DWebmaster Giselle Schneider
Background: The current trend in the world is to minimize the therapeutic trauma in patients, postoperative pain and recovery, and improved cosmetic results. Laparoscopy showed that the response to surgical aggression is directly proportional to the size of the abdominal incision and time exposure of the abdominal cavity during surgery. Cholecystectomy by natural orifices (NOTES) aims at surgery without leaving visible scars. The single-port surgery proves to be a possible alternative.
Objective: To report surgical technique and analyze short-term results.
Application place:Hospital Health Center "Zeno J. Santillan". San Miguel de Tucuman. Argentina.
Population: 25 patients.
Method: From December 2008 to February 2009, 25 patients with cholelithiasis were treated by Umbiliscopic Cholecystectomy (UC) evaluating difficulty surgical technique, operative time, postoperative symptoms, morbidity and degree of aesthetic patient satisfaction.
Results: 6 men, 19 women, mean age 35.5 years (r: 19-55) mean postoperative follow Time: 15 days (r: 1-30) Mean operative time: 50 minutes (r: 40-85). Average Hospital Stay: 1 day (r: 12 am-2 days). Conversion: 0%. Morbidity: 1 wound hematoma (4%). Mortality: 0. Regarding postoperative recovery found similar results to laparoscopic surgery. The aesthetic results reported by the patients were highly satisfactory.
Conclusions: Our initial experience with a short follow-up time, is encouraging and shows
The current trend in the world is to minimize the therapeutic trauma in patients and improve aesthetic results by introducing alternative techniques to traditional surgery. Laparoscopy has shown that the response to surgical aggression is directly proportional to the size of the abdominal incision and time exposure of the abdominal cavity during surgery (1).
In 1998, Dr. Michael Gagner, presented his initial experience in handling mini cholecystectomy instruments, calling needlescopic. (2)
A year later, Dr. Fausto Davila (3), presented at the Congress of SAGES, the first work of a single port cholecystectomy, with the support of per-cutaneous needle and calling it “no footprint”, documenting his experience in different publications (4)
In 2005, with his practice the development of magnetic surgical devices began , to replace the use of per-cutaneous needle (IMANLAP Project).
In March 2007 in Buenos Aires, Argentina, the first laparoscopic cholecystectomy was performed with one trocar, assisted by magnetic surgical devices and instruments designed by Dr. Guillermo Dominguez (5).
In March 2007, Dr. Ricardo Zorron performed the first case of transvaginal cholecystectomy (NOTES) in the University Hospital Teresopolis, Rio de Janeiro, Brazil (6)
In the province of Tucumán, Argentina, thanks to the invention of a minimally invasive surgical instrument kit, we have developed and tested a modification to the approach of laparoscopic cholecystectomy with optimal results.
The minimally invasive surgical instrument kit we use is made of several elements:
Objective: To report the technique and analyze the short-term results.
Material and Methods: Between December 2008 and February 2009, 25 patients diagnosed with gallstones were treated consecutively by Umbiliscopic Cholecystectomy (UC) in the surgical unit III of the Department of General Surgery Hospital Health Center "J. Zeno Santillan" in the city of San Miguel de Tucumán.
Patient selection criteria:
Access device separator of 20 mm diameter multivalvular (4 valves of 10 mm each), with four elastic openings allowing for the insertion of optics plus 3 instruments.
Traditional 10mm optics, 30°. 10 mm Grasper, semi-rigid and flexible with memory positioning and operating end with 360° without losing the angle determined by the surgeon.
Cautery articulated hook, which allows different angles in the surgical field.
Needle like grasper (1.8 mm diameter and head clamp 10 mm) and the rest of traditional laparoscopic instrument, of 5 to 10 mm as needed.
Operative technique: Patient supine reverse Trendelenburg position, rotated slightly to the left. Surgeon between the patient's legs, (French position) Assistants to the left, instrument assistant to right, monitor above patient’s head. (Figure 1) The navel is infiltrated with lidocaine, open Hasson technique, multivalvular single port is introduced and a pneumoperitoneum (12 mmHg) is realized through it.
Via the single port we introduce the optics, the tip for the needle grasper and the setup tool. Exploring concentric cavity. Under direct vision in the right flank, using the needle from our instrument (the needle grasper) a puncture is performed, which is connected at its distal end with the head of the needle grasper assisted by our setup tool (intracorporeal maneuver), and its proximal end is connected to the handle of the needle grasper (extracorporeal maneuver) being ready for use after intraoperative assembly and erection (Figure 2 and 3). In all cases, the head tip of the needle grasper presented pressure as a left hand counter-traction.
Via the single port , the flexible semi-rigid grasper is introduced which holds and moves the bottom of the gallbladder toward subphrenic right exposing the triangle of Calot.
Calot is dissected with the articulated hook, once the cystic duct and cystic artery are correctly identified, two proximal and one distal clip clips on the cystic are placed; using scissors a an incision of the cystic duct is performed. To evaluate the bile duct pressure and transcystic cholangiography, cystic artery is clipped and cholecystectomy is completed with just conventional laparoscopic technique. Wash, vacuum, and control of hemostasis. Under direct vision specimen is extracted through single port and the needle grasper unmounted. Closing surgette aponeurosis with nylon. Points separated from umbilical skin incision.
Statistical analysis: The interventions and data-questionnaire forms: aesthetic satisfaction were held electronically and
6 men, 19 women, mean age was 35.5 years. The mean postoperative follow-up was 15 days (r: 1-30) The average operative time was 50 min. The average hospital stay was 1 day (r: 12 hs- 2 days). There were no conversions to conventional laparoscopic surgery or open surgery nor mortality associated with this new method.
There was one case where a second needle grasper was placed in epigastric which served as a complement to the left hand and as organ mobilizer. The morbidity was 4%: 1 wound hematoma (n = 25). Regarding postoperative recovery we found better results to laparoscopic surgery given that tissue aggression is less and so is the postoperative pain. This allows for a rapid patient recovery and its application in the ambulatory surgery system.
The aesthetic results reported by the patients were highly satisfactory (Figure 1) utes (r: 40-85) (Table surgical time).
The Umbiliscopic Cholecystectomy (UC) is a type of surgical approach rather than a surgical technique because it uses the same principles as laparoscopic surgery. Every surgeon experienced in laparoscopic surgery will not find major obstacles in the learning curve of this surgical apprach.
Unlike transvaginal cholecystectomy (NOTES), the Umbiliscopic Cholecystectomy can be applied to both sexes.
Regarding the management of the new instruments: through an umbilical incision, with one access device (single port) with four working channels, working with semi-rigid ergonomic instrumental allowing movements of angulation and rotation, plus the assistance of a needle grasper, all of this allows for a cholecystectomy surgical of an acceptable speed (Table 1: operating time), demonstrating simplicity in the technique.
While placing accessory ports (trocars) was not necessary in our initial experience, we believe that this type of approach and the instruments used, allow for multiple combinations (for example placing a second needle grasper, etc) before conversion to traditional laparoscopic surgery or conventional open surgery, characterizing the UC as a versatile practice if there were some complication.
The aesthetic result was highly satisfactory. (Graphic 1) (Figures 4.5, 6 and 7)
Seeking long-term results, we have started a prospective and randomized work, comparative with conventional laparoscopic surgery.
In conclusion, given the low morbidity, simplicity of approach, better results to laparoscopic surgery with significant aesthetic benefit coupled with the versatility of the instrument used and inexpensive postoperative recovery, we find the Umbiliscopic Cholecystectomy (UC) as a viable alternative in the minimally invasive surgery.
* Surgeon working in General Surgery Department of Hospital Centro de Salud.
** Urologist Physician, Department of General Surgery, Regional Hospital Conception.
*** Surgeon Medical Director of Hospital Health Center. Head Teaching Assistant. Surgery Chair. UNT.
**** Prof. Adj. Chair of Surgery. UNT. Head of Surgical Unit III. Hospital Health Center.
1. Balagué C, Targarona E M, Trias m. Cirugía Laparoscópica e Infección Quirúrgica. Rev. Esp. de Cir. 2000; 67:184-191.
2. Gagner GM, García-Ruiz A. Technical aspects of minimally invasive abdominal surgery Performed with needlescopic instruments. Surg Laparosc and Endosc 1998; 8: 171-9.
3. Dávila F, Weber A, Dávila U Lemus J, López J, Reyes G, Dominguez V. Laparoscopic Cholecystectomy with only one port (with no trace) : a new technique. Scientific Session Abstracs SAGES. 1999; s29-58.
4. Dávila F. Colecistectomía laparoscópica con un puerto. Cirugía sin huella. México. Edit UNAM-FES Iztacala. 2002: 113-22.
5. Dominguez GM. Asociación Mexicana de Cirugía Endoscópica, A.C. Vol. 8 n°4 Oct-Dic. , 2007: 172-176.
6. Zorron R y col. Surgical Innovation. 2007, Vol.14, n°4:279-283.
Very satisfied: 19 patients (76%)
Satisfied: 4 patients (16%)
Not satisfied: 1 patient (4%)
Dissatisfied: 1 patient (4%)
-Vertical axis: surgical time in minutes.
-Horizontal axis: chronological order of surgery (25 patients).
-Average surgical time: 50 minutes
DWebmaster Giselle Schneider