Single-incision laparoscopic cholecystectomy: lessons learned for success

Abstract

Since its introduction approximately 20 years ago, laparoscopic cholecystectomy has rapidly become the treatment of choice for symptomatic cholelithiasis [1–3]. Conventional laparoscopic cholecystectomy generally is performed through four small incisions in the abdominal wall [4]. In recent years, a less invasive method has been sought in an effort to reduce postoperative pain and morbidities such as wound infection and trocar-site hernias while further enhancing the cosmetic results. Initial attempts to perform the procedure through three and then two ports or with reduced-diameter trocars (needlescopic surgery) [5–9] have since been superseded by even less invasive and more innovative techniques, namely, single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) [10–13]. Single-incision laparoscopic surgery is an attractive technique for cholecystectomy due to its superior cosmetic results and potential to reduce the rate of wound complications such as infection, hematoma, and hernia. This technique, however, is not straightforward. The technical complexity of SILS naturally results in a steep learning curve and increased operating room time and requires specialized equipment. The primary technical obstacles of SILS currently include 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. Several techniques have since evolved to overcome these potential pitfalls [14–16]. By incorporating a number of these techniques, we have created a simplified technique that has proved successful with both animal and human subjects. We describe both our experience and what we have learned, which have allowed simplification of a technical complex procedure.