Single port site cholecystectomy for symptomatic cholelithiasis

The reduction of the number of trocars is one of the ways to minimize the invasiveness of the surgical intervention. This video shows a cholecystectomy with a single site access, using a Gelport. This device was designed for hand-assisted surgery. Standard laparoscopic trocars are inserted through the gel. Articulated instruments are used to recreate the triangulation of a standard laparoscopy. The intervention itself is performed in a standard way.

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Single port site cholecystectomy for symptomatic cholelithiasis

Authors

D Mutter, J Marescaux

Abstract

The reduction of the number of trocars is one of the ways to minimize the invasiveness of the surgical intervention. This video shows a cholecystectomy with a single site access, using a Gelport. This device was designed for hand-assisted surgery. Standard laparoscopic trocars are inserted through the gel. Articulated instruments are used to recreate the triangulation of a standard laparoscopy. The intervention itself is performed in a standard way.

Classification

single port

Keywords

Single port site access, cholecystectomy, symptomatic cholelithiasis

Media type

Surgical video

Duration

06'07''

Publication

2008-11

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E-publication

WeBSurg.com, Nov 2008;8(11).
URL: http://www.websurg.com/doi-vd01en2433.htm

Single port site cholecystectomy for symptomatic cholelithiasis

1. Insertion of the Gelport 00'12''

The limitation of the number of incisions is one of the natural evolutions of laparoscopic cholecystectomy. To perform this procedure, we used a GelPort usually used for hand-assisted procedures. The GelPort is introduced in the abdomen and in the trocars are inserted in the gel. The GelPort allows good insufflation of the abdomen and a good access to the single incision in the abdomen. Through the port, we place a 10mm optic with a lateral view, including an operative channel in its side.

2. Dissection of Calot\'s triangle 00'55''

Further ports are inserted in the gel and allow the introduction of instruments. We usually use 3 entry ports to perform the procedure. The instruments are mainly articulated instruments, which allow to re-create the triangulation that is mandatory to have a good dissection of the Calot’s triangle. Angulated scissors allow to perform a progressive dissection of Calot’s triangle, identification of cystic duct and cystic artery. Instruments used for retraction are also articulated graspers. These allow to retract the gallbladder out of the operative view. The dissection is performed using monopolar cautery with a low voltage in order to prevent thermal injuries. We usually don’t perform intraoperative cholangiography in case of lack of risk of common bile duct stones. The Calot’s triangle is progressively dissected in order to clearly identify the common bile duct to avoid any injury, and the cystic duct and artery are clearly identified. An instrument inserted in the operative channel of the optic is also used to perform the dissection but the lack of triangulation renders its manipulation more difficult than with angulated instruments.

3. Control of cystic duct and artery 02'30''

This instrument is only used to retract the tissue, but not for coagulation as the identification of its tip is not possible due to the straight view. Another problem encountered is the clip applier. The clip appliers are not angulated and they always come from a very lateral angle into the operative field, as the triangulation cannot be achieved due to the lack of articulation. The dissection of the cystic duct is completed and here again the application of clips is performed with clips coming from the same axis as the view. This makes clip application more difficult than in conventional triangulation obtained with many ports. Nevertheless, this application can be safely performed and controlled thanks to the single port access.

4. Dissection of the bed 03'35''

In several cases, the insufflation length of the clip applier may constitute another problem for this single port cholecystectomy. After a good control of the cystic artery and the cystic duct, these can be divided and dissection of the gallbladder bed is completed with monopolar cautery. Re-exposure with the articulated instrument has to be performed several times in order to obtain a clear identification of the whole local anatomy. Nevertheless, coagulation and progressive division of the tissue will allow to perform a complete freeing of the gallbladder. In this video, we see very clearly the problem of instrument manipulation. In fact, due to the instruments crossing, instruments in the left hand of the surgeon operate on the right of the operative field and vice-versa. This lack of ergonomics represents a major difficulty for this single port site incision, and this makes it necessary to develop new instrumentation, or for the robotization of part of the procedure in order to simplify this dissection. The complete freeing of the gallbladder without injury can be obtained after progessive cautery and division of all the attachments of the gallbladder on the liver in a very standardized way. The 2cm incision in the umbilicus allows at the end of the procedure for an easy access of the bag in order to place the gallbladder and to remove it from the abdomen without enlarging any incision.

5. Extraction 05'45''

At the end of the procedure and after retraction of the gallbladder, the quality of the operative field can be controlled. The single port site laparoscopic cholecystectomy offers the patient a very high quality cosmetic result. The incision, performed very deep in the umbilicus, disappears completely 3 weeks after the surgical procedure.