Three-port Technique Research Articles

Effect of Notchplasty in Anterior Cruciate Ligament Reconstruction: A Biomechanical Study in Porcine Knees (SS-74)

Introduction: In anterior cruciate ligament (ACL) reconstruction, notchplasty is frequently performed by many surgeons. It is not well understood how notchplasty may effect tunnel placement and knee kinematics. The purpose of this study is to investigate the biomechanical effects of notchplasty on the ACL reconstructed knee. The hypothesis is that notchplasty will affect knee biomechanics in ACL reconstructed knee. Methods: Twelve (n 12) mature, fresh frozen porcine knees were tested using a robotic/universal force/moment sensor (UFS) testing system. All ACL reconstructions were performed via arthroscopy using a threeportal technique. Four knee states were compared: 1) intact ACL 2) ACL-Deficient 3) Anatomic single bundle (SB) ACL reconstruction and 4) Anatomic SB ACL reconstruction with a 5 mm notchplasty. The same tunnel was used for states 3 and 4. The graft was fixed at 60° of knee flexion and tensioned at 80-N with an Endobutton on the femur and a post-screw on the tibia. All knees were subjected to the following loading conditions: an 89-N anterior tibial load to test anterior tibial translation (ATT) and a 4 N-m internal rotation (IR) and external rotation (ER) tibial torque. The knee kinematics and in situ force obtained from the different knee conditions were compared. The data (mean standard deviation), was analyzed (Prism GraphPad Version 5.0a) using a two-tailed Paired t-test with the level of significance set at P 0.05. Results: There was no significant differences between pre and post notchplasty in ER at 30° (full extension in porcine knee) and 60° of flexion (p 0.05). However, a significant difference was found between pre and post notchplasty in ATT at 30° and 60° of flexion (p 0.05). In-situ force in anatomic single bundle reconstruction with notchplasty was significant lower than intact and anatomic reconstructed ACL pre-notchplasty at 30 °, 60° and 90° flexion of the knee (p 0.05). In response to an IR tibial torque, there were not significant differences between pre and post notchplasty at 30° of knee flexion (p 0.05). However, a significant difference was found between pre and post notchplasty in IR at 60° (p 0.05) of knee flexion. Conclusion: The results of this study showed that notchplasty did not result in an increase in ER at 30° and 60° degrees of knee flexion and IR at 30° degree of knee flexion; but lead to an increase in ATT at 30° and 60° degrees of knee flexion and in IR at 60° degree of knee flexion. Notchplasty had more effect on anterior stability than rotational stability. This change in knee kinematics could be detrimental to a bone healing and graft ligamentization and could lead to graft failure.

Laparoscopic appendectomy for complicated acute appendicitis does not result in increased surgical complications

Septic postoperative complications are debated in patients with complicated acute appendicitis treated with laparoscopic appendectomy (LA). The aim of this study was to investigate the results of LA in both complicated and uncomplicated cases of acute appendicitis. From January to December 2009, 94 patients with acute appendicitis underwent LA by the same surgeon using the three-port technique. Data were accumulated and compared between complicated and uncomplicated acute appendicitis. Of the 94 patients (45 women and 49 men), 19 had complicated and 75 uncomplicated acute appendicitis. The group with complicated acute appendicitis, as compared to the uncomplicated group, was significantly older (55.7 ± 20.5 years vs. 41.0 ± 18.0 years), and had a significantly increased operation time (117.6 ± 45.5 minutes vs. 78.2 ± 39.4 minutes), longer length of hospital stay (9.0 ± 3.3 days vs. 5.2 ± 6.0 days) and higher conversion rate (21.1% vs. 2.7%). No increase in surgical complications was noted in patients with complicated acute appendicitis, as compared to those with uncomplicated acute appendicitis. This study demonstrated no increase in surgical complications after LA in patients with complicated acute appendicitis when compared with those who had uncomplicated disease. Therefore, LA may be considered the first-choice treatment option for both uncomplicated and complicated acute appendicitis.

Single-port hernia repair: a prospective cohort of 102 patients

Single-port laparoscopic surgery (SPLS) for totally extraperitoneal (TEP) groin hernia repair is a novel procedure, ensuring safe and effective repairs. The aim of this study was to assess the intra-operative and post-operative outcome for 102 patients undergoing SPLS TEP inguinal hernia repair at the Royal Surrey County Hospital in Guildford, UK. This follows on from our previously published series of 16 patients, demonstrating the safety and feasibility of SPLS in our cohort (Agrawal et al. in Surg Endosc 24:952-956, 2010). Between October 2008 and August 2010, we performed hernia repairs on 102 patients (98 men, 4 women) aged between 21 and 89 years (median 60). Patient demographics, type of hernia, incision length, operating time, complications, post-operative hospital stay, and recurrence were collected prospectively. Post-operative outcome was measured in terms of days to return to normal activities, work, and analgesia required. Sixty patients had unilateral and 39 bilateral hernias, with 2 femoral hernias and one lipoma of cord. Operating time was 15-120 min (median 35 for unilateral and 45 for bilateral repairs). The incision length ranged between 15 and 40 mm (median 25). There was 1 intra-operative complication (major peritoneal incursion) and 13 minor post-operative complications, with 8 urinary retentions. There were no mortalities and one recurrence at follow-up (up to 713 days). The authors' experience has shown that SPLS TEP groin hernia repair is a feasible and safe alternative to three-port laparoscopic hernia repairs in a large patient cohort. There were minimal post-operative complications and good post-operative outcome. Recurrence rate was 0.98 %. Further studies are required to assess the long-term outcome of SPLS hernia repairs in direct comparison with three-port technique.

Laparoscopic treatment of urachal remnants

ObjectivesThe urachus is a vestigial obliterated structure derived from the alantois. Failure of this involution process originates patent urachal remnants. Surgery is the treatment of choice as it prevents both recurrence of symptoms and malignant transformation. The purpose of this study is to present our experience in the laparoscopic management of this pathology. Material and methodsThree male patients (mean age 39 years) underwent laparoscopic excision of urachal remnants. Two patients were diagnosed with an asymptomatic cyst and one patient with urachal sinus presenting with umbilical discharge. A three-port technique was used to remove the whole urachus tract from the umbilicus to the bladder dome, together with a small bladder patch. ResultsMean operating time was 94min and blood loss was minimal. One patient had small intra-operative bladder rupture, successfully managed with adequate closure. No post-operative complications were observed and all patients were discharged on the second postoperative day. Two years later there was no evidence of recurrence. ConclusionsUrachal remnants can be successfully treated by laparoscopic surgery, with advantages in terms of morbidity, recovery and cosmetic outcome. Large number, comparative studies are still needed to definitely establish it as the gold standard treatment.

Three Port Versus Four Port Laparoscopic Cholecystectomy

Objective: The objective of this study is to compare the outcome of three vs four port laparoscopic cholecystectomy and detect safety of three port laparoscopic cholecystectomy (LC) as routine procedure. Study Design: Simple comparative study. Setting: One year starting from June 2010 to May 2011. Sample size: 100 patients Methods: All patients were divided into two groups. Group A: three port laparoscopic cholecystectomy was done. Group B: Conventional four port laparoscopic cholecystectomy was done. Outcome is determined in terms of postoperative pain (determined by visual pain scale) and complications (bleeding, infection, bile duct injury). Results: 35 patients in Group A had low pain score and 15 were high pain score. In group B, 24 had low pain score and 26 high pain score. In group A only 10 patient needed nalbuphine as compared to 35 patient in group B. Both groups have almost same operating time (48.5min A and 48min B). Hospital stay is same (48h). Complications like port site bleeding (2 patient in A and 4 in B), wound infection (2 in A and 3 patients in B), abdominal pain (3 in group A and 4 in group B) of three port laparoscopic cholecystectomy are comparable with four port cholecystectomy. No patient in both groups suffered bile duct injury. Conclusion: The three-port technique is as safe as the standard four-port for LC. The main advantages of the three-port technique are that it is less painful, safe, less chances of wound infection and leaves fewer scars. Key Words: Laparoscopic cholecystectomy – three port cholecystectomy, four port cholecystectomy

Two-port vs. three-port laparoscopic appendicectomy: A bridge to least invasive surgery

INTRODUCTION:The conventional three-port technique for laparoscopic appendicectomy has proven its worth in the management of appendicular pathologies. From a cosmetic viewpoint, the umbilical and suprapubic port-sites are hidden by natural camouflages, the right Iliac fossa (RIF) port is the only visible external sign of surgery. The two-port technique avoids even this marker of abdominal invasion. In this study, we describe the technique of two-port laparoscopic appendicectomy (TPA) and compare it with conventional laparoscopic appendicectomy (CLA).MATERIALS AND METHODS:All patients studied underwent operation for acute appendicitis during a 6-month period. Data were collected prospectively for the TPA and retrospectively for the CLA. The TPA was performed with one 10 mm umbilical working port and one 5 mm suprapubic camera port. A hypodermic needle was introduced in the RIF to retract the appendix. The appendicular artery was controlled with diathermy or ultrasonic shears. The base was ligated with a loop knotted extracorporeally. CLA was performed via the conventional 10 mm umbilical, 5 mm suprapubic and 5 mm RIF ports. The appendicular stump was ligated with an endoloop or an intracorporeal knot.RESULTS:A total of 146 patients underwent surgery over the 6-month period for appendicitis. Out of 62 cases attempted, the TPA was successful in 51 cases, with conversion to the three-port technique in 11. The operative time, complication rates, return to work were comparable between the two groups. Patients who had TPA had a shorter postoperative stay.CONCLUSION:This is an initial experience with TPA. There is little difference in the operative time, postoperative stay and complications rates between this technique and the conventional three-port one. There is hence little to be lost and a likely benefit to be gained by performing the TPA although a randomised study is necessary.

LAPAROSCOPIC-ASSISTED OVARIECTOMY OF TIGERS (PANTHERA TIGRIS) WITH THE USE OF THE LIGASURE™ DEVICE

Laparoscopic ovariectomy was performed in seven tigers with the use of a vessel-sealing device and a three-port technique. A comparison group of seven tigers that underwent traditional ovariohysterectomy was assembled with the use of a medical records search. Mean operative times for laparoscopic ovariectomy were compared to standard ovariohysterectomy, and mean combined laparoscopic incision length compared to standard ovariohysterectomy incision lengths. Significance was set at P < or = 0.05. Mean surgical time for laparoscopic ovariectomy (82 min, range 71-126 min) was significantly shorter than standard ovariohysterectomy surgical time (129 min, range 80-165 min, P = 0.007). Mean combined laparoscopic incision length (8.07 cm, range 3.80-9.50 cm) was significantly shorter than the mean incision length for standard ovariohysterectomy (13.57 cm, range 12.00-20.00 cm, P = 0.009). There were no clinically important complications observed in either group. Laparoscopic ovariectomy has a significantly shorter surgical time and combined incision length compared to standard ovariohysterectomy in tigers, and appears to be a safe and rapid sterilization method for tigers. Equipment cost and the necessity for advanced training may limit its use in some institutions. Further prospective evaluation is warranted to determine whether it is associated with decreased morbidity, mortality, or cost.

Single-incision laparoscopic surgery for pyloric stenosis

Laparoscopy is the most common procedure for correction of congenital pyloric stenosis. The standard laparoscopic approach is based on the three-port technique. In contrast to the standard laparoscopic technique, the single-incision laparoscopic surgery (SILS) requires only one incision. We report on our experience with this surgical approach. Between September 2009 and August 2010 a total of 24 children underwent a laparoscopic pyloromyotomy, 12 in SILS technique. The single incision was carried through the center of the umbilicus. The working instruments were introduced in a two-dimensional direction into the peritoneal cavity via the same umbilical incision. The two groups were compared for patients' demographics, operative report and early postoperative outcomes. All SILS procedures were performed successfully with no conversion rate. There were no differences in the preoperative parameters between the two groups regarding age before surgery and body weight at operation. Operative time and time of full enteral intake was similar to comparable procedures with usage of a standard laparoscopic approach. There were no operative or postoperative complications. The early experience described in this study confirms that SILS can be applied for treatment of pyloric stenosis with outcomes similar to the standard laparoscopic surgery.

Silicone oil removal after rhegmatogenous retinal detachment: comparing techniques

To assess the outcome of silicone oil removal after rhegmatogenous retinal detachment (RRD) surgery, and to compare results of a two-port (infusion-extraction) versus a three-port (full vitrectomy) approach. Primary outcome measure was the rate of redetachment. Secondary outcome measures were visual acuity, rate of intraoperative and postoperative epiretinal membrane removal and complications. We included 147 consecutive cases. There were 15 cases of giant retinal tear, 26 cases of RRD without proliferative vitreoretinopathy (PVR) and 106 cases of RRD with PVR. The overall redetachment rate after silicone oil removal was 17.7%. In the group treated with the two-port technique (n=95), the retina redetached in 16 cases (16.8%), and in the group treated with the three-port technique (n=52), redetachment occurred in 10 cases (19.2%). This difference was not statistically significant (P=0.717; χ (2)-test). There was a significantly higher redetachment rate in cases with a short oil tamponade duration of <2 months. We reconfirm a relatively high redetachment rate after silicone oil removal. The risk of redetachment is not lower with the three-port compared with the two-port approach.

Author’s reply to V. Fazio’s invited comment on “Single incision laparoscopic colorectal surgery: a single surgeon experience of 102 consecutive cases”

The authors are thankful for the opportunity to address the comments made by Dr. Fazio and by Dr. Bergamaschi regarding our manuscript entitled ‘‘Single Incision Laparoscopic Colorectal Surgery: A Single Surgeon Experience of 102 Consecutive Cases.’’ The authors greatly appreciate both the insightful comments offered by Dr. Vic Fazio as well as his understanding that single-incision laparoscopic colorectal surgery is in its infancy. We also agree that benefits and outcomes will prove to be at least equivalent and likely superior to traditional laparoscopy, as its superiority to hand-assist surgery has been shown by others [1]. We are now indeed in the process of defining patient selection, disease processes, and limitations of a single-port technique. Further work is in process and results are forthcoming. As far as Dr. Bergamaschi’s comments, we agree that institutional review board (IRB) approval should be mandatory for such studies and greatly appreciate Dr. Bergamaschi’s acknowledgement that this was indeed the case in our study as we consider it routine. We also agree that there is a need for innovation in surgery and that this must be implemented in accordance with the rules of evidence. However, we cannot agree with his statement that laparoendoscopic single-site surgery (LESS) is neither technically simple nor random. Given the tremendous advances in new technology (Olympus endo-eye flexible tip 5-mm camera and 5-mm energy devices to name a couple), we are now able to perform even complex abdominal operations in an even less invasive fashion. In fact, the ergonomic challenges and time constraints of traditional laparoscopy are often greatly improved with a single-port technique. LESS is nothing more than grouping the ports together and operating through a single incision. Having performed well over 1,000 laparoscopic colorectal procedures primarily through a three-port technique popularized in the United States by John Marks, MD, the transition to single-incision surgery is quite simple. This has become our routine access as it is essentially a three-trocar technique with the grouping of the ports at a single-site. The authors also agree with Dr. Bergamaschi that the goal for innovative advances in surgery should be the improvement of patient benefit as that was the sole purpose of this study while better defining the patient selection, disease processes, and optimal technique. With regard to the actual technique, single-incision laparoscopy is in its infancy while standardized techniques have not yet been defined. However, it remains a three-trocar laparoscopic procedure. As we are now quickly approaching our second 100 cases, much has been learned. With the ports arranged in a triangular configuration directed to the pathology, the camera is best placed through the apical port with a grasper in the surgeon’s right hand and the energy device in the left. The same surgical principles that pertain to open surgery and utilized for a traditional laparoscopic approach are strongly adhered to with this access technique. Again, this simplified approach is a traditional three-trocar technique with the ports bunched together and we feel that this is readily adoptable by surgeons with the appropriate skill set utilized for a traditional laparoscopic resection. To date, over 100 surgeons with advanced laparoscopic experience have been proctored and report an excellent adoption rate. While others have D. Geisler (&) T. Garrett Pittsburgh, PA, USA e-mail: dgeisler@ma.rr.com

Tratamiento laparoscópico de los remanentes uracales

ObjectivesThe urachus is a vestigial obliterated structure derived from the alantois. Failure of this involution process originates patent urachal remnants. Surgery is the treatment of choice as it prevents both recurrence of symptoms and malignant transformation. The purpose of this study is to present our experience in the laparoscopic management of this pathology. Material and methodsThree male patients (mean age 39 years) underwent laparoscopic excision of urachal remnants. Two patients were diagnosed with an asymptomatic cyst and one patient with urachal sinus presenting with umbilical discharge. A three-port technique was used to remove the whole urachus tract from the umbilicus to the bladder dome, together with a small bladder patch. ResultsMean operating time was 94min and blood loss was minimal. One patient had small intra-operative bladder rupture, successfully managed with adequate closure. No post-operative complications were observed and all patients were discharged on the second postoperative day. Two years later there was no evidence of recurrence. ConclusionsUrachal remnants can be successfully treated by laparoscopic surgery, with advantages in terms of morbidity, recovery and cosmetic outcome. Large number, comparative studies are still needed to definitely establish it as the gold standard treatment.

What’s new on ACL surgery horizon?

The history of the treatment of anterior cruciate ligament (ACL) injuries is fascinating and filled with interesting anecdotes and sharp turns. Regrettably, it turned out that primary repair is not an option for the ruptured ACL due to its incapacity to heal [1]. Reconstruction with different augmentations devices has also only presented disheartening results. This has led orthopaedic surgeons to perform ACL reconstruction instead of repair. Initially ACL reconstruction was performed using arthrotomy with the goal to reproduce the native anatomy of the ACL. As with all modern surgery, minimally invasive surgical techniques were introduced in knee surgery and with it the start of arthroscopically-assisted ACL reconstruction [2]. In the beginning, arthroscopic ACL reconstruction was performed using a two-incision technique in which the femoral bone tunnel was drilled from outside-in. Over time this changed to one-incision technique in which the femoral bone tunnel is drilled inside-out through the tibial tunnel. Recent studies found that this traditional single-bundle reconstruction fails to reproduce native ACL anatomy and does not fully restore the rotational stability of the knee joint and a more anatomic approach to ACL reconstruction was proposed [3]. The double-bundle technique brought the focus of ACL reconstruction back to restoring anatomy. It has shown superior results in terms of rotational stability in both biomechanical [4] and clinical studies [5]. However, it is vital to differentiate between anatomic and double-bundle ACL reconstruction. The latter is merely a step closer to reproduce the native anatomy of the ACL; however, it can still be done non-anatomically. Moreover, anatomic ACL reconstruction can also be performed using a single-bundle technique. Non-anatomic tibial and femoral tunnel placement represents one of the most important causes of ACL graft failure [6]. When the tibial tunnels are placed too anteriorly, it may lead to roof impingement, which is associated with loss of extension and abrasion of the graft [7]. To prevent this, some surgeons move their tibial tunnel more posteriorly. However, this approach creates tunnel mismatch [8]. Often, a tibial tunnel positioned at the PL insertion site is combined with an (high) AM femoral tunnel. It results in tunnel placement outside of the native insertion site, which can result in abnormal knee kinematics [9]. Multiple studies have demonstrated that non-anatomic tunnel placement results in limited range of motion, higher than physiologic graft tension, and ultimately graft failure [10, 11]. Biological healing of the graft-bone interface may also be affected [12]. Anatomic ACL reconstruction can be defined as the functional restoration of the ACL to its native dimensions, collagen orientation, and insertion sites [13]. Use of a three-portal technique with a medial viewing portal facilitates a true anatomic ACL reconstruction. Anatomic ACL reconstruction can be performed in both single- and double-bundle reconstruction, and in primary, revision and augmentation surgery [14]. However, when different aspects of the surgery are compared, such as single- versus double-bundle techniques, it is necessary that both procedures are performed in an anatomic fashion. Most of the clinical studies comparing single-bundle to double-bundle reconstruction do not present a fair comparison since often one or both surgical techniques were not performed anatomically [15, 16]. In addition, associated injuries such as cartilage injuries, meniscus tears and osteoarthritic changes should be taken into account when conducting comparative clinical studies. Another future consideration is the further improvement of our outcome measures for ACL reconstruction. For example, in the office setting it is difficult to quantify differences in rotational stability in absolute terms [17]. New tools should be reliable, accurate, precise and valid. Examples of such tools that currently used for research purposes are dynamic stereo radiography, T2 MRI mapping of cartilage and quantification of graft healing on MRI [3, 18, 19]. Furthermore, there is a need of consensus on which outcome measures should be used, to facilitate homogeneous reporting of outcome amongst authors. For example, currently important outcome measures such as range of motion are underreported [20], even though it provides important clues to accuracy of tunnel placement and the presence of impingement. In addition, patient reported outcomes, such as the IKDC Subjective Knee Form, KOOS, Tegner Activity Scale and Marx Activity Scale, should be reported in all studies. The use of more accurate and standardized outcome measures could demonstrate the benefits of anatomic ACL reconstruction with regard to the restoration of normal structure and function of the knee. Anatomic ACL reconstruction intends to replicate normal anatomy, restore normal kinematics and protect long-term knee health. The road to anatomic ACL reconstruction has been long and winding. It is a detailed surgical procedure with a steep learning curve and many pitfalls. In the future, more reliable, accurate, precise and validated outcome measures are needed to evaluate its results.

VATS Thymectomy for Nonthymomatous Myasthenia Gravis Standardized Outcome Assessment Using the Myasthenia Gravis Foundation of America Clinical Classification

: Video-assisted thoracoscopic (VATS) thymectomy has been practiced in Australia for nearly two decades. Our aim was to assess the complete stable remission and asymptomatic disease rates after VATS thymectomy in nonthymomatous myasthenia gravis. There remains doubt that minimally invasive techniques achieve equal remission rates to open maximal operations. Therefore, we report our outcomes using the Myasthenia Gravis Foundation of America (MGFA) Clinical Classification and Kaplan-Meier analysis and compare the results to the literature. : A retrospective analysis of 78 consecutive patients undergoing right VATS thymectomy between April 1994 and March 2007 at two Thoracic Surgery Units in Melbourne, Australia, was undertaken. Patients with thymoma were excluded. Therefore, 57 patients were followed-up for a minimum of 12 months to apply the MGFA Clinical Classification. VATS thymectomy was performed by a three-port right side technique. : The complete stable remission rate was 15% at 3 years and 28% at 5 years. The asymptomatic disease rate was 59% at 5 years. Median follow-up was 32 months. No prognostic factors for remission were identified. The overall morbidity rate was 14% (8/57). : Right VATS thymectomy achieves comparable remission and asymptomatic disease rates to other minimally invasive and open techniques when compared with studies using either MGFA or older criteria.

Advances in the three-portal technique for anatomical single- or double-bundle ACL reconstruction

PurposeTo describe the “three-portal technique for anatomical ACL single- or double-bundle reconstruction” and the arthroscopic viewing improvement provided by this technique.MethodsA “high” anterolateral portal was placed 1 cm lateral to the patellar tendon and the most inferior portion of the portal at the level of the inferior pole of the patella. A “central” portal was placed using a spinal needle under arthroscopic visualization following the orientation of the previous ACL fibers. An accessory medial portal was also placed using a spinal needle respecting a 2-mm distance to the medial femoral condyle.ResultsThe “high” anterolateral portal permitted a broad and unobstructed view of the ACL tibial attachment. The “central” portal allowed a straightforward view of the ACL femoral remnant and bony landmarks in the intercondylar notch. The accessory medial portal enabled to reach the femoral native insertion site of the ACL.ConclusionThe three-portal technique provides a proper view of the soft tissue remnants and bony landmarks facilitating an anatomical positioning of the graft.

Traditional laparoscopic colorectal resections can be performed effectively using a three-port technique

Dear Editor, With the increasingly widespread use of laparoscopic surgery to treat colorectal diseases, many innovations have been made in attempts to develop the best technique. While the use of four or more ports has been routine in most laparoscopic colorectal resections, the drawbacks are the need for added manpower, consisting of the camera-person and another assistant to provide counter-traction, as well as costs and the unaesthetic effects of additional ports. Specimen extraction through an additional muscle-cutting incision may also result in increased postoperative pain and spoil the cosmetic results of laparoscopic surgery. We describe our technique of colorectal laparoscopy using only two ports and one camera port with extraction of specimen via the camera port. Between June 2008 and June 2009, we performed 49 colorectal resections using a three-port technique. This series includes 13 cases of segmental colectomy, 29 cases of anterior resection and 7 cases of total colectomy or total proctocolectomy. We recently published this technique of three-port laparoscopic ultra low anterior resection [1]. In applying the three-port technique to any resection, a sensible placement of the two manipulation ports is absolutely essential. Our manpower in the three-port laparoscopic procedure involved the operating surgeon, a nurse to hold the camera port and a scrub nurse who also held the uterine manipulator as the need arose. We utilized the umbilicus to remove the specimen in these cases, extending it to extract the specimen as needed. For left hemicolectomy and anterior resection or ultra low anterior resection, the first manipulation port (10/ 12 mm) was inserted medial to the right anterior superior iliac spine, and the second port (5 mm) was inserted in between the umbilical port and the first manipulation port (Fig. 1). The 5-mm port was used for tissue retraction and the 10/12-mm port was for the energy device as well as for insertion of staplers. In females, we used a Zumi 4.5TM (UA Medical Products Inc, Charlotte, NC, USA) uterine manipulator inserted via the vagina to manipulate the uterus when needed as this obviated the use of an additional port (Fig. 2). For right hemicolectomy, a 5-mm port a palms length below the umbilicus either in the midline or in the left iliac fossa and a 10/12-mm port to the left of the midline a palms length above the umbilicus were sufficient. In all cases, after dissection and sufficient mobilization, the umbilical port was removed and the wound lengthened only to the size needed for specimen extraction. After insertion of the stapler head in cases of left-sided colon cancer, the proximal colon was returned to the abdomen and the umbilical wound closed around the camera port for completion of the anastomosis after re-insufflation of the abdomen (Fig. 3). For right hemicolectomy and some cases of left hemicolectomy where the retained sigmoid colon was very long, the colon and tumor were exteriorized and transected and the anastomosis was performed extra-corporeally. We used either the Harmonic ACE (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA) or the LigaSure Atlas (Tyco Healthcare UK Ltd, Gosport, UK) device for dissection and I. Seow-En K.-Y. Tan M. A. B. Mohd Daud F. Seow-Choen (&) Seow-Choen Colorectal Centre, #03-09 Mt Elizabeth Medical Centre, Singapore 228510, Singapore e-mail: seowchoen@colorectalcentre.com

Single-Incision Cholecystectomy in about 200 Patients

Background and Aims. We describe our experience of performing transumbilical single-incision laparoendoscopic cholecystectomy as standard procedure for acute and chronic gallbladder diseases. Methods. Between September 2008 and March 2010, 220 patients underwent laparoscopic single-incision surgery. A single port was used for 196 patients and two conventional 5 mm and one 10 mm port in 24 cases. All operations were performed with straight instruments. Results. Single-incision surgery was successfully performed in 215 patients (98%). Three patients (1.4%) required conversion to a three-port technique and two patients (0.9%) to an open procedure. Average age of 142 women (65%) and 78 men (35%) was 47 years (range: 15–89), average ASA status 2 (range: 1–3) and BMI 28 (range: 15–49). Mean operative time was 62 minutes (range: 26–174) and 57 patients (26%) had histopathological signs of acute cholecystitis. Eleven patients (5%) developed to surgery-related complications and nine (4%) of these required a reoperation. The mean followup was 331.5 (range: 11–590) days. Conclusion. Transumbilical single-incision cholecystectomy is a feasible and safe new approach for routine cholecystectomy. After a short learning curve, operation time and complication rate are comparable with standard multiport operation. In addition, most cases of acute cholecystitis can be performed with this technique.

Video-assisted thoracoscopic surgery (VATS) lobectomy using a standardized anterior approach

Lobectomy using video-assisted thoracoscopic surgery (VATS) still is a controversial operation despite its many observed benefits. The controversy may be due to difficulties performing the procedure. This study addresses a standardized anterior approach facilitating the operation. This report describes 156 VATS lobectomies performed with a uniform anterior three-port technique. The surgeon and the assistant stand on the abdominal side of the patient, and the setup is independent of the lobe to be resected. From 2005 to 2007, 156 VATS lobectomies and 13 conversions (7.7%) were performed with an anterior three-port technique. No mortality occurred among the VATS lobectomies during a 30-day period. The major comorbidity rate was 78%. The comorbidities included former thoracic surgery (9%) or a history of another cancer (22%), indicating potentially difficult surgery and a nonselected population. The majority (92%) of the patients had lung cancer. The major postoperative problem was air leakage, which usually prolongs the tube time and the in-hospital stay, but a "no-touch fissure" technique significantly reduced the median tube time to 4 days and the postoperative hospital stay to 5 days. This study shows that VATS lobectomies can be performed using a standardized anterior approach with low rates of conversion and morbidity. A "no-touch fissure" technique lowers the postoperative tube time, the in-hospital stay, and the number of patients with prolonged air leakage. A uniform anterior approach facilitates VATS lobectomy and makes this advanced procedure more easily adaptable by many surgeons familiar with an open anterior approach. The findings show that VATS lobectomy can be performed safely for a large proportion of lung cancer patients.

Is Fourth Port Really Required in Laparoscopic Cholecystectomy?

Since the advent of four-port laparoscopic cholecystectomy, many modifications regarding port number and size have been tried. The feasibility of three-port technique has been found comparable to the conventional four-port laparoscopic cholecystectomy. To assess the feasibility and safety of three-port laparoscopic cholecystectomy in a prospective study. Between March 2007 and March 2009, fifty patients with cholelithiasis aged between 15 and 56years underwent three-port cholecystectomy in a prospective study in Government medical college, Srinagar. A single surgeon did all the cases and there was no criterion for the patient selection. These were consecutive fifty surgeries done by the surgeon. The outcome was assessed in terms of intra-operative and post-operative parameters. The mean (range) age was 45 (15-56) years and there were thirty-nine females and eleven males in the study. All the procedures were completed successfully without any conversions to open or any major complications; though three patients needed the addition of a fourth port as in conventional laparoscopic cholecystectomy. The mean (range) operative time was 55 (30-90) min and the average blood loss was 30ml. The mean (range) hospital stay was 1 (1-3) days. All patients returned to routine work within 1week of surgery. The mean follow-up was 5 (2-7) months. We conclude, from the results above, that three-port laparoscopic cholecystectomy is safe and feasible. There are only two visible surgical scars, better cosmetic appearance with no increased risk of bile duct injury. It reduces the manpower in the form of a second assistant. Thus, it can be recommended as a safe alternative procedure to conventional four-port laparoscopic cholecystectomy.

Single-Port-Cholezystektomie: Der neue Standard?

Single-port transumbilical laparoscopic cholecystectomy (SPTLC) may become a standard procedure in the surgical treatment of acute and chronic gallbladder diseases. The initial experience with this new technique is reported. 186 patients underwent laparoscopic single-port laparoscopic cholecystectomy between September 2008 and February 2010 at the Vivantes Klinikum Am Urban, Berlin, Germany. All these operations were performed with conventional straight laparascopic instruments using a single-port system. Conversion to a three-port technique or open procedure became necessary in four patients after failure to perform the single-port method. The average age of the 120 women (64%) and 66 men (36%) was 45 (range 15-88 years) years. The ASA grade (American Society of Anesthesiologists) averaged 2 (range, 1-3) and the BMI 28.5 (range 17-49). Mean operative time was 63 min (range, 28-17 min). 48 patients (26%) had histopathological evidence of acute cholecystitis. During a mean follow-up period of 39 weeks (range 1-78 weeks), 11 patients (6%) developed complications related to the surgery, five of these patients (3%) requiring a subsequent re-operation. Single-port transumbilical laparoscopic cholecystectomy for acute and chronic gallbladder disease is a feasible approach for routine cholecystectomy. After a short learning curve the operation time and rate of complications are comparable to standard multi-port laparoscopic cholecystectomy. A limitation of the procedure are very obese patients and multiple previously performed abdominal operations.

Single-Incision Multiport Laparoendoscopic (SIMPLE) Cholecystectomy

We thank you for your most astute comments regarding our article. We address these comments based not only on our original article on a series of 10 procedures, submitted in September 2008, but also on our experience that well exceeds 100 procedures in the past 1 years. Our method has changed with our experience. For example, we no longer perform this procedure during lithotomy. We have moved from a three-port trocar technique to a more stable and flexible port platform (Gelpoint; Applied Medical, Rancho Santa Margarita, CA, USA), which allows the insertion of multiple ports. We continue to use straight instruments preferentially, with occasional need for a right-angled instrument and even less need for articulating instruments. We also continue to use a rigid 30 angled scope. These technique changes address the issues raised in your letter. First, a critical view of safety is obtained in all cases. We have found that for most procedures this indeed can be achieved with a two-instrument technique [1] (Fig. 1). Retraction is imperative to obtaining this maneuver. Instead of reflecting the fundus of the gallbladder superolaterally and the infundibulum inferolaterally, as with the three-instrument dissection technique, we retract the only the infundibulum. But we grasp the infundibulum as close to the cystic duct as possible. This is important for two reasons. First, we create sufficient tension to achieve the dissection, thereby opening up Calot’s triangle, pulling the cystic duct and artery away from the liver’s edge and the underlying common bile duct. Second, internal retraction as close as possible to the area of dissection minimizes exterior lateral hand movement, thereby eliminating hand crisscrossing and clashing. Positioning the patient in the reverse Trendelenburg and slightly left laterally recumbent position has aided us in this maneuver. However, as you point out, a two-instrument technique is not possible in all cases, most notably when the patients have a high body mass index (BMI), fatty or enlarged liver, or acute cholecystitis. In these circumstances, we add a fourth port and proceed with the traditional three-instrument dissection. Often, we add this through our single umbilical incision, but occasionally we add it through an additional port, transforming the single-incision multiport laparoendoscopic (SIMPLE) procedure into a reduced-port procedure (or in our vernacular, a ‘‘DIMPLE’’). The second issue you raised questions the maneuverability restrictions of three trocars. We have found that extending the skin incision at the time of pneumoperitoneum, using the locking trocars, minimizes restriction and preserves the small single incision. A 4-cm skin incision with maximal abdominal distention decreases to a 2– 2.5 cm incision at desufflation. Nonetheless, our early experience with the locking trocars, as you mentioned, was limiting. We have since found that the Gelpoint system allows for much more freedom of movement through the same small skin incision. The fascial incision is a single incision as well, not the ‘‘Swiss cheese’’ type of penetration from closely approximated trocars, which can be problematic [2]. Also, the fascial incision can be as large as 5 cm or more through a small 2.5-cm skin incision. In addition, the fulcrum of the instruments is more external, at the level of the concaved Gelpoint, which is located 5 cm above skin level. Finally, four ports can be placed comfortably through the Gelpoint platform. All these factors contribute to minimal restriction of movement. B. M. Molinelli (&) A. Petrotos Department of Surgery, Greenwich Hospital, Greenwich, CT, USA e-mail: ssg06830@hotmail.com