Single‐incision laparoscopic cholecystectomy

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Abbreviations

FDA

US Food and Drug Administration

SILC

single‐incision laparoscopic cholecystectomy

Indications

Since the advent of laparoscopic cholecystectomy in 1985 by the German surgeon Erich Mühe, surgeons worldwide have sought to enhance technique and instrumentation in order to improve postoperative recovery and patient satisfaction while maintaining safety.1 As a result, patients have experienced shorter hospitalizations, less postoperative pain, and improved cosmesis. Laparoscopic cholecystectomy is now the gold standard for treating benign gallbladder pathology. In recent years, there has been a trend to reduce the number of incisions from the traditional four‐port technique. Thus, single‐port or single‐incision laparoscopic cholecystectomy (SILC) has been introduced to improve patient satisfaction in the hopes of reducing incisional pain and improving cosmetic outcomes. Herein we describe the technical aspects of this procedure and compare its outcomes with the traditional laparoscopic technique.

Technical Aspects

As the name suggests, single‐port or SILC utilizes one skin incision for the insertion of laparoscopic instruments and camera into the peritoneal cavity. Although initial attempts involved the utilization of standard laparoscopic instruments and ports, mostly through separate fascial stab incisions under the same skin incision, it was readily obvious that the lack of triangulation and adequate visualization make the procedure technically challenging and increase the risks of complications.2 Thus, various iterations of specialized ports and curved or articulating instruments have been developed by the surgical device industry (Fig. 1). With all these, technical challenges and safety concerns still persist; consequently, there has been a significantly downward trend in the utilization of SILC over the last few years. Surgical societies made attempts to standardize the technique.3 We strongly recommend that surgeons attend a training course if they are unfamiliar with this approach. In addition, it may be beneficial to have a proctor for the first several cases. Patient selection is also critical to success. While still new in utilizing SILC, surgeons should avoid patients with acute cholecystitis, morbid obesity, and previous abdominal operations. From a technical point of view, using long instruments can avoid collisions at the entry site to facilitate the procedure. Using angled laparoscopes also improves maneuverability and visualization while improving the range of motion for the working instruments. We prefer long 5‐mm 30‐degree angled scopes or deflectable tip scopes. Although we have moved away from using articulated instruments, they can be required for challenging cases. Table 1 lists some of the currently available ports and their features.

Figure 1.

Laparoscopic incision‐site ports: (A) SILS (Covidien); (B) Quadport+ (Advanced Surgical/Olympus); (C) GelPOINT Mini (Applied Medical).

Table 1.

Access Ports for Laparoscopic Single‐Incisions Surgery Currently Available from the Surgical Device Industry

Port	Manufacturer	Number of Instruments	Fixation	Incision Size (mm)
SILS port	Covidien	3	Soft foam port	15‐20
Triport +	Advanced Surgical/Olympus	4	Inner/outer rings	12‐25
Triport 15	Advanced Surgical/Olympus	3	Inner/outer rings	12‐25
Quadport+	Advanced Surgical/Olympus	5	Inner/outer rings	25‐65
Uni‐X	Pnavel Systems	3	Fascial suture	15
GelPOINT	Applied Medical	3	Inner/outer rings/gelport	15‐70
GelPOINT Mini	Applied Medical	3	Inner/outer rings/gelport	15‐30

In order to overcome some of the challenges, new platforms for single‐site surgery emerged and some of them received US Food and Drug Administration (FDA) approval. SPIDER Surgical System (TransEnterix, Durham, NC) provides abdominal access through a single cannula attached to the operating table, which accommodates a rigid instrument, two flexible instruments, and a laparoscopic camera. Upon intra‐abdominal deployment, the flexible instruments provide the working space and triangulation necessary to perform the cholecystectomy (Fig. 2).

Figure 2.

SPIDER Surgical System.

However, the system most widely utilized nowadays for SILC is likely the robotic da Vinci single‐site platform (Intuitive Surgical, Sunnyvale, CA). A pliable 4‐lumen single‐site port inserted through a 2.5‐cm fascial incision provides access to a standard laparoscopic instrument, a three‐dimensional laparoscope, and two curved semirigid‐robotic instruments (Fig. 3). The setup enables surgeons to perform SILC with improved dexterity, comfort, visualization, and ease of manipulation when compared with other single‐site modalities.4 No other robotic platforms are currently FDA‐approved for clinical use.

Figure 3.

Da Vinci single‐site platform. (A) single‐site setup; (B) single‐site setup attached to the robotic arms.

Complications

Although the same principles of traditional laparoscopic cholecystectomy apply to SILC, these less invasive techniques introduce unique challenges to the surgeon. Port placement during traditional laparoscopy is key to avoid contact between instruments and the ability to correctly expose key structures. In SILC, the instrument proximity can obstruct the surgeon's view and make manipulation of relevant anatomy difficult. Consequently, some surgeons experienced difficulty in achieving the critical view of safety, which resulted in increased common bile duct or vascular injuries (Fig. 4). Thus, robotic single‐platform cholecystectomy seems to be an exciting alternative to traditional laparoscopy, providing convenient instrumentation and enhanced surgical views.

Figure 4.

Critical view of safety: The proximal part of the gallbladder is separated from the liver bed; and only two 2 structures enter the gallbladder in the triangle of Calot, which is completely cleared of fat and fibrous tissue. The common bile duct does not need to be exposed.

Outcomes

A few randomized controlled trials have been published comparing SILC with traditional laparoscopic cholecystectomy. Most of them found that SILC is associated with slightly increased postoperative complications, wound‐related problems, and port‐site hernia incidence when compared with multiport cholecystectomy, as well as significantly higher operative time and improved cosmesis.5 The largest randomized study to date (100 patients in each arm) concluded that SILC is associated with significantly improved cosmesis and increased port‐site hernia rates at 1 year.6

No randomized studies have been published to date comparing robotic single‐site cholecystectomy with standard laparoscopy or SILC. However, the available literature suggests that the learning curve is steeper and the operative time is shorter with the robotic platform compared with SILC.7, 8

Pearls/Pitfalls

As referred to above, SILC can be quite challenging for the inexperienced surgeon. Whether performing it laparoscopically or robotically, a few factors can be helpful in achieving good outcomes:

• Proper surgeon training by attending courses or animal labs, assisting a more experienced colleague, and using a proctor for the initial cases.

• Proper patient selection by avoiding cases with potentially severe inflammation, previous operations, or morbid obesity.

• Proper identification of the anatomy by achieving the critical view of safety. Dissection of the peritoneal attachments at the gallbladder infundibulum starting high on the gallbladder allows for safe identification of the cystic duct and cystic artery as the only two elements in the cystic triangle.

• No hesitation to insert an additional port or convert to conventional laparoscopy or open surgery if the safety of the patient demands it.

• Upon completion of the procedure, it is important to achieve an adequate fascial closure in order to prevent development of incisional hernia.

Key Messages

• Although the desire for reduced incisional pain and improved cosmesis often is driven by patient preference, safe surgical technique and outcome should direct the technical approach to any operation.

• The need for conversion to standard laparoscopy or open procedure from SILC should be recognized immediately for the inability to correctly identify anatomy, uncontrollable bleeding, and bile duct injury.

• With adequate surgeon training and improved instrumentation, SILC is emerging as an excellent option for well‐selected candidates. The robotic platform shows promise, but good quality studies are still needed to demonstrate its superiority in this operation.

Conclusion

Single‐incision laparoscopic cholecystectomy is a viable option by adequately trained surgeons in selected patients. Further refinements of technology will likely lead to increased acceptance while maintaining outcomes similar to standard laparoscopic cholecystectomy.