Page 25 - World Journal of Laparoscopic Surgery

WJOLS

Modifications of Laparoscopic Cholecystectomy
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(number) LC. Good quality 3 mm instruments, especially of port positioning in laparoscopy. There is also evidence
dissectors, suction as well as 3 mm telescope for extraction that there are more chances of incisional hernia when the
of gallbladder from the 10 mm umbilical port are needed. incision around umbilicus is large. But there are literature
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Only intracorporeal ligation of cystic duct is possible to support easy tissue retrieval, decreased pain score, and
with this technique. The alternative is use of 10 mm clip better patient acceptance compared to standard LC.
applicator with 3 mm telescope. Some studies have demonstrated that single-incision
For selected straightforward cases, two-port LC can be LC is a safe procedure for the treatment of uncomplicated
done by using two traction sutures; one on the fundus of gallstone disease, with postoperative outcome similar to
gallbladder and another on the Hartmann’s pouch. Thus that of standard multiport LC. 10
with traction on the right lumbar suture, anterior dissection
of Calot’s triangle is possible, while with an epigastric su- Hybrid Laparoscopic Cholecystectomy
ture traction posterior dissection is possible. But the quality
of traction and countertraction will not be the same as with To get the advantages of triangular dissection of standard
instrument, as the traction is more or less fixed in axis rather multiport LC, some surgeons have developed a hybrid
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than variable and has a fixed direction of traction (Fig. 3). technique of traditional multiport surgery and single-site
surgery. In this technique three trocars are placed into
the umbilicus, and additional trocars or mini instruments
are used in different positions to aid in retraction or
dissection. This technique may be used as a bridge to
Fig. 3: Stryker mini alligator
single-site surgery while the surgeon is in a learning
curve from a multiport surgery to SSLS.
Some studies have shown that two-port laparoscopic
cholecystectomy resulted in less individual port-site pain
and similar clinical outcomes but fewer surgical scars NOTES Cholecystectomy
compared to four-port laparoscopic cholecystectomy. 7 Various techniques that have been used are transvaginal,
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transgastric, or transcolonic. 12,13 One 3 or 5 mm port is
Single-site Laparoscopic Surgery or Trans- placed in the umbilicus as an initial guide to puncture
umbilical Single-site Surgery (TUSS) (Fig. 4) 8 the peritoneum and at the end to assist in closure of the

In single-site laparoscopic surgery all ports are placed defect. The transgastric and the transcolonic techniques
at single site; here it is, in or around the umbilicus. Using use the flexible endoscope to perform the surgery with a
a single skin and sheath incision, one of the port devices, double-channel endoscope for at least two instruments.
such as SILS port (Covedien), Tri port or Quad port The major limitation is the light and visual axis travel in
(Olympus) or X cone (Storz) is introduced. This typically the same instruments arm which makes this an unstable
requires a larger skin incision, at least 20 mm. platform.
Several variations in design and types of instruments are In transvaginal technique a long angle telescope 45°
available. Instruments are roticulated and will be crossed or even a flexible endoscope is used. The umbilical trocar
inside to achieve triangulation. Vision achieved is tubular would also assist in retraction or dissection. The final
and violate some principles of base-ball diamond concept extraction is through the vaginal port and then sutured.
The limitations are in terms of instrumentations, the
risk of sepsis, dyspareunia in the long-term, and ethical
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dilemmas in using vagina. Injury to rectum during
vaginal puncture has also been reported. Currently
NOTES cholecystectomy is under evaluation and not
routinely performed.

CONCLUSION

In the era of laparoscopic surgery, less postoperative
pain and early recovery are major goals to achieve bet-
ter patient care and cost effectiveness. Several studies
demonstrated that less postoperative pain was associ-
ated with reduction in either size or number of ports.
But while performing modified LC, whether it is in
Fig. 4: Single site Laparoscopic surgery reduction in number of ports or the size of port it is
World Journal of Laparoscopic Surgery, May-August 2016;9(2):71-74 73