Single port cholecystectomy: impact of instrumentation in getting the critical view of safety

Single port access surgery may be the next generation of minimally invasive surgery thanks to the obvious advantages (e.g., scarless surgery, lesser pain, and faster postoperative recovery). Performing a cholecystectomy via a single trocar imposes a few technical constraints. The first is the necessity of correctly exposing the gallbladder, the second is to find the instrumentation that allows to perform the different dissection stages, ligature of the cystic duct and artery, but also to obtain an acceptable visualization of the Calot’s triangle. Various methods are proposed at the moment, along with different instruments: rigid, articulated, curved ones. In this video, we present two cholecystectomies, one is performed with conventional laparoscopic instruments, the other with curved instruments especially adapted for a unique trocar.

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Single   port   cholecystectomy:   impact   of   instrumentation   in   getting   the   critical   view   of   safety

Authors
B Dallemagne, J Leroy, J Marescaux
Abstract
Single port access surgery may be the next generation of minimally invasive surgery thanks to the obvious advantages (e.g., scarless surgery, lesser pain, and faster postoperative recovery). Performing a cholecystectomy via a single trocar imposes a few technical constraints. The first is the necessity of correctly exposing the gallbladder, the second is to find the instrumentation that allows to perform the different dissection stages, ligature of the cystic duct and artery, but also to obtain an acceptable visualization of the Calot’s triangle. Various methods are proposed at the moment, along with different instruments: rigid, articulated, curved ones. In this video, we present two cholecystectomies, one is performed with conventional laparoscopic instruments, the other with curved instruments especially adapted for a unique trocar.
Classification
new techniques, single port
Keywords
Single port cholecystectomy, instrumentation, safety
Media type
Duration
07'29''
Publication
2009-11
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Subtitles
en
E-publication
WeBSurg.com, Nov 2009;9(11).
URL: http://www.websurg.com/doi-vd01en2802.htm

Single   port   cholecystectomy:   impact   of   instrumentation   in   getting   the   critical   view   of   safety

4. Straight rigid instruments 03'06''
In this video, two straight and rigid instruments are used, and we notice immediately that there are conflicts in and out of the peritoneal cavity. This dissection example shows just how reduced the conflicts are. The identification of the Calot’s triangle different structures is perfect thanks to the endoscope’s angle, providing an optimal view of this triangle. If rigid instruments are used, a similar exposure may be obtained. However, it is obvious that the instrument conflicts with the camera, and this shows as the laparoscope’s views are constantly altered. The next step is the clipping. Using such angulated scopes allows for a perfect exposure of the operative field. No conflict is observed between instruments, which accounts for the steadiness of the image. Conventional straight scissors and a straight coagulating hook are used by the surgeon’s right hand. Once again, we obtain a very steady image as opposed to the use of the two straight instruments. These generate conflicts in the surgeon’s hands and with the manipulation of the scope, explaining the unstable image. This exposure of the Calot’s triangle is a golden rule when performing a single port cholecystectomy. Some of the techniques that have been recently described do not allow for sufficient safety. As a result, this video demonstrates the usefulness of developing specific instrumentation, not only to achieve a satisfactory exposure and retraction of the gallbladder, as in the present case, but also the importance of the shape of the instruments. Indeed, their shape may vary according to the surgeon’s preference and dominant hand, but they are important to maintain a good visual field and ensure a steady image, both essential aspects of a neat dissection.