Introduction:Currently, laparoscopic cholecystectomy

(LC) is indisputably regarded as the goldstandard for the treatment of symptomaticgallbladder stone disease, even in the case ofacute cholecystitis.1 In recent years, naturalorifice transluminal endoscopic surgery(NOTES) has been offered as the nextgeneration of minimally invasive surgery withno scars.2 However, serious drawbacksspecifically belonging to this technique suchas access, safety of closure, infection, lack ofappropriate instrumentation, and difficulty inorientation have discouraged the use of NOTESprocedures.3

Because of the inconvenience associatedwith NOTES, single incision laparoscopicsurgery (SILS)4 has gained greater interest andpopularity in the surgical community.

Single port or single incision laparoscopiccholecystectomy was reported first in 1997and then again in 1999.5 The recent popularityof this approach stems from an increasinglyaccepted shift away from the dogmatic conceptof triangulation in minimally invasive surgery.We believe this shift is directly due to thedevelopment of natural orifice transluminalendoscopic surgery (NOTES).6

Single port or single incision laparoscopicsurgery is a recent technical advancement in

Single-port laparoscopic cholecystectomy: Initial experience atAin Shams University Hospitals

Hassan Shaker, MD; Ali Mohamed El-Anwar, MD;Mohamed El -Shinawi, MD; Ahmed Nafae, MD

Department of General Surgery, Ain Shams University, Cairo, Egypt

AbstractBackground: As surgeons embrace the concept of increasingly less invasive surgery, techniques

using only a single small incision have begun to gain traction. Single-port access cholecystectomyis a new laparoscopic procedure using only one transumbilical placed port. We report one ofthe initial clinical experiences at Ain Shams University Hospitals with this new technique. Ourstudy aimed to assess whether these devices allow safe and reliable access for laparoscopiccholecystectomy (LC).

Methods: From December 2009 to March 2010, single port laparoscopic cholecystectomywas performed on 10 consecutive patients with mean age ±S.D. 31.0± 11.879 years (range, 18-50) years. The patients were 8 females and 2 males with mean weight ±S.D. 66.700± 10.252kg(range, 50-80) kg. Diagnoses for cholecystectomy were: chronic calcular cholecystitis (n=7),gallbladder polyp (n=1) and chronic non calcular cholecystitis (n=2) with exclusion of patientswith acute cholecystitis, history of jaundice, biliary pancreatitis and prior abdominal surgery.These restrictions were to facilitate the procedure since we are still in the beginning of thelearning curve. All procedures were done using the SILSTM port (Covidien, Inc., Norwalk, CT,USA). In our study, the operative time, reasons for conversion to standard four port laparoscopicsurgery, per operative and postoperative complications, as well as hospital stay were studied.

Results: Single port laparoscopic cholecystectomy was feasible in 8 cases (80%) 7 femalesand 1 male. Two cases (20%) were converted to four port laparoscopic surgery. No per operativeor post operative complications were recorded. The operative time was longer than in commonlaparoscopic cholecystectomy with mean time ±S.D. 125.0±37.796 (range, 90-180) minutes.The mean hospital stay ±SD. was 29.66±4.4 (range, 24-36) hours.

Conclusion: The results from this study show that single port laparoscopic cholecystectomyseems to be safe and feasible when performed by experienced laparoscopic surgeon.

Ain-Shams J Surg 2011; 4(1):73-84 73

minimally invasive surgery. The conceptrevolves around the idea that all thelaparoscopic instrumentation is introduced viathe same access point in the abdominal wall.7

Despite the recent enthusiasm for this newtype of minimal access surgery, theterminology remains confusing. The earlyname to merge for single-port surgery wassingle port access (SPA). Other names aresingle incision laparoscopic surgery (SILS),single site laparoscopy (SSL) and singleinstrument port laparoscopy (SIMPL).8

Whatever the terminology, all the reportsemphasize the feasibility and safety of suchtechnique. In this study, we report one of theinitial clinical experiences at Ain ShamsUniversity Hospitals with this new technique.Our study aimed to assess whether thesedevices allow safe and reliable access forlaparoscopic cholecystectomy (LC).

Patients and methods:From December 2009 to March 2010, single

port laparoscopic cholecystectomy wasperformed on 10 consecutive patients withmean age ±S.D. 31.0± 11.879years (range, 18-50) years. The patients were 8 females and 2males with mean weight ±S.D. 66.700±10.252kg (range, 50-80) kg. Diagnoses forcholecystectomy were: chronic calcularcholecystitis (n=7), gallbladder polyp (n=1)and chronic non calcular cholecystitis (n=2)with exclusion of patients with acutecholecystitis, history of jaundice, biliarypancreatitis and prior abdominal surgeryTable(1). These restrictions were to facilitatethe procedure since we are still in the beginningof the learning curve. All procedures weredone using the SILSTM port (Covidien, Inc.,Norwalk, CT, USA). In our study, the operativetime, reasons for conversion to standard fourport laparoscopic surgery, per operative andpostoperative complications, as well as hospitalstay were studied.

Ain-Shams J Surg 2011; 4(1):73-8474

Table (1): Patients' data.

No.

1

2

3

4

5

6

7

8

9

10

Age

40

47

18

38

28

50

20

19

23

27

Sex

Female

Male

Female

Female

Female

Female

Male

Female

Female

Female

Weight

75

80

57

64

60

80

70

50

72

59

Indication

Chronic calcular cholecystitis

Chronic calcular cholecystitis

Chronic calcular cholecystitis

Gall bladder polyp

Chronic non calcular cholecystits

Chronic calcular cholecystitis

Chronic non calcular cholecystits

Chronic calcular cholecystitis

Chronic calcular cholecystits

Chronic calcular cholecystitis

All patients were offered this approachafter providing informed consent. All patientsreceived information about surgical technique,the difference between the single incision andthe standard four-incision approach and therisks associated with cholecystectomy.

Operative technique:Following basic surgical principles, first

inject some local anesthetic in the umbilicaland periumbilical areas. Then, identify thedeepest point of the umbilical scar (inner ring),and evert the umbilicus from its normalposition, by lifting that area with toothedforceps or atraumatic graspers Figure(1). Amark is done at 6 and 12 o'clock of theumbilicus to mark the incision which shouldnot breach umbilical ring.

Ain-Shams J Surg 2011; 4(1):73-84 75

Figure (1): Evertion of the umbilicus from its normal position.A 2 cm vertical incision is used to cut

through the skin and the subcutaneous tissueto reach the fascia then a 2 cm fascial incisionis used to gain entrance into the abdominalcavity in preparation of SILS port placement.

One must be careful not to create a much largerincision, especially at the fascia; otherwise theport may be too loose, resulting in an inadequatepneumoperitonium due to gas leak around theblue flexible port Figure(2).

Figure (2): 2 cm vertical incision through the skin and the subcutaneous tissue 2 cm fascial incision is used to gain entrance into the abdominal cavity.

Next, the flexible SILSTM Port whichconsists of a blue flexible soft-foam port, withaccess channels for three cannulae Figure(3)is folded at its lower edge (contra lateral to theinsufflation system), and with the use of aproper surgical instrument (i.e., artery forceps)is advanced under direct vision into the

abdomen Figure(4). Once the bottom part ofthe port is inside the abdomen, the port isreleased from our surgical instrument. The5mm cannula may be interchanged at any timeduring the procedure with a 5mm to 12mmcannula Figure(5).

Figure (3): SILSTM port.

Ain-Shams J Surg 2011; 4(1):73-8476

Figure (4): Introduction of SILSTM port.

Figure (5): SILSTM port + cannulae.Following this, the SILSTM Port cannulae

are introduced through the access channels.Pneumoperitoneum may not be initiated untilthe three cannulae are placed inside the SILSTM

Port. A 5mm cannula may be exchanged asneeded with a 5mm to 12mm cannula. TheSILSTM Port adapts to either size, and continuesto maintain pneumoperitoneum Figure(6).

Figure (6): The three cannulae are placed insidethe SILSTM Port with initiation of pneumoperitoneum.

Ain-Shams J Surg 2011; 4(1):73-84 77

A 5 or 10 mm 30o scope is used to inspectthe abdominal cavity and visualize the surgicalfield. After the fundus of the gallbladder isvisualized, a 2-0 prolene suture on a straightneedle was introduced through the abdominal

wall; the suture was grasped and passed throughthe fundus of the gallbladder, then passed backthrough the abdominal wall. Traction on thesuture, which was clamped at the skin level,retracted the gallbladder figure(7).

Figure (7): A 2-0 prolene suture on a straight needle was introduced through the abdominalwall and passed through the fundus of the gallbladder, then passed back through the abdominalwall. Traction on the suture at the skin level, retracted the gallbladder.

A 5 mm roticulator grasper Figure(8) ispassed through the right port and held by theright hand to retract the infundibulum of thegall bladder Figure(9) while a 5 mm roticulatordissector Figure(10) is passed through the left

port and held by the left hand performing thedissection of the Callot triangle Figure(11).These roticulating instruments can bearticulating from 0 to 80 to allow triangulationfor retraction and dissection.

Ain-Shams J Surg 2011; 4(1):73-8478

Figure (8): Roticulator grasper.

Figure (9): Retraction of the infundibulum of the gall bladder.

Figure (10): Roticulator dissector.

Ain-Shams J Surg 2011; 4(1):73-84 79

Figure (11): Dissection of the Callot triangle using roticulator dissector.

After appropriate exposure of thehepatocystic triangle was obtained, the cystic

duct and artery were clipped and divided usingscissor Figures(12,13).

Figure (12): Clipping of the cystic duct and artery.

Figure (13): Endoscissor.

Ain-Shams J Surg 2011; 4(1):73-8480

The hook cautery and sometimes 5mmharmonic scalpel figure(14) held by the lefthand and passed through the left port is usedto open the medial side of the peritoneumbetween the gall bladder and the liver bed.Then the reticulator instrument is straightenedand switched with the hook which is held by

the right hand and is passed through the rightport to dissect the lateral side while theroticulator grasper is retracting theinfundibulum of the gall bladder medially.Finally the hook cautery is controlled by theleft hand and brought in through the left portto remove the gall bladder off the liver bed.

Figure (14): Gall bladder dissection off the liver bed.

Once the gall bladder is removed off theliver bed, instruments are removed as well asthe suture holding the gall bladder, followedby suction irrigation of the liver bed, checkinghaemostasis and that the clips are intact and

on the cystic duct and artery. Finally the SILS port along with the gall

bladder held with the grasper is removedFigure(15).

Figure (15): Removal of the gall bladder.

Wound closure should be carried in a correctand perfect way and in layers to avoid woundcomplications. The abdominal wall fascia isclosed using zero maxon followed by 3-0

polysorb suture to re-attach the base of theumbilicus to the fascia and finally the umbilicalskin is closed using absorbable suturefigure(16).

Ain-Shams J Surg 2011; 4(1):73-84 81

Results:Single port laparoscopic cholecystectomy

was attempted in 10 patients with mean age±S.D. 31.0±11.879 years (range, 18-50) years.The patients were 8 females and 2 males withmean weight ±S.D. 66.700±10.252kg (range,50-80) kg. Diagnoses for cholecystectomywere: chronic calcular cholecystitis (n=7),gallbladder polyp (n=1) and chronic noncalcular cholecystitis (n=2) with exclusion ofpatients with acute cholecystitis, history ofjaundice, biliary pancreatitis and priorabdominal surgery.All procedures were doneusing the SILSTM port (Covidien, Inc.,Norwalk , CT, USA) . S ing le por tcholecystectomy was completed successfullyin 8 cases (80%), they were 7 females and 1male, while conversion to standard four-portLC was carried in two cases (20%)(no=2&6).The cause of conversion in the two cases wasimproper orientation of the Callot triangle dueto the presence of adhesions; hindering the

proper view of the cystic duct and artery.The mean operative time was ±S.D.

125.0±37.796 (range, 90-18o) minutes. Westarted by 180 minutes in the first 2 cases thenthe operative time was decreased graduallyuntil it reached 90 minutes in the last 2 casesand this can be explained by the ascendanceof the learning curve Figure(17). We hadstrictly chosen the cases and the instrumentssuitable for this new technique.

No operative or post operative complicationswere recorded including bleeding or biliaryinjury. The post operative courses wereuneventful.The patients were almost pain freeand all were allowed to feed orally (fluids) inthe night. The mean hospital stay ±SD was29.66±4.4 (range, 24-36) hours. Follow upvisit was one week and one monthpostoperatively, none complained about theoperation and there were no incisioncomplications including infection or port sitehernia.

Table (2): Results.

No

12345678910

Age

40471838285020192327

Sex

FemaleMale

FemaleFemaleFemaleFemaleMale

FemaleFemaleFemale

Weight

75805764608070507259

Indication

Chronic calcular cholecystitisChronic calcular cholecystitisChronic calcular cholecystitis

Gall bladder polypChronic non calcular cholecystits

Chronic calcular cholecystitisChronic non calcular cholecystits

Chronic calcular cholecystitisChronic non calcular cholecystits

Chronic calcular cholecystitis

Procedure

SILSFour Port LC

SILSSILSSILS

Four Port LCSILSSILSSILSSILS

Operativetime (min)

180120180140120901001009090

Figure (16): The wound after completion of SILS.

Ain-Shams J Surg 2011; 4(1):73-8482

Discussion:Single port laparoscopic surgery is a

growing trend in minimally invasive surgery.The potential for less pain, faster recovery,and improved cosmesis has surgeons, theirpatients, and the industry interested in pushingthe technique forward.7

Of paramount importance, as with anyemergent technique, it only makes sense topractice a very careful patient selection,especially at the beginning of one's experience,using strict criteria to find ideal patients. Oncegreat expertise is achieved, these criteria canbe relaxed.9

In our study, the patients’ selection wasrestricted to those with weight range (50-80)Kg,and we excluded patients with acutecholecystitis, history of jaundice, biliarypancreatitis and prior abdominal surgery. Theserestrictions were to facilitate the procedure andthis also goes with the study carried by Sinanet al10 which stated that, patient related factorsdefinitely affect the success rates, particularlyin the learning period, and since. It waspreviously reported that the incidence of bileduct injury is three times higher with LC usedfor cases of acute cholecystitis than withelective cholecystectomy. Indeed, theseconsiderations were the main reasons why thecohort in their study was composed of patientswithout any signs of inflammation. Also, thepatients were selected from those without anycoexistent diseases or higher BMIs. Theseselection criteria provided them facility in thelearning period with reasonable operation times.

On the other hand Tacchino et al4 statedthat neither a BMI greater than 30 nor signsof cholecystitis are to be consideredcontraindications to SILS cholecystectomybecause in both cases, they experienced nomajor additional difficulties. Should any issuearise, a SILS procedure can always beconverted to a standard laparoscopiccholecystectomy easily, with no need for achange in operative position or additionalinstruments.

In our study, single port cholecystectomywas completed successfully in 8 cases (80%),they were 7 females and 1 male, whileconversion to standard four-port LC was carriedin two cases (20%)(no.2&6). The cause ofconversion in the two cases was improperorientation of the Callot triangle due to thepresence of adhesions; hindering the properview of the cystic duct and artery.

Romanelli et al7 stated that cholecystectomyis performed with a low morbidity rate acrossthe world, but one important factor withlaparoscopic approaches to the gallbladder isthe ability to see the critical view. Mostsurgeons who routinely perform laparoscopiccholecystectomy would be greatly disinterestedin a new technique if the critical view wascompromised. We believe that the inability toachieve the critical view at this time shouldresult in conversion to standard laparoscopiccholecystectomy.

The mean operative time±S.D. was125.0±37.796 minutes (range, 90-180) minutes.We started by 180 minutes in the first 2 cases

Figure (17): Operative time (min).

Ain-Shams J Surg 2011; 4(1):73-84 83

then the operative time was decreased graduallyuntil it reached 90 minutes in the last 2 casesand this can be explained by the ascendanceof the learning curve.

The operative time decreased considerably,from 3 hour for the first SILS cholecystectomyto 1 hour 45 min for the second intervention,then stabilized at an average of 50 min in thestudy carried by Tacchino et al4 thusdemonstrat ing not only that SILScholecystectomy is feasible for more than non-complicated cholecystectomies, but also thatthe learning curve is very short.

The learning curve for single portcholecystectomy primarily reflects the difficultyexperienced in understanding the spatialrestriction caused by the close proximity ofthe instruments and the camera. With multipletrocar surgery, the degree of instrument conflictis inversely related to the distance betweenport sites. However, in single port surgery, allinstruments pass through one fascial incisionand therefore only one focal point.11

As a matter of fact, the use of crossed overarticulating instruments requires a longoperative time for achievement of careful andprecise dissection, and some adjustments inthe strategy of exposure are necessary,particularly because less strength is applied totissue than with the standard laparoscopictechniques.4

The real challenge of SILS is to avoidconflict between the operative instruments andthe camera, to maintain the pneumo-peritoneumand reduce operative stress. The use of anextra-long scope or a scope with a cableconnection on the posterior rather than thelateral aspect permits full rotation of the 30o

optic device without interference from theoperative instruments. Nevertheless, anunderstanding between the operating surgeonand the camera assistant is essential becauseevery movement of the one can interfere withthe other.4

When a new technology is adopted, thequestion must be raised whether clinicians areadhering to important surgical principles.Certainly, with any new technique, thecomplication rate is expected to be higher forsurgeons early in their learning curve, as wasthe case with the introduction of laparoscopic

gallbladder surgery two decades ago. To date,the true complication rate of single incisionlaparoscopic cholecystectomy is unknown. Itcan only be hoped that the lessons learned inthe implementation of laparoscopiccholecystectomy will guide adherence to certaindogmatic principle in the name of patientsafety.7

No operative or post operative complicationswere recorded in our study including bleedingor biliary injury. The post operative courseswere uneventful. The patients were almostpain free and all were allowed to feed orally(fluids) in the night. The mean hospital stay±SD. was 29.66±4.4 (range, 24-36) hours.Follow-up visit was one week and one monthpostoperatively, none complained about theoperation and there were no incision (portsite) complications.

It should be noted that any port incision haspotential complications, although the rate ofincidence varies with the port size and type.Port complications may include hernias (0.65%to 2.8%), abdominal wall bleeding (0.2%),bowel injury (0.06%), and wound infection(0.06%). Reducing the number of incisionsfrom 4 to 1 should reduce the incidence ofthese morbidities.12

Uslu et al12 stated that the incidence oftrocar-site infection and herniation are welldocumented. After LC, the rate for infectionis reported to be 2% compared with 5.2% forherniation. Reasonably lessening the numberof trocars will lead to a decrease in thecomplication rates.

Also the incidence rate of majorcomplications (common bile duct and majorvessel injury) following three or four trocarlaparoscopic cholecystectomy is welldocumented at < 1% with an overallcomplication rate of ­3.13

Post laparoscopic cholecystectomy pain andrecovery time is also significantly lower whencompared to the alternative open procedure.14

Whether there is less postoperative painassociated with SILS is so far a subjectiveconclusion and systematic objectiveassessments of post procedural pain, as wellas procedure related complication rates, arelacking.15

Ain-Shams J Surg 2011; 4(1):73-8484

As a novel technique, cholecystectomy viaSILS has introduced some advantages of itsown. The prominent expectations for the shortand long terms are lower rates for pain,infection, and herniation. However, noprospective study has shown the superiorityof SILS with regard to postoperative paindespite the existence of such an opinion.15

Conclusion:The results from this study show that single

port laparoscopic cholecystectomy seems tobe safe and feasible when performed byexperienced laparoscopic surgeon and by usingthe proper instruments. Studies are needed toexamine the true impact of this new techniquein terms of outcomes.

References:1- Bittner R: Laparoscopic surgery: 15 years

after clinical introduction. World J Surg2006; 30: 1190-1203.

2- Marescaux J, Dallemagne B, Perretta S, etal: Surgery without scars: Report oftrnasluminal cholecystectomy in a humanbeing. Arch Surg 2007; 142: 823-826.

3- Fuente SG, DeMaria EJ, Reynolds JD, etal: New development in surgery: Naturalorifice transluminal endoscopic surgery(NOTES). Arch Surg 2007; 142: 295-297.

4- Tacchino R, Greco F, Matera D: Single-incision laparoscopic cholecystectomy:Surgery without a visible scar. Surg Endosc2009; 23: 896-899.

5- Piskun G, Rajpal S: Transumbilicallaparoscopic cholecystectomy utilizes noincisions outside the umbilicus. JLaparoendosc Adv Surg Tech A 1999; 9:361-364.

6- Esposito C: One trocar appendectomy inpediatric surgery. Surg Endosc 1998; 12:177-178.

7- Romanelli JR, Roshek TB, Lynn DC, et al:Single port laparoscopic cholecystectomy:Initial experience. Surg Endosc 2009; Doi:10.1007/s00464-009-0781-z.

8- Gumbs AA, Milone L, Sinha P, et al: Totallyt r a n s u m b i l i c a l l a p a r o s c o p i ccholecystectomy. J Gastrointest Surg 2009;13: 533.

9- Homero R, Esteban V, Daniel S: Single-incision laparoscopic cholecystectomy:Initial evaluation of a large series ofpatients. Surg Endosc 2009; DOI10.1007/s00464-009-0786-7.

10-Sinan E, Ozgur F, Murat S: Single-incisionlaparoscopic cholecystectomy: Is it morethan a challenge? Surg Endosc 2010; 24:68-71.

11-Amanda JK, Douglas I, Marc DB, et al:The learning curve with single portcholecystectomy. JSLS 2009; 13: 332-336.

12-Uslu HY, Erkek AB, Cakrmak A, et al:Trocar site hernia after laparoscopiccholecystectomy. J Laparoendosc Adv SurgTech A 2007; 17: 600-603.

13-Varadarajulu S, Tamhane A, DrelichmanER: Patient perception of natural orificetransluminal endoscopic surgery as atechnique for cholecystectomy. GastrointestEndosc 2008; 67: 854-860.

14-Bittner R: The standard of laparoscopiccholecystectomy. Langenbecks Arch Surg2004; 389: 157-163.

15-Ronald SC, Sujit VS: A comprehensivereview of single incision laparoscopicsurgery (SILS) and natural orificetranslumnial endoscopic surgery (NOTES)techniques for cholecystectomy. JGastrointest Surg 2009; 13: 1733-1740.