Safety and Feasibility of Needlescopic Grasper-Assisted Single-Incision Laparoscopic Cholecystectomy in Patients with Acute Cholecystitis: Comparison with Three-Port Laparoscopic Cholecystectomy

Introduction

Laparoscopic cholecystectomy, recognized as the standard treatment for gallbladder benign disease, has been performed worldwide and commonly. However, surgical standards of practice continue to evolve toward less invasive approaches; therefore many researchers have attempted to minimize the invasiveness by reducing the number and size of the ports. ¹ In this context, single-incision laparoscopic cholecystectomy (SILC) emerged in 1997 as reported by Navarra et al. ² Since that time, the number of SILCs has been increasing steadily, and its clinical outcome is favorable on the basis of recent publications.^3–5 Moreover, some institutions have already reported the safety and feasibility of SILC.^6–8 Nevertheless, some other points in technical aspect and concern about its safety are still active subjects of debate. During the cholecystectomy procedure, obtaining a critical view of safety (CVS) is the widely accepted method for preventing bile duct injury. This technique needs adequate traction on the gallbladder fundus and/or infundibulum to the cephalad and lateral directions. ⁹ However, adequate retraction of the gallbladder in each direction for obtaining CVS is very difficult in SILC because of repeated conflicts between operating instruments vying for space at the single-access site. Many reports have been published to describe methods for adequate traction, such as transabdominal sutures, use of articulating instruments, and use of internal grasper retractors, but, at present, none of the reported technical notes has become a standard yet. ¹⁰ For these reasons, SILC has been performed in selected patients, and most studies that reported the safety and feasibility of SILC were confined to selective gallbladder benign disease.

In our center, a needlescopic grasper and a snake liver retractor have been used for adequate lateral and cephalad traction while obtaining CVS. Before applying the technique, only selected patients with gallbladder benign disease were included in the criteria for SILC; however, the criteria have been extended to acute cholecystitis after applying this technique. Therefore, we introduce our needlescopic-assisted SILC technique and evaluate the safety and feasibility of the technique, applying our procedure for the treatment of the patients with acute cholecystitis in this study.

Patients and Methods

Operative methods

All operations were performed by the same surgical team, and techniques were standardized. The surgical team had experience with more than 100 cases of SILC and was at a plateau point in their learning curve. The operations were performed with the patient under general anesthesia with the supine position in a reverse Trendelenburg position and tilted to the left. For SILC, a 25-mm transumbilical incision was made longitudinally, and the natural umbilical defect was used to access the peritoneum. The peritoneum was opened under direct visualization, and the SILS™ port (Covidien, Mansfield, MA) was inserted under direct vision into the perinoneal cavity. Pneumoperitoneum was induced and maintained at 12 mm Hg with carbon dioxide during the operation, and a 12-mm trocar for laparoscope and two 5-mm trocars for the working instrument and snake liver retractor were inserted. While CVS was obtained, a 2-mm needlescopic grasper (Minilap grasper; Stryker, San Jose, CA) was additionally inserted through direct puncture on the right abdomen for lateral traction of the gallbladder, and a snake liver retractor was used for cephalad traction by pushing up the hepatic hilum toward the cephalad direction and clear visualization of the triangle of Calot (Figs. 1 and 2). Dissection was performed meticulously using an ENDOPATH^® electrosurgery Probe Plus^® system (Ethicon Endo-Surgery, Cincinnati, OH), composed of a suction unit, irrigation unit, and hook electrode, and CVS was achieved in almost all cases. After CVS was achieved, 5-mm Hem-o-lok^® (Weck; Teleflex^® Medical, Research Triangle Park, NC) clips were used to ligate the duct and artery, which were transected using laparoscopic scissors. After dissection of the gallbladder from the liver bed, it was removed using an endobag through the umbilicus. Finally, the abdominal wall was closed with absorbable suture, and the umbilicus was restored to its physiologic position.

OPEN IN VIEWER

FIG. 1.

External view of the needlescopic grasper-assisted single-incision laparoscopic cholecystectomy procedure. The needlescopic grasper (black arrow) was used for traction through a direct puncture on the right upper abdomen. The snake liver retractor (white arrow) was used for cephalad traction of the liver to obtain better visualization.

OPEN IN VIEWER

FIG. 2.

Intraabdominal view of the needlescopic grasper (black arrow)-assisted single-incision laparoscopic cholecystectomy using the snake liver retractor (white arrow). Clear visualization can be obtained by lateral and cephalad traction.

CLC was performed using three ports placed, respectively, at the umbilical, epigastric, and right abdomen areas as the routine maneuver.

Results

Discussion

Although SILC was introduced in the context of evolution of the minimal invasive technique, this technique has spread slowly until more recent years because of technical problems and the requirement for highly developed surgical skill. ¹¹ With technical improvements and new devices, SILC has become more attractive and adopted in many centers. Increasing numbers of publications mirror this development, and the clinical outcome is favorable on the basis of the recent publications. ¹² Although the technique is feasible, there are inherent difficulties that require increased laparoscopic competency, namely, restricted instrument mobility and arguably reduced visualization of key components of a cholecystectomy. ¹³ Because operating instruments come from a single port, there is a lack of triangulation, with repeated conflicts between operating instruments, as well as a lack of proprioception due to the crossing of instruments with difficult exposure of organs and structures. ⁵ In addition to this technical difficulty of SILC, acute inflammation makes traction of the gallbladder and obtaining clear visualization more difficult because of adhesion around tissues, gallbladder wall thickening, and severe dilatation of the gallbladder. For these reasons, most of the articles that reported the safety and feasibility of SILC have been confined to benign gallbladder disease with optimal conditions, such as lack of acute inflammation.

To overcome the technical problems of SILC, many technical variations have been attempted in different ways, and SILC has not been standardized yet. In our center, we have used a needlescopic grasper and a snake liver retractor to overcome the technical difficulty of SILC, such as lack of triangulation and unclear exposure of the triangle of Calot (Figs. 1 and 2). In practice, we focused on the adequate traction and clear visualization of the triangle of Calot. Using an auxiliary needlescopic grasper can allow improved exposure and adequate traction in achieving CVS owing to a wider angle between the two operative instruments as well as obtaining a similar cosmetic effect with pure SILC. Furthermore, this technique is superior to the transabdominal retracting suture technique in the oncological aspect because it can prevent seeding of potential neoplastic cells caused by bile spillage through the holes of the retracting sutures. Cephalad traction using a snake liver retractor through one of the SILS ports permits better visualization and a safe approach to the triangle of Calot. Our technique provides adequate traction and clear visualization and consequently make it possible to expand the indication of SILC to the case with acute inflammation.

Recently, many articles have been published to report the safety and feasibility of SILC in selected patients who have had not acute inflammation by comparison with CLC. In this study, we compared the surgical outcomes of SILC and CLC in patients with acute cholecystitis. A similar surgical outcome in both groups was observed in our study. There were no significant differences in operative time, CVS identification time, the rate of iatrogenic bile spillage, and the need for open conversion surgery between the SILC and CLC groups. In addition, no significant differences in postoperative hospital stay and postoperative wound problem were observed between the two techniques. Iatrogenic bile duct injury, one of the major concerns of SILC especially in patients with acute inflammation, was not observed in both groups. Although cosmetic outcome was not measured in this study, the superior cosmetic outcome of SILC has been reported by many researchers. These results showed that SILC with our technique can be applied safely not only in selected patients, but also in patients with acute inflammation.

This study may have some limitations. First, as a retrospective analysis based on medical records and video files, exact assessment of operation difficulty is impossible, and it may involve some bias. However, all video files recorded and kept until now were reviewed, and pathologic reports of all patients represented acute inflammation. Second, this study did not include enough patients to evaluate and compare the risk of bile duct injury between groups. However, there was no iatrogenic bile duct injury even in patients with acute gangrenous cholecystitis or severe inflammation.

In conclusion, even with the limitation of the small series of patients, the results of our study demonstrate that SILC with our technique is a safe procedure with a similar outcome to that of CLC in cases of acute inflammation. Therefore this technique is acceptable not only in selected patients who have not had acute inflammation, but also in patients with acute cholecystitis. However, more high-powered randomized control trials with large sample size will be needed to validate this result.