallbladder weight, total stone weight, maximum diameter of largest stone and shorter initial length of incision were independent predisposing factors for enlargement of the incision. Conclusions: In standard laparoscopic cholecystectomy the umbilical incision frequently requires secondary enlargement, especially if a large stone mass is involved. Therefore, the cosmetic result after laparoscopic cholecystectomy depends on more than only the technique used for access and the surgical technique for cholecystectomy should be chosen individually for each patient according to the stone mass.     

A newly designed magnet‐retracting forceps for laparoscopic cholecystectomy in a swine model

We designed a method for remote‐controlled endoscopic surgery using magnet‐retracting forceps. To evaluate the feasibility of this technique, laparoscopic cholecystectomy was attempted in a swine model. This method takes advantage of the attractive force between two magnets, one inserted into the peritoneal cavity and the other located outside the abdominal wall. An intra‐peritoneal magnet was fixed to the fundus of the gallbladder using an endovascular clip. Laparoscopic cholecystectomy was accomplished by magnetic retraction of the gallbladder. This magnet‐retracting forceps provided port‐less access to the abdominal cavity. Since the direction and range of retraction were unrestricted by the location of access‐ports fixed on the abdominal wall, surgery could be less invasive. In addition, this procedure provided surgeons with excellent endoscopic views, as retraction force was supplied without any shaft device in the abdomen. This operation system using magnetic retraction appears promising.     

Complications of “dropped” gallstones after laparoscopic cholecystectomy: technical considerations and imaging findings

New laparoscopic techniques have revolutionized the practice of surgery. Laparoscopic cholecystectomy has become one of the most commonly performed surgeries worldwide. Although shorter hospital stays and patient comfort have offered clear advantages over open cholecystectomy, the technique has resulted in several specific complications, including bile duct injury and gallbladder perforation. Although rarely clinically significant, intraperitoneal gallstone spillage can cause abscess formation and adhesions. Although these patients can present with a confusing clinical picture, their characteristic radiologic features should be recognized. We present two cases of complicated intraperitoneal gallstone spillage radiologically diagnosed and treated with laparoscopic and interventional radiologic techniques. Received: 13 April 1999/Accepted: 19 May 1999     

Laparolithic cholecystectomy: laboratory data and first clinical case

A method of laparoscopic cholecystectomy is described. After control of the cystic duct and artery, gallstones are emulsified with a laparoscopic lithotriptor and the debris aspirated from the gallbladder. The free wall of the gallbladder is excised and the remaining gallbladder mucosa ablated with holmium:yttrium-aluminum-garnet (Ho:YAG) laser. This technique eliminates the need for dissection of the gallbladder from the liver, thereby reducing the possibility of hemorrhage from the gallbladder fossa. At the same time stones and bile are aspirated so that the excised portion of gallbladder can be easily removed through an access port without spillage of contaminated bilious debris into the abdominal cavity or puncture wound that could cause infection. Acute and chronic animal studies confirm the feasibility of this technique. A clinical case is described.     

以胆管为导向的腹腔镜胆囊切除术疗效分析

目的:探讨以胆管为导向的腹腔镜胆囊切除术(laparoscopic cholecystectomy guided by the bile duct,LCGBD)的可行性、安全性及临床效果。方法:回顾性分析2013年3月至2017年4月接受腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的456例患者的临床资料。Calot三角的解剖以胆管(胆总管和肝总管)为标志,沿胆管右侧壁,分别显露胆总管、胆囊管、肝总管及胆囊动脉,于近胆管处夹闭胆囊管(不保留胆囊管),切断胆囊管和胆囊动脉后切除胆囊。结果:456例LC患者中,451例顺利完成LCGBD,完成率为98.9%。5例(1.1%)因三角区致密粘连、Mirrizzi综合征、胆道变异或出血未能完成LCGBD。术中发现各类管道变异75例,胆囊管微小结石32例。无胆道损伤、腹腔内大出血、胆瘘等并发症发生,无再次手术病例。2例因胆道变异或胆囊床出血中转开腹,术后并发腹腔残余感染3例,剑突下穿刺孔感染2例,均经保守治疗后痊愈。术后随访3~45个月,平均(25.1±14.6)个月,未发现胆管狭窄、胆道残余结石等并发症。结论:LCGBD安全、可行,更加便于解剖Calot三角内各管道结构和发现解剖变异,有利于降低胆管损伤、出血等并发症的发生率。     

The role of ERCP and laparoscopic cholecystectomy in gallstone-related pancreatitis

Summary

Laparoscopic surgery has become the routine for elective cholecystectomy, but its place in the management of gallstone-related pancreatitis has not yet been identified. We prospectively assessed a minimally invasive treatment regime for gallstone pancreatitis combining endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy, over a 24 month period. Twenty-two patients were found to have gallstone pancreatitis. The mean age was 52 ± 18 years. All patients presented with abdominal pain. Five were jaundiced. The Ranson score severity of pancreatitis averaged 1.6 (range 0–6). Our management protocol was to perform ERCP when clinical and biochemical markers had settled, followed by laparoscopic cholecystectomy during the same admission. The time interval between presentation and ERCP was 8.9d (range 2–15d), ERCP to surgery was 4.5d (range 2–35d) and surgery to discharge was 4d (range 1–21 d). The median hospital stay was 16d. ERCP showed stones in the common bile duct in five patients, four of whom had them removed at ERCP. Twenty patients underwent laparoscopy. The gallbladder was removed in 18 and two required conversion (one pseudocyst, one cystic artery bleed). Two patients had elective open cholecystectomy (one pseudocyst, one previous surgery). Only one patient developed a post-operative complication (pseudocyst). The majority of patients had multiple small stones in their gallbladder and it was not possible to predict the presence of common bile duct stones prior to ERCP. No patient developed post-operative pancreatitis. There was no mortality. This study shows that combined ERCP and laparoscopic cholecystectomy is an efficient and safe minimally invasive management for gallstone pancreatitis.     

Optimal timing of preoperative indocyanine green administration for fluorescent cholangiography during laparoscopic cholecystectomy using the PINPOINT® Endoscopic Fluorescence Imaging System

Introduction

The PINPOINT® Endoscopic Fluorescence Imaging System (Novadaq, Mississauga, Canada) allows surgeons to visualize the bile ducts during laparoscopic cholecystectomy. Surgeons can continue operation while confirming the bile ducts’ fluorescence with a bright‐field/color image. However, strong fluorescence of the liver can interfere with the surgery. Here, we investigated the optimal timing of indocyanine green administration to allow fluorescent cholangiography to be performed without interference from the liver fluorescence.

Methods

A total of 72 patients who underwent laparoscopic cholecystectomy were included in this study. The timing of indocyanine green administration was set immediately before surgery and at 3, 6, 9, 12, 15, 18, and 24 h before surgery. The luminance intensity ratios of gallbladder/liver, cystic duct/liver, and common bile duct/liver were measured using the ImageJ software (National Institutes of Health, Bethesda, USA). Visibility of the gallbladder and bile ducts was classified into three categories (grades A, B, and C) based on the degree of visibility in contrast to the liver.

Results

The luminance intensity ratio for the gallbladder/liver, cystic duct/liver, and common bile duct/liver was ≥1 in the 15‐, 18‐, and 24‐h groups. The proportion of cases in which evaluators classified the visibility of the gallbladder and bile ducts as grade A (best visibility) reached a peak in the 15‐h group and decreased thereafter.

Conclusions

In the present study, the optimal timing of indocyanine green administration for fluorescent cholangiography during laparoscopic cholecystectomy using the PINPOINT Endoscopic Fluorescence Imaging System was 15 h before surgery.     

Experimental comparison of the ultrasonically-activated scalpel to electrosurgery and laser surgery for laparoscopic use

Summary

Energy sources used in laparoscopic surgery are associated with thermal damage to tissues. In this study, we sought to compare the safety and efficacy of the ultrasonically-activated scalpel to electrosurgery and laser surgery in laparoscopic applications using an animal model (cholecystectomy). Variables examined were gall bladder perforation, bile spillage, smoke generation, operative time, tissue injury, bleeding, liver function tests and post-operative adhesion formation following laparoscopic cholecystectomy. Female pigs were randomized to one of three groups: laparoscopic cholecystectomy performed using electrosurgery (ES), laser surgery (LS), or ultrasonically-activated scalpel (UAS). At the termination of the procedure, the animals were either recovered for 7, 14, or 28 days or immediately euthanized with an intracardiac injection of saturated potassium chloride solution for necropsy (0 day). There was no difference in mean operative time between UAS, ES or LS. LS required greater smoke evacuation (67%) than ES (25%) or UAS (0%) (P < 0.001). Gall bladder perforation during dissection with the UAS was 17%, with ES 50% and with LS, 92% (P < 0.001). Post-operative adhesions occurred in 22% of the UAS group, 67% of the ES group and 89% of the LS group (P < 0.001). The ultrasonically-activated scalpel is more ideally suited for laparoscopic cholecystectomy than electrosurgery or laser surgery, and laser surgery is the least desirable of the three modalities.     

Application of near-infrared fluorescent cholangiography using indocyanine green in laparoscopic cholecystectomy

ObjectiveNear-infrared fluorescence cholangiography (NIRF-C) can help to identify the bile duct during laparoscopic cholecystectomy. This retrospective study was performed to investigate the effect of NIRF-C in laparoscopic cholecystectomy.MethodsConsecutive patients who underwent NIRF-C-assisted laparoscopic cholecystectomy (n = 34) or conventional laparoscopic cholecystectomy (n = 36) were enrolled in this study. Identification of biliary structures, the operation time, intraoperative blood loss, and postoperative complications were analyzed.ResultsLaparoscopic cholecystectomy was completed in all patients without conversion to laparotomy. The median operation time and intraoperative blood loss were not significantly different between the two groups. No intraoperative injuries or postoperative complications occurred in either group. In the NIRF-C group, the visualization rate of the cystic duct, common bile duct, and common hepatic duct prior to dissection was 91%, 79%, and 53%, respectively. The success rate of cholangiography was 100% in the NIRF-C group. NIRF-C was more effective for visualizing biliary structures in patients with a BMI of <25 than >25 kg/m².ConclusionsNIRF-C is a safe and effective technique that enables real-time identification of the biliary anatomy during laparoscopic cholecystectomy. NIRF-C helps to improve the efficiency of dissection.     

Port-site metastasis of unsuspected gallbladder carcinoma with ossification after laparoscopic cholecystectomy: A case report

BACKGROUNDUnsuspected gallbladder carcinoma (UGC) refers to cholecystectomy due to benign gallbladder disease, which is pathologically confirmed as gallbladder cancer during or after surgery. Port-site metastasis (PSM) of UGC following laparoscopic cholecystectomy is rare, especially after several years.CASE SUMMARYA 55-year-old man presenting with acute cholecystitis and gallstones was treated by laparoscopic cholecystectomy in July 2008. Histological analysis revealed unexpected papillary adenocarcinoma of the gallbladder with gallstones, which indicated that the tumor had spread to the muscular space (pT1b). Radical resection of gallbladder carcinoma was performed 10 d later. In January 2018, the patient was admitted to our hospital for a mass in the upper abdominal wall after surgery for gallbladder cancer 10 years ago. Laparoscopic exploration and complete resection of the abdominal wall tumor were successfully performed. Pathological diagnosis showed metastatic or invasive, moderately differentiated adenocarcinoma in fibrous tissue with massive ossification. Immuno-histochemistry and medical history were consistent with invasion or metastasis of gallbladder carcinoma. His general condition was well at follow-up of 31 mo. No recurrence was found by ultrasound and epigastric enhanced computed tomography.CONCLUSIONPSM of gallbladder cancer is often accompanied by peritoneal metastasis, which indicates poor prognosis. Once PSM occurs after surgery, laparoscopic exploration is recommended to rule out abdominal metastasis to avoid unnecessary surgery.     

Development of a novel controllable,multidirectional, reusable metallic port with a wide working space

Abstract

Background: Endoscopic surgery is currently a standard procedure in many countries. Furthermore, conventional four-port laparoscopic cholecystectomy is developing into a single-port procedure. However, in many developing countries, disposable medical products are expensive and adequate medical waste disposable facilities are absent. Advanced medical treatments such as laparoscopic or single-port surgeries are not readily available in many areas of developing countries, and there are often no other sterilization methods besides autoclaving. Moreover, existing reusable metallic ports are impractical and are thus not widely used. Material and methods: We developed a novel controllable, multidirectional single-port device that can be autoclaved, and with a wide working space, which was employed in five patients. Results: In all patients, laparoscopic cholecystectomy was accomplished without complications. Conclusion: Our device facilitates single-port surgery in areas of the world with limited sterilization methods and offers a novel alternative to conventional tools for creating a smaller incision, decrease postoperative pain, and improve cosmesis. This novel device can also lower the cost of medical treatment and offers a promising tool for major surgeries requiring a wide working space.     

Laparoscopic cholecystectomy with two incisions: an improved, feasible and safe technique with superior cosmetic outcomes

ObjectiveConventional laparoscopic cholecystectomy (CLC) is usually performed with four incisions. Minimally invasive surgery for gallbladder disease with less pain and smaller scars has become increasingly popular. This study reported a new, two-incision laparoscopic cholecystectomy (TILC) using conventional instruments.MethodsIn this prospective study, 43 patients were recruited to undergo TILC and were compared with 43 historical cases undergoing CLC. We evaluated operative time, postoperative pain, cosmesis and complications.ResultsThere was no significant difference in gender, age, body mass index, bile duct damage, blood loss and postoperative hospital stay between the two groups. The mean operation time was longer with TILC than with CLC, but the difference was not statistically different. Postoperative pain scores were significantly lower with TILC than with CLC. The mean cosmetic satisfaction score was significantly higher with TILC than that with CLC. There was no significant difference in the incidence of complications between the two groups.ConclusionOur work demonstrates that TILC generates less postoperative pain and significantly improved cosmesis for patients. TILC is a safe and feasible alternative to CLC.     

Laparoscopic surgery in the elderly

Summary

Patients over the age of 65, undergoing either laparoscopic cholecystectomy or laparoscopic groin hernia repair in two centres, were retrospectively reviewed. 114 patients (median age 73) case-notes were reviewed. 94 patients had undergone laparoscopic cholecystectomy and 20 laparoscopic hernia repair. 81 % were American society of Anaesthesiologists (ASA) Grade I or II, with 17% Grade III and 2% Grade IV. 8% of the laparoscopic cholecystectomy patients had unsuspected common bile duct stones detected on cholangiography. There was a 5% conversion to open procedure in the cholecystectomy group and 0% in the hernia group. Median hospital stay was 2 days. Mortality was 0% in both groups. Major post-operative morbidity occurred in 4% of the laparoscopic cholecystectomy patients, delaying their discharge. We conclude that laparoscopic surgery is a safe procedure in the elderly patient when accompanied by good patient selection and anaesthetic care.     

腹腔镜胆囊切除术转开腹的危险因素Logistic分析

目的 探讨腹腔镜胆囊切除术转开腹的主要危险因素.方法 回顾分析2009～2011年45例腹腔镜胆囊切除术中转开腹患者的临床资料,根据患者临床症状、体征以及临床指标对中转开腹的主要危险因素进行分析.结果 多因素Logistic回归结果显示,患者的胆囊壁厚度、胆囊炎发作次数、左上腹肌紧张程度、胆囊炎发作到手术时间、血清总胆红素、胆囊三角的清晰度以及墨菲征阳性程度均为胆囊切除术中转开腹的危险因素.结论 手术前对上述危险因素进行综合评估对成功施行腹腔镜胆囊切除术具有重要的临床指导意义.     

Closure of the cystic duct orifice in laparoscopic subtotal cholecystectomy for severe cholecystitis

Introduction

Laparoscopic subtotal cholecystectomy (LSC) has been recognized as an alternative to conversion to laparotomy for severe cholecystitis. However, it may be associated with an increased risk of recurrent stones in the gallbladder remnant. The objective of this study was to evaluate the safety and feasibility of the complete removal of the gallbladder cavity in LSC for severe cholecystitis using the cystic duct orifice suturing (CDOS) technique.

Methods

In a consecutive series of 412 laparoscopic cholecystectomies that were performed from January 2015 to June 2017, 12 patients who underwent LSC with CDOS were enrolled in this retrospective study. In this procedure, Hartmann's pouch was carefully identified, and the infundibulum–cystic duct junction was transected while the posterior wall adherent to Calot's triangle was left behind. The clinical records, including the operative records and outcomes, were analyzed.

Results

The median operating time and blood loss were 158 min and 20 mL, respectively. In all cases, LSC with CDOS was completed without conversion to open surgery. No injuries to the bile duct or vessels were experienced. The median postoperative hospital stay was 6 days. Postoperative complications occurred in two patients (bile leakage, n = 1: common bile duct stones, n = 1) and were successfully treated by endoscopic management. A gallbladder remnant was not delineated by postoperative imaging in any of the cases.

Conclusion

These results suggest that LSC with CDOS is a promising approach that can avoid dissection of Calot's triangle and achieve the complete removal of the gallbladder cavity in patients with severe cholecystitis.

     

腹腔镜胆囊切除术前静脉胆道造影的价值

目的：探讨腹腔镜胆囊切除术前常规作静脉胆道造影的价值。方法：回顾性总结我院1991年10月至1995年6月术前所作的静脉胆道造影1971例。分析造影结果与胆囊的病理改变,胆管结石,手术难度及手术时间长短的关系。结果：胆囊显影良好者,其胆囊的急性炎症、重度粘连、胆囊颈管的结石嵌顿、胆囊积液积浓脓、胆囊萎缩等病理改变的发生率均明显低于胆囊不显影、显影浅谈及肝外胆系不显影者,其平均手术时间也明显低于后三者。在B超未揭示胆管异常的情况下,发现胆管结石59例。占作静脉胆道造影病例的3%。均经手术证实。结论：腹腔镜胆囊切除术术前常规作IVC能充分预见胆囊及其周围的病理改变,发现胆道解剖结构的异常,预测手术难度,筛检胆管结石,避免胆道损伤,应作为LC术前的常规性检查。     

Case report. Lost gall stones

Summary

Laparoscopic cholecystectomy is the most common procedure performed by the minimally invasive laparoscopic surgeon [1,2,3,4]. Many complications are documented in the current literature [5,6]; of these, lost (spillage of) biliary stones is the least worrisome [7]. An unusual presentation of this rather benign complication is described here.     

Confocal laser endomicroscopy distinguishing benign and malignant gallbladder polyps during choledochoscopic gallbladder-preserving polypectomy: A case report

BACKGROUNDIn the last decade, confocal laser endomicroscopy (CLE) has emerged as a new endoscopic imaging modality for real-time in vivo histological examination at the microscopic level. CLE has been shown to be useful for distinguishing benign and malignant lesions and has been widely used in many digestive diseases. In our study, we used CLE for the first time to examine the morphology of cholesterol polyps as well as the different parts of normal gallbladder mucosa.CASE SUMMARYA 57-year-old woman was diagnosed by ultrasound with a polyp of 21 mm in the gallbladder wall. She consented to polyp removal by laparoscopic choledo-choscopy. During laparoscopic cholecystectomy combined with choledochoscopic polyp resection, CLE was used to observe the morphology of the polyp surface cells. The appearance of the mucosa and microvessels in various parts of the gallbladder were also observed under CLE. Through comparison between postoperative pathology and intraoperative CLE diagnosis, the reliability of intraoperative CLE diagnosis was confirmed. CLE is a reliable method to examine living cell pathology during cholecystectomy. Based on our practice, CLE should be prioritized in the diagnosis of gallbladder polyps.CONCLUSIONCompared with traditional histological examination, CLE has several advantages. We believe that CLE has great potential in this field.