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Over the last two decades, laparoscopic cholecystectomy
has replaced open cholecystectomy as the standard surgical procedure for majority of patients of gall stone disease. Till 1999, laparoscopic Cholecystectomy was being performed using multiple ports usually 3 or 4 ports.
Intensive desire of surgeon to reduce the number of ports led invention of two port cholecystectomy and then finally
single incision laparoscopic cholecystectomy (SILC) .

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  1. 1. SINGLE PORT ACCESS CHOLECYSTECTOMY: THE INITIAL LEARNING CURVE
  2. 2. Original Article SINGLE PORT ACCESS CHOLECYSTECTOMY: THE INITIAL LEARNING CURVE* Radha Govind Khandelwal, Kirubha Shankar and Prasanna Kumar Reddy Department of Surgical Gastroenterology and Minimal Access Surgery, Apollo Hospitals, 21Greens Lane, Off. Greams Road, Chennai 600 006, India. Correspondence to: Dr Prasanna Kumar Reddy, Head of Department of Surgical Gastroenterology, Apollo Hospitals, 21 Greams Lane, Off Greems Road, Chennai 600 006, India. e-mail: drpkreddy@hotmail.com Objective: Single port surgery is a rapidly advancing technique with a lot of enthusiasm among minimal access surgeons. Single port access cholecystectomy (SPAC) is one of the most commonly performed single port access surgery all over the world. To establish this technique as standard of care for management of benign biliary diseases, it needs strong comparison with traditional laparoscopic cholecystectomy. Initial learning curve, cost effectiveness, post operative pain, post operative recovery and complications rate is yet to be established. Methods: SPAC was performed on 19 selected patients for symptomatic gall stone disease by a single surgeon at our institute. The SILSTM port was placed in the umbilicus and combination of articulating and straight instruments were used. Patient characteristics and outcome were reviewed. Results: The main selection criteria for SPAC were based on clinical history, body mass index, and ultrasonographic findings. The SPAC had a mean time of 50 minutes. The first single port cholecystectomy took 120 minutes with sequential improvement in operating time for further cases. The average patient body mass index was 23. No major complications or conversion to traditional technique occurred. Conclusion: One of the largest series to date of SPAC for benign biliary diseases in India, performed by a single surgeon in a single institute is presented. We conclude that it is a safe and reproducible technique with short learning curve for appropriately trained minimal access surgeons with a higher cosmetic satisfaction for patients. Key words: Single port access cholecystectomy (SPAC), SILSTM port, Reproducible, Learning curve. INTRODUCTION METHODS Over the last two decades, laparoscopic cholecystectomy has replaced open cholecystectomy as the standard surgical procedure for majority of patients of gall stone disease. Till 1999, laparoscopic Cholecystectomy was being performed using multiple ports usually 3or 4 ports. Intensive desire of surgeon to reduce the number of ports led invention of two port cholecystectomy and then finally single incision laparoscopic cholecystectomy (SILC) . Until the beginning of July 2009, traditional multiport laparoscopic cholecystectomy was the standard of care for the majority of benign biliary diseases. Before that we tried SILC occasionally for selected cases but we found it to be difficult to perform. With the availability of SILSTM port in india, we started to perform single port access chole-cystectomy using multichannel SILSTM port in properly selected cases. We retrospectively reviewed the effect of this transition on operative times and surgical complications. Single incision laparoscopic surgery utilizes three fascial ports through the single skin incision at umbilicus [1]. With the introduction of single port with multiple sleeves, now single port access has become a vital option for cholecystectomies and other commonly performed laparo-scopic procedures. Single port access surgery is being considered as no scar surgery, because the single port is placed within the umbilical ring that is not visible at all. We conducted a prospective study to assess learning curve, reproducibility and advantages of this new technique at our centre, before offering it to all types of patients of benign biliary diseases. *Paper presented in IAGES – 2010 held at Delhi on 21 February 2010. Apollo Medicine, Vol. 7, No. 2, June 2010 132 All patients of symptomatic benign biliary diseases were evaluated thoroughly, only those patients who had history of biliary colic, BMI less than 23 and normal looking gall bladder with no evidence of acute or chronic cholecystitis and choledocholithiasis on ultra sonography were included in the study. Patients characteristics are demonstrated in (Table 1).16 patients of symptomatic gall stone disease and 3 patients of adenomyomatosis of gall bladder were selected for single port access cholecystectomy (Fig.1).
  3. 3. Original Article area for retraction because of obstruction of calot’s triangle by liver. Table 1. Demonstrating the patient characteristics Patient characteristics Number Male Female 15 Mean age 32 Mean BMI 28 Coronary artery disease Nil Diabetes mellitus RESULT 4 nil In first two cases both of symptomatic biliary colic that were attempted for single port access cholecystectomy, we required an additional ethilon suture for retracting the Hartman to expose the calot’s triangle. In initial five cases, we took long operative time due to poor coordination between assistant holding the Hartman with articulating grasper and surgeon doing dissection using straight instrument. In further cases both surgeon and assistant were tuned up, so operating time was reduced. In two cases the liver was enlarged and obstructing the calot’s triangle. To overcome this problem with exposure, an ethilon suture was passed around the falciform ligament from the left subcostal area to pull the liver up. Instead of anterior and posterior dissection of standard multiport laparoscopic cholecystectomy, right and left dissection in calot’s triangle performed to expose the cystic duct and cystic artery. Meticulous dissection was done to expose the critical window, as in standard LC. Fig.1.Preoperative indications for Single port cholcecystectomy Patients were placed in modified lithotomy position. A 20 mm incision was given entirely within the umbilical ring and single port deployed. Following access and placement of port, the surgeon stood in between the legs of patient with the assistant and camera person on left side of patient. 5 mm 30 degree scope was used in all cases. The single port access cholecystectomy was commenced by passing a straight needle with ethilon suture via right subcostal region for retraction of gall bladder fundus cephalad. Articulating grasper was used for lateral retraction of hartmann’s pouch for exposure of calot’s triangle. The surgeon held the single operating instrument for dissection, assisted retracted the Hartman pouch with articulating grasper. Single handed dissection carried out in calot triangle by surgeon using Maryland grasper or harmonic scalpel. After skeletoni-zation of cystic duct and cystic artery and creation of adequate posterior window, cystic artery and duct clipped using 5 mm clip applicator and divided. Harmonic scalpel was then used to remove the gall bladder from liver bed, and the specimen was removed along with the port. Additional traction suture was used for Hartman retraction in 2 cases. In 2 cases, a second ethilon suture was passed around the falciform from the left subcostal Therefore, 19 selected patients underwent SPAC without the need of additional ports or open conversion. No gross gallstones or spillage of bile noted with ethillon sutures. Operative time was reduced from 100-140 minutes (initial 4 cases) to 45-65 minutes (last 4 cases). None of the cases required placement of drain. All patients were discharged on the next day of surgery. The operative time of all successful 19 cases of single port cholecystectomy is shown in (Fig.2).Mean operative time for our first four cases was 122.5 minutes while mean operative time for last 4 cases was 62.5 minutes, that is almost similar to standard laparoscopic cholecystectomy at our centre. DISCUSSION Since 1990’s laparoscopic cholecystectomy using multiple ports around the abdomen is gold standard procedure for benign biliary diseases. The constant effort of surgeons to reduce the number of ports to reduce pain and higher cosmetic demand from patient led to introduction of Single port surgery in the field of minimal access surgery. In single port access cholecystectomy, the incision is placed in the umbilical ring (not around it). This permits a scar less operation, because the operative scar is hidden in natural scar i.e. umbilicus. Any port incision is associated with some potential complications, although the rate of incidence varies with the port size and type. Port complications may include hernias, abdominal wall 133 Apollo Medicine, Vol. 7, No. 2, June 2010
  4. 4. Original Article Like prior published series [4,5], we also included selected cases in our series to start this technique at our centre. In our series we found that this technique is associated with higher cosmetic satisfaction among patients. Furthermore the learning curve described is specific to the primary surgeon, a highly experienced laparoscopic surgeon, and may vary with the comfort level and technical skills of other surgeons. However, in our personal experience that after performing the 10 cases of single port access cholecystectomy, surgeon reaches an adequate level to perform single port cholecystectomy independently and effectively. CONCLUSION Fig. 2. Operative times ( x-axis - Patient, y-axis - Operative Time in minutes). bleeding , bowel injury and wound infection . Reducing the port incisions from 3 or 4 to one definitely reduces the incidence of these morbidities. Furthermore Bresadola, et al showed that in single incision transumbilical laparoscopic cholecystectomy, using only the periumbilical port incision reduces the level of pain engendered by traditional multiport laparoscopic surgery [2]. Kravetz AJ, et al performed single port access cholecystectomy on all types of biliary disease, including acute cholecystitis with inflammation and found that this form of surgery can be performed in all types of biliary disease with a short learning curve of approximately five cases, with an obvious cosmetic benefit [3]. Although initial 4 cases took long operative times, the last 4 cases were performed with operative times comparable to those with multiport cholecystectomy. Because we eliminated the additional time in putting the additional ports and the time in retrieving the gall bladder, we anticipate that our operative time will continue to diminish to a level below that of multiport cholecystectomy. One of the largest series to date of single port cholecystectomy for benign biliary diseases in India, performed by a single surgeon in a single institute is presented. We conclude that this technique can be applied effectively in selected group of patients with benign biliary diseases in comparable operative time to traditional laparoscopic cholecystectomy in a safe manner. It is a reproducible technique with short learning curve for appropriately trained minimal access surgeons with a higher cosmetic satisfaction for patients. The loss of basic laparo-scopic concept of triangulation, instrumental cluttering and unfamiliar ergonomics are pitfalls of this technique. With improvement in articulating instruments, laparoscope and advance training it may stand the test of time to become a standard technique for all patients with benign biliary diseases. REFERENCES The learning curve for single port cholecystectomy primarily reflects the difficulties experienced in understanding the spatial restriction due to instruments cluttering and the camera. As the traditional concept of laparoscopic triangulation, anterior and posterior dissection (to some extent), is lost in single port access surgery, so adoption of right and left dissection in calot’s triangle and acceptance of some instrumental cluttering by primary surgeon is crucial for performance of single port surgery. The use of articulating instrument may aid to manage the spatial conflict of instruments; however it does not eliminate the technical challenges associated with single port surgery. Apollo Medicine, Vol. 7, No. 2, June 2010 134 1. Piskun G, Rajpal S. Transumbilical laparoscopic cholecystectomy utilizes no incisions outside the umbilicus. J Laparoendosc Adv Surg Tech. 1999; 9: 361-364. 2. Bresadola F, Pasqualucci A, Donini A, et al. Elective transumbilical compared with standard laparoscopic cholecystectomy. Eur J Surg. 1999;165(1) :29-34. 3. Kravetz AJ, Iddings D, Basson MD, Kia MA. The learning curve with single port cholecystectomy. Journal of society of laparoendoscopic surgeons 2009;13 (3): 332336. 4. Hong TH, You YK, Lee KH. Transumbilical single-port laparoscopic cholecystectomy: scarless cholecystectomy. Surg Endosc. 2009;23(6):1393-1397. 5. Kuon Lee S, You YK, Park JH, Kim HJ, Lee KK, Kim 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.
  5. 5. A o oh s i l ht:w wa o o o p a . m/ p l o p a : t / w .p l h s i lc l ts p / l ts o T ie: t s / ie. m/o p a A o o wt rht :t t r o H s i l p l t p /w t c ts l Y uu e ht:w wy uu ec m/p l h s i ln i o tb : t / w . tb . a o o o p a i a p/ o o l ts d F c b o : t :w wfc b o . m/h A o o o p a a e o k ht / w . e o k o T e p l H s i l p/ a c l ts Si s ae ht:w wsd s aen t p l _ o p a l e h r: t / w .i h r.e/ o o H s i l d p/ le A l ts L k d : t :w wl k d . m/ mp n /p l -o p a i e i ht / w . e i c c a y o oh s i l n n p/ i n no o a l ts Bo : t :w wl s l e l . / l ht / w . t a h a hi g p/ e tk t n

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