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LESS/SILS Cholecystectomy at Bristol Laparoscopic Assoc.,

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06/12/2009

Early experience of LESS (Laparo Endoscopic Single Site) cholecystectomy using conventional instrumentation in an unselected consecutive series of patients

 

 Kat Gash, GL Greenslade, AR Dixon

Spire Hospital Bristol, UK, BS6 6UT

 

 

Correspondence to Mr AR Dixon

Anthony.Dixon@nbt.nhs.uk

 

 

Abstract

Background:  In attempting to reduce morbidity and improve cosmetic outcome, laparoscopic surgeons are now using fewer and smaller ports.

 

Methods: LESS (Laparo Endoscopic Single Site) cholecystectomy was performed using either TriPortTM (Olympus, Southend, UK) or SILSTM (Covidien, Gosport, UK) single-port and conventional laparoscopic instruments; straight 5-mm fenestrated grasper, hook, scissors and a 30-degree 10-mm laparoscope.

 

Results:  18 unselected and consecutive patients with symptomatic cholelithiasis underwent trans-umbilical LESS cholecystectomy (16 females; median age, 40 (range, 29–54) years); body mass index 25 to 37 (median 29).  One case (BMI 37) required an additional epigastric port; suture retraction or conversion to a standard 4 port-laparoscopy was unnecessary.  The median operative time was 40 (range, 30–200) minutes.  The median postoperative stay was 20hrs (range, 6–26 hrs).  There were no postoperative complications.

 

Conclusions:  Our experience of LESS cholecystectomy in this small un-selected series is encouraging.  All procedures were completed successfully within a reasonable time.  LESS is a promising alternative for the treatment of patients with symptomatic gallstones with the advantage of an almost scarless intervention.  Despite these preliminary and optimistic results, an experienced laparoscopic skill set is essential for its safe and effective completion. Randomised studies are required before LESS can be recommended as a standard procedure.

 

 

 

Keywords  Trans-umbilical Single-port – Laparoscopic cholecystectomy,  LESS, SILS

 

 

Introduction.  Laparoscopic surgery has always had a focus on minimizing surgical trauma and improving cosmesis.  Cholecystectomy as performed with three or four ports has for almost two decades been considered the standard for the treatment of symptomatic cholelithiasis.  Whilst by definition it is less invasive than open surgery, it still requires several incisions for port placement as well as an extraction site.  Each of these is painful, impacts on the final cosmetic appearance and has the potential for bleeding, inter-fascial haematoma formation, visceral injury, sub-costal nerve irritation and in the long-term, incisional hernia development.  Cosmesis is increasingly demanded by increasingly discerning patients.  

Natural Orifice Transluminal Endoscopic Surgery (NOTES) e.g., trans-vaginal cholecystectomy whilst currently in evolution is considered by enthusiasts as the next surgical frontier.  NOTES procedures are protracted and require expensive specialized equipment and last but not least extensive training.   NOTES cholecystectomy as it currently stands probably has no clinical application.  A more viable alternative is Laparo Endoscopic Single Site (LESS) surgery.  Other acronyms used include single incision (SILSTM) and E(embryological)NOTES.  Single port access surgery is a rapidly progressing surgical approach, which allows the performance of standard laparoscopic surgery through a single trans-parietal port instead of the surgeon relying upon multiple port accesses.

These approaches all use multi-lumen ports sited through the umbilicus.  Flexible instrumentation is also promoted to obviate the need for triangulation, which up to now has been considered a fundamental component of laparoscopic surgery.  Conventional instrumentation however, was used in the first reported case series of this type of surgery; 53 retroperitoneal adrenalectomies.     Single port appendicectomy and cholecystectomy were first described back in 1998 before the methodology was re-visited and utilized in urology in 2005 by Hirano et al. 

In theory, LESS (LaparoEndoscopic Single Site) cholecystectomy could be associated with better pain control, a quicker recovery and a superior cosmetic appearance.  LESS in requiring only one trans-parietal port may also be associated with a reduced rate of parietal complications or possibly the converse may apply.  We report out initial experience using this novel approach and normal laparoscopic instrumentation.

 

 

Patients and methods:  18 consecutive, unselected patients with symptomatic cholelithiasis: biliary colic (10), resolved acute cholecystitis (6), acute on chronic cholecystitis (2)) were offered LESS cholecystectomy.  Patients with potential choledocholithiasis were excluded.  All were informed of the early stage of this technologies development and offered standard 3-4port cholecystectomy as an alternative. 

We used either the ASC (Advanced Surgical Concepts, Dublin, Ireland) TriPortTM (Olympus, Southend, UK) or the SILSTM (Covidien, Gosport, UK) systems.  The former is a multichannel pathway allowing two instruments and one laparoscope to enter simultaneously through only one incision.  Using the introducer, the inner ring of the TriPortTM was inserted through a 2cm trans-umbilical incision into the abdominal cavity.  The inner ring of the TriPortTM is connected to two outer rings via a doubled over cylindrical plastic sleeve. The sleeve is then pulled outwards and put under tension by drawing the inner and the outer ring as close as possible together.  This tension creates a pathway for the passage of the laparoscopic instruments by retracting the incision. The latter is a flexible, “solid” multiple channel (x3) access port that allows for a secure peritoneum and plume extraction.

Operations were all conducted with the patient in a supine position with the surgeon standing on the patients’ right hand side.  A 10-mm rigid 30° laparoscope was used throughout.  After inserting either port, the subsequent steps were carried out following the exact same principles employed by the standard 3 or 4-port technique.  Dissection was started in most cases with mobilization of the inferior/posterior aspect of the body of the gallbladder with particular concentration focused upon the approach to Hartmann’s pouch.  This was followed by dissection of the fundus and finally the anterior/superior aspect; hook dissection continued to define Hartmann’s pouch and the cystic duct.  In performing LESS it is imperative not to accept any compromise in defining the anatomy of Calot’s triangle.  5mm Hem-o-Loc clips (Teleflex Medical, High Wycombe, UK) were used for the control of any bleeding and ligation of the cystic duct.  Endo-loops were deployed to thick walled or wide cystic ducts.  Drains were not used.  Peri and postoperative analgesia was provided by a combination of transversus abdominals plane (TAP) blocks, short acting intra-operative opiods and post-operative intravenous paracetamol.

 

Results

All 18 LESS procedures were successfully completed using regular instrumentation inserted through the two different types of port.  There were 16 females and 2 males, median age 40 (range, 29–54) years; body mass index 25 to 37 (median 29).  No case required suture retraction or conversion to a standard 4 port-laparoscopy.  The median operative time was 40 (range, 30–300) minutes.  One patient (BMI 37 with acute on chronic cholecystitis required an additional 5mm epigastric port to enable safe dissection of cystic and CBD ducts and liver retraction; part of the protracted surgery (300mins) involved gallstone collection following early spillage.

TAP blocks augmented by intravenous paracetamol provided good post-operative analgesia in all cases and as a result patient recovery was impressively quick.  The median hospital stay was 20hrs (6-23hrs).  There were no conversions to 4-port cholecystectomy, post-operative complications or readmissions.

 

Discussion

Single-port trans-umbilical laparoscopic surgery was first used 10 years ago for appendicectomy and cholecystectomy and it was probably only through the perceived technical limitations of the instrumentation at the time that it failed to gain any sort of momentum.  LESS/SILSTM has recently been re-visited with the expressed aims of potentially enhancing the cosmetic benefits and further reducing the morbidity of minimally invasive surgery.

At first glance, inserting two operating instruments and a laparoscope through the same port appears to negate one of the first principles of laparoscopy, namely triangulation.  Successful LESS/SILSTM as has been described to date has been based on this very same assertion and its performance/achievement has required the development of articulating or pre-bent instrumentation introduced via a fixed and stable platform or alternatively small, adjacently placed ports.  Instrument articulation allows for intra-corporeal triangulation of parallel instruments.  However, straight instruments can diverge and this is due in part to the flexibility of both types of ports.  Flexibility is at its best using the TriPortTM (Olympus, Southend, UK); flexible valves externally and a low profile port which remains flush with the abdominal wall both on the inside and outside.  The flat profile of the port also allows free play of the instruments in spite of their proximity to each other.  Unlike SILSTM (Covidien, Gosport, UK) the TriPortTM (Olympus, Southend, UK) also allows the insertion of instruments with angulated shafts, which give the effect of triangulation.

Unlike conventional laparoscopic surgery, optimal instrument utilization in LESS/SILSTM demands that the operating surgeon makes greater use of his/her none dominant hand and have the ability to cross their hands and continue with operating.  It is also mandatory to have an expertise in directing, using and interpreting the image produced by a 300 laparoscope and total concentration.  Whilst not absolutely essential we believe that a 5mm video-laparoscope or an extended length scope probably reduces clutter and instrument collision and may improve performance.  It is these very differences and the tendency for instrument collision that makes this technique inherently difficult to learn and by definition, teach.  A final consideration is the need for quality laparoscopes and light cables; less than perfect optics makes this approach very frustrating and potentially dangerous.

That said, we were very surprised at the ease and speed at which we were able to perform what amounted to complex laparoscopic maneuvers.  This ease of adaption probably relates to the experience of the senior author in performing pragmatic three-port complex laparoscopic colorectal surgery and not relying on an assistant to provide traction and more recently our performance of LESS colectomy.  Gravity and natural tissue planes are used to provide counter traction to a highly active none-dominant hand and a relatively “still” operating-dominant right hand as well as having the ability to cross over hands when required.  Using the approach described above we found it unnecessary to use a series of trans-parietal sutures to provide retraction to the fundus and Hartmann’s pouch.  The longer operating time was caused by the limited space, and a need to constantly think about “what one was doing” and “how to do it”.   We consider it important to keep the laparoscope in a relatively fixed position just inside the abdominal cavity - if it is too far in it will restrict the operating instrumentation.  Nether the less, instrument collision still remains a challenge.  It is also necessary to periodically rotate either port and swap operating hands to optimize the placement and use of the instrumentation.

Each port has its own drawbacks. The ASC-TriPort (Olympus, Southend, UK) requires the instruments to be lubricated to allow easier passage through the elastomeric valve; laparoscopes are best lubricated using lens cleaning or anti fog solutions whilst, water-soluble gel is adequate for the operating instruments.  The SILS™ (Covidien, Gosport, UK) access port is harder to insert, requires a larger incision, which in our experience resulted in more peri-umbilical bruising.  The individual SILSTM component ports also tend to fill with droplets of blood and makes cleaning of the lens very difficult.  The valve of the 12mm port is also far too bulky and tends to cause even more instrument collision and reduced mobility; the ports are also too long and this again limits mobility.

Although this early limited experience of LESS/SILSTM cholecystectomy is promising, experienced laparoscopic skills are both mandatory and essential for its safe and effective completion.  Patient selection as we have learnt is important and at this time in its development it seems sensible to avoid LESS in thick walled or shrunken chronically inflamed gallbladders as well as patients with high BMIs.  Evolving articulating instrumentation which are reputed to offer surgeons seven degrees of freedom all within the control of one hand and the newer deflectable tip laparoscopes advocated for LESS/SILSTM are expensive and require considerable training and practice, and it is our view that for the former this is probably best gained by repeated visits to an animal and then cadaveric lab.

The observation of a complete lack of shoulder tip pain when the TAP blocks were working would suggest that it is referred pain form parietal injury/irritation at the port of entry, and not retained CO2 and diaphragmatic irritation that is responsible for its development. One patient developed shoulder pain refractory to intravenous paracetamol after 13hrs.   A repeat TAP block eliminated the pain within 10 minutes and patient was discharged home.  We have observed this same phenomenon in patients who have had a LESS colectomy and “conventional” three port laparoscopic colorectal surgery. This is potentially a very important observation and if substantiated could allow for higher rates of day case cholecystectomy. 

 The LESS technique is a new and safe method for the carrying out laparoscopic surgery.  By placing the systems platform trans-umbilically, the result is practically “scarless” and patient recovery to allow for normal social duties is quick.  Furthermore access-related injuries and complications may be reduced by the one incision. ?? Given our positive findings we have encountered to date we now use a trans-umbilical placed trocar at the start of every laparoscopic cholecystectomy.  We have also successfully carried out all the major resectional colorectal procedures using the LESS technique. ?

By using the trans-umbilical route, LESS is much easier for the surgeon than NOTES to adapt to and there is no need for expensive endoscopic instruments, which are prone to fracture.  Furthermore, it uses a conventional laparoscope and camera; there is also no need for multi-channel endoscopes.  There are, however, some concerns.  The difficulty level with LESS is far more than a standard laparoscopic cholecystectomy, making it unsuitable for the beginner.  It is also challenging even for an experienced laparoscopic surgeon.  Both of these factors should/will limit the widespread adoption of the technique. The loss of retraction and triangulation means that in some instances there is a tendency for sub-optimal exposure of Calot's triangle.  Hence it is not recommended that the technique be not used for “difficult” cholecystectomies until more experience is gained.  The use of a “fundus first” approach is a safe compromise.  An alternative may be to use an additional Verres needle cited in the right hypochondrium for fundus or liver retraction. 

Our early results encouraged us to continue offering LESS, even when we predicted that cases were going to become difficult (high BMIs of 35 & 37 in patients with acute on chronic cholecystitis).  As a result operative time was substantially increased.  The difficulties encountered largely arose from the long distance between umbilicus and gallbladder i.e., the instrumentation was at its limits.  The use of reticulating instrumentation (hook) for dissection was found to be unhelpful as all tactile sensation was lost.   Progress in fully dissecting out Hartmann’s pouch was only achieved in the highest BMI case by using an additional 5-mm epigastric port.

Improved instrumentation and the use of articulating graspers and dissectors may further decrease or paradoxically (as we found) increase the difficulty level; the latter due to the introduction of yet one more variable to think about and loss of tactile sensation.   It also remains to be seen whether or not Robotics would be better suited to a single port procedure.  Other than the obvious and assumed cosmetic advantage and the fact that the overall cost is probably not increased, randomized studies are needed to see whether or not LESS doesn’t just lead to more conversions and in its early phase of introduction more complications.  The latter would be unacceptable give that the standard alternative should in competent hands be associated with few mishaps.  It is also necessary to see if it can reduce pain scores and analgesic requirements and as a result lead to an enhanced recovery with a greater proportion of operations performed as day cases in comparison to the standard four-port technique.  Long-term follow-up will determine if LESS poses any increased risk of our patients developing an incissional hernia.  As a final thought, LESS may serve as a bridge, transition or more likely an alternative to NOTES cholecystectomy.


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