Page 13 - Journal of WALS

WJOLS

10.5005/jp-journals-10007-1122
REVIEW ARTICLE Immunological Response of Postcholecystectomy: SILS vs NOTES
Immunological Response of Postcholecystectomy:

Single Incision Laparoscopic Surgery (SILS) vs

Natural Orifice Transluminal Endoscopic

Surgery (NOTES)

2
1 E Ray-Offor, RK Mishra
1 Department of Surgery, University of Port-Harcourt Teaching Hospital, Nigeria
2 Senior Consultant, Laparoscopic Surgeon, Professor in Minimal Access Surgery, Chairman and Director, World Laparoscopic
Hospital Pvt Ltd, DLF Cyber City, Gurgaon, Haryana, India

ABSTRACT
Introduction: Surgery evokes complex metabolic, neuroendocrine and immunological responses. These are reparatory but when
exaggerated may cause immunosuppression with morbidity and mortality. It is well-known that these responses are attenuated in
laparoscopic cholecystectomy, which is the gold standard for treatment of cholelithiasis. Current novel minimal access techniques of
natural orifice transluminal endoscopic surgery (NOTES) and single incision laparoscopic surgery (SILS) consolidate on the gains of
better cosmesis, reduced postoperative pain and rapid recovery; however, they are yet to be fully evaluated in terms of comparative
advantage on immunological basis.
Aims: This study aims to compare the immunological changes following the techniques of NOTES and SILS in cholecystectomy with a
view to ascribe relative advantage.
Methods: Literature review of immunological changes following NOTES and SILS from Medline, Cochrane Database, Google and
SpringerLink. Cross references from list of major articles on subject were read with other relevant journals from a laparoscopic
research institute library.
Results: Pneumoperitoneum affects the local peritoneal immune environment resulting in alterations in cytokine production and phagocytic
function. Interleukin-1 (IL-1), tumor necrosis factor and particularly IL-6 are potent systemic mediators of the immune and acute phase
response following surgery. Various animal model studies have shown that NOTES and SILS evoke similar levels of inflammatory
cytokine profiles but for a late-phase tissue necrosis factor-alpha (TNF-alpha) depression with NOTES.
Conclusion: Minimal access techniques of cholecystectomy have reduced immune response compared to open surgery. There is limited
immunological data available comparing NOTES and SILS postcholecystectomy. Large randomized studies are needed to ascribe
immunological advantage between these two techniques of cholecystectomy.
Keywords: Single incision laparoscopic cholecystectomy, NOTES, Immune response.

INTRODUCTION technique of gallbladder removal through a transluminal
endoscopic device. The first description of natural orifice
Surgery evokes complex metabolic, neuroendocrine and transluminal endoscopic surgery (NOTES) is credited to Kallo
immunological responses. These are reparatory but when et al. This has evoked much enthusiasm with the prospect of
6
exaggerated may cause immunosuppression with morbidity and consolidating on the gains of cosmesis, reduced postoperative
mortality. It is well-known that these responses are attenuated pain and rapid recovery. The need to compare the various
in laparoscopic surgery. Cholelithiasis is a major cause of aspects of both techniques thus exists.
morbidity in the Western world with 500,000 and 21,000
cholecystectomies performed annually in the USA and AIMS
Netherland respectively. 1,2 Open cholecystectomy was This study is designed to compare the immunological responses
popularized by Carl Langenbuch in the nineteenth century. 3 following the techniques of NOTES and SILS in chole-
This practice has undergone a paradigm shift in the last two cystectomy with a view to ascribe relative advantage.
decades heralded by the efforts of Eric Muhe and Phillipe Mouret
in 1985 and 1987 respectively, by performing laparoscopic MATERIALS AND METHODS
4,5
cholecystectomy. Laparoscopic cholecystectomy is widely Literature search was conducted using Medline, Cochrane
accepted and presently the gold standard for the treatment of database, Google and SpringerLink. Search words were “NOTES
cholelithiasis. Conventionally, this procedure is carried out surgery”, “single incision laparoscopic cholecystectomy” and
through four ports but more recently through a single incision “immune response”. A selection criterion for further reading
(SILS). Rapid advances in technology have led to a novel was literature written in English language. Cross references,

World Journal of Laparoscopic Surgery, May-August 2011;4(2):85-88 85