Single-incision laparoscopic cholecystectomy versus traditional four-port cholecystectomy

Transcription

1 Single-incision laparoscopic cholecystectomy versus traditional four-port cholecystectomy Brittney L. Culp, MD, Veronica E. Cedillo, MSN, RN-BC, and David T. Arnold, MD Laparoscopic cholecystectomy has traditionally been performed using multiple small sites. Single-incision laparoscopic surgery has emerged as an alternative technique to improve cosmesis and minimize complications associated with multiple incisions. A retrospective study was performed of all patients who underwent laparoscopic cholecystectomy by a single surgeon (DTA) from April 2008 to August Charts were reviewed for surgical indication, operative technique (multiple vs. single transumbilical incision), operative time, length of stay, and surgical complications. Sixty-three patients underwent laparoscopic cholecystectomy using a traditional approach of four skin incisions, while 62 patients underwent a single-incision transumbilical approach. Average age and sex were comparable between the two groups. Indications for surgery included cholelithiasis, cholecystitis, biliary dyskinesia, biliary pancreatitis, and porcelain gallbladder. Of those undergoing single-incision cholecystectomy, 85% (53/62) went home the same day, compared with 70% (44/63) of those undergoing four-incision cholecystectomy (P = 0.03). Among those not discharged on the same day of surgery, the average length of stay trended shorter in the single-incision group (2.8 days, range 1 6) compared with the four-incision group (3.3 days, range 1 12; P = NS). Operative time was slightly longer for those undergoing single-incision surgery (65 minutes, range ) versus traditional four-incision surgery (51 minutes, range ) (P < 0.001). With this single surgeon s single-incision transumbilical technique, costs were comparable between the two groups. One patient who underwent traditional four-incision cholecystectomy was readmitted for biliary pancreatitis and bacteremia on postoperative day 3. In the single-incision group, one patient was readmitted 1 month later with pancreatitis. In conclusion, single-incision transumbilical laparoscopic cholecystectomy can be an effective alternative to traditional four-incision cholecystectomy, with the added benefit of minimized scarring and a shorter length of stay. A longer operative time may be needed initially to adjust for a learning curve. This technique can be performed safely for patients with a multitude of gallbladder diseases without resulting in additional complications. Laparoscopic cholecystectomy has been performed since 1985, and throughout the next two decades this procedure became the standard of care for gallbladder disease (1). Laparoscopic cholecystectomy has traditionally been performed using multiple small incisions/port sites. Singleincision, or single-site, laparoscopic surgery has emerged as an Proc (Bayl Univ Med Cent) 2012;25(4): alternative technique to improve cosmesis and minimize complications associated with multiple incisions. The first published report of a single skin incision laparoscopic cholecystectomy was by Navarra in 1997 (2). Since that time, the idea of scarless surgery has gained increasing popularity among patients as well as surgeons. Theoretical benefits of single-incision laparoscopic surgery include less pain and less narcotic requirements postoperatively, shorter hospital stays, quicker return to work, and better cosmesis while continuing to limit operative complications and costs (3). There have been many reports describing multiple techniques and the feasibility of single-incision surgeries. However, very few studies exist that compare single-incision surgeries to traditional laparoscopic techniques. This study evaluated a single surgeon s experience using single-incision laparoscopic cholecystectomy (SILC) compared with traditional four-port laparoscopic cholecystectomy (4PLC). Primary endpoints were length of stay, operative time, and cost of the procedure and the hospital visit. METHODS A retrospective chart review was performed for patients who underwent laparoscopic cholecystectomy by a single surgeon from April 2008 to August Patients underwent either 4PLC or SILC. The technique used for SILC was similar to that described by Elsey and Feliciano (4) (Figure 1). A single, curvilinear infraumbilical incision was made followed by wide separation of the subcutaneous tissues off the linea alba. A 5-mm trocar was inserted under direct visualization. A 0-degree laparoscopic camera was inserted and the abdomen was insufflated to a pressure of 15 mm Hg with carbon dioxide. Once adequate visualization of the gallbladder was confirmed, the camera was exchanged for a 30-degree camera. Two additional, low-profile 5-mm trocars were then placed approximately 1 cm superolateral on both sides of the initial camera port. A grasping instrument was placed through the right trocar, and a dissecting instrument was placed through From the Department of Surgery, Baylor University Medical Center at Dallas. Corresponding author: David T. Arnold, MD, Department of Surgery, Baylor University Medical Center at Dallas, 3808 Swiss Avenue, Dallas, Texas ( arnoldmd@sbcglobal.net). 319

2 a b Figure 1. Placement of trocars for single-incision laparoscopic cholecystectomy: (a) photograph and (b) diagram. the left trocar. Finally, a blunt retractor for the fundus was placed directly through the fascia just inferior to the right port without using a trocar. Division of the peritoneum underlying the gallbladder was followed by dissection of the cystic duct and artery. The critical view was obtained in all cases prior to using a 5-mm clip applier and ligating the cystic duct and artery. The gallbladder was further dissected from the hepatic bed and placed into a laparoscopic retrieval bag. The camera was switched to the lateral right port and the specimen was passed through the 5-mm trocar. Using a single PDS figureof-eight suture, all but the retractor incision were reapproximated. The skin was closed using 4-0 Monocryl in a running subcuticular fashion. Follow up included a postoperative visit 2 to 6 weeks after surgery. Data were collected on patient age, sex, date of admission, date of surgery, date of discharge, surgical complications, operative time, hospital costs for the procedure, costs of the overall hospital visit, and readmissions. Means and ranges were reported for each data point. All categorical variables were analyzed using the chi-square test and Fisher exact test when appropriate. Proportions were calculated by the count of the variable in the treatment status divided by the total of nonmissing patients (N). All continuous variables were analyzed using the t test (when the variable had a normal distribution in the group) or the nonparametric Wilcoxon rank sum test (when the assumption of normality failed for either group). For continuous variables, mean/median, minimum, and maximum values were provided. Statistical signifi cance was defi ned as P < RESULTS From April 2008 to August 2011, 62 patients underwent SILC and 63 patients underwent traditional 4PLC. Results are summarized in Table 1. The average age of the patients was 45 years (range 22 84) in the SILC group and 52 years (range 20 90) in the 4PLC group (P = 0.02). Indications for the operation were similar between the groups (Table 2). None of the SILC surgeries required conversion to a traditional technique, nor did any patient require conversion to an open technique. The average length of stay, including inpatient and outpatient surgeries, was 0.34 days (range 0 6) after SILC compared with 0.98 days (range 0 12) after 4PLC (P = 0.03). After undergoing SILC, 85% of patients (53 of 62) went home the same day, while 70% of patients (44 of 63) went home the same day following 4PLC (P = 0.03). When scheduled for elective surgery, 91% of patients undergoing SILC, and 79% of patients undergoing 4PLC, went home the same day (P = 0.05). Of those Table 1. Results for patients undergoing transumbilical single-incision laparoscopic cholecystectomy versus traditional multipleincision laparoscopic cholecystectomy Variable Single incision (n = 62) Multiple incision (n = 63) P value Age (years) Length of stay (days, range) 0.34 (0 6) 0.98 (0 12) 0.03 Home same day (%, n) 85% (53/62) 70% (44/63) 0.03 Elective surgery home same day (%, n) 91% (53/58) 79% (44/52) 0.05 Length of stay (at least 1 night) (days, range) 2.8 (1 6) 3.3 (1 12) 0.73 Operative time (minutes, range) 65 (35 141) 51 (24 109) <0.001 Cost of procedure (US dollars, range) $3700 ($3020 $6050) $3450 ($2910 $7040) 0.02 Cost of hospital visit (US dollars, range) $6710 ($4360 $19,470) $7530 ($4220 $24,080) 0.23 Readmissions (n) Baylor University Medical Center Proceedings Volume 25, Number 4

3 Table 2. Indications for cholecystectomy in patients undergoing a transumbilical single-incision laparoscopic procedure versus a traditional multiple-incision laparoscopic procedure Indication Single incision (n = 62) Multiple incision (n = 63) Biliary dyskinesia 5 2 Acute cholecystitis 3 5 Chronic cholecystitis 9 7 Symptomatic cholelithiasis Porcelain gallbladder 1 1 Biliary pancreatitis 0 2 No operative complications were noted in any patient. In both groups, one patient was readmitted postoperatively. The patient who had undergone SILC was admitted 17 days postoperatively with midepigastric pain, nausea, and vomiting. She was diagnosed with a urinary tract infection but was not found to have any biliary complications. After 4PLC, one patient was readmitted 3 days postoperatively with midepigastric pain, nausea, vomiting, leukocytosis, elevated liver function tests, and elevated lipase. She underwent endoscopic retrograde cholangiopancreatography and was found to have a narrowed pancreatic duct, which was treated with a stent. Follow up was limited to one to two postoperative office visits. No complications were noted in this period. requiring an overnight stay after surgery, the average length of stay after SILC was 2.8 days (range 1 6) compared with 3.3 days (range 1 12) after 4PLC; however, this difference was not statistically significant. Operative time was significantly longer in the SILC group. An average of 65 minutes was needed to complete a SILC (range ) versus 51 minutes (range ) for a 4PLC (P < 0.001). When comparing surgeries performed at a teaching institution, there was no trend in operative time. However, when comparing a subset of patients undergoing surgery at an ambulatory surgery center where residents did not assist with surgery, the operative time was noted to decline over time (Figure 2). Average costs for the surgical procedure were calculated using TrendStar. The cost for surgery was significantly higher in the SILC group, with an average of $3700 (range $3020 $6050) compared with $3450 (range $2910 to $7040) for the 4PLC group (P = 0.02) (Figure 3a). Average hospital visit costs were lower after SILC compared with 4PLC: $6710 (range $4360 $19,470) and $7530 (range $4220 $24,080), respectively (P = 0.23) (Figure 3b). Figure 2. Operative time for single-incision laparoscopic cholecystectomy over 3 years for a single surgeon. DISCUSSION Eighty-five percent of patients undergoing SILC went home the day of surgery. This is similar to findings in other reports (4). There was a statistically significant shorter length of stay for the SILC group. Patients in the SILC group stayed in the hospital on average 12 hours less than those undergoing 4PLC. These results are similar to those of Joseph et al (5), who noted that the mean postoperative hospital stay for SILC patients was 12.7 hours shorter than that of 4PLC patients (5). Although we did not study the time to normal activity, others reported that patients undergoing SILC tend to return to normal activity earlier than those undergoing 4PLC (6). Similar to other studies, operative time was significantly longer in the SILC group than in the 4PLC group. The mean operative time for SILC was 14 minutes longer than that for 4PLC. According to Greaves and Nicholson, the average difference in operative times among other studies is 12 minutes (7). Longer operative times are likely related to technical difficulties and a learning curve inherent in a new technique (3). In this study, operative times that significantly deviated from the mean were often due to difficulties such as placing the gallbladder in the retrieval bag, performing a cholangiogram, obtaining a liver biopsy, and dealing with severe inflammation of the gallbladder. SILC is technically difficult due to poor ergonomics, theorized decreased visualization, and inadequate retraction due to limitation of movement (8). However, much of this difficulty is overcome with experience of both the surgeon and the assistant. The learning curve for SILC has been studied multiple times. According to Hernandez et al (9), the slow beginning of the learning curve is associated with high rates of conversions and increased complications. This is followed by the steep acceleration phase during which rapid procedural learning takes place. This phase ends with proficiency, after which the curve plateaus. Hernandez et al reported that the learning curve for single-incision surgery actually begins near profi ciency. After 75 surgeries, the mean operative time for a single surgeon signifi cantly decreased (9). Qiu et al reported that after 20 October 2012 Single-incision laparoscopic cholecystectomy versus traditional four-port cholecystectomy 321

4 a b Figure 3. Costs for (a) procedure and (b) hospital visit in patients undergoing a transumbilical singleincision laparoscopic procedure versus a traditional multiple-incision laparoscopic procedure. procedures, the training phase appeared to be complete, and after 40 procedures, operative times seemed to stabilize (10). In the current study, patients undergoing surgery at an outside hospital without resident involvement had a significantly shorter mean operative time. This cohort reflects the experience of a single surgeon alone, and within this group there was a trend toward shortened operative times over time. After five surgeries, the operative time decreased substantially and then seemed to plateau or decrease only slightly in this group. While it is likely that a longer learning curve exists, other studies have also shown comparably short learning curves (8, 11 13). A recent systematic review showed no statistically significant difference in complication rates or postoperative pain scores for those undergoing SILC versus 4PLC (14). However, Phillips et al published a study that showed higher pain scores for those undergoing SILC, but no difference in analgesic use between SILC and 4PLC patients. They also reported higher rates of superficial wound complications after SILC (15). With multiple incisions in the fascia in such close proximity and a longer skin incision, there is a theoretical increased risk of incisional hernias. In a series of 125 patients with follow up as long as 22 months, Cui reported that no patient had presented with an incisional hernia (16). Follow up in our study was limited to 6 weeks; however, we noted no incidence of incisional hernia or wound complications. The higher cost of SILC was statistically significant, although the difference seemed small ($250). The higher operative costs seemed to be overcome by lower overall hospital visit costs for those undergoing SILC. However, there was no statistically significant difference in hospital visit costs. Our results concerning costs were similar to those in other studies. Love et al showed that total operating room cost was approximately $100 more for SILC than 4PLC, but they also showed lower hospital charges in the SILC group than in the 4PLC group (17). As in the study of Joseph et al (5), we used similar instrumentation for both groups. Therefore, any difference in costs is likely related to operative time. Weaknesses of this study include its retrospective design and lack of true standardization. As with many other reported series in single-incision surgery, there was a noted inherent selection bias (7). However, an appropriate selection bias would be necessary when introducing a new technique into a surgeon s practice. Clinical judgment should allow the surgeon to minimize operative complications and risks while optimizing patient satisfaction. In previously reported studies, patients were often excluded from SILC due to previous abdominal surgery, acute cholecystitis or pancreatitis, atypical symptoms, malignancy, American Society of Anesthesiologists score of III or more, or obesity based on body mass index. These exclusion criteria should be considered when first adopting SILC into one s practice (11, 14). 1. Reynolds W Jr. The first laparoscopic cholecystectomy. JSLS 2001;5(1): Navarra G, Pozza E, Occhionorelli S, Carcoforo P, Donini I. One-wound laparoscopic cholecystectomy. Br J Surg 1997;84(5): Philipp SR, Miedema BW, Thaler K. Single-incision laparoscopic cholecystectomy using conventional instruments: early experience in comparison with the gold standard. J Am Coll Surg 2009;209(5): Elsey JK, Feliciano DV. Initial experience with single-incision laparoscopic cholecystectomy. J Am Coll Surg 2010;210(5): , Joseph S, Moore BT, Sorensen GB, Earley JW, Tang F, Jones P, Brown KM. Single-incision laparoscopic cholecystectomy: a comparison with the gold standard. Surg Endosc 2011;25(9): Chang SK, Tay CW, Bicol RA, Lee YY, Madhavan K. A case-control study of single-incision versus standard laparoscopic cholecystectomy. World J Surg 2011;35(2): Greaves N, Nicholson J. Single incision laparoscopic surgery in general surgery: a review. Ann R Coll Surg Engl 2011;93(6): Baylor University Medical Center Proceedings Volume 25, Number 4

5 8. Brody F, Vaziri K, Kasza J, Edwards C. Single incision laparoscopic cholecystectomy. J Am Coll Surg 2010;210(2):e9 e Hernandez J, Ross S, Morton C, McFarlin K, Dahal S, Golkar F, Albrink M, Rosemurgy A. The learning curve of laparoendoscopic singlesite (LESS) cholecystectomy: definable, short, and safe. J Am Coll Surg 2010;211(5): Qiu Z, Sun J, Pu Y, Jiang T, Cao J, Wu W. Learning curve of transumbilical single incision laparoscopic cholecystectomy (SILS): a preliminary study of 80 selected patients with benign gallbladder diseases. World J Surg 2011;35(9): Erbella J Jr, Bunch GM. Single-incision laparoscopic cholecystectomy: the first 100 outpatients. Surg Endosc 2010;24(8): Khambaty F, Brody F, Vaziri K, Edwards C. Laparoscopic versus singleincision cholecystectomy. World J Surg 2011;35(5): Chow A, Purkayastha S, Aziz O, Pefanis D, Paraskeva P. Single-incision laparoscopic surgery for cholecystectomy: a retrospective comparison with 4-port laparoscopic cholecystectomy. Arch Surg 2010;145(12): Markar SR, Karthikesalingam A, Thrumurthy S, Muirhead L, Kinross J, Paraskeva P. Single-incision laparoscopic surgery (SILS) vs. conventional multiport cholecystectomy: systematic review and meta-analysis. Surg Endosc 2012;26(5): Phillips MS, Marks JM, Roberts K, Tacchino R, Onders R, DeNoto G, Rivas H, Islam A, Soper N, Gecelter G, Rubach E, Paraskeva P, Shah S. Intermediate results of a prospective randomized controlled trial of traditional four-port laparoscopic cholecystectomy versus single-incision laparoscopic cholecystectomy. Surg Endosc 2012;26(5): Cui H. Single incision laparoscopic cholecystectomy using the oneincision three-trocar technique with all straight instruments: how I do it? Front Med 2011;5(3): Love KM, Durham CA, Meara MP, Mays AC, Bower CE. Single-incision laparoscopic cholecystectomy: a cost comparison. Surg Endosc 2011;25(5): October 2012 Single-incision laparoscopic cholecystectomy versus traditional four-port cholecystectomy 323