Kasr El Aini Journal of Surgery VOL., 12, NO 2 May

Transcription

1 Kasr El Aini Journal of Surgery VOL., 12, NO 2 May Comparison Between Single Incision Laparoscopic Cholecystectomy [SILS] and the novel Two Ports, Two Threads Mini-laparoscopic Cholecystectomy; A Prospective Study George A. Nashed MD., MRCS, Hatem Helmy MD., Nader Shaaban MD., Mohamed Yehia MRCS. Department of Surgery, Cairo University ABSTRACT Background: Laparoscopic cholecystectomy is the standard treatment for gall bladder diseases. Recent innovators have pioneered the use of single incision laparoscopic surgery [SILS] which has the potential of reducing the trauma of surgical access. This may lead to reduction of postoperative pain and improve patient cosmoses. In this study we tried to compare the feasibility of this technique with a modified two ports two threads technique in terms of ergonomics, feasibility, cost and patient cosmoses.methods: Between June 2008 and May 2010, 30 patients with calcular gall bladder disease indicated for cholecystectomy were enrolled in a prospective non-randomized study. Half of them underwent SILS cholecystectomy while the other half underwent the two threads, two ports technique which is a modification of the conventional four ports one.results: Comparing the results of both techniques it was found that our new technique is simple, feasible and less expensive and may be more ergonomic and needs less training than the SILS technique. On the other hand SILS technique is more cosmetic and may be suitable for more difficult cases of laparoscopic cholecystectomy. Conclusions: The thread retracting technique for laparoscopic cholecystectomy is simple, feasible and easy when performed by an experienced laparoscopic surgeon for selected cases of laparoscopic cholecystectomy. When compared to SILS it is found to be less costy and appears to be more ergonomic and moreover it does not need neither sophisticated instruments nor special training. Key words: Laparoscopic cholecystectomy, SILS, thread retraction in laparoscopic surgery INTRODUCTION The first laparoscopic cholecystectomy [LC] was performed in 1987 by Phillip Mouret, and it was later established by Dubois and Perissat in 1990 [1,2]. Today, it has become the gold standard for cholecystectomy and the most commonly performed minimally invasive laparoscopic intervention [3]. Usually; the standard laparoscopic cholecystectomy is done using four trocars [the American variable]. In recent years, many investigators have attempted to improve the established technique of laparoscopic cholecystectomy. The goal has been to minimize the invasiveness of this procedure by reducing the number of operating ports and this consequently leads to improved outcome [4]. This has led to the description of two and three port techniques for laparoscopic cholecystectomy [5]. The first reported cases of single incision laparoscopic cholecystectomy were published in1997, when Navarra et al. described a series of 30 cases performed with two 10 mm trocars placed via a single umbilical incision [6] Today, and because of technological explosion surgery may be driven from small incisions to incisionless passing by reduced port surgery, and SILS techniques [7 12]. In recent years, natural orifice transluminal endoscopic surgery [NOTES] has been offered as the next generation of minimally invasive surgery with no scars [13]. However, serious drawbacks specifically belonging to this technique such as access, safety of closure, infection, lack of appropriate instrumentation, and difficulty in orientation have discouraged the use of NOTES procedures [14]. Because of the inconvenience associated with NOTES, single-incision laparoscopic surgery [SILS] has gained greater interest and popularity in the surgical community [15]. SILS can be performed using refinements of existing technology, and surgeons can perform SILS without any new instruments, specific competence, or training. SILS may offer the advantages of reducing postoperative pain, and

2 Kasr El Aini Journal of Surgery VOL., 12, NO 2 May virtually scarless surgery as the surgical scar can often be hidden within the umbilicus [7]. The major difficulty with SILS is the surgeon s need to adapt to the new method of instrumentation. Moreover the SILS technique is not ergonomic technique because the traditional laparoscopic principles are lost [16]. This prospective non-randomized study aims at comparing the feasibility, difficulties and outcome of laparoscopic cholecystectomy using a two ports and two thread retraction technique and the single port technique[sils] regarding rate of conversion either to the classic four ports or open technique, operative time, intra and post operative complications, post operative pain, hospital stay and the cost of operation. PATIENTS & METHODS Between June 2008 and May 2010, 30 patients with calcular gallbladder disease indicated for cholecystectomy were enrolled in a prospective non-randomized study. The Patients history and clinical assessment were verified by ultrasonography and routine laboratory blood tests. Exclusion criteria included obese patients with body mass index [BMI] more than 30; history of acute attack and pervious abdominal surgery. All patients were informed about the techniques with full explanation of the procedures, and written consent was signed by each patient. Patients were divided into two groups: Group A: included 15 patients who underwent laparoscopic cholecystectomy using the two ports, two threads technique. Group B: included 15 patients who underwent laparoscopic cholecystectomy using the single port technique [SILS]. Operative technique Single port technique [SILS] Fig. [1]: SILS port [Covedien] Fig. [2]: Reticulator grasper [Covedien] Single port access cholecystectomy was performed by using a surgical technique similar to standard laparoscopic cholecystectomy, except that it was conducted through a single umbilical port. Patients were placed in supine position with the operating surgeon standing between the legs of the patient and the assistant on the patient left side. A 20 mm infraumbilical incision is made and SILS [covidien] port is inserted through an open technique[fig1]. This is a foam port that is inserted through a 2-cm fascial incision and expands once inserted to prevent air leakage. Small holes within the foam accommodate 5-mm or 12-mm trocars. The trocars used with this port have a very small diameter and low profile head. Gallbladder suspension and exposition was achieved by placing transparietal stitches monocryl or prolene 2/0 mounted on straight needle passed through the fundus of the gall bladder. The main surgical instruments used for this procedure are the reticulating Covidien Endo Grasp and Endo Dissect[fig.2]. The scope used is 30, 5-mm laparoscope. The operation was completed in the usual fashion using 5mm stappling device and the gall bladder was extracted through the umbilical incision. No drains were used and fascial closure of the incision was done. The novel two ports, two threads technique With our technique, we used 5-mm trocar at the umbilicus for the scope. The camera was inserted through 5mm umbilical port. A working port 10-12mm was inserted in the epigastrium in the subxiphoid position to the left of the midline.instead of inserting the two other retracting ports the following retracting stitches were inserted as follows:

3 Kasr El Aini Journal of Surgery VOL., 12, NO 2 May /0 prolene suture on straight needle is passed through the abdominal wall under vision [figure3] at the right mid clavicular line a hand s breadth below the right costal margin and then passed through the fundus of the gall bladder [figure 4]and back again through the abdominal wall and tied on the outside of the abdominal wall for the retraction of the fundus of the gall bladder fundus [figure 5&6] We choose to place our sutures in the following manner: the fundus of the gallbladder is grasped with endograsper introduced through the epigastric working port and elevated to the anterior abdominal wall. The fundus was pushed cranially to demonstrate the desired exposure of the undersides of the gall bladder and the liver. Simultaneous palation of the abdominal wall showed the optimum site of insertion of the first retracting stitch and it was in most of cases in the midclavicular line at the subcostal border. The two ends of the suture were held and tied together. Traction on this suture allowed the elevation and retraction of the gallbladder fundus. A second retracting stitch for the Hartmann s pouch; after retracting the fundus of the gall bladder to the abdominal wall the Hartman s pouch comes into view a second prolene stitch is passed either through the Hartman s pouch or in the body of the gall bladder just above the Hartman s pouch. This retracting stitch is passed through the abdominal wall at the anterior axillary line at the level of the umbilicus then passed through the gall bladder and finally out again one hand s breadth from the entery site [fig. 7]. The operation is completed in a routine fashion using the 5-mm stappling device and at the end of the operation[ after separation of the gall bladder from the liver ], both prolene stitches were cut and pulled out. The gall bladder was extracted through the subxiphoid working port and no drains were left. In only three patients of our series a third retracting thread was added for the retraction of the body of the gall bladder and its position on the abdominal wall was determined per case according to the situation mostly inbetween the other two stitches. In both techniques the procedures were recorded and the operative time, difficulties and complications were recorded. Postoperative course, analgesic requirements, cosmetic appearance, wound complications and hospital stay were recorded as well. RESULTS Thirty patients underwent laparoscopic cholecystectomy, half of them with two ports two threads technique and the other half with SILS technique from June 2008 through May 2010 [Table1]. Median age of patients who underwent SILS cholecystectomy was 39 years. The median age of patients who underwent two port cholecystectomy was 40 years. Median body mass index [BMI] for all patients was 26 kg/m2. No patients had acute cholecystitis. Mean Operative time for patients who underwent SILS cholecystectomy was 63 min vs.55 min for those who underwent two port laparoscopic cholecystectomy. All patients had less than 60 cc of estimated blood loss. No patients required conversion to neither open nor conventional four ports laparoscopic technique. No postoperative complications occurred in any patients. Analgesic requirement was less in patients who underwent SILS compared to the other technique. Length of hospital stay for all patients was 1 day. At the start of our experience SILS cholecystectomy was found more challenging and more difficult than the two ports technique especially with the use of the reticulating instruments. No wound complications were encountered.

4 Kasr El Aini Journal of Surgery VOL., 12, NO 2 May Table 1 A comparison of SILS Cholecystectomy vs. Two ports two threads Laparoscopic Cholecystectomy Single-incision laparoscopic cholecystectomy Two port laparoscopic cholecystectomy Number of patients Gender 8 females/ 7males 10 females/ 5 males Age 39 years [26-57] 40 years [25-56] BMI 26.6 kg/m2 [22-31] 26.8 kg/m2 [22-31] Operative time 63 min [45-90] 55 min [40-70] Blood loss Minimal Minimal Pathology Chronic cholecystitis Chronic cholecystitis Length of hospital stay 1 day 1 day Complications None None Fig. [3]: A straight needle is passed through the abdominal wall Fig. [5]: The needle is passed back through the abdominal wall Fig. [4]: Needle passed through the fundus of the gall bladder Fig. [6]: Retraction of the fundus of gall bladder to the abdominal wall

5 Kasr El Aini Journal of Surgery VOL., 12, NO 2 May Fig. [7]: The two ports, two threads technique. Fig. [8]: The abdomen after completion of SILS cholecystectomy Discussion Laparoscopic cholecystectomy has traditionally been done using the four ports technique [ the American variable] but recently there has been a strong move towards reduced ports operation [12]. The major difficulty with SILS is the surgeon s need to adapt to the use of new instruments. Moreover the SILS technique is not ergonomic technique because the traditional laparoscopic principles are lost [16]. In this study the BMI of patients undergoing SILS cholecystectomy were similar to patients undergoing two ports, laparoscopic cholecystectomy Patients undergoing cholecystectomy in this study represent a highly selected group of patients based upon the anticipated technical challenges for both techniques. Technical challenges of SILS cholecystectomy in our experience included retraction of the gallbladder and exposure of the Calot s triangle, clashing of the instruments, and the mirror-effect concerning the handling of reticulating instruments [14]. In our new modified technique we omitted both the midclavicular port used for retraction of the fundus as well as the anterior axillary port which was used for retraction of the Hartman s pouch and instead we used two retracting threads in most of our cases and in only three patients at the start of our experience we used an additional retracting stitch for the body of the gall bladder as well. The operation was technically feasible, attractive, reproducible and easy to perform in the hands of experienced laparoscopic surgeon. In the initial experience of this new technique we spent a lot of time in choosing the best positioning of the retracting stitches as well as in their manipulation during performance. Careful suture placement allowed the operator to puppeteer the gall bladder, thus replicating the movements that would normally be performed by the surgeon s left hand in the traditional laparoscopic cholecystectomy [16]. When comparing the use of prolene threads to silk or vicryl threads it was found that polypropelene being monofilamentous slides easier through the abdominal wall as well as through the gall bladder. There was no reported complications at the needle puncture sites in the abdominal wall in any of our patients and this adds to the safety of this procedure. When comparing our new technique for laparoscopic cholecystectomy with SILS cholecystectomy, the later technique needs special port with multiple enteries for the introduction of reticulating instruments which as well needs special training to use them in performing such procedure [17]. The major advantage of SILS is mainly cosmetic and related to patient satisfaction which is as well present in the thread technique without any visible abdominal scars which was easily concealed within or just below the umbilicus. However this Cosmetic advantage was counter balanced by longer operative time, nonsignificant differences in postoperative pain, significant

6 Kasr El Aini Journal of Surgery VOL., 12, NO 2 May higher cost of the SILS port which costs about 4500 L.E.in addition to 1500 L.E. of the articulating instruments, and a theoretical higher incidence of umbilical incisional hernia due to a larger umbilical incision, which in our experience was 2.5 cm wide. In addition to the major advantage of the retracting threads technique of the low cost as compared with the SILS one, this technique as well does not interfere with the concept of triangulation to which laparoscopic surgeons are accustomed so it is considered more ergonomic than SILS technique [17]. Although SILS technique appears to be less ergonomic than the retracting thread tehnique, yet with more training it becomes more feasible to do especially when training is done with the special reticulating instruments and angled scopes. Another major advantage of SILS over the thread technique is the feasibility to use it for the more difficult cases of laparoscopic cholecystectomies as well as for patients with higher BMI in the contrary to the later technique which requires careful patient selection. However further trials on more difficult cases may be successful. From our study we found that cholecystectomy via SILS with infraumblical access is a feasible, safe, and reproducible technique. The most important feature of cholecystectomy via SILS that discriminates it from NOTES is the feasibility of the technique with existing instruments. Also, the orientation and safety landmarks suggested for conventional laparoscopic cholecystectomy are not different for this technique [12,13]. Additionally; not only the surgeon but also the camera assistant must be familiar with reverse handling of the grasper and dissector. [14] Conclusion The two ports two thread retraction technique for laparoscopic cholecystectomy is simple, feasible and easy when performed by an experienced laparoscopic surgeon for selected cases of laparoscopic cholecystectomy. When compared to Sils, it is less costy and appears to be more ergonomic and moreover it does not need neither sophisticated instruments nor special training. REFERENCES 1. Dubois F, Icard P, Berthelot G et al: Coelioscopic cholecystectomy:premilary report of 36 cases [1990]. Ann Surg 211:60 2. Litynski GS: Profiles in laparoscopy: Mouret, Dubois, and Perissat the laparoscopic breakthrough in Europe [ ] [1999]. JSLS 3: Cerci C, Tarhan OR, Barut I et al: Threeport versus fourport laparoscopic cholecystectomy [2007]. Hepatogastroenterology54:15 4. Poon CM, Chan KW, Lee DW, Chan KC, Ko CW, Cheung HY,Lee KW: Two-port versus four-port laparoscopic cholecystectomy[2003]. Surg Endosc 17: Novitsky YW, Kercher KW, Czerniach DR et al: Advantages of mini-laparoscopic vs conventional laparoscopic cholecystectomy: results of a prospective randomized trial[2005]. Arch Surg140: Navarra G, Pozza E, Occhinoorelli S, Carcoforo P,Donini I: one- wound laparoscopic cholecystectomy [1997]. Br J Surg 84: Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D,Coumaros D.: Surgery without scars: report of transluminal cholecystectomy in a human being [2007]. Arch Surg; 142: Cuesta M, Berends F, Veenhof A :The invisible cholecystectomy : 9. A transumbilical laparoscopic operation without a scar [2007]. SurgEndosc; 22: Navarra G, Pozza E, Occhionorelli S et al: One-wound laparoscopic cholecystectomy [1997]. Br J Surg; 84: Ng WT, Kong CK, Wong YT: One-wound laparoscopic cholecystectomy [1997].Br J Surg; 84: Powell JJ, Siriwardena AK: One-wound laparoscopic cholecystectomy [1997].Br J Surg ; 84: Park PO, Bergstrom M, Ikeda K, Fritscher-Ravens A, Swain P: Experimental studies of transgastric gallbladder surgery: chole- cystectomy and cholecysto gastric anastomosis [2005]. Gastrointest Endosc ; 61:

7 Kasr El Aini Journal of Surgery VOL., 12, NO 2 May Kagaya T: Laparoscopic cholecystectomy via two ports, using the twin-port system [2001]. J Hepatobiliary Pancreat Surg; 8: Sinan Ersin, Ozgur Firat, Murat Sozbilen: Single-incision laparoscopic cholecystectomy: is it more than a challenge? [2010]. Surg Endosc 24: Fuente SG, DeMaria EJ, Reynolds JD, Poertenier DD, Pryor AD: New development in surgery: natural orifice transluminal endoscopic surgery [NOTES] [2007]. Arch Surg 142: Andre Chow, Sanjay Purkayastha, Omer Aziz, Paraskevas Paraskeva; Single- incision laparoscopic surgery for cholecystectomy: an evolving technique [2010]. Surg Endosc 24: John R, Romanelli, David B E.: single port laparoscopic surgery: an overview [2009]. Surg Endosc 23:

8 Kasr El Aini Journal of Surgery VOL., 12, NO 2 May