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SILC for SILC: Single Institution Learning Curve for Single-Incision Laparoscopic Cholecystectomy  [PDF]
Chee Wei Tay,Liang Shen,Mikael Hartman,Shridhar Ganpathi Iyer,Krishnakumar Madhavan,Stephen Kin Yong Chang
Minimally Invasive Surgery , 2013, DOI: 10.1155/2013/381628
Abstract: Objectives. We report the single-incision laparoscopic cholecystectomy (SILC) learning experience of 2 hepatobiliary surgeons and the factors that could influence the learning curve of SILC. Methods. Patients who underwent SILC by Surgeons A and B were studied retrospectively. Operating time, conversion rate, reason for conversion, identity of first assistants, and their experience with previous laparoscopic cholecystectomy (LC) were analysed. CUSUM analysis is used to identify learning curve. Results. Hundred and nineteen SILC cases were performed by Surgeons A and B, respectively. Eight cases required additional port. In CUSUM analysis, most conversion occurred during the first 19 cases. Operating time was significantly lower (62.5 versus 90.6?min, P = 0.04) after the learning curve has been overcome. Operating time decreases as the experience increases, especially Surgeon B. Most conversions are due to adhesion at Calot’s triangle. Acute cholecystitis, patients’ BMI, and previous surgery do not seem to influence conversion rate. Mean operating times of cases assisted by first assistant with and without LC experience were 48 and 74 minutes, respectively (P = 0.004). Conclusion. Nineteen cases are needed to overcome the learning curve of SILC. Team work, assistant with CLC experience, and appropriate equipment and technique are the important factors in performing SILC. 1. Introduction Single-incision laparoscopic cholecystectomy (SILC) has been increasingly performed for benign gallbladder disease over the last few years with comparable operative results with conventional 4-port laparoscopic cholecystectomy (CLC). With results from randomized controlled trials (RCTs) [1–5] and series of publications [6–9] showing that SILC is equally safe, with no obvious additional scar and potentially have less postoperative pain and earlier return to daily activity [5], more surgeons are embarking on learning the technique. As SILC is a new approach to gallbladder disease, many aspects of this new technique have not been studied in detail. Most surgeons embarking on this technique are concerned with its learning curve, conversions, and potential longer operating time. To date, very limited work has been done to look into this important issue and few publications have looked into learning curve of SILC from conversion point of view. To perform SILC safely and successfully, there may be changes in surgical technique, need of new equipment, and modifications in the role of assistant. In this study, we report an SILC learning experience of a tertiary university hospital
Single-incision laparoscopic cholecystectomy: How I do it?  [cached]
Bhandarkar Deepraj,Mittal Gaurav,Shah Rasik,Katara Avinash
Journal of Minimal Access Surgery , 2011,
Abstract: Single-incision laparoscopic cholecystectomy (SILC) is a relatively new technique that is being increasingly used by surgeons around the world. Unlike the multi-port cholecystectomy, a standardised technique and detailed description of the operative steps of SILC is lacking in the literature. This article provides a stepwise account of the technique of SILC aimed at surgeons wishing to learn the procedure. A brief review of the current literature on SILC follows.
Single-incision laparoscopic cholecystectomy: Initial experience with different multichannel ports  [PDF]
Ra?natovi? Zoran J.,Zari? Nemanja D.,?ura?i? Ljubomir M.,Leki? Neboj?a S.
Acta Chirurgica Iugoslavica , 2012, DOI: 10.2298/aci1201067r
Abstract: Single-incision laparoscopic cholecystectomy is a relatively new minimally invasive surgical technique in treatment of benign gallbladder diseases. It is considered a bridge technique between conventional laparoscopic cholecystectomy (LC) and NOTES. We are presenting our initial experiences in SILC (single-incision laparoscopic cholecystectomy). Seventeen patients underwent SILC (11 women and 6 men) with an average age of 43 years. Mean BMI score was 29,4 kg/m2. The mean operative time was 93,5 minutes. There were conversions to conventional LC in two cases (11,6%). Average pain score measured on visual-analogue scale (VAS) 8h after the operation was 2,00. All patients expressed satisfaction with achieved cosmetic effect. We conclude that SILC is safe and feasible procedure, with excellent cosmetic effect, but further prospective studies are required before SILC can be generally accepted.
Technical Progress in Single-Incision Laparoscopic Cholecystectomy in Our Initial Experience  [PDF]
Tomohiko Adachi,Tatsuya Okamoto,Shinichiro Ono,Takashi Kanematsu,Tamotsu Kuroki
Minimally Invasive Surgery , 2011, DOI: 10.1155/2011/972647
Abstract: Single-incision laparoscopic cholecystectomy (SILC) has rapidly spread throughout the world because of its low invasiveness and because it is a scarless procedure. Various surgical methods of performing SILC are present in each institute; however, it is necessary to develop a standardized procedure that we can perform safely, such as the conventional 4-port laparoscopic cholecystectomy (LC). The SILC experiment in our institute was started by use of the commercial SILS Port and changed from a 3-port method via an umbilicus to a 2-port method to improve some problems. Although none of the conversions to conventional 4-port LC and also none of the complications such as bile duct injury occurred in each method, the 2-port method functioned best and was also economical. However, it is most important to adopt strict criteria and select the patients suitable for SILC to demonstrate SILC safety same as 4-port LC. 1. Introduction Laparoscopic cholecystectomy (LC) was first demonstrated by Philippe Mouret in France in 1987 [1]. Since then, LC has become the standard procedure for the treatment of gallstones, cholecystitis, or gallbladder polyps. Traditionally, LC has involved four ports. Many laparoscopic techniques have been developed using this 4-port LC, and it has become possible to perform these techniques safely. Now, having established the safety of LC, our interest focused on reducing the invasiveness and scarring caused by the procedure. Cuesta et al. reported single-incision laparoscopic cholecystectomy (SILC), in which two 5?mm ports were introduced through the umbilicus, and a Kirschner wire hook was introduced through the right subcostal area to pull in an upright direction in order to visualize Calot’s triangle [2]. Several surgeons have described performing SILC using three 5?mm ports from the umbilicus [3, 4]. Meanwhile, Merchant et al. also performed SILC by inserting a Gelport (Applied Medical, Rancho Santa Margarita, CA, USA) to stretch the umbilical fascia incision for easy access with instruments into the abdominal cavity [5]. Furthermore, a technique involving several transumbilical-placed ports for single-incision laparoscopic surgery was newly developed, and SILC by means of the ASC Triport (Advanced Surgical Concepts, Wicklow, Ireland) has been described successively [6–8]. On the other hand, an interesting new instrument named SPIDER (TransEnterix, Inc., Research Triangle Park, NC) for use in single-incision surgery was developed, and its use in SILC in an animal experiment has been reported [9]. As a result of these clinical studies,
Single incision laparoscopic surgery cholecystectomy in children – preliminary experience  [cached]
Marcin ?osin,Piotr Czauderna,Andrzej Go??biewski
Videosurgery and Other Miniinvasive Techniques , 2010,
Abstract: Introduction: Laparoscopic cholecystectomy has become the gold standard for cholecystectomy, since Mouret introducedit in 1987. In 1997 Navarra described “one incision” cholecystectomy, but only recently has single incisionlaparoscopic surgery (SILS) gained wider acceptance, mostly due to technological developments. The primary goals ofSILS are avoidance of visible scarring and minimizing surgical trauma.Aim: We present our first experience of 3 cases of children (2 females, 1 male; ages 2.5-17 years) treated with SILScholecystectomy.Methods and results: One child had undergone previous open left adrenalectomy for neuroblastoma. We used a CovidienSILS Port in one case and 3 single-use low-profile ports in the others. Percutaneous stay suture was used to suspendthe gallbladder, and standard cholecystectomy was performed using 1 straight and 1 disposable articulatinginstrument. There were no postoperative complications. Average operating time was 70 min. Hospital stay varied from2 to 4 days.Conclusion: Our early experience with SILS cholecystectomy in children suggests that it is safe and effective, but furtherstudies and greater numbers will be required to investigate the potential benefits of this approach.
Original single-incision laparoscopic cholecystectomy for acute inflammation of the gallbladder  [cached]
Kazunari Sasaki,Goro Watanabe,Masamichi Matsuda,Masaji Hashimoto
World Journal of Gastroenterology , 2012, DOI: 10.3748/wjg.v18.i9.944
Abstract: AIM: To investigate the safety and feasibility of our original single-incision laparoscopic cholecystectomy (SILC) for acute inflamed gallbladder (AIG). METHODS: One hundred and ten consecutive patients underwent original SILC for gallbladder disease without any selection criteria and 15 and 11 of these were diagnosed with acute cholecystitis and acute gallstone cholangitis, respectively. A retrospective review was performed not only between SILC for AIG and non-AIG, but also between SILC for AIG and traditional laparoscopic cholecystectomy (TLC) for AIG in the same period. RESULTS: Comparison between SILC for AIG and non-AIG revealed that the operative time was longer in SILC for AIG (97.5 min vs 85.0 min, P = 0.03). The open conversion rate (2/26 vs 2/84, P = 0.24) and complication rate (1/26 vs 3/84, P = 1.00) showed no differences, but a need for additional trocars was more frequent in SILC for AIG (5/24 vs 3/82, P = 0.01). Comparison between SILC for AIG and TLC for AIG revealed no differences based on statistical analysis. CONCLUSION: Our original SILC technique was adequately safe and feasible for the treatment of acute cholecystitis and acute gallstone cholangitis.
Single-Incision Laparoscopic Cholecystectomy: Is It a Plausible Alternative to the Traditional Four-Port Laparoscopic Approach?  [PDF]
Juan Pablo Arroyo,Luis A. Martín-del-Campo,Gonzalo Torres-Villalobos
Minimally Invasive Surgery , 2012, DOI: 10.1155/2012/347607
Abstract: The current standard-of-care for treatment of cholecystectomy is the four port laparoscopic approach. The development of single incision/laparoendoscopic single site surgery (SILC/LESS) has now led to the development of new techniques for removal of the gallbladder. The use of SILC/LESS is now currently being evaluated as the next step in treatment of cholecystectomy. This review is an attempt to consolidate the current knowledge and analyze the feasibility of world-wide implementation of SILC/LESS. 1. Introduction The ultimate goal of surgery has always been providing the best and most effective procedure with the least amount of postoperative complications, and pain and the best possible aesthetic results. Surgery of the biliary tract is by no means the exception. The first reported elective cholecystectomy was carried out by Langenbuch in 1882 [1] and open cholecystectomy became the standard-of-care well into the 1980s with mortality rates at less than 1%, and bile duct injuries affecting 0.1-0.2% of patients [2, 3]. This approach however required a large abdominal incision associated with significant postoperative pain and a longer convalescence. A revolution in the surgical treatment of biliary disease came in the 1980s with the introduction of laparoscopic surgery. The first laparoscopic cholecystectomy was performed by Mühe [4] however his approach did not become popular until both French and American groups popularized the four-port technique in the early 1990s. The idea of minimally invasive surgery for the removal of the gallbladder had now become a plausible technique that was rapidly accepted as the standard-of-care. Patients quickly learned of the new procedure and began to request it on the basis of a shorter hospital stay, less pain, and smaller scars [5]. The possibility of performing laparoscopic cholangiography, common bile duct exploration, and choledochotomy expanded the role of laparoscopic surgery in the treatment of biliary disease [6] and further advanced the idea of minimally invasive surgery as the gold-standard for surgery of the biliary tract. Recently the development of natural orifice transluminal endoscopic surgery (NOTES) opened the field of incision-less surgery. The main goal of NOTES is to eliminate the need for skin incisions along with other theoretical advantages which include: decreased postoperative pain, performing procedures in the out-patient setting, reduced incidence of hernias, reduced hospital stay, and increased overall patient satisfaction [5, 7]. The idea of accessing internal organs through the wall of
Single-Incision Laparoscopic Cholecystectomy with Conventional Instruments: A Surgeon’s Initial Experience  [PDF]
Mehmet Zafer Sabuncuoglu, Aylin Sabuncuoglu, Isa Sozen, Gulsum Tozlu, Mehmet Fatih Benzin, Recep Cetin
Surgical Science (SS) , 2014, DOI: 10.4236/ss.2014.57050
Abstract:

Purpose: Since the early 1990s, laparoscopic cholecystectomy has become the gold standard for cholecystectomy. Single-incision laparoscopic surgery (SILS) is a rapidly evolving field as a bridge between traditional laparoscopic surgery and natural orifice transluminal endoscopic. The results are presented here of a single surgeon’s initial experience with single-incision laparoscopic cholecystectomy with conventional laparoscopic instruments through his first 11 cases. Materials and Methods: A single curved intra-umbilical 25-mm incision was made by pulling out the umbilicus. A 12-mm trocar was placed through an open approach, and the abdominal cavity was explored with a 10-mm laparoscope. One 10-mm and one 5-mm port were inserted laterally from the laparoscope port. Dissection was performed using a dissector, which was not articulated. The gallbladder was investigated with an Endograsper, which was not articulated either. The hilum was dissected, and the cystic duct and artery were clipped and divided. Results: The patients are comprised of 9 females and 2 males with a mean age of 43.3 years and mean body mass index (BMI) of 27.6 kg/m2. Open cholecystectomy was not required. The mean operative time was 69.9 min. Length of stay was only one day. All procedures were completed successfully without any perioperative or postoperative complications. In all cases, there was no need to extend the skin incision. Postoperative follow-up did not reveal any umbilical wound complications. The cosmetic results were scored as excellent by all patients. Conclusion: These results suggest that single-incision laparoscopic cholecystectomy is feasible, safe and effective and a promising alternative method to four-port and SILS-port laparoscopic cholecystectomy and as scarless abdominal surgery for the treatment of some patients with gallbladder disease with standard laparoscopic instruments.

Postoperative pain after cholecystectomy: Conventional laparoscopy versus single-incision laparoscopic surgery  [cached]
Prasad A,Mukherjee K,Kaul S,Kaur M
Journal of Minimal Access Surgery , 2011,
Abstract: Background: This study was undertaken to compare the postoperative pain after cholecystectomy done by single-incision laparoscopic surgery (SILS) versus conventional four-port laparoscopy [conventional laparoscopic surgery (CLS)]. SILS is a feasible and a promising method for cholecystectomy. It is possible to do this procedure without the use of special equipments. While there are cosmetic advantages to SILS, it is not clear whether or not the pain is also reduced. Methods: Patients undergoing cholecystectomy for symptomatic gallstones were offered the choice of the two methods and the first 100 consecutive patients from each group were included in this observational study. Only conventional instruments were used to keep the cost of surgery comparable. Pain scores were checked 8 hours after the surgery using visual analogue score. Student′s t test was done to check the statistical significance. Results: We observed no significant difference in the pain score between the CLS and SILS (2.78 versus 2.62). The operative time (OT) was significantly lower in the CLS group (28 versus 67 minutes). Comparing the OTs of the first 50 patients undergoing SILS with the second 50 patients showed a significantly lower OT (79 versus 54 minutes). We also compared the pain score between these three groups. The second half of SILS group had a significantly lower pain score compared to the first half (2.58 versus 2.84). This group also had a lower pain score compared to conventional laparoscopy group but the difference was not statistically significant (2.58 versus 2.78). Conclusion: Although there was no significant difference in the overall postoperative pain as OT decreases with surgeon′s experience in single-incision laparoscopic cholecystectomy, postoperative pain at 8 hours appears to favour this method over conventional laparoscopic cholecystectomy.
Experiences of Single Incision Cholecystectomy
Huseyin Yilmaz, Husnu Alptekin, Fahrettin Acar, Ilhan Ciftci, Ahmet Tekin, Mustafa Sahin
International Journal of Medical Sciences , 2013,
Abstract: Purpose: Single incision laparoscopic surgery in suitable cases is preferred today because it results in less postoperative pain, a more rapid recovery period, more comfort, and a better cosmetic appearance from smaller incisions. This study aims to present our experiences with single incision laparoscopic cholecystectomy to evaluate the safety and feasibility of this procedure. Methods: A total of 150 patients who underwent single incision laparoscopic cholecystectomy between January 2009 and December 2011 were evaluated retrospectively. In this serial, two different access techniques were used for single incision laparoscopy. Results: Single incision laparoscopic cholecystectomy was performed successfully on 150 patients. Median operative time was 29 (minimum-maximum=5-66) minutes. Median duration of hospital stay was found to be 1.33 (minimum-maximum=1-8) days. Patients were controlled on the seventh postoperative day. Bilier complication was not seen in the early period. Five patients showed port site hernia complications. Other major complications were not seen in the 36-month follow-up period. Conclusion: Operation time of single incision laparoscopic cholecystectomy is significantly shortened with the learning curve. Single incision laparoscopic cholecystectomy seems a safe method.
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