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Single incision laparoscopic cholecystectomy

Single incision laparoscopic cholecystectomy. Dr Lam Shek Ming Sherman Kwong Wah Hospital. Outline. Introduction Review of literature Conclusion. Introduction. In 1882, first open cholecystectomy was performed by Carl Langenbach on a 42-year-old man with gallstones. Introduction.

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Single incision laparoscopic cholecystectomy

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  1. Single incision laparoscopic cholecystectomy Dr Lam Shek Ming Sherman Kwong Wah Hospital

  2. Outline • Introduction • Review of literature • Conclusion

  3. Introduction • In 1882, first open cholecystectomy was performed by Carl Langenbach on a 42-year-old man with gallstones.

  4. Introduction • In 1985, the first laparoscopic cholecystectomy was performed by Prof Dr Med Erich Mühe

  5. Introduction • Since 1990s, laparoscopic cholecystectomy had been the gold standard for removal of gallbladder • Laparoscopic cholecystectomy. The new 'gold standard'? Soper NJ et. al. Arch Surg. 1992 Aug;127(8):917-21; discussion 921-3. • Laparoscopic cholecystectomy: an analysis of 777 cases. Perissat J et. al. Baillieres Clin Gastroenterol. 1992 Nov;6(4):727-42. • Laparoscopic cholecystectomy as standard intervention in symptomatic cholecystolithiasis. Experiences with 1,277 patients Faust H et. al. Chirurg. 1994 Mar;65(3):194-9.

  6. Ways to minimize surgical access trauma • Reduce size of incisions • Needlescopic surgery (2-3mm ports) • Reduce number of incisions • Single incision laparoscopic surgery

  7. Single incision laparoscopic surgery • Single incision laparoscopic surgery • Single port access surgery • Laparoscopic endoscopic single-port surgery

  8. Single incision laparoscopic cholecystectomy • In 1997, Navarra G and his colleague performed the first single incision laparoscopic cholecystectomy One-wound laparoscopic cholecystectomy. Navarra G et. al. Br J Surg. 1997 May; 84(5):695

  9. Single incision laparoscopic cholecystectomy • 3 methods • special, purpose-made access devices or ports for introducing the laparoscope and instruments • passing three trocars side-by-side through the fascia after exposing a wide area via a single umbilical incision • using two trocars at the umbilicus along with suspension sutures to retract the gallbladder. Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et. al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23.

  10. Single incision laparoscopic cholecystectomy • 3 methods • special, purpose-made access devices or ports for introducing the laparoscope and instruments • passing three trocars side-by-side through the fascia after exposing a wide area via a single umbilical incision • using two trocars at the umbilicus along with suspension sutures to retract the gallbladder. Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et. al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23.

  11. Method 1: Special devices

  12. Single incision laparoscopic cholecystectomy • 3 methods • special, purpose-made access devices or ports for introducing the laparoscope and instruments • passing three trocars side-by-side through the fascia after exposing a wide area via a single umbilical incision • using two trocars at the umbilicus along with suspension sutures to retract the gallbladder. Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et. al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23.

  13. Method 2 : Three trocars side-by-side

  14. Single incision laparoscopic cholecystectomy • 3 methods • special, purpose-made access devices or ports for introducing the laparoscope and instruments • passing three trocars side-by-side through the fascia after exposing a wide area via a single umbilical incision • using two trocars at the umbilicus along with suspension sutures to retract the gallbladder Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et. al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23.

  15. Method 3:Two trocars and suspension sutures

  16. Single incision laparoscopic cholecystectomy • length of incision: 1.5-2 cm • remaining steps are similar to the conventional laparoscopic cholecystectomy Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et. al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23.

  17. Single incision laparoscopic cholecystectomy • The primary technical obstacles: • Collision of instruments both within and outside the abdomen as a result of their common entry point (“sword fighting”) • Inadequate triangulation • Compromised field of view due to obstruction by instruments entering the common port • Inadequate exposure and retraction. • Single-incision laparoscopic cholecystectomy: lessons learned for success. Noam Shussman et. al. Surg Endosc. 2011 February; 25(2): 404–407.

  18. Single incision laparoscopic cholecystectomy • Potential advantages: • Better cosmesis • Less pain • Potential disadvantages: • Steep learning curve • Compromised safety

  19. Review of the literature

  20. Systematic review • Single-incision laparoscopic cholecystectomy: a systematic review. Antoniou SA et. al. Surg Endosc. 2011 Feb;25(2):367-77. Epub 2010 Jul 7.

  21. Antoniou SA et. al. 2011 • 29 case series • 1,166 patients • many studies excluded acute cholecystitis • conversion to conventional laparoscopic cholecystectomy: 9.3% • obscure anatomy at Calot’s triangle (5.2%) • inadequate exposure of the Calot’s triangle due to insufficient gallbladder retraction (2.6%) • inability to maintain pneumoperitoneum (1.4%) • conversion to open cholecystectomy 0.4% • intraoperative complication rates: 0-20% (cumulative rate: 2.7%) • gallbladder perforation/bile spillage (2.2%) • haemorrhage (0.3%) • bile duct injury (0.09%) • mortality: 0%

  22. [1] Single-incision laparoscopic cholecystectomy: a systematic review. Antoniou SA et. al. SurgEndosc. 2011 Feb;25(2):367-77. Epub 2010 Jul 7. • [2] Minilaparoscopic (needlescopic) cholecystectomy: a study of 1,011 cases. Lee PC et. al. SurgEndosc. 2004 Oct;18(10):1480-4. Epub 2004 Aug 24. • [3] Laparoscopic cholecystectomy: a review of 12,397 patients. Scott TR et. al. SurgLaparoscEndosc. 1992 Sep;2(3):191-8.

  23. Randomized control trials • 3 randomized control trials • Randomized clinical trial of single-incision laparoscopic cholecystectomy versus minilaparoscopiccholecystectomy. Lee PC at. el. Br J Surg. 2010 Jul;97(7):1007-12. • Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial. Tsimoyiannis EC et. al. SurgEndosc. 2010 Aug;24(8):1842-8. Epub 2010 Feb 20. • Prospective randomized comparative study of single incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy. Lai EC et. al. Am J Surg. 2011 Sep;202(3):254-8.

  24. Lee PC at. el. 2010 • 70 patients • 35 single-incision laparoscopic cholecystectomy vs 35 minilaparoscopic cholecystectomy

  25. Lee PC at. el. 2010 • 70 patients • 35 single-incision laparoscopic cholecystectomy vs 35 minilaparoscopic cholecystectomy

  26. Lee PC at. el. 2010 • 70 patients • 35 single-incision laparoscopic cholecystectomy vs 35 minilaparoscopic cholecystectomy

  27. Tsimoyiannis EC et. al. 2010 • 40 patients • 20 single-incision laparoscopic cholecystectomy vs 20 minilaparoscopic cholecystectomy

  28. Tsimoyiannis EC et. al. 2010

  29. Tsimoyiannis EC et. al. 2010

  30. Lai EC et. 2011 • 51 patients • 24 single incision laparoscopic cholecystectomy vs 27 four-ports laparoscopic cholecystectomy

  31. Lai EC et. 2011 • 51 patients • 24 single incision laparoscopic cholecystectomy vs 27 four-ports laparoscopic cholecystectomy

  32. Learning curve • The Learning Curve for Single-Port Laparoscopic Cholecystectomy by Experienced Laparoscopic Surgeon. Soon Hwa Youn et. al. J Korean Surg Soc 2011;80:119-124

  33. Learning curve • Single-incision laparoscopic cholecystectomy: lessons learned for success. Noam Shussman et.al. Surg Endosc. 2011 February; 25(2): 404–407.

  34. Structured specialized training • A specialized course of basic skills training for single-port laparoscopic surgery. Yang et. al. Surgery Volume 149, Number 6

  35. Structured specialized training • A specialized course of basic skills training for single-port laparoscopic surgery. Yang et. al. Surgery Volume 149, Number 6

  36. Conclusion • Single incision laparoscopic cholecystectomy is a safe option for treatment of symptomatic gallstone in early studies • Published RCTs so far support the advantage of better cosmesis, yet controversial in reduction of pain and shortening of hospital stay • It requires 20-30 to master the technique for experienced laparoscopic surgeons • Structured specialized training may be helpful in overcoming the learning curve

  37. Thank you

  38. Structured specialized training

  39. Structured specialized training

  40. Structured specialized training

  41. Structured specialized training

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