Single-Port Cholecystectomy

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Laparoscopic cholecystectomy is a widely performed procedure that has been shown to result in less postoperative pain and a shorter hospital stay than the corresponding open procedure. This article describes a newer approach to laparoscopic cholecystectomy that is referred to as single-port cholecystectomy. [1, 2, 3, 4]

The first laparoscopic cholecystectomy was performed in 1985 by Erich Mühe in the County Hospital of Böblingen, Germany. Mühe’s original technique, especially the maintenance of pneumoperitoneum, proved to be so cumbersome that after performing the first six pure laparoscopic cholecystectomies, he abandoned the optically guided transumbilical approach with pneumoperitoneum for a single 3-cm subcostal incision approach in which the gallbladder was removed under direct visualization. [5, 6]

Since 1985, many competitive approaches have been developed to minimize the invasiveness of laparoscopic cholecystectomies, with surgeons developing instruments and techniques to reduce postoperative pain and improve cosmesis by decreasing the number and size of necessary ports. [7, 8, 9]  The most recent developments in laparoscopic surgery have been the combined advances in orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS), as exemplified here by single-port cholecystectomy. [10]

Indications for single-port cholecystectomy include the following:

In any single-port cholecystectomy, it is important to maintain a low threshold for conversion to a standard laparoscopic cholecystectomy or open cholecystectomy.

Absolute contraindications for single-port cholecystectomy are pregnancy and an American Society of Anesthesiologists (ASA) classification of 3 or 4. Relative contraindications include acute cholecystitis and previous upper abdominal surgical procedures. These patients should not be considered for single-port cholecystectomy, and a standard four-port laparoscopic cholecystectomy should be performed instead.

Qiu et al reviewed 40 studies of 3711 patients who underwent surgery for benign gallbladder diseases between 1997 and 2012. The study concluded that single-port laparoscopic cholecystectomy is safe and effective and leads to better cosmetic results. [12]

In a nonrandomized, age-matched single-center trial comparing the safety of single-port laparoscopic cholecystectomy with that of standard laparoscopic cholecystectomy, [13] van der Linden et al found operating time to be significantly shorter in the single-port group but reported no statistically significant differences between the two groups with respect to complication rate, length of hospital stay, readmission rate, or mortality.

Aprea et al reported successful use of laparoscopic single-site cholecystectomy in the elderly. [14] Rosales-Velderrain et al al found single-port robotic laparoscopic cholecystectomy to be feasible and safe in pediatric patients. [15]

In a randomized controlled trial by Aktimur et al, single-port cholecystectomy using a facilitating maneuver for better exposure was found to be comparable to four-port cholecystectomy with regard to ease of performance, operating time, reproducibility, and patient safety. [16]  Hajong et al reported similar clinical outcomes for the two approaches but noted that operating time was longer for the single-port approach. [17]  

Gumbs AA, Milone L, Sinha P, Bessler M. Totally transumbilical laparoscopic cholecystectomy. J Gastrointest Surg. 2009 Mar. 13(3):533-4. [Medline].

Mutter D, Leroy J, Cahill R, Marescaux J. A simple technical option for single-port cholecystectomy. Surg Innov. 2008 Dec. 15(4):332-3. [Medline].

Pryor AD, Tushar JR, DiBernardo LR. Single-port cholecystectomy with the TransEnterix SPIDER: simple and safe. Surg Endosc. 2010 Apr. 24(4):917-23. [Medline]. [Full Text].

Vemulapalli P, Agaba EA, Camacho D. Single incision laparoscopic cholecystectomy: A single center experience. Int J Surg. 2011. 9(5):410-3. [Medline].

Reynolds W Jr. The first laparoscopic cholecystectomy. JSLS. 2001 Jan-Mar. 5(1):89-94. [Medline]. [Full Text].

Mühe E. Long-term follow-up after laparoscopic cholecystectomy. Endoscopy. 1992 Nov. 24(9):754-8. [Medline].

Kimura T, Sakuramachi S, Yoshida M, Kobayashi T, Takeuchi Y. Laparoscopic cholecystectomy using fine-caliber instruments. Surg Endosc. 1998 Mar. 12(3):283-6. [Medline].

Piskun G, Rajpal S. Transumbilical laparoscopic cholecystectomy utilizes no incisions outside the umbilicus. J Laparoendosc Adv Surg Tech A. 1999 Aug. 9(4):361-4. [Medline].

Li L, Tian J, Tian H, R, Wang Q, Yang K. The efficacy and safety of different kinds of laparoscopic cholecystectomy: a network meta analysis of 43 randomized controlled trials. PLoS One. 2014. 9(2):e90313. [Medline]. [Full Text].

van den Boezem PB, Velthuis S, Lourens HJ, Cuesta MA, Sietses C. Single-incision and NOTES cholecystectomy, are there clinical or cosmetic advantages when compared to conventional laparoscopic cholecystectomy? A case-control study comparing single-incision, transvaginal, and conventional laparoscopic technique for cholecystectomy. World J Surg. 2014 Jan. 38 (1):25-32. [Medline].

Joong Choi C, Roh YH, Kim MC, Choi HJ, Kim YH, Jung GJ. Single-Port Laparoscopic Cholecystectomy for Gall Bladder Polyps. JSLS. 2015 Jul-Sep. 19 (3):[Medline].

Qiu J, Yuan H, Chen S, He Z, Han P, Wu H. Single-Port Versus Conventional Multiport Laparoscopic Cholecystectomy: A Meta-analysis of Randomized Controlled Trials and Nonrandomized Studies. J Laparoendosc Adv Surg Tech A. 2013 Oct. 23(10):815-31. [Medline].

van der Linden YT, Bosscha K, Prins HA, Lips DJ. Single-port laparoscopic cholecystectomy vs standard laparoscopic cholecystectomy: A non-randomized, age-matched single center trial. World J Gastrointest Surg. 2015 Aug 27. 7 (8):145-51. [Medline].

Aprea G, Rocca A, Salzano A, Sivero L, Scarpaleggia M, Ocelli P, et al. Laparoscopic single site (LESS) and classic video-laparoscopic cholecystectomy in the elderly: A single centre experience. Int J Surg. 2016 Sep. 33 Suppl 1:S1-3. [Medline].

Rosales-Velderrain A, Alkhoury F. Single-Port Robotic Cholecystectomy in Pediatric Patients: Single Institution Experience. J Laparoendosc Adv Surg Tech A. 2017 Apr. 27 (4):434-437. [Medline].

Aktimur R, Güzel K, Çetinkünar S, Yıldırım K, Çolak E. Prospective randomized comparison of single-incision laparoscopic cholecystectomy with facilitating maneuver vs. conventional four-port laparoscopic cholecystectomy. Ulus Cerrahi Derg. 2016. 32 (1):23-9. [Medline]. [Full Text].

Hajong R, Hajong D, Natung T, Anand M, Sharma G. A Comparative Study of Single Incision versus Conventional Four Ports Laparoscopic Cholecystectomy. J Clin Diagn Res. 2016 Oct. 10 (10):PC06-PC09. [Medline]. [Full Text].

Ma J, Cassera MA, Spaun GO, Hammill CW, Hansen PD, Aliabadi-Wahle S. Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy. Ann Surg. 2011 Jul. 254(1):22-7. [Medline].

Kroh M, Chalikonda S, Chand B, Walsh RM. Laparoscopic completion cholecystectomy and common bile duct exploration for retained gallbladder after single-incision cholecystectomy. JSLS. 2013 Jan-Mar. 17 (1):143-7. [Medline]. [Full Text].

Allemann P, Demartines N, Schäfer M. Remains of the day: biliary related to single-port laparoscopic cholecystectomy. World J Gastroenterol. 2014 Jan 21. 20(3):843-51. [Medline]. [Full Text].

Lee Y, Roh Y, Kim M, Kim Y, Kim K, Kang S, et al. Analysis of post-operative complication in single-port laparoscopic cholecystectomy: A retrospective analysis in 817 cases from a surgeon. J Minim Access Surg. 2018 Jan 10. [Medline].

Kurt E Roberts,  Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Heather Lynn Yeo, MD Categorical Surgical Resident, Yale University School of Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England

Disclosure: Nothing to disclose.

The thanks his wife, Annette, for her support in writing this article.

Single-Port Cholecystectomy

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