The invisible cholecystectomy: a different way

Abstract

Letter to the Editor We read with interest the article from Cuesta et al. [1] regarding the so-called invisible cholecystectomy. We had the same enthusiasm after performing the first one-wound laparoscopic cholecystectomy back in 1997 [2], when the concept of no scar surgery, which became natural orifice transluminal endoscopic surgery (NOTES), did not exist. With our technique, we used two 10-mm trocars parallel to one another on the right and the left sides of the umbilical scar, leaving a small bridge of tissue between them, as described by Cuesta et al. [1]. At that time, we preferred to use 10-mm ports simply because the technology, in our opinion, did not allow clear vision with 5-mm scopes, and because we did not have available the 5-mm clip applier. In contrast to Cuesta et al. [1], we placed three transabdominal stay sutures mounted on a straight needle through the fundus and through both the medial and lateral aspects of the infundibulum to retract, stabilize, flag laterally the gallbladder, and expose the Calot triangle. We do not think it is possible using only one Kirschner wire to expose both the medial and the lateral aspects of the Calot triangle and obtain the same vision and safety achieved by the standard four-trocar approach. Instead, we suggest the use of more than one wire, or better yet, judging from our experience, transabdominal stay sutures. Our enthusiasm for this technique disappeared, however, after we conducted a prospective randomized study comparing the one-wound technique with the conventional fourtrocar approach. Cosmetic advantage was counterbalanced by longer operative time, nonsignificant differences in postoperative pain, nonsignificant cost-effectiveness advantages, and a higher incidence of umbilical incisional hernia due to a larger umbilical incision, which in our experience was 2.5 cm wide, compared with a width of 1.5 to 2 cm in the Cuesta experience. We have been offering and using the technique occasionally during the past 10 years only if the patient strongly desires the use of two 5-mm ports. The advent of NOTES [3], the actual limitations of the available flexible endoscopes, and the idea that the umbilicus is a scar existing since birth made us think to plan and then use a hybrid technique in which vision and specimen extraction are performed via an endoscope inserted transvaginally. Traction is obtained using transabdominal stay sutures, and cholecystectomy is performed through a 5-mm port inserted at the umbilicus using conventional 5-mm laparoscopic instruments. Our preliminary experience with the aforementioned technique seems to overcome the limitation of both the one-wound technique and pure NOTES.