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Single-Port Cholecystectomy Using a Completely Reusable Port Device: Standardized Technique

2011; Volume: 21; Issue: 6 Linguagem: Inglês

10.1089/vor.2011.0058

2373-3063

Katica Krajinovic, Alexander Wierlemann, Christoph‐Thomas Germer, J. Reibetanz,

Gastrointestinal Tumor Research and Treatment

Introduction: Laparoscopic cholecystectomy has been the gold standard for removal of the gallbladder since the early 1990s, and the advantages of minimally invasive surgery have been widely accepted.1,2 Compared with open approach, reduction of access trauma by laparoscopic-assisted surgery has proven beneficial in view of patients short-term outcome.3 To further minimize or completely vanish the abdominal wall trauma and emend cosmetic results, single-port access (SPA) surgery displays a substantial progress in minimally invasive surgery. At the same time, increased costs by using disposable systems are raising concerns about the method. Therefore, we demonstrate our technique using a completely reusable multichannel port device for single-port cholecystectomy (SPC) in a standardized technique that allows the maintenance of a safe critical view throughout the entire procedure.4 Methods: SPA cholecystectomy was performed using the totally reusable X-Cone™ single-port laparoscopic device (KARL STORZ GmbH, Tuttlingen, Germany). This steel device is composed of two tapered half shells (one with an insufflation tap), each of it exhibiting an angulated clamp at its distal end. The initial incision was a 1.5- to 2-cm vertical incision made directly in the umbilicus while keeping the umbilical insertion untouched. After the skin and fascial incision and placement of two fascial holding sutures, the distally closed port was trocar-like placed into the abdominal cavity via the open approach. By visually controlled folding of the proximal half shell of the port, the clamps were spread and the port was fixed in the abdominal wall. For sealing, a reusable rubber cap offering five gas-proof working-channels (up to 12 mm) was applied. A 50-cm-long, 30°, 5-mm laparoscope (KARL STORZ GmbH) was used. The gallbladder was identified, and the gallbladder fundus was retracted cephalad by a straight 3-mm grasper placed in the lowest working channel, which for static retraction was fixed in a reusable self-restraint system. For exposition of the gallbladder infundibulum, a curved rotating grasper (KARL STORZ GmbH) was used. Once fixed, the infundibulum region could be turned left and right like a page of a book by using the rotating function of the curved grasper, thus achieving a very good exposition of the anterior and dorsolateral view of the hepatocystic triangle. In each patient, the primary goal was to clearly expose the hepatocystic triangle and identify the anatomic landmarks. This entailed isolation of the cystic duct and artery, clearing the hepatocystic triangle of all extraneous tissue, and separating the lower part of the gallbladder from the liver bed before clipping any ductal structures. The cystic duct and cystic artery were doubly clipped with a 10-mm reusable clip applier (Challenger Ti™, Aesculap AG; Tuttlingen, Germany) and then divided. The gallbladder was then dissected of the liver bed using a dissector electrocautery, placed in an endobag (Inzii™, Applied Medical; Rancho Santa Margerita, CA), and removed at the port site. The fascial defect at the umbilicus was closed using absorbable sutures (Vicryl 0/PDS 1), and the single skin incision site was closed with a 4-0 absorbable running subcuticular suture. Beside conventional laparoscopic instruments, some equipment modifications that were essential to these procedures to minimize crowding of hands and clashing of instruments at the umbilical port were a right-angle light cord adapter, the 50-cm optical device, and the reusable curved rotating grasper. Results: Between July 2009 and May 2011, 78 patients (54 women; median age, 42 years; age range, 18–85 years]) underwent SPC for symptomatic cholelithiasis, including seven cases of acute cholecystitis. Histological workup revealed acute cholecystitis in seven cases and confirmed the clinical diagnosis. The median body mass index was 25.4 kg/m2 (range, 17–39 kg/m2). In one patient, an additional 5-mm trocar was placed subcostally to manage bleeding from the liver bed. There were no other intraoperative complications. The postoperative course of all patients during the hospital stay was uneventful. Postoperatively, 6 (7.6%) patients presented with a superficial umbilical wound infection, which resolved without additional therapy. There were no other procedure-related complications observed until follow-up visits. Conclusions: The results of this series demonstrated the safe feasibility of SPC with the totally reusable multichannel port device. A safe and clear exposition of Calot's triangle and reusability of all parts of the used device are the mainstays of this standardized technique. Katica Krajinovic is a medical consultant for KARL STORZ GmbH, Tuttlingen, Germany. Christoph-Thomas Germer received travel grants from KARL STORZ. For Joachim Reibetanz and Alexander Wierlemann, no competing financial interests exist. Runtime of video: 6 mins 57 secs