Single-incision Laparoscopic Surgery Cholecystectomy Research Articles

Single Incision Cholecystectomies for Acute Cholecystitis: A Single Surgeon Series from the Caribbean.

Introduction Single incision laparoscopic surgery (SILS) is accepted as a safe alternative to conventional multiport laparoscopic (MPL) cholecystectomy for benign gallbladder disease. Since many surgeons carefully select patients without inflammation, there are limited data on SILS for acute cholecystitis. We report a single surgeon experience with SILS cholecystectomy for patients with acute cholecystitis. Materials and Methods After securing ethical approval, we performed an audit of all SILS cholecystectomies for acute cholecystitis by a single surgeon from January 1, 2009, to December 31, 2019. The following data were extracted: patient demographics, intraoperative details, surgical techniques, specialized equipment utilized, conversions (additional port placement), morbidity, and mortality. Data were analyzed using SPSS 12.0. Results SILS cholecystectomy was performed in 25 females at a mean age of 35 ± 4.1 (SD) years and a mean BMI of 31.9 ± 3.8 (SD) using a direct fascial puncture technique without access platforms. The operations were completed in 83 ± 29.4 minutes (mean ± SD) with an estimated blood loss of 76.9 ± 105 (mean + SD). Three (12%) patients required additional 5 mm port placement (conversions), but no open operations were performed. The patients were hospitalized for 1.96 ± 0.9 days (mean ± SD). There were 2 complications: postoperative superficial SSI (grade I) and a diaphragmatic laceration (grade III). No bile duct injuries were reported. There were 9 patients with complicated acute cholecystitis, and this sub-group had longer mean operating times (109.2 ± 27.3 minutes) and mean postoperative hospital stay (1.3 ± 0.87 days). Conclusion The SILS technique is a feasible and safe approach to perform cholecystectomy for acute cholecystitis. We advocate a low threshold to place additional ports to assist with difficult dissections for patient safety.

The use of single incision laparoscopic surgery techniques and natural orifice transluminal endoscopic surgery – a nationwide survey

Abstract Objective Since the first report of transgastric peritoneoscopic surgery in 2004, minimal invasive surgery (MIS) including conventional laparoscopy, natural orifice transluminal endoscopic surgery (NOTES), single incision laparoscopic surgery (SILS), and robotic surgery have gained traction in general and visceral surgery. While laparoscopic surgery is now the gold standard in many institutions, other MIS approaches lag behind in spite of the enthusiasm of few promoters. The present study investigates the current role of NOTES and SILS in Switzerland. Methods All Swiss surgical departments where queried. Heads of department were asked to complete a detailed questionnaire regarding the use of NOTES and SILS techniques, reminders were sent twice. Results Of 93 departments queried, 63 (68%) answered the survey and most were public hospitals (92%). One third of general surgery departments and 46% of visceral surgery departments had the highest accreditation level A and V1, respectively. While up to 27% of the responding hospitals had performed NOTES in the past, only about 9% still use the technique today. Since January 2019, only two departments performed NOTES cholecystectomy, one department NOTES colectomy and three departments NOTES total mesorectal excision. The main reasons for not performing NOTES anymore were lack of perceived benefits, higher costs, increased morbidity in routine procedures, no patient demand, and the lack of surgical expertise. A similar picture was found regarding the use of SILS, with 37% of hospitals having past experience with SILS and only 13% still performing SILS procedures. Yet, significantly more institutions performed a broader range of SILS procedures today: SILS appendectomy (n = 2), SILS cholecystectomy (n = 4), SILS thyroidectomy (n = 1), SILS small bowel resection (n = 2), SILS colonic resection (n = 5), and SILS rectal resection (n = 2). The main reasons for not performing routinely SILS were similar to the rationale against NOTES. Conclusion Due to technical limitations and lack of perceptible benefits, NOTES and SILS are less frequently performed nowadays than they were in the past. Only a minority of departments are still performing NOTES and SILS, including cholecystectomies, appendectomies, thyroidectomies, and bowel resections. Whether the rise in use of robotic techniques correlates with the decrease of NOTES and SILS needs further investigation.

SINGLE INCISION MULTI-PORT LAPAROSCOPIC SURGERY (SIMPLS), A NOVEL TECHNIQUE IN IRAQ

Background 
 Single incision laparoscopic surgery (SILS) is a natural evolution of minimally invasive surgery (MIS) era.The advent of SILS was in the field of gynecology 1969. The first published report in general surgery appeared in 1992 with appendectomies. The first report of SILS cholecystectomy came in 1997 in a letter to the editor in the British Journal of Surgery by Navarra.Curcillo et al., developed Single Port Access (SPA™) surgery in April 2007 as a novel and innovative platform of minimal access surgery. Saber et al. reported the first series of single-incision laparoscopic SG in 7 patients in 2008. SILS recently becoming an interest of both patients and minimally invasive surgeons. Purposes were esthetic (scarless surgery), minimize parietal trauma, less pain and fast patient postoperative recovery. Despite these advantages, there is a concerned report of complications. Aiming to overcome the SILS complications, this novel technique; Single Incision Multiport Laparoscopic Surgery SIMPLS innovated in Iraq.
 Objectives 
 To introduce SIMPLS (Single Incision Multiport Laparoscopic Surgery) as a novel technique in Iraq and assess safety, cost, aesthetic and any associated complications. To evaluate its use in some advanced laparoscopic procedures.
 Materials and Methods
 SIMPLS is a single surgeon prospective study conducted from Aug. 2009- Dec. 2016, in four hospitals in Iraq with the same laparoscopic platforms. Technique tested in different laparoscopic operative procedures on 129 different cases.
 Results
 Cholecystectomy (n=76), sleeve gastrectomy (n=20), appendectomy (n=9), diagnostic laparoscopy (n=8), hydatid cystectomy liver (n=4), fundoplication (n=4), ovarian cystectomy (n=3), renal cystectomy (n=3), combined sleeve gastrectomy and hiatal hernia repair (n=1), and small bowel tumor(n=1). Time spend initiating ports ranging from 9-12 minutes. No much difficulty or struggle faced using standard laparoscopy instruments. Time spend in procedures noticed to be acceptable and less than SILS. P value couldn’t see any significant difference with SILS. No conversion was reported till today. The cosmetic outcome found to be extremely acceptable by patients.Specific complications and difficulties, one case difficult intra-corporal liver retraction, gall bladder retraction in a severely inflamed gall bladder, bleeding at (angle of His),hematoma and ecchymosis, no port incision infection, and no incisional hernia. 
 Conclusion
 SIMPLS technique is introduced by the author as a novel procedure in IRAQ 2009. Similar technique started few years before in some countries in the word. Benefits of the procedure: technically feasible, reproducible for expert devoted surgeons, shorter time ports initiation, excellent esthetic results, lowest cost, not associated with incisional hernia. I advise wider practice, more trials to confirm these findings and I suggest it for interested experienced minimally invasive surgeons.

A Prospective Study Comparing Quality of Life and Cosmetic Results between Single-Port and Conventional Laparoscopic Cholecystectomy

Background: Multiple studies from the last five years have demonstrated that single-incision laparoscopic surgery cholecystectomy (SILS) is not only feasible but also produces a result comparable with that of conventional laparoscopic cholecystectomy (CLC). Methods and results: In this bicentric study, we used the Short Form (36) (SF-36) and Nottingham Health Profile (NHP) surveys to estimate and compare the post-operative quality of life up to the 28th post-operative day for 66 patients who had undergone either CLC (n = 32) or SILS (n = 34). Additionally, we investigated patient satisfaction with the cosmetic results after one year. The curves summarizing the eight sections in the physical sum scale and in the mental sum scale (SF-36) were the same within the confidence interval with a confidence level of 95%. Thus, post-operative quality of life could be assumed to be equivalent for the two groups. Evaluation of the NHP survey produced similar results. The perceived cosmetic results were significantly better for the SILS group (1.3 on a scale of 1 - 5 with 1 being the best) than for the CLC group (1.9) (p = 0.016). Conclusions: This study did not demonstrate better quality of life for the single-port procedure as it had been expected. Instead, the single-port procedure produced subjectively better cosmetic results.

Single Incision Laparoscopic Cholecystectomy for Gallbladder Duplication.

Duplication of the gallbladder is a rare congenital anomaly of the gallbladder, with an estimated prevalence of 1–3 per 3800 individuals. Unless properly diagnosed preoperatively, it can lead to biliary tract injuries and postoperative complications which may require reoperative surgeries. While previously reported cases have been treated with conventional laparoscopic cholecystectomy (LC), treatment with single incision laparoscopic surgery (SILS) has not been reported yet. We herein present the case of a 58-year-old female with gallbladder duplication who was successfully treated with SILS cholecystectomy.

Clinical Outcomes of Single Incision Laparoscopic Cholecystectomy in the Anglophone Caribbean: A Multi Centre Audit of Regional Hospitals

Introduction: There has been no report on Single-Incision Laparoscopic Surgery (SILS) cholecystectomy outcomes since it was first performed in the Anglophone Caribbean in 2009. Methods: A retrospective audit evaluated the clinical outcomes of SILS cholecystectomies at regional hospitals in the 17 Anglophone Caribbean countries. Any cholecystectomy using a laparoscopic approach in which all instruments were passed through one access incision was considered a SILS cholecystectomy. The following data were collected: patient demographics, indications for operation, intraoperative details, surgeon details, surgical techniques, specialized equipment, conversions, morbidity and mortality. Descriptive statistics were generated using SPSS 12.0. Results: There were 85 SILS cholecystectomies in women at a mean age of 37.4 ± 8.5 years with a mean BMI of 30.9 ± 2.8. There were 59 elective and 26 emergent cases. Specialized access platforms were used in the first 35 cases and reusable instruments were passed directly across fascia in the latter 50 cases. The mean operative time was 62.9 ± 17.9 minutes. There was no mortality, 2 conversions to multi-trocar laparoscopy and 5 minor complications. Ambulatory procedures were performed in 43/71 (60.6%) patients scheduled for elective operations. Conclusion: In the Caribbean setting, SILS cholecystectomy is a feasible and safe alternative to conventional multi-trocar laparoscopic cholecystectomy for gallbladder disease.

Single-incision laparoscopic cholecystectomy for cholecystolithiasis coinciding with cavernous transformation of the portal vein: report of a case

BackgroundCavernous transformation of the portal vein (CTPV) is a rare vascular deformity. It is thought to be secondary to extra-hepatic portal vein obstruction, with formation of serpiginous collateral vessels around the extra-hepatic bile duct, and even the gallbladder. Surgery is difficult because the vessels have irregular courses, are somewhat fragile and bleed easily. Single-incision laparoscopic cholecystectomy, an emerging procedure for symptomatic cholecystolithiasis, has limitations especially in anatomically complex cases.Case presentationWe describe a 44-year-old woman with symptomatic cholecystolithiasis. Computed tomography revealed a series of tortuous collateral veins at the liver hilum, with the extra-hepatic portal vein occluded at the level of the spleno-portal junction. However, the distended vessels were not particularly close to the cystic duct. We performed single-incision laparoscopic surgery (SILS) for cholecystectomy via a trans-umbilical incision. By pulling the cystic duct out along with neighboring cavernous vessels, we were able to secure detachment of the cystic duct from Calot’s triangle and ligation of the cystic artery. Total operating time was 132 minutes and blood loss was 370 grams. The patient was discharged on postoperative day 2 with no perfusion abnormalities in the liver.ConclusionWe must pay meticulous attention to the area of Calot’s triangle when performing SILS cholecystectomy with CTPV. SILS cholecystectomy might be an option in highly experienced facilities.

The comparison of single incision laparoscopic cholecystectomy and three port laparoscopic cholecystectomy: prospective randomized study

PurposeLaparoscopic techniques have allowed surgeons to perform complicated intra-abdominal surgery with minimal trauma. Single incision laparoscopic surgery (SILS) was developed with the aim of reducing the invasiveness of conventional laparoscopy. In this study we aimed to compare results of SILS cholecystectomy and three port conventional laparoscopic (TPCL) cholecystectomy prospectively.MethodsIn this prospective study, 100 patients who underwent laparoscopic cholecystectomy for gallbladder disease were randomly allocated to SILS cholecystectomy (group 1) or TPCL cholecystectomy (group 2). Demographics, pathologic diagnosis, operating time, blood loss, length of hospital stay, complications, pain score, conversion rate, and satisfaction of cosmetic outcome were recorded.ResultsForty-four SILS cholesystectomies (88%) and 42 TPCL cholecystectomies (84%) were completed successfully. Conversion to open surgery was required for 4 cases in group 1 and 6 cases in group 2. Operating time was significantly longer in group 1 compared with group 2 (73 minutes vs. 48 minutes; P < 0.05). Higher pain scores were observed in group 1 versus group 2 in postoperative day 1 (P < 0.05). There was higher cosmetic satisfaction in group 1 (P < 0.05).ConclusionSILS cholecystectomy performed by experienced surgeons is at least as successful, feasible, effective and safe as a TPCL cholecystectomy. Surgeons performing SILS should have a firm foundation of advanced minimal access surgical skills and a cautious, gradated approach to attempt the various procedures. Prospective randomized studies comparing single access versus conventional multiport laparoscopic cholecystectomy, with large volumes and long-term follow-up, are needed to confirm our initial experience. (ClinicalTrials.gov Identifier: NCT01772745.)

A prospective, randomized comparison of pain, inflammatory response, and short-term outcomes between single port and laparoscopic cholecystectomy

The purpose of this study was to compare the postoperative inflammatory response and severity of pain between single-incision laparoscopic surgery (SILS) cholecystectomy and conventional laparoscopic cholecystectomy (LC). Two groups of 20 patients were prospectively randomized to either conventional LC or SILS cholecystectomy. Serum interleukin-6 (IL-6) levels were assayed before surgery, at 4-6 h, and at 18-24 h after the procedure. Serum C-reactive protein (CRP) levels also were assayed at 18-24 h after surgery. Pain was measured at each of three time points after surgery using the visual analogue scale (VAS). The number of analgesia doses administered in the first 24 h after the procedure also was recorded and 30-day surgical outcomes were documented. The groups had equivalent body mass index (BMI), age, and comorbidity distribution. Peak IL-6 levels occurred 4-6 h after surgery, and the median level was 12.8 pg/ml in the LC and 8.9 pg/ml in the SILS group (p = 0.5). The median CRP level before discharge was 1.6 mg/dl in the LC and 1.9 mg/dl in the SILS group (p = 0.38). There was no difference in either analgesic use or pain intensity as measured by the VAS between the two groups (p = 0.72). The length of the surgical procedure was significantly longer in the SILS group (p < 0.001). No intraoperative complications occurred in either group. Single-incision laparoscopic surgery does not significantly reduce systemic inflammatory response, postoperative pain, or analgesic use compared with LC.

Analysis of perioperative factors and cost comparison of single-incision and traditional multi-incision laparoscopic cholecystectomy

Recent technological advances in single-incision platforms have allowed many general surgeons to add single-incision laparoscopic cholecystectomy (SILC) to their armamentarium. However, adopting new surgical technologies comes at a cost to the patient and the surgeon. This study compared retrospective case-matched SILC and traditional multi-incision laparoscopic cholecystectomy (MILC) to evaluate the effects of SILC on perioperative outcomes and patient cost. The study compared 50 patients who underwent SILC with a case-matched population of individuals who underwent traditional MILC. The SILC technique was performed using one of three commercially available single-incision platforms currently used for single-incision laparoscopic surgery (SILS) cholecystectomies. All the SILS platforms were placed in a 2-cm supraumbilical incision. All statistical analyses were performed using Microsoft Excel 2008 for Macintosh, with statistical significance determined by a p value of 0.05 or less. The average operative time was 42 min for the SILC group and 45 min for the MILC group. The difference was not statistically significant. Similarly, the average estimated blood loss was 14 ml for the SILC group and 11 ml for the MILC group. Again, the difference was not statistically significant. Moreover, the body mass index (BMI) did not differ statistically between the SILC group (28.4 kg/m(2)) and the MILC group (32.2 kg/m(2)). The average patient cost was $18,447 for SILC and $17,701 for MILC, yielding a cost difference of $746. This difference was not statistically significant. At the authors' institution, SILS cholecystectomy was performed with blood loss, operating room time, and cost equal to that for MILC. Further research is necessary to assess the economic feasibility of SILC and the trade-off of cost with the improved cosmesis, decreased pain, greater patient satisfaction, reduced postoperative analgesic requirement, and faster return to work to determine the overall value and superiority of SILC compared with MILC.

Authors’ reply to: single-incision laparoscopic surgery (SILS) vs. conventional multiport cholecystectomy: systematic review and meta-analysis

We thank Garg et al. [1] for their interest in our publication [2]. The meta-analysis was aimed at comparing clinical outcome following single-incision (SILS) vs. multiport laparoscopic cholecystectomy. We demonstrated that SILS cholecystectomy was a safe procedure with a similar clinical outcome to standard multiport laparoscopic cholecystectomy. In their letter Garg et al. [1] raise four points of interest that we wish to deal with in turn. First, we agree that improved cosmesis is one of the major benefits of single-incision surgery. However, with the advent of any new surgical technique, patient safety must be the primary concern before the focus can turn to more subjective outcomes such as cosmesis or pain. This meta-analysis clearly demonstrated that SILS cholecystectomy is a safe procedure for uncomplicated gallstone disease in the hands of experienced laparoscopic surgeons. There was insufficient comparable data to allow the analysis of cosmesis as a primary outcome measure. As part of the discussion in our article we described three studies that reported improved patient wound satisfaction scores (different scoring systems were used making meta-analysis impossible). We also alluded to the need for future highpowered randomized studies to examine patient wound satisfaction associated with these different techniques. Second, the authors suggested that postoperative pain may reflect a function of wound tension. This may be a contributing factor, yet not one of the papers that they cited made any correlation of wound tension with the subjective nature of pain. This makes their conclusions difficult to follow. More importantly, the extent of dissection, the site of the incision, wound infection rates, and the method of closure will also affect the pain response. Therefore, to imply that wound tension is solely responsible is a gross oversimplification. One of the major benefits of laparoscopic cholecystectomy has been the significant reduction in postoperative pain when compared to standard open cholecystectomy. In several institutions across the world, laparoscopic cholecystectomy is performed as a day-case procedure, which directly reflects the benefits in postoperative pain seen with this technique. Thus, as the authors suggest, it may be challenging to demonstrate a significant improvement in pain associated with SILS cholecystectomy as multiport laparoscopic cholecystectomy has already dramatically improved pain associated with open surgery. However, this meta-analysis does demonstrate equivalent short-term pain scores for both techniques. Third, Garg et al. [1] raised concerns regarding the methodology employed in trial selection. In particular, they highlighted the inclusion of the Asakuma et al. [3] study. A method of quasirandomization was used by Asakuma et al. [3], with ‘‘allocation to SILS or conventional multiport cholecystectomy based solely on the day of the week.’’ As Garg et al. [1] mentioned in their correspondence, ‘‘there was no attempt to randomize patients blindly, and patient requests for a particular procedure were honored.’’ While we agree with their statement that this method of treatment allocation is not randomization in its purest sense, Asakuma et al. [3] attempted to randomize patients to each treatment. However, we are happy to acknowledge that differences in opinion may exist regarding the inclusion and exclusion of trials based on the methodology of randomization employed. Fourth, Garg et al. [1] suggested that an error occurred in the Table 5 in reporting the incidence of bile leak in the Lee et al. [4] paper. In their paper Lee et al. [4] described S. Markar (&) J. Kinross Academic Surgical Unit, St. Mary’s Hospital, 10th Floor, Praed Street, London W2 1NY, UK e-mail: sheraz_markar@hotmail.com

Single-Incision Laparoscopic Cholecystectomy for Day Surgery Procedure: Are We Prepared?

Single-incision laparoscopic surgery (SILS) for cholecystectomy is a well-established procedure and represents the next step in developing the concept of fast track surgery. This report describes our experience with SILS cholecystectomy in patients that stay overnight. Between February 2009 and July 2010, patients referred for cholecystectomy to the day surgery unit who agreed to undergo SILS were included in a prospective study. All operations were performed by the same surgical team specially trained in this type of surgery and the same operative technique was used in all cases. Postoperative pain and nausea were assessed using a 10-cm visual analogue scale on a self-completion questionnaire on the night of operation and the morning of discharge. A total of 107 patients (58% women, mean age 56 years) with symptomatic gallstones were included in the study. SILS was successfully performed in all patients and no patient required conversion to an open procedure. There were no significant differences in the median visual analogue scale for postoperative pain and nausea between the night of surgery and the next morning. The mean length of hospital stay was 23 hours, and 98 per cent of patients were satisfied with the results of surgery and would be willing to undergo the same procedure again. SILS cholecystectomy is a valid alternative to standard laparoscopic cholecystectomy as an outpatient surgery or overnight stay procedure. According to these promising results, SILS cholecystectomy could be included in a major ambulatory surgery program.

Single-incision Laparoscopic Cholecystectomy Learning Curve Experience Seen in a Single Institution

Single-incision laparoscopic surgery (SILS) is laparoscopic surgery done by one incision through the umbilicus. Cholecystectomy lends itself well to a SILS approach. As these procedures have become more widely adapted, it is important to determine the approximate learning curve to decrease two surgical endpoints: (1) time to completion of the procedure; and (2) decreased incidence of conversion. We prospectively reviewed our series of 50 cholecystectomies done using the SILS approach between May 2008 to September 2008. All cases were performed by two advanced laparoscopic surgeons at a single institution. Data was collected immediately after the case and entered into an Excel database. Cases were performed by insufflating the abdomen with a Veress needle through the umbilicus followed by placement of 5-mm ports at the umbilicus. Patient ages ranged between 21 and 82 years with a median age of 45 years. Body mass index (BMI) range was 21 to 42 kg/m with a mean of 30 kg/m. Average length of time for cases was 1 hour 9 minutes with a range between 55 minutes and 120 minutes. The average length of time for the first 25 cases was 80 minutes. When compared with cases 26 to 50 the average length of time was 60 minutes (P<0.05). The conversion rate to conventional laparoscopic cholecystectomy was 10%. Conversion was accomplished through the addition of a 5-mm port elsewhere on the abdominal cavity. After the tenth case, the incidence of conversion went down to zero. When conversions were further stratified, they occurred within each individual surgeon's first ten cases. The learning curve for successful consistent completion of SILS cholecystectomy cases appears to be after 25 cases. In addition, conversion rates drop dramatically after the first ten cases.

The outcomes of SILS cholecystectomy in comparison with classic four-trocar laparoscopic cholecystectomy.

IntroductionGeneral approval of laparoscopy as well as persistent urge to minimize operative trauma with still existing difficulties in putting natural orifice transluminal endoscopic surgery (NOTES) into practice have contributed to the introduction of laparoscopic operations through one incision in the umbilicus named single incision laparoscopic surgery (SILS).AimThe main aim of this study was to assess the benefits to patients of applying SILS cholecystectomy as a method of gallbladder removal based on the comparison with classic four-port laparoscopic cholecystectomy.Material and methodsBetween 18.03.2009 and 09.12.2009, 100 patients were included in the study and they underwent elective gallbladder removal by applying the laparoscopic technique. All patients were divided into two equal groups: qualified for SILS cholecystectomy (group I) and qualified for classic four-trocar laparoscopic cholecystectomy (group II), whose ASA physical status was I and II. BMI was limited to 35 kg/m2. Outcome measures included operative time, intensity of postoperative pain and consumption of painkillers, hospital stay, need for conversion, complications, and cosmetic effects.ResultsMean operating time in group I was 66 min and in group II 47.2 min. Intensity of pain evaluated by using the visual analogue scale (VAS) 6 h after the operation in group I was 3.49 and in group II 4.53, whereas 24 h after the operation in group I it was 1.18 and in group II 1.55. The painkiller requirement in group I was smaller than in group II. Mean hospital stay after the operation in group I was 1.33 days and in group II 1.96 days. There were 4 conversions in group I and one conversion in group II. Among the complications in group I there were noted 2 cases of right pneumothorax, 1 case of choleperitonitis and 4 complications connected with wound healing. There was one injury of the duodenum and one wound infection in group II.ConclusionsSingle-incision laparoscopic surgery cholecystectomy can be an alternative to classic laparoscopic cholecystectomy, especially with reference to young people with body mass index less than 35 kg/m2, without serious systemic diseases, operated on electively due to benign gallbladder diseases.

Single-Incision Versus Conventional Laparoscopic Cholecystectomy: a Case Control Study

Background : Single-incision laparoscopic surgery (SILS) is a minimally invasive technique which can be used for treatment of gallbladder disease. To evaluate our initial experience, patients treated with SILS cholecystectomy were compared with a comparable group of patients treated with a conventional four trocart technique (LC). Methods : Between May 2009 and April 2010, 60 SILS cholecystectomies were performed. These patients were matched by Body Mass Index (BMI) with 60 cases of conventional LC.Results : The operative time was significantly longer in the SILS group 55 min (range, 25–126 min) compared to 49 min (range, 28–75 min) for the LC group. Excluding the first 15 SILS cases the operative time became comparable to the conventional technique, with a mean operative time of 51 min (range, 25–90 min). No patients were converted to open cholecystectomy. In the SILS group 3 patients developed a wound infection, in the conventional LC group 2. Conclusion : SILS cholecystectomy seems to be a safe and feasible procedure when performed by an experienced laparoscopic surgeon. Complication rates are comparable to conventional LC. With a learning curve of around 10 to 15 procedures, operative times approach those of conventional LC.

Single-incision laparoscopic surgery (SILS) vs. conventional multiport cholecystectomy: systematic review and meta-analysis

Single-incision laparoscopic surgery (SILS) has gained increasing attention due to the potential to maximize the benefits of laparoscopic surgery. The aim of this systematic review and pooled analysis was to compare clinical outcome following SILS and standard multiport laparoscopic cholecystectomy for the treatment of gallstone-related disease. An electronic search of Embase and Medline databases for articles from 1966 to 2011 was performed. Publications were included if they were randomised controlled studies in which patients underwent either single-incision or multiport cholecystectomy. The primary outcome measures for the meta-analysis were postoperative complications and postoperative pain score [visual analogue scale (VAS) on the day of surgery]. Secondary outcome measures were operating time and length of hospital stay. Weighted mean difference was calculated for the effect size of SILS on continuous variables, and pooled odds ratios were calculated for discrete variables. In total, 375 cholecystectomy operations from 7 randomised controlled trials were included, 195 by single-incision (SILS) and 180 by conventional multiport. Operating time was significantly longer in the SILS group compared to the standard multiport laparoscopic cholecystectomy group (weighted mean difference = 2.13; P = 0.0001). There was no significant difference in the incidence of postoperative complications, postoperative pain score (VAS), or the length of hospital stay between the two groups. The results of this meta-analysis demonstrate that single-incision laparoscopic cholecystectomy is a safe procedure for the treatment of uncomplicated gallstone disease, with postoperative outcome similar to that of standard multiport laparoscopic cholecystectomy. Future high-powered randomized studies should be focused on elucidating subtle differences in postoperative complications, reported postoperative pain, and cosmesis following SILS cholecystectomy in more severe biliary disease.

Single-Incision Laparoscopic Surgery (SILS) in Biliary and Pancreatic Diseases

Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common laparoscopic procedure worldwide. With the advent of laparoscopic surgery and its continuous development, the focus has shifted to 'scarless' surgery. In recent times, the innovative technique of single-incision laparoscopic surgery (SILS) has been applied in gallbladder removal and even more complex biliopancreatic procedures to further minimize the invasiveness of the surgery. Newer developments in laparoscopic equipments and instrumentation have helped to further evolve this field of minimally invasive surgery. Literature search was performed using the following online search engines: Google, Medline, PubMed, Cochrane, and the online Springer link library. The terms used for the search were as follows: SILS, LESS, single-incision laparoscopic surgery, single-port laparoscopic surgery, SILS cholecystectomy, and SILS pancreatic surgery. Articles that matched the search criteria were selected and extensively reviewed. Moreover, pertinent information on instrumentation and technology for SILS and LESS was obtained by accessing websites of manufacturers. Although SILS represents the search for an essentially scarless surgery, there is still not a widespread use and uniformity of this procedure. SILS is performed either by single- or multiple-port technique. In the present article, we present a review of the potential benefits, limitations, and risks of SILS in biliary and pancreatic diseases. There are many studies showing benefits in cholecystectomy. A few case reports have also emerged about its feasibility in procedures such as cystogastrostomy and limited pancreatic resection. Further research and development of this technique is needed to arrive at a tangible conclusion about the perceived benefits of SILS. Randomized studies to compare SILS with traditional laparoscopy are essential.

A Technique for Gall Bladder Fundal Traction in Single-incision Laparoscopic Cholecystectomy

The last 2 years have seen numerous reports on single-incision laparoscopic surgery (SILS) in the surgical literature. Achieving an appropriate fundal traction is one among the many technical challenges while performing a SILS cholecystectomy. We describe herein an innovative method of suture traction of gall bladder fundus during SILS cholecystectomy. Prospective data of patients who underwent SILS cholecystectomy from July 2009 to till date in the Department of Surgical Gastroenterology at Manipal Institute of Liver and Digestive Diseases, Bangalore, were analyzed. Twenty-eight patients, 8 male and 20 female patients, with the age ranging from 24 to 62 years have undergone SILS cholecystectomy for cholelithiasis. The suture technique described herein was performed in the last 25 patients. There was no complication related to the use of this suture technique. Technological innovations would ultimately find an easier solution for gall bladder retraction in SILS cholecystectomy. Till such time we believe that the suture technique described herein would offer the most satisfactory fundal traction during SILS cholecystectomy and would find application in the vast majority of patients undergoing SILS cholecystectomy. In addition, this technique could be extended for application in a variety of other SILS procedures.

Single-Center Experience in Systemic Stress and Short-Term Morbidity of Single-Incision Cholecystectomy

Single-incision laparoscopic surgery (SILS) aims to reduce the number and size of skin incisions. The authors compared systemic stress and perioperative outcome of SILS and laparoscopic (LAP) cholecystectomy. Twenty-nine subjects (8 males and 21 females; mean age = 47 years; mean body mass index = 27) were included in the study. There was no statistical difference in mean operative time (LAP = 89 minutes; SILS = 113 minutes; P = ns), and no intraoperative complications were reported. There were no statistically significant differences observed in white cell count, C-reactive protein, interleukin-6, and tumor necrosis factor-α between SILS and LAP groups. The mean hospital length of stay (LAP = 1.8 days; SILS = 1.4 days) and Visual Analogue Scale scores for pain at 6 hours (LAP = 5.14; SILS = 4.46) and 24 hours (LAP = 3.9; SILS = 2.815) were similar with no perioperative morbidity. These results suggest that the systemic stress response in LAP and SILS cholecystectomy does not appear to be significantly different. SILS cholecystectomy appears safe with no perioperative morbidity or complications encountered in this series.

Single-Incision Versus Standard Laparoscopic Cholecystectomy: Comparison of Surgical Outcomes from a Single Institution

Laparoscopic cholecystectomy via the three-trocar technique is widely used for symptomatic gallbladder stones. Single-incision laparoscopic surgery (SILS) for cholecystectomy is a well-established procedure and represents the next step in developing the concept of mini-invasive surgery. We here described our 24-month experience SILS cholecystectomy. Between February 2009 and 2011, patients referred for cholecystectomy to the General and Endocrine Unit of our institution who agreed to undergo SILS were included in a prospective study. All operations were performed by the same surgical team specially trained in this type of surgery. The umbilicus was the sole point of entry for all patients. The same operative technique was used in all patients. Data of patients undergoing SILS cholecystectomy were compared with those from an uncontrolled group of patients undergoing standard laparoscopic cholecystectomy during the same study period. The SILS and standard cholecystectomy groups included 120 patients each. SILS was performed in all patients and none of them required conversion to an open procedure. The median operating time of 45 minutes in the SILS group was not significantly different from that in the standard laparoscopic cholecystectomy group. We suture fascial edge with simple stitches under direct vision, thus reducing the risk of incisional hernia in SILS group (P=.046). SILS cholecystectomy was technically feasible and safe and represents a reproducible alternative to standard laparoscopic cholecystectomy in selected patients. The definitive clinical, esthetic, and functional advantages of this technique require further analysis.