Laparoendoscopic Single-site Cholecystectomy Research Articles

From 3-Port to New Laparoendoscopic Single-Site (LESS) Cholecystectomy

In recent years, laparoendoscopic single-site surgery (LESS) has gained greater interest and diffusion for the treatment of gallstones. This critical review aims to evaluate the feasibility and safety of LESS cholecystectomy versus the 3-port technique (TPT) through a comparative analysis of 5 parameters: mean operative time, intraoperative and postoperative complications, conversion to open, conversion to the 4-trocar technique and postoperative hospital stay. The authors performed a systematic search of the medical literature through a search of PubMed and Ovid EMBASE. Inclusion criteria were as follows: publication date between January 1, 2005, and December 31, 2010; English or Italian language; human participants and series of 20 operations or more. There were 5 manuscripts meeting the inclusion criteria for TPT and 23 for LESS. Only one prospective randomized controlled trial comparing TPT and LESS was identified. Operative time is significantly longer in the single-incision group. Complications and conversion rates to the 4-port technique are higher in LESS. Postoperative hospital stay is similar in the 2 groups. Rate of conversion to open is higher in TPT. Despite the number of publications on LESS cholecystectomy, the vast majority of data available in the literature are from small case series without any comparative data. Although LESS cholecystectomy is a fashionable technique there are few data available for an evidence-based determination as to the real benefits of this technique. Well-designed comparative studies are suggested to validate the clinical benefits and ensure that there are no new complications or added costs associated with the new technique.

Laparoendoscopic Single-site Cholecystectomy

Laparoendoscopic single-site (LESS) surgery has emerged as a viable and widely applicable minimally invasive technique. Presented here are the steps necessary to perform LESS cholecystectomy using a readily available gelport device. To perform LESS cholecystectomy we make a 2 cm incision through the umbilicus until the fascia is identified. The fascia is opened 2 cm and a wound protector is inserted. Through the gelport we insert a 5 mm trocar with a balloon tip for the insufflation and three 5 mm trocars as working ports. Three of the trocars are placed in the lower third in a semilunar configuration before mounting the gelport onto the wound protector. A fourth trocar can then be placed at the superior aspect of the gelport. Intra-abdominal visualization is obtained with an articulating 5 mm laparoscope. At our institution 19 patients have undergone LESS cholecystectomy out of 20 attempts (5% conversion rate), with the first 15 patients undergoing a single skin incision, multifascial incision approach and the last 5 done using a gelport device and single fascial incision. One patient in the multifascial group required conversion to a dual incision laparoscopic cholecytectomy due to cystic duct bleeding. Overall, procedures averaged 81 minutes (range, 43 to 181 min), the average length of stay was <1 day (range, 0 to 2 d). To date, 1 patient developed a wound infection that responded to oral antibiosis (5% overall complication rate), and no hernias have developed with a mean follow-up of 9 months (range, 3 to 12 mo). The gelport may allow for the widespread use of this exciting technology even in nonspecialized centers because of the familiarity of minimally invasive surgeons with this device. The elasticity of this device seems to facilitate the use of 4 trocars, thus, replicating the "critical view" of the structures of the triangle of Calot seen in standard multi-incision laparoscopic cholecystectomy.

α-Defensins and hsCRP levels in inflammatory response of standard and laparoendoscopic single-site cholecystectomy

Laparoendoscopic single-site (LESS) surgery is an evolution of laparoscopic surgery aiming at decreasing the patient's parietal trauma associated with abdominal operations. LESS has been found so far to be efficient and have the same good results as the standard four-port laparoscopic cholecystectomy. α-Defensins are antimicrobial peptides of the organism. They are the first cell components against pathogens. Cytokines are also mediators in the response to trauma. The aim of this study was to compare the inflammatory reaction in LESS and four-port laparoscopic cholecystectomy. Forty patients with noncomplicated cholelithiasis were randomly assigned into one of two groups. Group A included the patients who would undergo four-port laparoscopic cholecystectomy and group B included the patients who would undergo LESS cholecystectomy. These patients had a BMI < 30, were ASA I or II, and had no previous upper-GI surgery. Blood was taken preoperatively and 6 and 24 h postoperatively. hsCRP (with automated analyzer) and α-defensins (using ELISA) were calculated for each sample. The same postoperative protocol was followed for both groups. Mann-Whitney U test was used to analyze the results. Pain was calculated with a visual analog scale (VAS) for shoulder and abdomen at 6 and 24 h. Hospital stay, nausea, and pain medication needed was noted. The α-defensins value was statistically significantly higher in the 24-h samples (P < 0.001) for LESS cholecystectomy. No statistically significant difference was shown for hsCRP, even though P = 0.05 for the 24-h samples with the values of LESS higher. No LESS was converted to a classical laparoscopic cholecystectomy, and none of the patients of either group needed conversion to open cholecystectomy. Pain was statistically significantly less for the LESS group at the 24-h interval (P < 0.0001). Less medication was needed for LESS patients after the 6th postoperative hour (P = 0.007). Higher inflammatory reaction in LESS cholecystectomy could be the result of greater tension on the tissues. More studies are needed to conclude if this has a significant clinical expression.

Randomized clinical trial of laparoendoscopic single-siteversusconventional laparoscopic cholecystectomy

Conventional laparoscopy with three or more ports remains the 'gold standard' for cholecystectomy, but a laparoendoscopic single-site (LESS) approach is emerging, designed to decrease parietal trauma and improve cosmesis. This study compared conventional laparoscopic (CL) with LESS cholecystectomy, with short-term clinical results as the main outcomes. A randomized trial of CL and LESS cholecystectomies involving 150 patients was undertaken. Follow-up was for 1 month after surgery. The primary endpoint was body image results evaluated by means of validated scales. Secondary endpoints were: postoperative pain measured on a visual analogue scale, analgesia requirement, morbidity, quality of life (QoL) measured with Short Form 12, duration of operation, hospital stay, time to return to work and cost analysis. Operating times and complications were similar in the two groups. Two LESS procedures (3 per cent) were converted to two-port laparoscopy owing to difficulties with exposure, and one CL operation was achieved through a single port because extensive fibrous peritoneal adhesions prevented placement of other ports. There were three and four port-site seroma/haematomas in the LESS and CL groups respectively. Better pain profiles and lower analgesia requirements were recorded in the LESS group (P < 0·001). QoL, body image and scar scale results were also better (P < 0·001). Operative costs were higher for LESS procedures (P < 0·001), although median time to return to work was shorter (P = 0·003). LESS is an alternative to CL cholecystectomy associated with better cosmesis, body image, QoL and an improved postoperative pain profile.

Laparo-endoscopic single site cholecystectomy versus standard laparoscopic cholecystectomy: results of a pilot randomized trial

Background In recent years, new devices providing multiple channels have made the performance of laparoscopic cholecystectomy through a single access site not only feasible but much easier. The potential benefits of laparoendoscopic single-site (LESS) cholecystectomy may include scarless surgery, reduced postoperative pain, reduced postoperative length of stay, and improved postoperative quality of life. There are no comparative data between LESS cholecystectomy and standard laparoscopic cholecystectomy (LC) available at present with which to quantify these benefits. Methods This study was a prospective, randomized, dual-institutional pilot trial comparing LESS cholecystectomy with standard LC. The primary end point was postoperative quality of life, measured as length of hospital stay, postoperative pain, cosmetic results, and SF-36 questionnaire scores. Secondary end points included operative time, conversion to standard LC, difficulty of exposure, difficulty of dissection, and complication rate. Results No significant differences in postoperative lengths of stay were found in the two groups. Postoperative pain evaluation using a visual analogue scale showed significantly better outcomes in the standard LC arm on the same day of surgery ( P = .041). No differences in postoperative pain were found at the next visual analogue scale evaluation or in the postoperative administration of pain-relieving medications. Cosmetic satisfaction was significantly higher in the LESS group at 1-month follow-up (mean, 94.5 ± 9.4% vs 86 ± 22.3%; median, 100% vs 90%; P = .025). Among the 8 scales of the SF-36 assessing patients' physical and mental health, scores on the Role Emotional scale were significantly better in the LESS group (mean, 80.05 ± 29.42 vs 68.33 ± 25.31; median, 100 vs 66.67; P < .0001). Conclusions In this pilot trial, LESS cholecystectomy resulted in similar lengths of stay and improved cosmetic results and SF-36 Role Emotional scores but performed less well on pain immediately after surgery. A larger multicenter trial is needed to confirm and further investigate these results.

Laparoendoscopic single-site cholecystectomy: A randomized controlled study

This study reports the initial experience with laparoendoscopic single-site (LESS) cholecystectomy and compares it with laparoscopic cholecystectomy (LC) through a randomized controlled trial. Sixty selective patients diagnosed with cholelithiasis or polyp lesion of the gallbladder (PLG) were randomly divided into two groups undergoing either LESS cholecystectomy or LC separately. The clinical data about operations and recovery of the two groups were compared. In the LESS group 28 of 30 patients underwent LESS cholecystectomy successfully and the remaining two (6.7%) were converted to standard laparoscopic surgery. LC was successfully performed in all patients in the control group. Mean operative time of LESS cholecystectomy group and LC group was 55.6 ± 25.7 versus 42.7 ± 18.6 (p < 0.05). Mean postoperative hospital stay was 3.7 ± 1.3 versus 3.8 ± 0.8 days (p < 0.05). Mean pain index was 2.8 ± 0.6 versus 3.7 ± 1.1 (p < 0.05). A questionnaire revealed that the mean scores of satisfaction with the operation were 8.9 ± 0.7 versus 8.1 ± 1.5 (p < 0.05). LESS cholecystectomy is safe, feasible, minimally invasive, and cosmetic. It is a reasonable alternative to selective patients with uncomplicated cholelithiasis and PLG. But larger controlled studies are still needed.

Completely Intracorporeal Retraction of the Gallbladder for Laparoendoscopic Single Site (LESS) Surgery

Laparoendoscopic single site surgery (LESS) cholecystectomy requires a creative solution to retract the gallbladder. Transabdominal suture retraction is a commonly used technique to achieve adequate exposure of the critical structures within Calot's triangle. To avoid the multiple punctures of the gallbladder and abdominal wall required by such suture retraction, we developed a novel internal retractor specifically for use during LESS cholecystectomy. This retractor consists of a laparoscopic bulldog clamp fitted with a small metal hook, and was successfully used in a recent case of LESS cholecystectomy.

Laparoendoscopic Single-Site Combined Cholecystectomy and Hysterectomy

Laparoendoscopic single-site (LESS) surgery has gained increased acceptance among surgeons in various specialties. The universal nature of port placement in the umbilicus during LESS surgery may enable concomitant procedures to be performed in these surgical specialties via this single incision. This case report presents a 37-year-old woman who underwent concomitant LESS cholecystectomy and hysterectomy to treat a symptomatic fibroid uterus and symptoms of cholelithiasis. The surgical procedure was performed in approximately 3 hours without any complications, and the patient was discharge to home 18 hours after the procedure. This case demonstrates that increasingly complex concomitant procedures can be performed using a LESS surgical approach.

The Learning Curve of Laparoendoscopic Single-Site (LESS) Cholecystectomy: Definable, Short, and Safe

The applications of laparoendoscopic single-site (LESS) surgery, including cholecystectomy, are occurring quickly, although little is generally known about issues associated with the learning curve of this new technique including operative time, conversion rates, and safety. We prospectively followed all patients undergoing LESS cholecystectomy, and compared operations undertaken at our institutions in cohorts of 25 patients with respect to operative times, conversion rates, and complications. One-hundred fifty patients of mean age 46 years underwent LESS cholecystectomy. No significant differences in operative times were demonstrable between any of the 25-patient cohorts operated on at our institution. A significant reduction in operative times (p < 0.001) after completion of 75 LESS procedures was, however, identified with the experience of a single surgeon. No significant reduction in the number of procedures requiring an additional trocar(s) or conversion to open operations was observed after completion of 25 LESS cholecystectomies. Complication rates were low, and not significantly different between any 25-patient cohorts. For surgeons proficient with multi-incision laparoscopic cholecystectomy, the learning curve for LESS cholecystectomy begins near proficiency. Operative complications and conversions were infrequent and unchanged across successive 25-patient cohorts, and were similar to those reported for multi-incision laparoscopic cholecystectomy after the learning curve.

Gasless laparoendoscopic single-site surgery with abdominal wall lift in general surgery: initial experience

Laparoendoscopic single-site surgery (LESS) was motivated by the desire to make minimally invasive surgery even more "minimal." We performed gasless laparoendoscopic single-site surgery (GLESS) with abdominal wall lift (AWL) for cholecystectomy and fenestration of liver cyst. This study aims to assess the safety and feasibility of the techniques. From June to December 2009, 18 cases of gasless laparoendoscopic single-site cholecystectomy (GLESC) and 4 cases of fenestration of liver cyst (GLESF) were performed in Qilu Hospital of Shandong University, Shandong, China. Subcutaneous abdominal wall lifting system, LAP protector, flexible laparoscopes, and bent and articulating instruments were used during the procedures. Clinical data regarding patient demographics, operating time, blood loss, complications, and postoperative hospital stay were collected and analyzed retrospectively in the study. 17 cases of GLESC and 4 cases of GLESF were performed successfully, and 1 case of GLESC was converted to laparoendoscopic single-site cholecystectomy using AWL combined with low-pressure pneumoperitoneum. Mean body mass index was 23.7 ± 3.1 kg/m(2) for GLESC and 22.9 ± 1.5 kg/m(2) for GLESF. Mean operating time was 64 ± 17 min for GLESC and 101 ± 10 min for GLESF. Mean blood loss was 8 ± 3 ml for GLESC and 24 ± 11 ml for GLESF. Despite minor wound complication, no postoperative complications were observed during mean follow-up of 118 and 95 days for GLESC and GLESF, respectively. GLESS with AWL is safe and feasible for cholecystectomy and fenestration of liver cyst. The techniques provide satisfactory operative field exposure and an easier access method for LESS. Instrument collisions are greatly ameliorated both extra- and intracorporeally through use of flexible laparoscopes and bent and articulating instruments. This may prove to be a better approach for LESS techniques.

Laparoendoscopic Single-Site (LESS) Combined Cholecystectomy and Hysterectomy

Study Objective: To present a video of a combined Laparoendoscopic Single-Site (LESS) cholecystectomy and hysterectomy Materials and Methods: A 37 year old G2P2 presented with combined complaints of a symptomatic fibroid uterus and symptomatic cholelithiasis. Evaluation demonstrated a 12 week size uterus which was globular in appearance consistent with adenomyosis and a non-mobile hyperechoic focus in the neck of the gallbladder consistent with cholelithiasis. The patient underwent a combined Laparoendoscopic Single-Site (LESS) cholecystectomy and hysterectomy procedure.

From single-port access to laparoendoscopic single-site cholecystectomy

From single-port access to laparoendoscopic single-site cholecystectomy

Laparoendoscopic Single Site Cholecystectomy: The First 100 Patients

Laparoendoscopic single site (LESS) surgery promises improved cosmesis and possibly less pain. However, given the small series reported to date, true estimates of the advantages and possible disadvantages of LESS surgery remain unknown. This study was undertaken to evaluate the first 100 patients undergoing LESS cholecystectomy at our institution. Patients referred for cholecystectomy since November 2007 were considered for LESS cholecystectomy. Outcomes, including blood loss, operative time, complications, and length of stay, were recorded. Outcomes are compared with an uncontrolled concurrent group of patients undergoing multi-incision laparoscopic (i.e., conventional) cholecystectomy. One hundred patients with a median age of 44 years underwent LESS cholecystectomy; 30 patients with a median age of 46 years underwent conventional cholecystectomy over the same time period. Median operative time (70 vs 66 minutes, P = 0.67, Mann-Whitney) and hospital length of stay (1 vs 1 day, P = 0.81, Mann-Whitney) were not different for patients undergoing LESS or multi-incision cholecystectomies, respectively. Five patients undergoing LESS cholecystectomy had postoperative complications: cystic duct stump leak (one), pain control issues (three), and urinary retention (one). LESS cholecystectomy is a safe and effective alternative to conventional cholecystectomy. It can be undertaken without added operative time and provides patients with minimal, if any, scarring.

Totally Transumbilical Laparoscopic Cholecystectomy

A recently convened Consortium at the Cleveland Clinic agreed on the term Laparo-Endoscopic Single-Site (LESS) surgery to describe minimally invasive techniques that use a single incision to accomplish laparoscopic procedures. These procedures are done by using either a single port through one fascial incision or multiple ports placed through separate fascial incisions. Because of cost containment issues and the lack of widespread availability of a single port, we currently use multiple reusable ports placed through three separate fascial incisions via a transumbilical incision. As opposed to standard laparoscopic cholecystectomy, a deflecting laparoscope and one articulating instrument are utilized to improve the safety and ease of this procedure. Presented in this video are the steps necessary to perform a LESS cholecystectomy via a transumbilical incision with commercially available instruments.