Single Incision Single Incision Laparoscopic Laparoscopic CholecystectoCholecystectomy: Is it the my: Is it the way to go?way to go?

Clarence MakClarence Mak

Prince of Wales HospitalPrince of Wales Hospital

IntroductionIntroduction

The firstThe first laparoscopic cholecystectomy laparoscopic cholecystectomy was performed in 1987 by Phillip Mouretwas performed in 1987 by Phillip Mouret

Advantages of laparoscopic Advantages of laparoscopic cholecystectomy -less postoperative cholecystectomy -less postoperative painpain

-shorter recovery times-shorter recovery times -better cosmetic results-better cosmetic results Laparoscopic cholecystectomy Laparoscopic cholecystectomy gold standard of care for gallbladder gold standard of care for gallbladder

removalremoval

IntroductionIntroduction

Efforts have been made to further Efforts have been made to further reduce surgical access traumareduce surgical access trauma

Reducing wound sizeReducing wound size

needlescopic surgery (2-3mm port needlescopic surgery (2-3mm port

size)size) Reducing wound numberReducing wound number

single incision laparoscopic surgerysingle incision laparoscopic surgery

The single incision technique for The single incision technique for laparoscopic cholecystectomy was first laparoscopic cholecystectomy was first described in 1997 by Navarra et aldescribed in 1997 by Navarra et al

10mm trocars placed inside a single 10mm trocars placed inside a single umbilical incision, and 3 trans-abdominal umbilical incision, and 3 trans-abdominal stay sutures to aid in gallbladder stay sutures to aid in gallbladder retractionretraction

Navarra G, Pozza E, Occhionorelli S, et al. One-woundNavarra G, Pozza E, Occhionorelli S, et al. One-woundlaparoscopic cholecystectomy. Br J Surg. 1997;84:695.laparoscopic cholecystectomy. Br J Surg. 1997;84:695.

Different Methods/ Different Methods/ Variations of SILCVariations of SILC

Multiple trocars/ ports placed side by Multiple trocars/ ports placed side by side via a single long umbilical side via a single long umbilical incision of 1.5 incision of 1.5 –– 2.0cm 2.0cm

Special techniques such as sutures Special techniques such as sutures and hooks to replace retraction and hooks to replace retraction instruments, reducing the number of instruments, reducing the number of instruments requiredinstruments required

Different Methods/ Different Methods/ Variations of SILCVariations of SILC

Special Special access access devices for devices for the the introduction introduction of of laparoscope laparoscope and multiple and multiple instrumentsinstruments

Proposed benefits of Proposed benefits of SILCSILC Fewer port sites with a reduced Fewer port sites with a reduced

risk of wound infectionrisk of wound infection Faster recoveryFaster recovery Less post-operative painLess post-operative pain Improved cosmesisImproved cosmesis

Possible Possible disadvantages of SILCdisadvantages of SILC

Technical challengesTechnical challenges

-Conflicts between instruments-Conflicts between instruments ““Sword Sword fightingfighting””

-Reduced triangulation-Reduced triangulation Steep learning curveSteep learning curve Prolonged operation timeProlonged operation time Safety concernSafety concern

Decreased visualization or exposure, ? Decreased visualization or exposure, ? leading to an increased risk of CBD injuriesleading to an increased risk of CBD injuries

Review of current Review of current evidenceevidence

Conversion rateConversion rate Operation timeOperation time PainPain CosmesisCosmesis Complications & Bile Duct Injury Complications & Bile Duct Injury

RateRate

Conversion rateConversion rate

Conversion rateConversion rate

Single-incision laparoscopicSingle-incision laparoscopic

cholecystectomy: a systematic reviewcholecystectomy: a systematic reviewStavros A. Antoniou,   Rudolph Pointner and Stavros A. Antoniou,   Rudolph Pointner and 

Frak A. GranderathFrak A. Granderath

Surg Endoscopy (2011) 25: 367-377Surg Endoscopy (2011) 25: 367-377

•29 studies including 1166 patients in total

•Success rate of 90.7 % (conversion rate 9.3%)

• 0.4% of patients required conversion to open surgery0.4% of patients required conversion to open surgery

•Common reasons for technical failureCommon reasons for technical failureobscure anatomy of the Calotobscure anatomy of the Calot’’s triangle due tos triangle due to adhesions, acute or chronic inflammation (5.2%)adhesions, acute or chronic inflammation (5.2%)inadequate exposure of the Calotinadequate exposure of the Calot’’s triangle due tos triangle due to insufficient gallbladder retraction (2.6%)insufficient gallbladder retraction (2.6%)

Conversion rateConversion rate

•8 of included prospective RCTs reported on conversion rates8 of included prospective RCTs reported on conversion rates

•SILC groupSILC group 9.63% 9.63%

•Conventional LC groupConventional LC group 0.67% 0.67%

•Meta-analysis of conversions confirmed the results with a Meta-analysis of conversions confirmed the results with a pooled OR of pooled OR of

7.177.17ANZ J Surg 82 (2012) 303-310

Operation timeOperation time

Operation timeOperation time

•Thirteen of the RCTs reported on the length of operationThirteen of the RCTs reported on the length of operation

•One study showed a mean time of 88.5min in SILC vs 44.8min One study showed a mean time of 88.5min in SILC vs 44.8min in conventional LC in conventional LC

•Pooled estimatePooled estimate mean difference of 11.6 in favour of mean difference of 11.6 in favour of conventional LCconventional LC

Surg Laparosc Endosc Percutan Tech Surg Laparosc Endosc Percutan Tech 2012;22:4872012;22:487––497497

Operation timeOperation time

•Operative times tended to be longer in studies enrolling Operative times tended to be longer in studies enrolling patients with a patients with a BMI > 30kg/m2BMI > 30kg/m2 (83.4 vs 74.5) (83.4 vs 74.5)

•Acute cholecystitisAcute cholecystitis as an inclusion criteria resulted in an as an inclusion criteria resulted in an increase of surgical time (78.1 vs 70.6min)increase of surgical time (78.1 vs 70.6min)

Operative timeOperative time

Sources of bias:Sources of bias:Steep part of learning curve when small Steep part of learning curve when small

studies were published during early studies were published during early experience of SILCexperience of SILC

Included studies with a Included studies with a wide variation wide variation of technical methods of technical methods with regard to with regard to the number, type, and size of the trocars, the number, type, and size of the trocars, the instrumentation, and the preferred the instrumentation, and the preferred method of gallbladder anchorage and method of gallbladder anchorage and exposure of the Calotexposure of the Calot’’s triangles triangle

Pain Pain

Pain Pain

•40 patients included in this RCT40 patients included in this RCT

•Assessment of post-op painAssessment of post-op pain

-visual analog scale (1-10)-visual analog scale (1-10)

-2, 4, 6, 12, 24, 48, 72 hours postoperatively-2, 4, 6, 12, 24, 48, 72 hours postoperatively

•Significantly lower abdominal pain scores observed in SILS group > 12 Significantly lower abdominal pain scores observed in SILS group > 12

hourshours

•Total pain non-existent after the first 24 hour in SILS groupTotal pain non-existent after the first 24 hour in SILS group

•Request for analgesics significantly less in SILS groupRequest for analgesics significantly less in SILS group

Pain Pain

Pain Pain

•51 patients with symptomatic 51 patients with symptomatic gallstones or GB polyps gallstones or GB polyps randomizedrandomized

• Difference in pain score of 1 Difference in pain score of 1 in the visual analog scale (1-in the visual analog scale (1-10)10)

•Statistically significant, but Statistically significant, but clinical significance to be clinical significance to be determineddetermined

CosmesisCosmesis

CosmesisCosmesis

•Difference in cosmetic score Difference in cosmetic score at 3 months after surgery of 1at 3 months after surgery of 1

CosmesisCosmesis

•6 of the included RCTs examined cosmesis at 1 month6 of the included RCTs examined cosmesis at 1 month

•Pooled analysis showed improved cosmesis in SILC group at 1 Pooled analysis showed improved cosmesis in SILC group at 1 monthmonth

Surg Laparosc Endosc Percutan Tech 2012;22:487Surg Laparosc Endosc Percutan Tech 2012;22:487––497497

CosmesisCosmesis

RCTRCTpatients not blinded, leading to biaspatients not blinded, leading to bias

Meta-analysisMeta-analysisPatient only given chance to rate own Patient only given chance to rate own

scars, with no chance to compare scars, with no chance to compare cosmetic result of another procedurecosmetic result of another procedure

Short follow-up times in most studies Short follow-up times in most studies with time dependent changes with time dependent changes (scarring) not assessed(scarring) not assessed

Complications & Bile Complications & Bile Duct Injury Duct Injury

ComplicationsComplications

•Complication rate 6.1%Complication rate 6.1%

•Common intra-operative complicationsCommon intra-operative complications

- gallbladder perforation/ bile spillage (2.2%)- gallbladder perforation/ bile spillage (2.2%)

- hemorrhage (0.3%)hemorrhage (0.3%)

•Common post operative complicationsCommon post operative complications

-wound infection and hematoma (2.1%)-wound infection and hematoma (2.1%)

-bile leakage (0.4%)-bile leakage (0.4%)

ComplicationsComplications

Annals of Surgery Annals of Surgery Volume 256, Number 1, July Volume 256, Number 1, July 20122012

•45 studies included, total of 2626 patients

ResultsResults

Complication Complication raterate

- complications were complications were graded according to graded according to the Dindo-Clavien the Dindo-Clavien Classification Classification System System

- aggregate - aggregate complication rate complication rate was 4.2%was 4.2%

ResultsResults

Bile Duct InjuryBile Duct Injury

Bile duct injuries were Bile duct injuries were classified according to the classified according to the Strasberg Bile Duct Injury Strasberg Bile Duct Injury ClassificationClassification

Nineteen bile duct injuries Nineteen bile duct injuries were identified for awere identified for a SILC-associated bile SILC-associated bile duct injury rate of duct injury rate of 0.72%.0.72%.

58% (11 out of the 19) 58% (11 out of the 19) were categorized as type were categorized as type AA

ComplicationsComplications

Short follow-up periodsShort follow-up periods

Long term wound Long term wound complications such as complications such as incisional hernia incisional hernia could not be could not be assessedassessed

Bile Duct InjuryBile Duct Injury

Accepted historic bile duct injury Accepted historic bile duct injury rate of 0.4% to 0.5% for standard rate of 0.4% to 0.5% for standard laparoscopic cholecystectomy*laparoscopic cholecystectomy*

0.76% for SILC0.76% for SILC

*Nuzzo G, Giuliante F, Giovannini I, et al. Bile duct injury during laparoscopiccholecystectomy: results of an Italian national survey on 56 591 cholecystectomies.Arch Surg. 2005;140:986–992.Waage A, Nilsson M. Iatrogenic bile duct injury: a population-based studyof 152,776 cholecystectomies in the Swedish Inpatient Registry. Arch Surg.2006;141:1207–1213.Flum DR, Dellinger EP, Cheadle A, et al. Intraoperative cholangiographyand risk of common bile duct injury during cholecystectomy. JAMA.2003;289:1639–1644.

However, the rate of However, the rate of bile duct injuries may bile duct injuries may even be higher, even be higher, sincesince…………..

1. Most SILCs performed under ideal 1. Most SILCs performed under ideal conditionsconditions

absence of acute cholecystitis absence of acute cholecystitis (90.6%)(90.6%)

2. Publication bias2. Publication bias compilation of results using compilation of results using

multiple small studiesmultiple small studies important negative events important negative events

(i.e. bile duct injury) (i.e. bile duct injury) underreportedunderreported

Bile Duct InjuryBile Duct Injury

Is there a more accurate way to know Is there a more accurate way to know the exact incidence?the exact incidence?

Low incidence of bile duct injury Low incidence of bile duct injury known (0.4%)known (0.4%)

High powered randomized controlled High powered randomized controlled study not feasible since a large study not feasible since a large number of patients would have to be number of patients would have to be enrolled (i.e up to thousands)enrolled (i.e up to thousands)

Is SILC the way to Is SILC the way to go?go?

Conventional laparoscopic Conventional laparoscopic cholecystectomy is a well cholecystectomy is a well established technique with established technique with satisfactory outcome and satisfactory outcome and hard to improve uponhard to improve upon

Cosmesis being a major Cosmesis being a major attraction of SILCattraction of SILC

““As surgeons, As surgeons, should we should we advocate for an advocate for an improved cosmetic value improved cosmetic value over safetyover safety??””

To concludeTo conclude……....

• Limited evidence on SILC vs conventional Limited evidence on SILC vs conventional LC may have shown improved pain and LC may have shown improved pain and cosmesiscosmesis

• Incidence of bile duct injury apparently Incidence of bile duct injury apparently higher, with exact incidence still unknown higher, with exact incidence still unknown

• Until there is further data to suggest that Until there is further data to suggest that SILC is as safe as conventional LC, it should SILC is as safe as conventional LC, it should not be adopted as a routine surgical not be adopted as a routine surgical procedure for the removal of gallbladder procedure for the removal of gallbladder

• SILC is an exciting technological SILC is an exciting technological advancement in minimally invasive advancement in minimally invasive surgerysurgery

• Development of new instruments to Development of new instruments to overcome technical barriers, such as overcome technical barriers, such as curved instruments, may make SILC curved instruments, may make SILC easier and safer to perform in the easier and safer to perform in the futurefuture

Thank youThank you

With a special thanks to my With a special thanks to my mentors:mentors:Dr. KF Lee, Dr. Sunny CheungDr. KF Lee, Dr. Sunny Cheung& Dr. HC Yip& Dr. HC YipHBP team, PWH SurgeryHBP team, PWH Surgery