SINGLE PORT ACCESS CHOLECYSTECTOMY: THE INITIAL LEARNING CURVE

Original Article

INTRODUCTION

Over the last two decades, laparoscopic chole-cystectomy has replaced open cholecystectomy as thestandard surgical procedure for majority of patients of gallstone disease. Till 1999, laparoscopic Cholecystectomy wasbeing performed using multiple ports usually 3or 4 ports.Intensive desire of surgeon to reduce the number of ports ledinvention of two port cholecystectomy and then finallysingle incision laparoscopic cholecystectomy (SILC) .

Single incision laparoscopic surgery utilizes threefascial ports through the single skin incision at umbilicus[1]. With the introduction of single port with multiplesleeves, now single port access has become a vital optionfor cholecystectomies and other commonly performedlaparo-scopic procedures. Single port access surgery isbeing considered as no scar surgery, because the singleport is placed within the umbilical ring that is not visible atall. We conducted a prospective study to assess learningcurve, reproducibility and advantages of this newtechnique at our centre, before offering it to all types ofpatients of benign biliary diseases.

METHODS

Until the beginning of July 2009, traditional multiportlaparoscopic cholecystectomy was the standard of carefor the majority of benign biliary diseases. Before that wetried SILC occasionally for selected cases but we found itto be difficult to perform. With the availability of SILSTM

port in india, we started to perform single port accesschole-cystectomy using multichannel SILSTM port inproperly selected cases. We retrospectively reviewed theeffect of this transition on operative times and surgicalcomplications.

All patients of symptomatic benign biliarydiseases were evaluated thoroughly, only thosepatients who had history of biliary colic, BMI lessthan 23 and normal looking gall bladder with noevidence of acute or chronic cholecystitis andcholedocholithiasis on ultra sonography wereincluded in the study. Patients characteristics aredemonstrated in (Table 1).16 patients of symptomatic gallstone disease and 3 patients of adenomyomatosis of gallbladder were selected for single port accesscholecystectomy (Fig.1).

SINGLE PORT ACCESS CHOLECYSTECTOMY: THE INITIAL LEARNING CURVE*

Radha Govind Khandelwal, Kirubha Shankar and Prasanna Kumar Reddy

Department of Surgical Gastroenterology and Minimal Access Surgery, Apollo Hospitals, 21Greens Lane,Off. Greams Road, Chennai 600 006, India.

Correspondence to: Dr Prasanna Kumar Reddy, Head of Department of Surgical Gastroenterology, Apollo Hospitals, 21Greams Lane, Off Greems Road, Chennai 600 006, India.

e-mail: drpkreddy@hotmail.com

Objective: Single port surgery is a rapidly advancing technique with a lot of enthusiasm among minimalaccess surgeons. Single port access cholecystectomy (SPAC) is one of the most commonly performed singleport access surgery all over the world. To establish this technique as standard of care for management ofbenign biliary diseases, it needs strong comparison with traditional laparoscopic cholecystectomy. Initiallearning curve, cost effectiveness, post operative pain, post operative recovery and complications rate is yet tobe established. Methods: SPAC was performed on 19 selected patients for symptomatic gall stone disease bya single surgeon at our institute. The SILSTM port was placed in the umbilicus and combination of articulatingand straight instruments were used. Patient characteristics and outcome were reviewed. Results: The mainselection criteria for SPAC were based on clinical history, body mass index, and ultrasonographic findings. TheSPAC had a mean time of 50 minutes. The first single port cholecystectomy took 120 minutes with sequentialimprovement in operating time for further cases. The average patient body mass index was 23. No majorcomplications or conversion to traditional technique occurred. Conclusion: One of the largest series to date ofSPAC for benign biliary diseases in India, performed by a single surgeon in a single institute is presented. Weconclude that it is a safe and reproducible technique with short learning curve for appropriately trained minimalaccess surgeons with a higher cosmetic satisfaction for patients.

Key words: Single port access cholecystectomy (SPAC), SILSTM port, Reproducible, Learning curve.

*Paper presented in IAGES – 2010 held at Delhi on 21 February 2010.

Apollo Medicine, Vol. 7, No. 2, June 2010 132

Original Article

133 Apollo Medicine, Vol. 7, No. 2, June 2010

area for retraction because of obstruction of calot’striangle by liver.

RESULT

In first two cases both of symptomatic biliary colic thatwere attempted for single port access cholecystectomy, werequired an additional ethilon suture for retracting theHartman to expose the calot’s triangle. In initial five cases,we took long operative time due to poor coordinationbetween assistant holding the Hartman with articulatinggrasper and surgeon doing dissection using straightinstrument. In further cases both surgeon and assistantwere tuned up, so operating time was reduced. In twocases the liver was enlarged and obstructing the calot’striangle. To overcome this problem with exposure, anethilon suture was passed around the falciform ligamentfrom the left subcostal area to pull the liver up.

Instead of anterior and posterior dissection of standardmultiport laparoscopic cholecystectomy, right and leftdissection in calot’s triangle performed to expose thecystic duct and cystic artery. Meticulous dissection wasdone to expose the critical window, as in standard LC.

Therefore, 19 selected patients underwent SPACwithout the need of additional ports or open conversion.No gross gallstones or spillage of bile noted with ethillonsutures. Operative time was reduced from 100-140minutes (initial 4 cases) to 45-65 minutes (last 4 cases).None of the cases required placement of drain.

All patients were discharged on the next day ofsurgery. The operative time of all successful 19 cases ofsingle port cholecystectomy is shown in (Fig.2).Meanoperative time for our first four cases was 122.5 minuteswhile mean operative time for last 4 cases was 62.5minutes, that is almost similar to standard laparoscopiccholecystectomy at our centre.

DISCUSSION

Since 1990’s laparoscopic cholecystectomy usingmultiple ports around the abdomen is gold standardprocedure for benign biliary diseases. The constant effort ofsurgeons to reduce the number of ports to reduce pain andhigher cosmetic demand from patient led to introduction ofSingle port surgery in the field of minimal access surgery. Insingle port access cholecystectomy, the incision is placed inthe umbilical ring (not around it). This permits a scar lessoperation, because the operative scar is hidden in naturalscar i.e. umbilicus. Any port incision is associated withsome potential complications, although the rate ofincidence varies with the port size and type. Portcomplications may include hernias, abdominal wall

Patients were placed in modified lithotomy position. A20 mm incision was given entirely within the umbilicalring and single port deployed. Following access andplacement of port, the surgeon stood in between the legs ofpatient with the assistant and camera person on left side ofpatient. 5 mm 30 degree scope was used in all cases. Thesingle port access cholecystectomy was commenced bypassing a straight needle with ethilon suture via rightsubcostal region for retraction of gall bladder funduscephalad. Articulating grasper was used for lateralretraction of hartmann’s pouch for exposure of calot’striangle. The surgeon held the single operating instrumentfor dissection, assisted retracted the Hartman pouch witharticulating grasper. Single handed dissection carried outin calot triangle by surgeon using Maryland grasper orharmonic scalpel. After skeletoni-zation of cystic duct andcystic artery and creation of adequate posterior window,cystic artery and duct clipped using 5 mm clip applicatorand divided. Harmonic scalpel was then used to removethe gall bladder from liver bed, and the specimen wasremoved along with the port.

Additional traction suture was used for Hartmanretraction in 2 cases. In 2 cases, a second ethilon suturewas passed around the falciform from the left subcostal

Table 1. Demonstrating the patient characteristics

Patient characteristics Number

Male 4

Female 15

Mean age 32

Mean BMI 28

Coronary artery disease Nil

Diabetes mellitus nil

Fig.1.Preoperative indications for Single port cholcecystectomy

Original Article

Apollo Medicine, Vol. 7, No. 2, June 2010 134

Like prior published series [4,5], we alsoincluded selected cases in our series to start thistechnique at our centre. In our series we found thatthis technique is associated with higher cosmeticsatisfaction among patients. Furthermore the learningcurve described is specific to the primary surgeon, ahighly experienced laparoscopic surgeon, and may varywith the comfort level and technical skills of othersurgeons. However, in our personal experience that afterperforming the 10 cases of single port accesscholecystectomy, surgeon reaches an adequate level toperform single port cholecystectomy independently andeffectively.

CONCLUSION

One of the largest series to date of single portcholecystectomy for benign biliary diseases in India,performed by a single surgeon in a single institute ispresented. We conclude that this technique can be appliedeffectively in selected group of patients with benignbiliary diseases in comparable operative time to traditionallaparoscopic cholecystectomy in a safe manner. It is areproducible technique with short learning curve forappropriately trained minimal access surgeons with ahigher cosmetic satisfaction for patients. The loss of basiclaparo-scopic concept of triangulation, instrumentalcluttering and unfamiliar ergonomics are pitfalls of thistechnique. With improvement in articulating instruments,laparoscope and advance training it may stand the test oftime to become a standard technique for all patients withbenign biliary diseases.

REFERENCES

1. Piskun G, Rajpal S. Transumbilical laparoscopiccholecystectomy utilizes no incisions outside theumbilicus. J Laparoendosc Adv Surg Tech. 1999; 9:361-364.

2. Bresadola F, Pasqualucci A, Donini A, et al. Electivetransumbilical compared with standard laparoscopiccholecystectomy. Eur J Surg. 1999;165(1) :29-34.

3. Kravetz AJ, Iddings D, Basson MD, Kia MA. The learningcurve with single port cholecystectomy. Journal ofsociety of laparoendoscopic surgeons 2009;13 (3): 332-336.

4. Hong TH, You YK, Lee KH. Transumbilical single-portlaparoscopic cholecystectomy: scarless cholecystec-tomy. Surg Endosc. 2009;23(6):1393-1397.

5. Kuon Lee S, You YK, Park JH, Kim HJ, Lee KK, Kim DG.Single-port transumbilical laparoscopiccholecystectomy: a preliminary study in 37 patients withgallbladder disease. J Laparoendosc Adv Surg Tech A.2009; 19(4):495-499.

bleeding , bowel injury and wound infection . Reducing theport incisions from 3 or 4 to one definitely reduces theincidence of these morbidities. Furthermore Bresadola,et al showed that in single incision transumbilicallaparoscopic cholecystectomy, using only the periumbilicalport incision reduces the level of pain engendered bytraditional multiport laparoscopic surgery [2].

Kravetz AJ, et al performed single port accesscholecystectomy on all types of biliary disease, includingacute cholecystitis with inflammation and found that thisform of surgery can be performed in all types of biliarydisease with a short learning curve of approximately fivecases, with an obvious cosmetic benefit [3].

Although initial 4 cases took long operative times, thelast 4 cases were performed with operative times compara-ble to those with multiport cholecystectomy. Because weeliminated the additional time in putting the additionalports and the time in retrieving the gall bladder, weanticipate that our operative time will continue to diminishto a level below that of multiport cholecystectomy.

The learning curve for single port cholecystectomyprimarily reflects the difficulties experienced in under-standing the spatial restriction due to instruments clutteringand the camera. As the traditional concept of laparoscopictriangulation, anterior and posterior dissection (to someextent), is lost in single port access surgery, so adoption ofright and left dissection in calot’s triangle and acceptance ofsome instrumental cluttering by primary surgeon is crucialfor performance of single port surgery. The use of arti-culating instrument may aid to manage the spatial conflictof instruments; however it does not eliminate the technicalchallenges associated with single port surgery.

Fig. 2. Operative times ( x-axis - Patient, y-axis - OperativeTime in minutes).

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