Single-Incision Technique for Cholescystectomy Explored
By Richard Hyer
Elsevier Global Medical News
Single-incision laparoscopic surgery is safe in the hands of experienced surgeons and produces short-term outcomes comparable to those of standard laparoscopic cholecystectomy, based on results of a retrospective study.
“Clearly, laparoscopic cholecystectomy still is the gold standard treatment for gallbladder disease, but SILS [single-incision laparoscopic surgery] may have a role in those patients that want improved cosmesis without sacrificing safety,” said Dr. Jeffrey Fronza at the annual meeting of the Central Surgical Association in Chicago.
The single-incision technique uses the umbilical point of access, and retraction techniques include the Keith needle and needle grasper. Reticulating instruments are commercially available, said Dr. Fronza of Northwestern University, Chicago. “That can be helpful in overcoming the in-line viewing, which is often the problem with the SILS technique,” he explained.
He compared results achieved with the new single-incision procedure performed in 25 patients versus those of traditional laparoscopic cholecystectomy in 25 patients. Three experienced surgeons performed all of the procedures from February 2008 through May 2009.
The patient groups were similar, most patients were female (23 in the single-incision group and 21 in the traditional laparoscopic group), and their median ages were 44 years and 40 years, respectively. The single-incision group had lower body mass indexes (25 kg/m2) than did the traditional laparoscopic group (31 kg/m2). The indications also were similar and included biliary colic, common bile duct (CBD) stone, and pancreatitis. Operative time was longer in the single-incision group: 101 minutes, versus 65 minutes in the traditional laparoscopic group.
The time needed to execute the single-incision technique did not decrease significantly during the study period, said Dr. Fronza. “This may reflect more difficult operative mechanics using the SILS technique, or [the fact] that we’re still at the early part of our learning curve,” he said.
Neither estimated blood loss nor length of stay were significantly different between the two groups, nor was there any significant difference in pain scores on discharge. “The critical view of safety was clearly documented in 24 of the 25 patients who underwent SILS cholecystectomy, and the last patient may have had the critical view obtained, but it was not clearly documented,” said Dr. Fronza.
All patients who underwent standard laparoscopic cholecystectomy had the critical view of safety documented. Four of the 25 single-incision patients (16%) required conversion to laparoscopic cholecystectomy, but finished the procedures without significant unwarranted side effects. There were three readmissions in the single-incision group, all for less than 24 hours. There were two readmissions in the laparoscopic group, one for pneumonia and one for a retained CBD stone.
Dr. Fronza acknowledged the study’s limitations, including small sample size, early learning curve, and relatively short, 30-day follow-up. Despite the 16% conversion rate and the overall longer operative time for the single-incision group, pain and complications were comparable between the two groups, he noted.
Dr. Raymond J. Joehl, an ACS Fellow and director of the surgical residency program at Loyola University Medical Center in Maywood, Ill., asked whether any patients had requested SILS. Dr. Fronza said they had not, but added that hospitals in New York and Philadelphia are marketing the practice.
“This seems to be an industry-driven procedure,” said Dr. Daniel Conway, an ACS Fellow and general surgeon in group practice in Arlington Heights, Ill. “I hope we don't repeat the errors of the early 1990s, where cosmesis drove everything.” He noted that the scars from traditional cholecystectomy were tiny and almost invisible, and expressed concern about the potential for injuring a bile duct.
Another ACS Fellow and general surgeon in group practice in Arlington Heights, Dr. Alan B. Loren, said that for him, the difficulty of performing the single-incision procedure had resulted in severe tennis elbow.
Dr. L. Michael Brunt, an ACS Fellow with Washington University, St. Louis, Mo., asked whether costs were higher in the single-incision group. Admitting that they were, Dr. Fronza said it’s unclear whether the increased costs are worthwhile.
Dr. Fronza reported no relevant financial interests. The study was sponsored by Northwestern University.