Page 15 - WJOLS - Journal of Laparoscopic Surgery

Mohammad O Tabrez et al
umbilicus and epigastrium and 5-mm ports are placed surgery and limits the use of these minimally invasive
at right midclavicular below subcostal margin and ante- techniques to a few centers. Two-port mini LC scores over
rior/midaxillary line at level of umbilicus (Fig. 1). The the conventional techniques as it requires minimal new
main advantages of laparoscopic surgery include better instruments and can be performed at all laparoscopic
cosmetic results, decreased postoperative pain, faster centers without any new cost inputs and simultaneously
functional recovery, and less complications as compared to achieve the goal of minimal access surgery.
with the open surgery. Operative time varies with different studies as few
require less and few more than the conventional tech-
Two-port Mini LC nique. 10-14 The operative difficulty is based on the status
of gallbladder, adhesions around the gallbladder fossa,
In two-port laparoscopic surgery, one 10-mm port is
placed at umbilical area and one 5-mm epigastric port is Calot’s triangle, and cystic duct anatomy. The conversion
rates from two-port mini LC to four-port LC and open
placed to the left of the falciform ligament. One special cholecystectomy in many studies are in the range of 23 to
2.3-mm alligator graspers (Stryker Corporation, USA) 38%. 13,15,16 The main reasons for conversions are difficult
(Fig. 2) is used transabdominally for grasping the Hart- anatomy due to dense inflammation from cholecystitis,
mann pouch of the gallbladder for its retraction and common bile duct injury, and instrument failure. A
manipulation respectively. Using the standard Maryland planned two-port surgery must be given up in the event
laparoscopic instrument, the cystic duct and artery are of such difficult anatomy on initial diagnostic exploration
dissected as in the four-port technique. For clipping the to proceed further with conversion. 17,18
cystic duct and artery, a 5-mm clip applicator was used
with 200-mm clips. In case of wider cystic duct, single Single-incision Laparoscopic Cholecystectomy
hand suturing of the duct was done with 2/0 silk. The or Single-port Access
structures are divided and dissection proceeded by It proposes a single site port placement, and it is in or
reversing the laparoscope and dissecting instruments around umbilicus using a special port devices. This
to their original sites. Gallbladder specimen is retrieved usually requires a larger skin incision of 20 mm. However,
through the umbilical port by railroad technique or using the technique is more demanding as dissection becomes
5-mm 30° scope through the epigastric port and 10-mm more difficult due to clashing of instruments, loss of
jaw forceps from the umbilical port. normal triangulation, restricted vision, and depth of dis-
In two-port mini LC when compared with SILC, section. A special large port, angulated instruments, and
surgery becomes much easier due to restoration of trian- scopes are needed for better dissection (Fig. 3). All these
gulation, and learning curve becomes shorter; however, factors lead to a steeper learning curve and increase the
it causes minimal violation of anterior abdomen due to risk of large scar due to 20-mm port than conventional
less number of port and sizes leading to lesser postopera- port or two-port LC. It increases the postoperative pain
tive pain and less cosmesis when compared with SILC as compared with SILC due to larger port size, and also
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or four-port LC. With the newer techniques, the need there is increased wound-related complications including
for more sophisticated instruments escalates the cost of hernia formation. 4

Fig. 1: Port placement in CLC Fig. 2: Mini alligator for two-port LC

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