Surg Today (2015) 45:305–309 DOI 10.1007/s00595-014-1003-4

ORIGINAL ARTICLE

Single‑incision laparoscopic cholecystectomy for cholecystitis requiring percutaneous transhepatic gallbladder drainage Tsuyoshi Igami · Taro Aoba · Tomoki Ebata · Yukihiro Yokoyama · Gen Sugawara · Masato Nagino 

Received: 1 April 2013 / Accepted: 1 April 2014 / Published online: 21 August 2014 © Springer Japan 2014

Abstract  Purpose Single-incision laparoscopic cholecystectomy (SILC) has been performed for patients with gallbladder stones but without acute cholecystitis. We report our experience of performing SILC for patients with cholecystitis requiring percutaneous transhepatic gallbladder drainage (PTGBD). Methods  We performed SILC via an SILS-Port with additional 5-mm forceps through an umbilical incision in ten patients with cholecystitis requiring PTGBD. Results  All procedures were completed successfully. The mean operative time was 124 min (range 78–169 min) and there were no intraoperative or postoperative complications. The mean postoperative hospital stay was 2.7 days. All patients were satisfied with the cosmetic results. Conclusions  Our procedure may represent an alternative to conventional laparoscopic cholecystectomy (CLC) for patients who fervently demand the cosmetic advantages, despite cholecystitis requiring PTGBD. SILC should be performed carefully to avoid bile duct injury because the only advantage of SILC over CLC is cosmetic. Keywords  Single-incision laparoscopic cholecystectomy · Percutaneous transhepatic gallbladder drainage · Cholecystitis

transhepatic gallbladder drainage (PTGBD) is indicated for severe inflammation, followed by surgery only after the inflammation subsides. Before 2009, we performed open cholecystectomy for patients with cholecystitis requiring PTGBD. Since 2010, we have been performing conventional laparoscopic cholecystectomy (CLC) and a few patients with cholecystitis requiring PTGBD have been managed with CLC in our hospital. After introducing single-incision laparoscopic cholecystectomy (SILC), this procedure was adopted for patients with cholecystitis requiring PTGBD. Since Navarra et al. [2] introduced SILC, numerous reports have been published [3–12]. According to these reports, lifting the fundus of the gallbladder to expose Calot’s triangle is difficult during SILC. When the gallbladder wall is soft without any inflammations, the lifting procedure is easy and promotes successful SILC. Thus, SILC is a suitable procedure for patients with gallbladder stones without any inflammations. Furthermore, as both inflammations and adhesions of Calot’s triangle are recognized as the reasons for SILC failure [12], acute cholecystitis is typically excluded from SILC indication criteria [3–7, 11, 12]. However, we have been performing SILC successfully for patients with cholecystitis requiring PTGBD. This report introduces our technique of SILC for cholecystitis requiring PTGBD and evaluates our initial experience.

Introduction The Tokyo Guidelines recommend antimicrobial therapy as the initial treatment for acute cholecystitis [1]. Percutaneous

Patients and methods Patients

T. Igami (*) · T. Aoba · T. Ebata · Y. Yokoyama · G. Sugawara · M. Nagino  Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai‑cho, Showa‑ku, Nagoya 466‑8550, Japan e-mail: [email protected]‑u.ac.jp

SILC was introduced at Nagoya University Hospital in July 2010. Between that date and November 2012, we performed SILC in 57 patients who had not undergone any other converted procedures. Ten of these patients had

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Table 1  Ten patients who underwent single-incision laparoscopic cholecystectomy for cholecystitis requiring percutaneous transhepatic gallblader drainage Age

Gender

BMI

WBC (/μl)

CRP (mg/dl)

Period between PTGBD and surgery (days)

Operative time (min)

Blood loss (ml)

Postoperative hospital stay (days)

1 2 3 4 5 6 7 8 9

63 42 73 71 50 42 73 40 62

Male Male Male Male Male Male Male Male Female

28.3 32.6 28.0 22.2 25.3 22.4 23.2 21.7 24.6

14300 15400 13800 16200 14800 14200 44100 16200 13900

27.37 32.64 20.12 20.57 17.00 17.45 29.35 25.02 21.15

23 31 33 20 14 36 10 7 21

169 154 95 96 89 167 78 125 127

100 0 0 1 0 30 20 3 12

3 3 2 2 2 3 3 3 3

10

80

Male

32.0

18700

36.42

18

142

0

3

Case

BMI body mass index, WBC white blood cell count, CRP C-reactive protein, PTGBD percutaneous transhepatic gallbladder drainage

cholecystitis requiring PTGBD. This group comprised nine men and one woman with a mean age of 60 years (range 40–80 years). We retrospectively reviewed the clinical records of these ten patients, to evaluate the efficacy and safety of SILC for cholecystitis requiring PTGBD. Definition of cholecystitis The severity of cholecystitis was classified, according to the Tokyo Guidelines, as moderate (grade II) acute cholecystitis in all ten patients [13]. The mean white blood cell count and the mean serum level of C-reactive protein were 18200/μl (range 13800–44100/μl) and 24.71 mg/dl (range 17.00–36.42 mg/dl), respectively (Table 1). All ten patients underwent PTGBD [14] and received antimicrobial therapy [1]. After the local inflammation had subsided and the blood test results had improved, all ten patients underwent surgery [15]. The mean period between PTGBD and SILC was 21.3 days (range 7–36 days). SILC for cholecystitis requiring PTGBD SILC for cholecystitis requiring PTGBD was performed by two surgeons (TI and TA), who had completed the Professional Educational Seminar approved by the Japan Society for Endoscopic Surgery. The patient was placed in the reverse Trendelenburg position with the legs open wide. The operating surgeon stood between the patient’s legs and the assistant surgeon stood on the patient’s left side. A single 2–2.5-cm-long vertical incision was made across the umbilicus, through which an SILS-Port (Covidien) was placed. The three holes of the SILS-Port were placed in the 1, 5, and 9 o’clock positions of the umbilical incision, respectively. After placing three 5-mm ports in the holes

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of the SILS-Port with 12-mmHg pneumoperitoneum using carbon dioxide, a 5-mm flexible scope (Olympus) was inserted through the port positioned at 5 o’clock to explore the abdominal cavity. Next, 5-mm forceps were inserted through the umbilical incision at the 7 o’clock position outside the SILS-Port to lift the fundus (Fig. 1a). A 5-mm flexible instrument for the infundibulum was inserted through the port positioned at 9 o’clock and a 5-mm straight instrument was inserted through the port positioned at 1 o’clock. Standard techniques such as dissection with a hook and/ or bipolar coagulation carry a risk of bile duct injury caused by severe inflammation and/or severe fibrosis of Calot’s triangle in patients with severe cholecystitis. Blunt dissection was attempted initially with forceps, and then with the suction-irrigation apparatus. After dissection in Calot’s triangle with or without distinction between the cystic artery and the cystic duct, the 5-mm port for a straight instrument was changed to a 12-mm port. When the cystic artery could be separated from the cystic duct (Fig. 1b), it was initially cut with clippers. Because a 12-mm clip was not long enough to cut a cystic duct with severe inflammation, the cystic duct was cut using an endoscopic linear stapler (ELS; Fig. 1c). When the cystic artery could not be separated from the cystic duct, encirclement of both the cystic artery and the cystic duct en bloc was required to obtain a so-called “critical view of safety” (Fig. 1d). Thereafter, the cystic artery and the cystic duct were cut together by the ELS (Fig. 1e). After cutting the cystic duct, the PTGBD catheter was removed. No special treatment was necessary for the holes left on the parietal peritoneum and on the liver surface after removal of the PTGBD catheter. The gallbladder was then dissected from the gallbladder bed using laparoscopic coagulating shears (Ethicon) and placed inside the retrieval bag. After irrigating the abdominal cavity, the specimen was removed through

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Fig. 1  Intraoperative findings of single-incision laparoscopic cholecystectomy for patients with cholecystitis requiring percutaneous transhepatic gallbladder drainage. a Additional 5-mm forceps (solid arrow) were inserted through the umbilical incision. b After dissecting in Calot’s triangle, the cystic artery (dotted arrow) could be separated from the cystic duct (solid arrow). c The cystic duct was cut

using an endoscopic linear stapler. d Although the cystic artery (dotted arrow) could not be separated from the cystic duct (solid arrow) after dissection in Calot’s triangle, we could encircle both the cystic artery and the cystic duct en bloc. e After removal of the specimen, there was no bleeding from the cut edges of the cystic duct or cystic artery (solid arrows)

the umbilical incision. The umbilical incision was carefully closed without placing any drainage tubes.

PTGBD. The mean operative time and mean blood loss were 124 min (range 78–169 min) and 17 ml (range 0–100 ml), respectively. None of the patients suffered intraoperative or postoperative complications associated with the surgical procedure. Seven of the ten patients were discharged on postoperative day (POD) 3 and three were discharged on POD 2. All patients were satisfied with the cosmetic results and were well 1 month after surgery at their routine outpatient visit.

Results Table  1 summarizes the clinical characteristics of the ten patients undergoing SILC for cholecystitis requiring

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Discussion Although many SILC procedures have been reported [2–12], most involve lifting the fundus of the gallbladder to expose Calot’s triangle. The two most common lifting procedures require either the placement of two to three percutaneous sutures between the gallbladder and the abdominal wall utilizing a loop retractor [2–6] or the insertion of three umbilical ports utilizing multiport systems and/ or glove methods [7–11]. The lifting procedure with percutaneous sutures is helpful for exposing Calot’s triangle, but it cannot be used in patients with cholecystitis requiring PTGBD. Because the gallbladder wall is thickened by inflammation and/or fibrosis, traction of the gallbladder via the sutured thread could tear the gallbladder wall and/or the gallbladder bed with or without the thread snapping. Conversely, the lifting procedure using the multiport system can be performed in patients with cholecystitis requiring PTGBD because 5-mm straight forceps are used to lift the fundus of the gallbladder similarly to CLC. Furthermore, our procedure, which uses the SILS-Port with additional forceps through the umbilical incision, resembles CLC in the utilization of four ports and it exposes Calot’s triangle [10, 11]. Therefore, our procedure could be well adapted for patients with cholecystitis requiring PTGBD. Because the cystic duct is thickened by inflammation and fibrosis, a 12-mm clip is often not long enough to cut a cystic duct affected by severe inflammation. An ELS is often utilized to cut the neck of the gallbladder in laparoscopic subtotal cholecystectomy [16]; therefore, we selected ELS to cut the cystic duct with severe inflammation. Although the present study involved a limited number of patients, it demonstrated clearly the success of using this procedure, without any intraoperative or postoperative surgery-related complications. It is difficult to establish any benefits of SILC over CLC other than the cosmetic advantages. Previous reports are conflicting, with some data indicating that the level of postoperative pain associated with SILC was significantly lower than that associated with CLC [17], and other data indicating the opposite pattern [18]. Furthermore, the operative time for SILC is longer than that for CLC, while the length of hospital stay is similar for the two procedures CLC [19– 21]. The cost of SILC is greater than that for CLC because it requires special equipment such as the SILS-Port and flexible forceps [12, 19–21]. The benefits associated with SILC are strictly cosmetic, but our procedure seems to be a feasible alternative to CLC for patients who fervently demand cosmetic advantages despite cholecystitis requiring PTGBD. As both SILC and CLC are associated with a potential risk of bile duct injury in patients with cholecystitis requiring PTGBD, we consider that our procedure

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should be performed only in patients with cholecystitis in which dissection of Calot’s triangle is possible. SILC for patients with cholecystectomy requiring PTGBD is more technically demanding than CLC as SILC limits the moving range of instruments to dissect Calot’s triangle and it is difficult to separate the cystic artery from the cystic duct. In this situation, it is important to encircle both the cystic artery and the cystic duct en bloc. The view after encircling (Fig. 1d) is similar to the “critical view of safety”. After making the so-called “critical view of safety”, we can safely use ELS to cut the cystic artery and cystic duct together. In conclusion, our procedure extends the indication criteria for SILC to patients with cholecystitis requiring PTGBD, although its benefits over CLS are strictly cosmetic; therefore, SILC should be performed carefully to avoid intraoperative complications such as bile duct injury. Further investigations are required in large prospective series to establish the safety of this technique and the degree to which it increases patient satisfaction. Conflict of interest  Drs. T. Igami, T. Aoba, T. Ebata, Y. Yokoyama, G. Sugawara, and M. Nagino have no conflicts of interest or financial ties to disclose.

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Single-incision laparoscopic cholecystectomy for cholecystitis requiring percutaneous transhepatic gallbladder drainage.

Single-incision laparoscopic cholecystectomy (SILC) has been performed for patients with gallbladder stones but without acute cholecystitis. We report...
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