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Asian J Endosc Surg ISSN 1758-5902
O R I G I N A L A RT I C L E
Single-incision multiport laparoendoscopic surgery using a short-type flexible endoscope and its usefulness in cholecystectomy Takashi Yamaguchi,1 Nobutsugu Abe,2 Shuuichiro Matsunobu,3 Hideaki Mizuno,4 Osamu Yanagida,1 Hirohisa Takeuchi,2 Tadahiko Masaki,2 Toshiyuki Mori2 & Masanori Sugiyama2 1 Department of Surgery, Nakanokouseikai General Hospital, Tokyo, Japan 2 Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan 3 Department of Surgery, Seibo General Hospital, Tokyo, Japan 4 Department of Surgery, Mejiro Second General Hospital, Tokyo, Japan
Keywords flexible endoscope; laparoscopic surgery; single incision Correspondence Nobutsugu Abe, Department of Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan. Tel: +81 422 47 5511 Fax: +81 422 47 9926 Email: [email protected] Received 21 August 2014; revised 12 September 2014; accepted 21 September 2014 DOI:10.1111/ases.12148
Abstract Introduction: We previously demonstrated the advantages of a short-type flexible endoscope as a working scope in laparoscopic surgery through singleincision procedures in animal experiments. In this report, we examined the outcomes of laparoscopic surgery through a single incision using a flexible endoscope in a clinical setting. Specifically, we performed cholecystectomy using single-incision multiport laparoendoscopic (SIMPLE) surgery. Methods: Thirteen patients with cholecystolithiasis or gallbladder polyp underwent SIMPLE cholecystectomy using a newly developed short-type flexible endoscope with a working length of 60 cm. Twenty-seven patients underwent standard single-incision laparoscopic cholecystectomy using a 5-mm rigid laparoscope. We retrospectively compared the surgical outcomes between the two groups. Results: SIMPLE cholecystectomy using the short-type flexible endoscope was successfully carried out. No gallbladder perforation occurred, but perforation occurred in four cases in the standard laparoscopic cholecystectomy group; however, the difference was not statistically significant. Although no other surgical outcomes differed between the two groups, the flexible endoscope had several advantages over the standard laparoscope. The scope provided a flexible view of the operating field. The gallbladder dissection using the cutting device via the scope was easier and safer than that in standard single-incision laparoscopic cholecystectomy. The water-jet, suctioning, and self-cleaning lens functions of the scope served the surgery well. Conclusions: SIMPLE cholecystectomy using a short-type flexible endoscope has surgical outcomes equivalent to those of standard single-incision laparoscopic cholecystectomy, but this endoscope with multiple functions may make the surgical procedures less stressful and safer.
Introduction Laparoscopic surgery through a single incision and reduced port surgery have been used to treat various conditions in recent years (1–5). Although the surgical safety of these procedures has been verified in several clinical trials, such surgery has disadvantages (1,2,5),
including the increased surgeon stress and technical difficulty, when compared with conventional multiport laparoscopic surgery (6). Furthermore, the interference between different forceps or between forceps and the laparoscope often disturbs the visual field. Our animal experiments revealed that use of a flexible endoscope instead of a standard laparoscope during
Asian J Endosc Surg •• (2014) ••–•• © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
1
Flexible endoscopy-assisted surgery
T Yamaguchi et al.
Table 1 Patients backgrounds
Gender, M:W (n) Mean age (range), years Diagnosis (n) Cholecystolithiasis Gallbladder polyp Acute cholecystitis
SIMPLE group (n = 13)
Standard group (n = 27)
7:6 53 (22–81)
8:19 51 (29–83)
11 1 1
25 1 1
M, men; SIMPLE, single-incision multiport laparoendoscopic; W, women.
Figure 1 Schematic of single-incision multiport laparoendoscopic cholecystectomy. Arrow, the newly developed short-type flexible endoscope; arrowhead, the small diameter grasping forceps.
laparoscopic surgery through a single incision might resolve some of these problems (7,8). A flexible endoscope has several functions, including increased flexibility, forward water jet, suction, forceps channel, and self-cleaning lens, that a standard laparoscope lacks. These functions may make laparoscopic surgery through a single incision safer and easier (8,9). We have employed this type of surgery (laparoscopic surgery through a single incision using a flexible endoscope) to remove the gallbladder in clinical settings (Figure 1). We call this type of surgery single-incision multiport laparoendoscopic (SIMPLE) surgery. The purpose of this study was to retrospectively investigate the surgical outcomes of SIMPLE cholecystectomy and to determine its usefulness.
Patients and Methods Thirteen patients underwent SIMPLE cholecystectomy between November 2011 and October 2012. The patients included seven men and six women with a mean age of 53 years (range, 22–81 years) (Table 1). Before SIMPLE
2
cholecystectomy was performed, each patient provided informed consent. Twelve patients had symptomatic cholecystolithiasis not accompanied by severe cholecystitis and one patient had a benign gallbladder polyp (Table 1). Additionally, 27 patients underwent standard singleincision laparoscopic cholecystectomy using a rigid laparoscope between October 2009 and October 2011. There were 8 men and 19 women with a mean age of 51 years (range, 29–83 years). In this group, 26 patients had cholecystolithiasis and 1 patient had a benign gallbladder polyp (Table 1). We retrospectively compared the surgical outcomes between SIMPLE cholecystectomy and standard singleincision laparoscopic cholecystectomy. The surgical outcomes included operating time, estimated blood loss, time taken to dissect the gallbladder (the time from transection of the cystic artery and duct until complete dissection of the gallbladder from its fossa), presence of intraoperative gallbladder injury, number of times the scope had to be reinserted, postoperative complications, and duration of postoperative hospital stay. Data were compared using the Fisher’s exact tests, nonparametric tests, or the Wilcoxon rank sum test. Techniques of SIMPLE cholecystectomy A newly developed short-type flexible endoscope (ELK2990i; Hoya Pentax, Nakano, Japan) was used as a working scope in SIMPLE cholecystectomy (Figure 2) (9). The scope has a megapixel charge-coupled device mounted on the distal end, a 600-mm working length, a 2.8-mm working channel, a 58-mm length of bending section, a diameter of 10.8 mm, tip deflection of 210° up/120° down/120° right/120° left, an lens-cleaning function, a forward water-jet function, and a suctioning function. The four-way tip deflection increases the operating range and helps create a broad field of view. An EZ Access port (Hakko, Nagano, Japan) that was 75 mm in diameter was placed in the mini-laparotomy (3 cm in length) in the umbilicus. The short-type flexible endoscope was inserted via a 12-mm trocar (Versaport
Asian J Endosc Surg •• (2014) ••–•• © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Flexible endoscopy-assisted surgery
T Yamaguchi et al.
The scope operator was a gastroenterological surgeon (NA) well experienced both in laparoscopic surgery and advanced endoluminal endoscopic interventions (7–9). The scope operator simply manipulated the scope and performed procedures using endoscopic devices; however, different surgeons (TY, n = 7; SM, n = 3; HM, n = 3) performed the other procedures. Techniques for standard single-incision laparoscopic cholecystectomy Figure 2 The short-type flexible endoscope.
An EZ Access port was placed in the mini-laparotomy (3 cm in length) in the umbilicus. A 5-mm rigid laparoscope (LTF Type VP; Olympus, Tokyo, Japan) inserted via a 5-mm trocar placed in the EZ Access was used to establish the operating field. A 3-mm port and 5-mm port were placed and used as working trocars. The gallbladder fundus was elevated with small diameter forceps via the EZ Access. A monopolar hook device was used for dissection of the gallbladder from its fossa.
Results
Figure 3 The endoscopic cutting device, Mucosectom.
Plus; Covidien, Mansfield, USA) placed in the EZ Access. The gallbladder fundus was elevated with a small diameter grasping forceps via the EZ Access port (Figure 1). Two additional 5-mm trocars placed into the EZ Access port as working trocars. After dissection of Calot’s triangle, cholecystectomy was conducted at the neck to the fundus. Intraoperative cholangiography was selectively performed. During SIMPLE cholecystectomy, we used the functions of the short-type flexible endoscope proactively. The forward water-jet function of the scope was used to confirm bleeding points and for intraperitoneal irrigation, and the suction function was used to aspirate smoke, blood, and fluid after intraperitoneal irrigation. In some cases (n = 3), an endoscopic grasping forceps was inserted via the working channel in the endoscope to assist the surgery. The Mucosectom (Hoya Pentax), an endoscopic cutting device (Figure 3), was also inserted via the channel in the scope and used for dissection of the gallbladder from its fossa in all cases.
SIMPLE cholecystectomy was successfully carried out without any intraoperative complications. The mean operating time and estimated blood loss were 111 min (range, 82–176 min) and 3 mL (range, 3–75 mL), respectively (Table 2). None of the patients developed postoperative complications, such as hemorrhage, bile leakage, or surgical-site infection (Table 2). In SIMPLE cholecystectomy, J-turn view by the endoscope enabled us to confirm that the EZ Access port was adequately placed and that the trocars and forceps did not injure any organs (Figure 4a). The scope was useful for developing the operating field to ensure the critical view of safety and for completing the surgical procedure thereafter. The scope enabled us to confirm that the entire width of blood vessels and cystic ducts was clipped (Figure 4b). While the scope and the instruments often crowded, it was generally easier to maintain the operating field with the flexible endoscope than with the standard rigid laparoscope. Inserting the grasping forceps and endoscopic cutting device (Mucosectom) via the scope facilitated various surgical procedures. For example, the grasping forceps was used for catheterization in the cystic duct in intraoperative cholangiography (Figure 4c). During gallbladder dissection, the tip of the scope could be delivered into the space between the gallbladder and its fossa, and dissection by the Mucosectom could easily be completed without gallbladder perforation (Figure 4d). The water-jet function of the flexible endoscope rapidly supplied saline, which facilitated identification of
Asian J Endosc Surg •• (2014) ••–•• © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
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Flexible endoscopy-assisted surgery
T Yamaguchi et al.
Table 2 Operative outcomes
Operating time (range), min Duration of GB dissection (range), min Estimated blood loss (range), mL Number of times the scope had to be reinserted Intraoperative GB perforation (n) Postoperative complications (n) Duration of postoperative hospital stay (range), days
SIMPLE group (n = 13)
Standard group (n = 27)
P-value
111 (82–176) 27 (4–57) 9 (3–75) 3 0 0 4 (3–5)
113 (61–189) 28 (7–65) 10 (3–200) 3 4 0 4 (3–10)
NS NS NS NS NS NS NS
GB, gallbladder; NS, not significant; SIMPLE, single-incision multiport laparoendoscopic.
Figure 4 Procedures for SIMPLE cholecystectomy using the short-type flexible endoscope. (a) Under J-turned endoscopic observation, two additional trocars (arrows) and a small diameter grasping forceps (arrowhead) were introduced into the peritoneal cavity through the EZ Access port. (b) Endoscopic view during clipping of the cystic duct using the 5-mm clip applier (arrowhead). (c). Endoscopic view during intraoperative cholangiography. The grasping forceps (arrowhead) inserted via the flexible endoscope could be used to aid insertion of the catheter into the cystic duct (arrow). (d) Endoscopic view of the Mucosectom (arrow), which was inserted via the endoscope, dissecting the gallbladder from its fossa. GB, gallbladder; SIMPLE, single-incision multiport laparoendoscopic.
the bleeding points in hemostasis. The self-cleaning lens function maintained a clearly visible surgical field while the suction function enabled us to evacuate smoke and fluid. A comparison of the surgical outcomes between the SIMPLE group and the standard single-incision laparoscopic cholecystectomy group revealed no significant differences in operating time, duration of gallbladder dissection, number of times the scope had to be reinserted, estimated blood loss, or duration of postoperative hospital stay (Table 2). No gallbladder perforation occurred in the SIMPLE group, but there were four cases of perforation in the standard group; however, the difference did not reach statistical significance (Table 2).
Discussion In the present study, the surgical outcomes were not significantly different between the SIMPLE and standard
4
laparoscopic surgery through a single incision groups in terms of the overall operating time, time taken to dissect the gallbladder, or the number of times the scope had to be replaced. However, the use of a short-type flexible endoscope rather than standard laparoscope actually provided many merits, including the following (9): (i) the J-turned endoscopic view allowed for the safe insertion of trocars; (ii) the scope could be flexed at its tip to acquire a good view of the operating field; (iii) the scope allowed some degree of freedom to the working laparoscopic instruments without compromising the field of view; (iv) crowding of the laparoscopic instruments and the scope in the outside of the EZ Access could be minimized; (v) the scope working channel enabled the use of another endoscopic device such as the Mucosectom; (vi) inserting devices and laparoscopic instruments via the scope enabled triangulation during dissection; (vii) excess smoke from diathermic cautery could be actively evacuated by the endoscopic suctioning function; and (viii) the
Asian J Endosc Surg •• (2014) ••–•• © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Flexible endoscopy-assisted surgery
T Yamaguchi et al.
water-jet function enabled easy identification of bleeding sites. These advantages contributed to the reduction of surgeon stress. In contrast to the standard group, no gallbladder injuries occurred in the SIMPLE group, but there was no significant difference in this regard. The Mucosectom, an endoscopic submucosal dissection device used in the SIMPLE surgery, has an insulated part that decreases current to the external parts and reduces the risk of gallbladder injuries (10). In addition, the flexible endoscope has a localized magnifying effect. The tip of the scope can be delivered into the space between the gallbladder and its fossa. In this study, meticulous dissection by the Mucosectom prevented gallbladder injury. Moreover, inserting the Mucosectom and the laparoscopic instruments via the scope enabled triangulation during operations. Based on the above considerations, SIMPLE cholecystectomy is effective for reducing injuries to the gallbladder wall. Despite these benefits, the flexible endoscope’s large size (approximately 10-mm diameter) may present a disadvantage. It requires a trocar with a diameter greater than 11 mm. Also, surgical cooperation becomes more complex because the scope operator must perform various manipulations. However, increased experience can strengthen surgical cooperation, which contributes to shortened operating time and improved maneuverability. In recent years, NOTES has emerged. NOTES involves the introduction of a flexible endoscope via natural openings, such as the stomach, rectum, or vagina, to facilitates surgical procedures (11). This new technique has been used clinically in thousands of patients around the world and may replace conventional laparoscopic surgery (12–18). The SIMPLE surgical technique was derived from NOTES and can be considered to be an intermediary between NOTES and laparoscopic surgery through a single incision (8–10). Thus, SIMPLE surgery is a useful technique that may represent an important step toward the popularization and dissemination of NOTES. In conclusion, SIMPLE cholecystectomy using a shorttype flexible endoscope has surgical outcomes equivalent to those of standard single-incision laparoscopic cholecystectomy, but the endoscope offers multiple functions that may make surgical procedures less stressful and safer.
Acknowledgment The authors do not have any conflicts of interest to disclose and received no financial support for this study.
References 1. Podolsky ER & Curcillo PG 2nd. Reduced-port surgery: Preservation of the critical view in single-port-access cholecystectomy. Surg Endosc 2010; 24: 3028–3043. 2. Pfluke JM, Parker M, Stauffer JA et al. Laparoscopic surgery performed through a single incision: A systemic review of the current literature. J Am Coll Surg 2010; 212: 113–118. 3. John PH, Thanakumar J, Krishnan A. Reduced port laparoscopic repair of Bochdalek hernia in an adult: A first report. J Minim Access Surg 2012; 8: 158–160. 4. Kunisaki C, Ono HA, Oshima T et al. Relevance of reducedport laparoscopic distal gastrectomy for gastric cancer: A pilot study. Dig Surg 2012; 29: 261–268. 5. Monclova JL, Targarona EM, Vidal P et al. Single incision versus reduced port splenectomy-searching for the best alternative to conventional laparoscopic splenectomy. Surg Endosc 2013; 27: 895–902. 6. Joseph M, Phillips MR, Farrell TM et al. Single incision laparoscopic cholecystectomy is associated with a higher bile duct injury rate: A review and a word of caution. Ann Surg 2012; 256: 1–6. 7. Abe N, Takeuchi H, Ueki H et al. Cholecystectomy by a combined transgastric and transparietal approach using two flexible endoscopes. J Hepatobiliary Pancreat Surg 2009; 16: 25–30. 8. Abe N, Takeuchi H, Ueki H et al. Single-port endoscopic cholecystectomy: A bridge between laparoscopic and translumenal endoscopic surgery. J Hepatobiliary Pancreat Surg 2009; 16: 633–638. 9. Abe N, Takeuchi H, Ohki A et al. Single-incision multiport laparoendoscopic surgery using a newly developed shorttype flexible endoscope: A combined procedure of flexible endoscopic and laparoscopic surgery. J Hepatobiliary Pancreat Sci 2012; 19: 426–430. 10. Kawahara Y, Hori K, Takenaka R et al. Endoscopic submucosal dissection of esophageal cancer using the Mucosectom2 device: A feasibility study. Endoscopy 2013; 45: 869–875. 11. Auyang ED, Santos BF, Enter DH et al. Natural orifice translumenal endoscopic surgery (NOTES): A technical review. Surg Endosc 2011; 25: 3135–3148. 12. Khashab MA & Kalloo AN. Natural orifice translumenal endoscopic surgery. Curr Opin Gastroenterol 2010; 26: 471– 477. 13. Zorron R, Palanivelu C, Galvao Neto MP et al. International multicenter trial on clinical natural orifice surgery–NOTES IMTN study: Preliminary results of 362 patients. Surg Innov 2010; 17: 142–158. 14. Lehmann KS, Ritz JP, Wibmer A et al. The German registry for natural orifice translumenal endoscopic surgery: Report of the first 551 patients. Ann Surg 2010; 252: 263–270. 15. Wood SG, Panait L, Duffy AJ et al. Complications of transvaginal natural orifice transluminal endoscopic surgery: A series of 102 patients. Ann Surg 2014; 259: 744– 749.
Asian J Endosc Surg •• (2014) ••–•• © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
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16. Horgan S, Meireles OR, Jacobsen GR et al. Broad clinical utilization of NOTES: Is it safe? Surg Endosc 2013; 27: 1872– 1880. 17. Mofid H, Emmermann A, Alm M et al. Is the transvaginal route appropriate for intra-abdominal NOTES procedures?
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Experience and follow-up of 222 cases. Surg Endosc 2013; 27: 2807–2812. 18. Arezzo A, Zornig C, Mofid H et al. The EURO-NOTES clinical registry for natural orifice transluminal endoscopic surgery: A 2-year activity report. Surg Endosc 2013; 27: 3073–3084.
Asian J Endosc Surg •• (2014) ••–•• © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Asian J Endosc Surg ISSN 1758-5902
O R I G I N A L A RT I C L E
Single-incision multiport laparoendoscopic surgery using a short-type flexible endoscope and its usefulness in cholecystectomy Takashi Yamaguchi,1 Nobutsugu Abe,2 Shuuichiro Matsunobu,3 Hideaki Mizuno,4 Osamu Yanagida,1 Hirohisa Takeuchi,2 Tadahiko Masaki,2 Toshiyuki Mori2 & Masanori Sugiyama2 1 Department of Surgery, Nakanokouseikai General Hospital, Tokyo, Japan 2 Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan 3 Department of Surgery, Seibo General Hospital, Tokyo, Japan 4 Department of Surgery, Mejiro Second General Hospital, Tokyo, Japan
Keywords flexible endoscope; laparoscopic surgery; single incision Correspondence Nobutsugu Abe, Department of Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan. Tel: +81 422 47 5511 Fax: +81 422 47 9926 Email: [email protected] Received 21 August 2014; revised 12 September 2014; accepted 21 September 2014 DOI:10.1111/ases.12148
Abstract Introduction: We previously demonstrated the advantages of a short-type flexible endoscope as a working scope in laparoscopic surgery through singleincision procedures in animal experiments. In this report, we examined the outcomes of laparoscopic surgery through a single incision using a flexible endoscope in a clinical setting. Specifically, we performed cholecystectomy using single-incision multiport laparoendoscopic (SIMPLE) surgery. Methods: Thirteen patients with cholecystolithiasis or gallbladder polyp underwent SIMPLE cholecystectomy using a newly developed short-type flexible endoscope with a working length of 60 cm. Twenty-seven patients underwent standard single-incision laparoscopic cholecystectomy using a 5-mm rigid laparoscope. We retrospectively compared the surgical outcomes between the two groups. Results: SIMPLE cholecystectomy using the short-type flexible endoscope was successfully carried out. No gallbladder perforation occurred, but perforation occurred in four cases in the standard laparoscopic cholecystectomy group; however, the difference was not statistically significant. Although no other surgical outcomes differed between the two groups, the flexible endoscope had several advantages over the standard laparoscope. The scope provided a flexible view of the operating field. The gallbladder dissection using the cutting device via the scope was easier and safer than that in standard single-incision laparoscopic cholecystectomy. The water-jet, suctioning, and self-cleaning lens functions of the scope served the surgery well. Conclusions: SIMPLE cholecystectomy using a short-type flexible endoscope has surgical outcomes equivalent to those of standard single-incision laparoscopic cholecystectomy, but this endoscope with multiple functions may make the surgical procedures less stressful and safer.
Introduction Laparoscopic surgery through a single incision and reduced port surgery have been used to treat various conditions in recent years (1–5). Although the surgical safety of these procedures has been verified in several clinical trials, such surgery has disadvantages (1,2,5),
including the increased surgeon stress and technical difficulty, when compared with conventional multiport laparoscopic surgery (6). Furthermore, the interference between different forceps or between forceps and the laparoscope often disturbs the visual field. Our animal experiments revealed that use of a flexible endoscope instead of a standard laparoscope during
Asian J Endosc Surg •• (2014) ••–•• © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
1
Flexible endoscopy-assisted surgery
T Yamaguchi et al.
Table 1 Patients backgrounds
Gender, M:W (n) Mean age (range), years Diagnosis (n) Cholecystolithiasis Gallbladder polyp Acute cholecystitis
SIMPLE group (n = 13)
Standard group (n = 27)
7:6 53 (22–81)
8:19 51 (29–83)
11 1 1
25 1 1
M, men; SIMPLE, single-incision multiport laparoendoscopic; W, women.
Figure 1 Schematic of single-incision multiport laparoendoscopic cholecystectomy. Arrow, the newly developed short-type flexible endoscope; arrowhead, the small diameter grasping forceps.
laparoscopic surgery through a single incision might resolve some of these problems (7,8). A flexible endoscope has several functions, including increased flexibility, forward water jet, suction, forceps channel, and self-cleaning lens, that a standard laparoscope lacks. These functions may make laparoscopic surgery through a single incision safer and easier (8,9). We have employed this type of surgery (laparoscopic surgery through a single incision using a flexible endoscope) to remove the gallbladder in clinical settings (Figure 1). We call this type of surgery single-incision multiport laparoendoscopic (SIMPLE) surgery. The purpose of this study was to retrospectively investigate the surgical outcomes of SIMPLE cholecystectomy and to determine its usefulness.
Patients and Methods Thirteen patients underwent SIMPLE cholecystectomy between November 2011 and October 2012. The patients included seven men and six women with a mean age of 53 years (range, 22–81 years) (Table 1). Before SIMPLE
2
cholecystectomy was performed, each patient provided informed consent. Twelve patients had symptomatic cholecystolithiasis not accompanied by severe cholecystitis and one patient had a benign gallbladder polyp (Table 1). Additionally, 27 patients underwent standard singleincision laparoscopic cholecystectomy using a rigid laparoscope between October 2009 and October 2011. There were 8 men and 19 women with a mean age of 51 years (range, 29–83 years). In this group, 26 patients had cholecystolithiasis and 1 patient had a benign gallbladder polyp (Table 1). We retrospectively compared the surgical outcomes between SIMPLE cholecystectomy and standard singleincision laparoscopic cholecystectomy. The surgical outcomes included operating time, estimated blood loss, time taken to dissect the gallbladder (the time from transection of the cystic artery and duct until complete dissection of the gallbladder from its fossa), presence of intraoperative gallbladder injury, number of times the scope had to be reinserted, postoperative complications, and duration of postoperative hospital stay. Data were compared using the Fisher’s exact tests, nonparametric tests, or the Wilcoxon rank sum test. Techniques of SIMPLE cholecystectomy A newly developed short-type flexible endoscope (ELK2990i; Hoya Pentax, Nakano, Japan) was used as a working scope in SIMPLE cholecystectomy (Figure 2) (9). The scope has a megapixel charge-coupled device mounted on the distal end, a 600-mm working length, a 2.8-mm working channel, a 58-mm length of bending section, a diameter of 10.8 mm, tip deflection of 210° up/120° down/120° right/120° left, an lens-cleaning function, a forward water-jet function, and a suctioning function. The four-way tip deflection increases the operating range and helps create a broad field of view. An EZ Access port (Hakko, Nagano, Japan) that was 75 mm in diameter was placed in the mini-laparotomy (3 cm in length) in the umbilicus. The short-type flexible endoscope was inserted via a 12-mm trocar (Versaport
Asian J Endosc Surg •• (2014) ••–•• © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Flexible endoscopy-assisted surgery
T Yamaguchi et al.
The scope operator was a gastroenterological surgeon (NA) well experienced both in laparoscopic surgery and advanced endoluminal endoscopic interventions (7–9). The scope operator simply manipulated the scope and performed procedures using endoscopic devices; however, different surgeons (TY, n = 7; SM, n = 3; HM, n = 3) performed the other procedures. Techniques for standard single-incision laparoscopic cholecystectomy Figure 2 The short-type flexible endoscope.
An EZ Access port was placed in the mini-laparotomy (3 cm in length) in the umbilicus. A 5-mm rigid laparoscope (LTF Type VP; Olympus, Tokyo, Japan) inserted via a 5-mm trocar placed in the EZ Access was used to establish the operating field. A 3-mm port and 5-mm port were placed and used as working trocars. The gallbladder fundus was elevated with small diameter forceps via the EZ Access. A monopolar hook device was used for dissection of the gallbladder from its fossa.
Results
Figure 3 The endoscopic cutting device, Mucosectom.
Plus; Covidien, Mansfield, USA) placed in the EZ Access. The gallbladder fundus was elevated with a small diameter grasping forceps via the EZ Access port (Figure 1). Two additional 5-mm trocars placed into the EZ Access port as working trocars. After dissection of Calot’s triangle, cholecystectomy was conducted at the neck to the fundus. Intraoperative cholangiography was selectively performed. During SIMPLE cholecystectomy, we used the functions of the short-type flexible endoscope proactively. The forward water-jet function of the scope was used to confirm bleeding points and for intraperitoneal irrigation, and the suction function was used to aspirate smoke, blood, and fluid after intraperitoneal irrigation. In some cases (n = 3), an endoscopic grasping forceps was inserted via the working channel in the endoscope to assist the surgery. The Mucosectom (Hoya Pentax), an endoscopic cutting device (Figure 3), was also inserted via the channel in the scope and used for dissection of the gallbladder from its fossa in all cases.
SIMPLE cholecystectomy was successfully carried out without any intraoperative complications. The mean operating time and estimated blood loss were 111 min (range, 82–176 min) and 3 mL (range, 3–75 mL), respectively (Table 2). None of the patients developed postoperative complications, such as hemorrhage, bile leakage, or surgical-site infection (Table 2). In SIMPLE cholecystectomy, J-turn view by the endoscope enabled us to confirm that the EZ Access port was adequately placed and that the trocars and forceps did not injure any organs (Figure 4a). The scope was useful for developing the operating field to ensure the critical view of safety and for completing the surgical procedure thereafter. The scope enabled us to confirm that the entire width of blood vessels and cystic ducts was clipped (Figure 4b). While the scope and the instruments often crowded, it was generally easier to maintain the operating field with the flexible endoscope than with the standard rigid laparoscope. Inserting the grasping forceps and endoscopic cutting device (Mucosectom) via the scope facilitated various surgical procedures. For example, the grasping forceps was used for catheterization in the cystic duct in intraoperative cholangiography (Figure 4c). During gallbladder dissection, the tip of the scope could be delivered into the space between the gallbladder and its fossa, and dissection by the Mucosectom could easily be completed without gallbladder perforation (Figure 4d). The water-jet function of the flexible endoscope rapidly supplied saline, which facilitated identification of
Asian J Endosc Surg •• (2014) ••–•• © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
3
Flexible endoscopy-assisted surgery
T Yamaguchi et al.
Table 2 Operative outcomes
Operating time (range), min Duration of GB dissection (range), min Estimated blood loss (range), mL Number of times the scope had to be reinserted Intraoperative GB perforation (n) Postoperative complications (n) Duration of postoperative hospital stay (range), days
SIMPLE group (n = 13)
Standard group (n = 27)
P-value
111 (82–176) 27 (4–57) 9 (3–75) 3 0 0 4 (3–5)
113 (61–189) 28 (7–65) 10 (3–200) 3 4 0 4 (3–10)
NS NS NS NS NS NS NS
GB, gallbladder; NS, not significant; SIMPLE, single-incision multiport laparoendoscopic.
Figure 4 Procedures for SIMPLE cholecystectomy using the short-type flexible endoscope. (a) Under J-turned endoscopic observation, two additional trocars (arrows) and a small diameter grasping forceps (arrowhead) were introduced into the peritoneal cavity through the EZ Access port. (b) Endoscopic view during clipping of the cystic duct using the 5-mm clip applier (arrowhead). (c). Endoscopic view during intraoperative cholangiography. The grasping forceps (arrowhead) inserted via the flexible endoscope could be used to aid insertion of the catheter into the cystic duct (arrow). (d) Endoscopic view of the Mucosectom (arrow), which was inserted via the endoscope, dissecting the gallbladder from its fossa. GB, gallbladder; SIMPLE, single-incision multiport laparoendoscopic.
the bleeding points in hemostasis. The self-cleaning lens function maintained a clearly visible surgical field while the suction function enabled us to evacuate smoke and fluid. A comparison of the surgical outcomes between the SIMPLE group and the standard single-incision laparoscopic cholecystectomy group revealed no significant differences in operating time, duration of gallbladder dissection, number of times the scope had to be reinserted, estimated blood loss, or duration of postoperative hospital stay (Table 2). No gallbladder perforation occurred in the SIMPLE group, but there were four cases of perforation in the standard group; however, the difference did not reach statistical significance (Table 2).
Discussion In the present study, the surgical outcomes were not significantly different between the SIMPLE and standard
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laparoscopic surgery through a single incision groups in terms of the overall operating time, time taken to dissect the gallbladder, or the number of times the scope had to be replaced. However, the use of a short-type flexible endoscope rather than standard laparoscope actually provided many merits, including the following (9): (i) the J-turned endoscopic view allowed for the safe insertion of trocars; (ii) the scope could be flexed at its tip to acquire a good view of the operating field; (iii) the scope allowed some degree of freedom to the working laparoscopic instruments without compromising the field of view; (iv) crowding of the laparoscopic instruments and the scope in the outside of the EZ Access could be minimized; (v) the scope working channel enabled the use of another endoscopic device such as the Mucosectom; (vi) inserting devices and laparoscopic instruments via the scope enabled triangulation during dissection; (vii) excess smoke from diathermic cautery could be actively evacuated by the endoscopic suctioning function; and (viii) the
Asian J Endosc Surg •• (2014) ••–•• © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
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water-jet function enabled easy identification of bleeding sites. These advantages contributed to the reduction of surgeon stress. In contrast to the standard group, no gallbladder injuries occurred in the SIMPLE group, but there was no significant difference in this regard. The Mucosectom, an endoscopic submucosal dissection device used in the SIMPLE surgery, has an insulated part that decreases current to the external parts and reduces the risk of gallbladder injuries (10). In addition, the flexible endoscope has a localized magnifying effect. The tip of the scope can be delivered into the space between the gallbladder and its fossa. In this study, meticulous dissection by the Mucosectom prevented gallbladder injury. Moreover, inserting the Mucosectom and the laparoscopic instruments via the scope enabled triangulation during operations. Based on the above considerations, SIMPLE cholecystectomy is effective for reducing injuries to the gallbladder wall. Despite these benefits, the flexible endoscope’s large size (approximately 10-mm diameter) may present a disadvantage. It requires a trocar with a diameter greater than 11 mm. Also, surgical cooperation becomes more complex because the scope operator must perform various manipulations. However, increased experience can strengthen surgical cooperation, which contributes to shortened operating time and improved maneuverability. In recent years, NOTES has emerged. NOTES involves the introduction of a flexible endoscope via natural openings, such as the stomach, rectum, or vagina, to facilitates surgical procedures (11). This new technique has been used clinically in thousands of patients around the world and may replace conventional laparoscopic surgery (12–18). The SIMPLE surgical technique was derived from NOTES and can be considered to be an intermediary between NOTES and laparoscopic surgery through a single incision (8–10). Thus, SIMPLE surgery is a useful technique that may represent an important step toward the popularization and dissemination of NOTES. In conclusion, SIMPLE cholecystectomy using a shorttype flexible endoscope has surgical outcomes equivalent to those of standard single-incision laparoscopic cholecystectomy, but the endoscope offers multiple functions that may make surgical procedures less stressful and safer.
Acknowledgment The authors do not have any conflicts of interest to disclose and received no financial support for this study.
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