0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Article |

Single-Incision Multiport Laparoscopic Cholecystectomy:  Things to Overcome FREE

Hyung-Joon Han, MD; Sae-Byeol Choi, MD; Wan-Bae Kim, MD; Sang-Yong Choi, MD
[+] Author Affiliations

Author Affiliations: Department of Surgery, Korea University Guro Hospital, Seoul, Republic of Korea.


Arch Surg. 2011;146(1):68-73. doi:10.1001/archsurg.2010.287.
Text Size: A A A
Published online

Objectives  To report on our initial experience with single-incision multiport laparoscopic cholecystectomy, together with its clinical outcomes.

Design  Nonrandomized prospective study.

Setting  University department of surgery.

Patients  Sixty-four patients with gallstones and gallbladder polyps were enrolled after providing informed consent. Based on our experience, we excluded patients with acute cholecystitis, concomitant choledocholithiasis, a history of previous upper abdominal surgery, and a suspicion of gallbladder cancer.

Main Outcome Measures  We analyzed the outcomes and complications, based on our experience, according to the clinicopathologic and operative factors. We also compared patients who underwent single-incision multiport laparoscopic cholecystectomy with those who were converted to conventional laparoscopic cholecystectomy.

Results  There were 2 bile duct injuries and 4 surgical site infections. We had difficulties in visualizing the Calot triangle in 22 patients. Higher levels of inflammatory markers, longer operation times, and more frequent bile juice spillage were significantly observed in those patients. Ten patients were converted to conventional laparoscopic cholecystectomy. The mean age of patients who underwent conversion surgery was significantly older than that of the no-conversion group. The more the body mass index increased, the more the conversion rate increased.

Conclusions  Experienced laparoscopic surgeons can safely perform cholecystectomy using conventional and curved laparoscopic instruments in selected patients. We recommend that you consider performing conventional laparoscopic cholecystectomy or that you use additional retraction devices for patients with a higher body mass index or acute cholecystitis.

Figures in this Article

Laparoscopic cholecystectomy is the criterion standard for the treatment of benign gallbladder diseases, and it is the most common laparoscopic surgery worldwide.1 Surgeons are performing more minimally invasive surgical techniques because of the well-recognized advantages of laparoscopic surgery, including better cosmetic results, less postoperative pain, and a faster recovery and return to normal life.2 These efforts have led surgeons to find ways to reduce the number and size of the incisions or to eliminate skin incisions in the case of natural orifice transluminal endoscopic surgery.3 However, intraperitoneal infection from an iatrogenic visceral scar and the technological limitations prevent the use of natural orifice transluminal endoscopic surgery in clinical practice.4 Navarra et al,5 in 1997, performed the first laparoscopic cholecystectomy using 2 transumbilical trocars and 3 transabdominal gallbladder stay sutures, and single-incision multiport laparoscopic surgery has recently become a focus of minimally invasive surgery. We can perform scarless surgery with the conventional laparoscopic instruments during single-incision multiport laparoscopic surgery.6 However, the advantages of this type of procedure over standard laparoscopic surgery, other than cosmesis, have not been determined, although 1 retrospective study7 showed a benefit for reduced pain. We have no consensus on the surgical techniques and exclusion criteria for this single-incision procedure in clinical practice. Herein, we describe our initial experience with 64 patients who underwent single-incision multiport laparoscopic cholecystectomy. We report on the clinical outcomes of this procedure, and we determined the exclusion criteria based on our experience.

PATIENTS

We prospectively documented and subsequently analyzed data from 64 patients who underwent single-incision multiport laparoscopic cholecystectomy for gallstones and gallbladder polyps at the Division of Hepatobiliopancreas, Department of Surgery, Korea University Guro Hospital, between January 1, 2009, and June 30, 2009. Informed consent was obtained from all the patients. We planned to exclude patients with acute cholecystitis, concomitant choledocholithiasis, a history of upper abdominal surgery, and the suspicion of gallbladder cancer on imaging studies. Ten of 64 patients were converted to conventional laparoscopic cholecystectomy. We compared patients who underwent single-incision multiport laparoscopic cholecystectomy (the no-conversion group) with patients who were converted to conventional laparoscopic cholecystectomy (the conversion group) according to the patient's age, sex, operation time, complications, histopathologic results, and duration of hospital stay after surgery.

OPERATIVE STEPS AND SKILLS

Patients were placed in the supine position using general endotracheal anesthesia; the abdominal cavity was assessed using a 10-mm rigid or flexible telescope via an umbilical 12-mm trocar with a transumbilical or periumbilical incision. The patient was then placed right side up in the reverse Trendelenburg position. When we decided to perform the single-incision multiport surgery, the incision was extended to a 2-cm length. The tips of the middle, index, and ring fingers of a No. 8 surgical glove were cut away, and a 12-mm trocar and two 5-mm trocars were placed into the glove's respective fingers and then tied. An Alexis wound retractor (Applied Medical, Rancho Santa Margarita, California) and the glove with trocars were used as a single port (Figure 1). Carbon dioxide gas was insufflated into a 12-mm trocar with 12 mm Hg of intra-abdominal pressure. A 30° rigid 10-mm telescope with a vertical light cable or a flexible 10-mm telescope with a coaxial light cable (Olympus, Tokyo, Japan) was used. Standard laparoscopic instruments and reticulating instruments (an L-hook electrocautery and dissector) (CambridgeEndo, Framingham, Massachusetts) were used (Figure 2). After inserting the laparoscopic instruments into the abdominal cavity, retrieving the trocars from the fascia allows us to create space and increase the range of motion of instruments for performing the cholecystectomy. Antegrade dissection was usually performed, and retrograde dissection was performed for patients who had difficult exposure of the cystic duct and artery. The cystic and common bile ducts were identified using a laparoscopic grasper to retract the fundus, and the position of the dissection was assessed. We tried to obtain the critical view of safety for patients who had difficult exposure of the cystic duct and artery. First, we exchanged the position of the laparoscopic instruments. When the fundus was retracted using a grasper and the surgeon's right hand via the right-sided trocar, we exchanged the position of each instrument and retracted the gallbladder using the surgeon's left hand via the left-sided trocar. Exchanging the position of the instruments could provide new sights for identifying the Calot triangle. Second, we performed medial dissection between the gallbladder and the liver and then confirmed the absence of the bile duct from the gallbladder to the liver. Third, retrograde dissection was performed to obtain the safe dissection. The cystic artery was clipped using 5-mm endoclips (Endo Clip; Covidien Autosuture, Mansfield, Massachusetts), and then it was divided. The cystic duct was clipped using a 5-mm ligating clip (Hem-o-lok; Weck Closure Systems, Research Triangle Park, North Carolina) and a 5-mm endoclip, and then it was divided. Occasionally, the cystic duct was ligated using a laparoscopic ligation device (OpenLoop; Sejong Medical, Paju, Korea). When the gallbladder was freed from its bed, the gallbladder specimen in an Endobag was retrieved from the abdominal cavity and then grasped using a Kelly clamp in the surgical glove. After warm saline irrigation and careful hemostasis, the surgical glove with the trocars and the Endobag with the specimen were removed. The wound retractor was removed, and the umbilical incision was closed in layers (Figure 3).

Place holder to copy figure label and caption
Figure 1

The wound retractor and glove were placed through a single incision. The tips of the index, middle, and ring fingers of a surgical glove were resected, and one 12-mm trocar and two 5-mm trocars were placed and tied in the respective fingers (small figure).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2

A and B, Standard laparoscopic instruments and reticulating instruments were used. A 30° rigid 10-mm telescope with a vertical light cable or a flexible 10-mm telescope with a coaxial light cable was used as an optical device.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3

The single-incision multiport laparoscopic cholecystectomy procedure is described. A, During retraction of the body of the gallbladder, we identify the point of dissection. B, Antegrade dissection shows the cystic duct and artery. C, The cystic duct and artery are divided by using endoclips and ligating clips (Hem-o-loks; Weck Closure Systems, Research Triangle Park, North Carolina). D, After we divide the cystic artery, the gallbladder is detached from the liver using a hook electrocautery.

Graphic Jump Location
STATISTICAL ANALYSIS

The χ2 test was used for qualitative variables, the t test was used for quantitative variables, and the Mann-Whitney test was used for nonparametric quantitative variables to compare between the 2 groups. Univariate and multivariate logistic regression analyses were used to determine the effect of multiple risk factors on conversion to conventional laparoscopic cholecystectomy. P < .05 was considered statistically significant.

CLINICAL CHARACTERISTICS AND OUTCOMES

Of the 64 patients, 24 were men and 40 were women. The mean (SD) age of the patients was 47.0 (13.3) years. The mean (SD) body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) was 23.9 (3.1). The preoperative inflammatory marker levels were within the reference ranges for almost all the patients: the median erythrocyte sedimentation rate (ESR) was 20.5 mm/h (25th-75th percentile, 0.16-89.22 mm/h), the median C-reactive protein (CRP) level was 0.81 mg/L (25th-75th percentile, 0.48-1.57 mg/L) (to convert to nanomoles per liter, multiply by 9.524), and the mean (SD) white blood cell count was 6275/μL (1819/μL) (to convert to ×109, multiple by 0.001). Eighteen patients were asymptomatic, and abdominal ultrasonography was the primary imaging study for all the patients. The mean (SD) operation time (from skin incision to skin closure) was 91.9 (31.1) minutes. The pathologic reports revealed cholelithiasis (n = 50), gallbladder polyps (n = 7), gallbladder adenomas (n = 6), acute cholecystitis (n = 3), adenocarcinoma (n = 1), chronic cholecystitis (n = 52), and cholesterolosis (n = 9). The adenocarcinoma, which developed from a gallbladder polyp, was confined to the lamina propria, and the patient has been observed by regular examinations. Ten patients (16%) were converted to conventional laparoscopic cholecystectomy, and 1 additional trocar at the epigastrium was used in half of the patients. The mean (SD) duration of the postoperative hospital stay was 2.3 (1.7) days. Bile juice spillage during the operation was observed in 18 patients (28%). Complications occurred in 6 patients (9%): 2 bile duct injuries and 4 surgical site infections. The bile duct injuries (3%) were classified as types C and E2.8 One was the injury of a suspected accessory right posterior hepatic duct, and this was found after cystic duct division. Clipping of the bile duct was performed because the transected duct was of a small diameter and was an accessory duct. The patient had no clinical symptoms, and there has been no sequelae until now. The other injury was transsection of the common bile duct, discovered after discharge. The patient noted mild nausea during the postoperative period, yet nothing was noticed on physical examination, laboratory findings, and postoperative abdominal computed tomography. The patient then visited the outpatient department because of abdominal distention, nausea, vomiting, and poor oral intake. Abdominal computed tomography showed a large fluid collection in the abdominal cavity. We performed endoscopic retrograde cholangiopancreatography, and this showed the image of the cutoff common bile duct; therefore, Roux-en Y hepaticojejunostomy was performed. The patient is doing well without any other complications. The surgical site infections (n = 4, 6%) were all superficial, and the patients were treated without complications at the outpatient department.

ANALYSIS OF PATIENTS WITH DIFFICULTIES IN OBTAINING THE CRITICAL VIEW OF SAFETY

We obtained the critical view of safety in 44 patients (69%, the easy group) and had difficulties in visualizing the Calot triangle in 22 patients (31%, the difficult group). Most patients in the difficult group eventually were secured for the safety view, but the others were converted to conventional laparoscopic cholecystectomy. The mean (SD) operation time in the easy group (85.3 [26.8] minutes) was shorter than that in the difficult group (106.3 [35.6] minutes, P = .01). The mean (SD) ESR (32.4 [15.2] mm/h) and the mean CRP level (13.0 mg/L; 25%-75%, 0.75-9.89 mg/L) in the difficult group were higher than those in the easy group (ESR, 21.9 [18.6] mm/h, P = .02; CRP level, 1.5 mg/L; 25%-75%, 0.75-1.18 mg/L; P = .03).

Bile juice spillage was significantly observed in patients with difficulties in obtaining the safety view (odds ratio [OR], 3.182; 95% confidence interval [CI], 1.012-10.006; P = .048). However, difficulties in visualization of the Calot triangle did not affect the rate of complications (OR, 1.777; 95% CI, 0.356-8.748; P = .57) or the rate of conversion to conventional laparoscopic cholecystectomy (2.600; 0.657-10.285; P = .17). Moreover, bile juice spillage showed no significant difference for the prevalence rate of surgical site infection (OR, 1.012; 95% CI, 0.357-21.187; P = .33).

COMPARISON BETWEEN THE NO-CONVERSION AND CONVERSION GROUPS

The mean (SD) age of patients who underwent conversion surgery (56.4 [9.0] years) was significantly higher than that of the no-conversion group (45.1 [13.3] years, P = .01). The mean (SD) BMI was slightly higher in the conversion group (25.8 [2.4] vs 23.5 [3.1]), and the difference was significant (P = .03). The conversion rates were different according to the operators, yet there was no significance for this factor (P > .05). The mean (SD) operation time in the conversion group (95.7 [26.6] minutes) was longer than that in the no-conversion group (91.2 [32.0] minutes), but the difference was not significant (P = .68). The mean (SD) duration of the postoperative hospital stay showed no difference between the no-conversion and conversion groups (2.3 [1.8] vs 2.4 [1.2] days), and the mean (SD) values of the preoperative inflammatory markers, including white blood cell count (6227 [1866] vs 6530 [1605]/μL), ESR (24.6 vs 27.8 mm/h), and mean CRP levels (4.5 vs 9.8 mg/L), were not different between the 2 groups.

Increased age was correlated with an increased rate of conversion during single-incision multiport laparoscopic surgery (OR, 1.081; 95% CI, 1.013-1.155; P = .02). The more the BMI increased, the more the rate of conversion increased (OR, 1.348; 95% CI, 1.022-1.777; P = .03). However, there was no significant difference in the rate of conversion according to sex, levels of preoperative inflammatory markers, operation time, and operator. On multivariate analysis, only BMI showed a significant difference for the rate of conversion to conventional laparoscopic cholecystectomy (OR, 1.426; 95% CI, 1.003-2.027; P = .048).

In this study, we performed single-incision multiport laparoscopic cholecystectomy in 64 patients with symptomatic gallstones and gallbladder polyps, and we excluded patients with acute cholecystitis, previous upper abdominal surgery, choledocholithiasis, and a suspicion of malignancy. We demonstrated that a higher BMI could be the risk factor for conversion when performing single-incision multiport laparoscopic cholecystectomy. Considering that the early experiences with laparoscopic cholecystectomy were associated with higher rates of bile duct injuries,9 we conclude that performing single-incision multiport laparoscopic cholecystectomy with conventional laparoscopic instruments is safe and feasible, especially in well-selected patients, for experienced surgeons with a low threshold for conversion to conventional laparoscopic cholecystectomy.

In this study, there were 2 bile duct injuries. The most common complication in clinical studies1013 of single-incision multiport laparoscopic cholecystectomy has been bile duct injury. Other complications were liver injury,1 abdominal wall hematoma,1 surgical site infection,7 mesenteric injury,10 pain,13 and urinary incontinence.13 Of those complications, bile duct injury is a devastating complication that has been shown to be associated with significant perioperative morbidity and mortality and shortened long-term survival.14 Laparoscopic bile duct injuries originate principally from visual perceptual illusion and not from errors in skill, knowledge, and judgment.15 The most difficult and challenging task in performing single-incision multiport laparoscopic cholecystectomy is to get the critical view because of the limited angle and number of instruments. The use of laparoscopic instruments, when used through a single incision with a multiport, often results in inadequate retractions, loss of triangulation, unintended movement, and hands or trocars fighting for space, which all lead to a prolonged operation time, inadequate exposure of the Calot triangle, and development of complications. Therefore, a low threshold for conversion to conventional laparoscopic cholecystectomy or additional methods for obtaining the safety view are required when there are difficulties in visualizing the Calot triangle when performing single-incision multiport laparoscopic cholecystectomy.

Efforts to obtain the critical view of safety can be divided into 2 groups based on the clinical trials. Some research groups,6,10,1619 including the present study, selected the patients according to their own exclusion criteria, and other groups1,11,13,1618,2023 used additional percutaneous punctures of the gallbladder to guarantee the critical view. In previous studies, the most common exclusion was acute cholecystitis,6,10,1619 and other minor exclusions were previous upper abdominal surgery,6,10 a suspicion of malignancy,10 a high BMI,6,16 a poor American Society of Anesthesiologists class,16,19 and gallstone pancreatitis.17 A few studies have reported surgical success in the setting of acute cholecystitis12,23,24 or obese patients1,13 with use of an additional traction device. Percutaneous suture, a suspension hook for gallbladder retraction, or a smaller size of trocar or instrument can serve to obtain better visualization for dissection. Such maneuvers may cause spillage of bile juice and may lead to an increased chance of wound contamination and then increase the risk of surgical site infection,25 particularly in the setting of acute cholecystitis.4

In the present study, there were 4 surgical site infections, yet all the patients improved without complications or a prolonged hospital stay. Although the bile juice spillage was not correlated with the occurrence of complications in this study, bile juice spillage occurred in 3 patients with surgical site infections. Considering the high rates of gallbladder perforation in single-incision multiport laparoscopic surgery,10 there have been few successful studies without percutaneous suture and exclusion criteria,26,27 and more careful gallbladder dissection and percutaneous sutures in selected patients can help in the development of single-incision multiport laparoscopic surgery and improve the outcomes. Because wound contamination might be the most likely cause of surgical site infection rather than gallbladder perforation or bile juice spillage,25 meticulous management of the surgical site is probably required for cosmesis, which is the only known benefit of single-incision multiport laparoscopic surgery.

Beyond the known benefits to cosmesis and pain management, it is necessary to evaluate the safety,7 efficacy, complication rates, immunologic response, and potential benefits, if any, that single-incision multiport laparoscopic surgery may provide. Before patients demand this minimally invasive surgery in the same way that forced the explosion of laparoscopic surgery 20 years ago, we expect that randomized prospective studies will provide the pros and cons of single-incision multiport laparoscopic surgery.

In conclusion, single-incision multiport laparoscopic cholecystectomy is an emerging operative method that can obtain a scarless abdomen. Experienced laparoscopic surgeons can safely perform this operation using conventional and curved laparoscopic instruments. We recommend consideration of conventional laparoscopic cholecystectomy or use of additional retraction devices for patients with a higher BMI or acute cholecystitis in difficult situations for obtaining the critical safe view.

We are unsure whether this operation will become a bridge to natural orifice transluminal endoscopic surgery or whether it will open up a new field of minimally invasive surgery. Yet, keeping an open mind for conversion to conventional laparoscopic cholecystectomy and assigning priority to the safety of patients over cosmesis will help avoid serious complications when surgeons encounter difficulties during this type of operation.

Correspondence: Sang-Yong Choi, MD, Department of Surgery, Korea University Guro Hospital, 80 Guro-dong, Guro-gu, Seoul 152-703, Republic of Korea (sschoi@korea.ac.kr).

Accepted for Publication: November 17, 2009.

Author Contributions:Study concept and design: Han and S.-Y. Choi. Analysis and interpretation of data: S.-B. Choi and Kim. Drafting of the manuscript: Han and S.-B. Choi. Critical revision of the manuscript for important intellectual content: Kim and S.-Y. Choi. Administrative, technical, and material support: Han, S.-B. Choi, and Kim. Study supervision: S.-Y. Choi.

Financial Disclosure: None reported.

Tacchino  RGreco  FMatera  D Single-incision laparoscopic cholecystectomy: surgery without a visible scar. Surg Endosc 2009;23 (4) 896- 899
PubMed Link to Article
Bittner  R The standard of laparoscopic cholecystectomy. Langenbecks Arch Surg 2004;389 (3) 157- 163
PubMed Link to Article
Marescaux  JDallemagne  BPerretta  SWattiez  AMutter  DCoumaros  D Surgery without scars: report of transluminal cholecystectomy in a human being. Arch Surg 2007;142 (9) 823- 827
PubMed Link to Article
Chamberlain  RSSakpal  SV A comprehensive review of single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) techniques for cholecystectomy. J Gastrointest Surg 2009;13 (9) 1733- 1740
PubMed Link to Article
Navarra  GPozza  EOcchionorelli  SCarcoforo  PDonini  I One-wound laparoscopic cholecystectomy. Br J Surg 1997;84 (5) 695
PubMed Link to Article
Hong  THYou  YKLee  KH Transumbilical single-port laparoscopic cholecystectomy: scarless cholecystectomy. Surg Endosc 2009;23 (6) 1393- 1397
PubMed Link to Article
Bresadola  FPasqualucci  ADonini  A  et al.  Elective transumbilical compared with standard laparoscopic cholecystectomy. Eur J Surg 1999;165 (1) 29- 34
PubMed Link to Article
Strasberg  SMHertl  MSoper  NJ An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180 (1) 101- 125
PubMed
Shea  JAHealey  MJBerlin  JA  et al.  Mortality and complications associated with laparoscopic cholecystectomy: a meta-analysis. Ann Surg 1996;224 (5) 609- 620
PubMed Link to Article
Kuon Lee  SYou  YKPark  JHKim  HJLee  KKKim  DG Single-port transumbilical laparoscopic cholecystectomy: a preliminary study in 37 patients with gallbladder disease. J Laparoendosc Adv Surg Tech A 2009;19 (4) 495- 499
PubMed Link to Article
Palanivelu  CRajan  PSRangarajan  MParthasarathi  RSenthilnathan  PPraveenraj  P Transumbilical flexible endoscopic cholecystectomy in humans: first feasibility study using a hybrid technique. Endoscopy 2008;40 (5) 428- 431
PubMed Link to Article
Chow  APurkayastha  SParaskeva  P Appendicectomy and cholecystectomy using single-incision laparoscopic surgery (SILS): the first UK experience. Surg Innov 2009;16 (3) 211- 217
PubMed Link to Article
Hernandez  JMMorton  CARoss  SAlbrink  MRosemurgy  AS Laparoendoscopic single site cholecystectomy: the first 100 patients. Am Surg 2009;75 (8) 681- 686
PubMed
Connor  SGarden  OJ Bile duct injury in the era of laparoscopic cholecystectomy. Br J Surg 2006;93 (2) 158- 168
PubMed Link to Article
Way  LWStewart  LGantert  W  et al.  Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg 2003;237 (4) 460- 469
PubMed
Cuesta  MABerends  FVeenhof  AA The “invisible cholecystectomy”: a transumbilical laparoscopic operation without a scar. Surg Endosc 2008;22 (5) 1211- 1213
PubMed Link to Article
Rao  PPBhagwat  SMRane  ARao  PP The feasibility of single port laparoscopic cholecystectomy: a pilot study of 20 cases. HPB (Oxford) 2008;10 (5) 336- 340
PubMed Link to Article
Ersin  SFirat  OSozbilen  M Single-incision laparoscopic cholecystectomy: is it more than a challenge? Surg Endosc 2010;24 (1) 68- 71
PubMed Link to Article
Vidal  OValentini  MEspert  JJ  et al.  Laparoendoscopic single-site cholecystectomy: a safe and reproducible alternative. J Laparoendosc Adv Surg Tech A 2009;19 (5) 599- 602
PubMed Link to Article
Bucher  PPugin  FBuchs  NOstermann  SCharara  FMorel  P Single port access laparoscopic cholecystectomy (with video). World J Surg 2009;33 (5) 1015- 1019
PubMed Link to Article
Chow  APurkayastha  SAziz  OParaskeva  P Single-incision laparoscopic surgery for cholecystectomy: an evolving technique. Surg Endosc 2010;24 (3) 709- 714
PubMed Link to Article
Zhu  JFHu  HMa  YZXu  MZLi  F Transumbilical endoscopic surgery: a preliminary clinical report. Surg Endosc 2009;23 (4) 813- 817
PubMed Link to Article
Piskun  GRajpal  S Transumbilical laparoscopic cholecystectomy utilizes no incisions outside the umbilicus. J Laparoendosc Adv Surg Tech A 1999;9 (4) 361- 364
PubMed Link to Article
Merchant  AMCook  MWWhite  BCDavis  SSSweeney  JFLin  E Transumbilical Gelport access technique for performing single incision laparoscopic surgery (SILS). J Gastrointest Surg 2009;13 (1) 159- 162
PubMed Link to Article
Shindholimath  VVSeenu  VParshad  RChaudhry  RKumar  A Factors influencing wound infection following laparoscopic cholecystectomy. Trop Gastroenterol 2003;24 (2) 90- 92
PubMed
Zhu  JFHu  HMa  YZXu  MZ Totally transumbilical endoscopic cholecystectomy without visible abdominal scar using improved instruments. Surg Endosc 2009;23 (8) 1781- 1784
PubMed Link to Article
Langwieler  TENimmesgern  TBack  M Single-port access in laparoscopic cholecystectomy. Surg Endosc 2009;23 (5) 1138- 1141
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1

The wound retractor and glove were placed through a single incision. The tips of the index, middle, and ring fingers of a surgical glove were resected, and one 12-mm trocar and two 5-mm trocars were placed and tied in the respective fingers (small figure).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2

A and B, Standard laparoscopic instruments and reticulating instruments were used. A 30° rigid 10-mm telescope with a vertical light cable or a flexible 10-mm telescope with a coaxial light cable was used as an optical device.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3

The single-incision multiport laparoscopic cholecystectomy procedure is described. A, During retraction of the body of the gallbladder, we identify the point of dissection. B, Antegrade dissection shows the cystic duct and artery. C, The cystic duct and artery are divided by using endoclips and ligating clips (Hem-o-loks; Weck Closure Systems, Research Triangle Park, North Carolina). D, After we divide the cystic artery, the gallbladder is detached from the liver using a hook electrocautery.

Graphic Jump Location

Tables

References

Tacchino  RGreco  FMatera  D Single-incision laparoscopic cholecystectomy: surgery without a visible scar. Surg Endosc 2009;23 (4) 896- 899
PubMed Link to Article
Bittner  R The standard of laparoscopic cholecystectomy. Langenbecks Arch Surg 2004;389 (3) 157- 163
PubMed Link to Article
Marescaux  JDallemagne  BPerretta  SWattiez  AMutter  DCoumaros  D Surgery without scars: report of transluminal cholecystectomy in a human being. Arch Surg 2007;142 (9) 823- 827
PubMed Link to Article
Chamberlain  RSSakpal  SV A comprehensive review of single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) techniques for cholecystectomy. J Gastrointest Surg 2009;13 (9) 1733- 1740
PubMed Link to Article
Navarra  GPozza  EOcchionorelli  SCarcoforo  PDonini  I One-wound laparoscopic cholecystectomy. Br J Surg 1997;84 (5) 695
PubMed Link to Article
Hong  THYou  YKLee  KH Transumbilical single-port laparoscopic cholecystectomy: scarless cholecystectomy. Surg Endosc 2009;23 (6) 1393- 1397
PubMed Link to Article
Bresadola  FPasqualucci  ADonini  A  et al.  Elective transumbilical compared with standard laparoscopic cholecystectomy. Eur J Surg 1999;165 (1) 29- 34
PubMed Link to Article
Strasberg  SMHertl  MSoper  NJ An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180 (1) 101- 125
PubMed
Shea  JAHealey  MJBerlin  JA  et al.  Mortality and complications associated with laparoscopic cholecystectomy: a meta-analysis. Ann Surg 1996;224 (5) 609- 620
PubMed Link to Article
Kuon Lee  SYou  YKPark  JHKim  HJLee  KKKim  DG Single-port transumbilical laparoscopic cholecystectomy: a preliminary study in 37 patients with gallbladder disease. J Laparoendosc Adv Surg Tech A 2009;19 (4) 495- 499
PubMed Link to Article
Palanivelu  CRajan  PSRangarajan  MParthasarathi  RSenthilnathan  PPraveenraj  P Transumbilical flexible endoscopic cholecystectomy in humans: first feasibility study using a hybrid technique. Endoscopy 2008;40 (5) 428- 431
PubMed Link to Article
Chow  APurkayastha  SParaskeva  P Appendicectomy and cholecystectomy using single-incision laparoscopic surgery (SILS): the first UK experience. Surg Innov 2009;16 (3) 211- 217
PubMed Link to Article
Hernandez  JMMorton  CARoss  SAlbrink  MRosemurgy  AS Laparoendoscopic single site cholecystectomy: the first 100 patients. Am Surg 2009;75 (8) 681- 686
PubMed
Connor  SGarden  OJ Bile duct injury in the era of laparoscopic cholecystectomy. Br J Surg 2006;93 (2) 158- 168
PubMed Link to Article
Way  LWStewart  LGantert  W  et al.  Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg 2003;237 (4) 460- 469
PubMed
Cuesta  MABerends  FVeenhof  AA The “invisible cholecystectomy”: a transumbilical laparoscopic operation without a scar. Surg Endosc 2008;22 (5) 1211- 1213
PubMed Link to Article
Rao  PPBhagwat  SMRane  ARao  PP The feasibility of single port laparoscopic cholecystectomy: a pilot study of 20 cases. HPB (Oxford) 2008;10 (5) 336- 340
PubMed Link to Article
Ersin  SFirat  OSozbilen  M Single-incision laparoscopic cholecystectomy: is it more than a challenge? Surg Endosc 2010;24 (1) 68- 71
PubMed Link to Article
Vidal  OValentini  MEspert  JJ  et al.  Laparoendoscopic single-site cholecystectomy: a safe and reproducible alternative. J Laparoendosc Adv Surg Tech A 2009;19 (5) 599- 602
PubMed Link to Article
Bucher  PPugin  FBuchs  NOstermann  SCharara  FMorel  P Single port access laparoscopic cholecystectomy (with video). World J Surg 2009;33 (5) 1015- 1019
PubMed Link to Article
Chow  APurkayastha  SAziz  OParaskeva  P Single-incision laparoscopic surgery for cholecystectomy: an evolving technique. Surg Endosc 2010;24 (3) 709- 714
PubMed Link to Article
Zhu  JFHu  HMa  YZXu  MZLi  F Transumbilical endoscopic surgery: a preliminary clinical report. Surg Endosc 2009;23 (4) 813- 817
PubMed Link to Article
Piskun  GRajpal  S Transumbilical laparoscopic cholecystectomy utilizes no incisions outside the umbilicus. J Laparoendosc Adv Surg Tech A 1999;9 (4) 361- 364
PubMed Link to Article
Merchant  AMCook  MWWhite  BCDavis  SSSweeney  JFLin  E Transumbilical Gelport access technique for performing single incision laparoscopic surgery (SILS). J Gastrointest Surg 2009;13 (1) 159- 162
PubMed Link to Article
Shindholimath  VVSeenu  VParshad  RChaudhry  RKumar  A Factors influencing wound infection following laparoscopic cholecystectomy. Trop Gastroenterol 2003;24 (2) 90- 92
PubMed
Zhu  JFHu  HMa  YZXu  MZ Totally transumbilical endoscopic cholecystectomy without visible abdominal scar using improved instruments. Surg Endosc 2009;23 (8) 1781- 1784
PubMed Link to Article
Langwieler  TENimmesgern  TBack  M Single-port access in laparoscopic cholecystectomy. Surg Endosc 2009;23 (5) 1138- 1141
PubMed Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 13

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles