Natural Orifice Transumbilical Cholecystectomy Using a Tri-Port Trocar and Conventional Instruments

Vol. 210, No. 6, June 2010

independent risk factor for intra-, peri-, and postoperative complications. These reports will be used to make decisions regarding patient selection and procedure selection, as well as patient care. Such a course of action may be erroneous. Before the enhanced difficulty of operating on the obese patient is accepted as evidence that obesity is an independent risk factor, I would recommend that all surgeons consider that the independent risk factor may well be the lack of expertise of surgeons in operating on the obese and not the obesity per se. I am far more comfortable blaming adverse outcomes in the obese on ourselves and not on the patient. Surgery on the obese patient is as different a discipline from operating on the normal weight individual as pediatric surgery is from adult surgery. Thus, either all abdominal surgery in the obese (30% and rising of the general adult population) should be performed only by surgeons trained in the specialty of metabolic and bariatric surgery or all abdominal surgeons should be trained in the techniques of operating on the obese. In teaching our trainees surgical technique, should we not teach them the fine points of opening, closing, placing trocars, exposure, dissecting, sewing, and so forth, uniquely adapted to operating on and in an obese body? Indeed, all trainees, and possibly practicing surgeons as well, should be schooled in operating on the obese. If this concept were to be transformed into reality, then obesity would not have to be heralded as an independent risk factor, surgeons would be appropriately trained for operating on the general patient population, and, above all, surgery, in particular abdominal surgery, would be safer. REFERENCE 1. Johnson ON III, Sidawy AN, Scanlon JM, et al. Impact of obesity on outcomes after open surgical and endovascular abdominal aortic aneurism repair. J Am CoIl Surg 2010;210:166–177.

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Pneumothorax in the Ventilated Patient: A Difficult Problem to Recognize Harish V Iyer, MD Philadelphia, PA I read with interest the report in the Image section by Abdulrehman and Maull in the recent issue of the Journal.1 They describe a patient with multiple trauma who was resuscitated and mechanically ventilated. This patient then went on to have a tension pneumothorax that was missed on the chest

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x-ray. I commend the authors for discussing this case, which has great educational value; this is a critical complication in the intensive care unit and I would like to add a couple of comments that might benefit your readers, especially trainees. In a supine patient, like most patients on mechanical ventilation, the radiographic signs of a pneumothorax can be very subtle. It is important to remember that free air in the pleural space usually collects in the least dependent part of the chest; in the supine position, this is often in the inferior aspect. In some cases, the air collects in the lateral costophrenic recess, making it appear abnormally deepened, and is associated with lucency of the lateral costophrenic angle. This is called the “deep sulcus sign” and can be diagnostic of a pneumothorax in the mechanically ventilated patient.2 Additionally, if the pleural defect is causing a 1-way valve, air will progressively increase in the pleural space and, when the intrapleural pressure exceeds intra-alveolar pressure, a “tension pneumothorax” is the result. This can lead to circulatory collapse and subsequent death in seconds if not recognized promptly. Clinically, this can manifest with the presence of subcutaneous emphysema and jugular venous distension, along with hypotension and tachycardia. In the mechanically ventilated patient, the sudden increase in the plateau airway pressure and, in some cases, decrease in expiratory volume, can be useful clues, and needle decompression can be lifesaving. REFERENCES 1. Abdulrahman Y, Maull KI. Hemothorax, pneumothorax, both or neither? J Am Coll Surg 2009;209:285. Epub 2009 Apr 2. 2. Kong A. The deep sulcus sign. Radiology 2003;228:415–416.

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Natural Orifice Transumbilical Cholecystectomy Using a Tri-Port Trocar and Conventional Instruments Duilio Pagano, MD Gabriel J Echeverri, MD Bruno Gridelli, MD Marco Spada, MD Palermo, Italy Ivan Botrugno, MD Pavia, Italy Carlo Bartoccelli, MD Varese, Italy

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It was with great interest that we read the article by Dr. Philipp and co-authors,1 and we strongly agree with their approach to, and concerns about, single-incision laparoscopic cholecystectomy using conventional instruments, a procedure that leaves no visible abdominal scars. Recently, Dr Frederik Keus and his colleagues2 showed that there are indeed many equally valuable ways to perform a small-incision cholecystectomy (defined as an 8-cm incision), with the same outcomes in terms of short hospital stay, decreased need for postoperative analgesia, good cosmetic results, fast recovery to full preoperative activity, and avoidance of long-term complications. In the last few decades, laparoscopic cholecystectomy has become more frequent in a number of surgical departments, not only as a surgical practice for a fast track management, but also as an initial approach to abdominal urgency of unknown etiology. Excluding gallbladder perforation, a correct approach to certain urgent abdominal conditions is laparoscopy, even if solely for diagnosis, eventually supported by laparoscopic ultrasound. The natural orifice transumbilical surgery (NOTUS) described by Dr. Nguyen and colleagues3 underscores the feasibility of performing cholecystectomy with a one-port technique. We have used conventional laparoscopic equipment for performing laparoscopic cholecystectomy, using a Tri-port trocar (Advanced Surgical Concepts) and 3 conventional laparoscopic instruments placed within the umbilicus. We believe that as surgeons become increasingly familiar with this minimal-incision procedure, the scarless cholecystectomy will prove to be a valuable addition to the surgeon’s toolbox,4 and one that can help avoid the high cost of flexible instruments. As a means of prompting the use of this laparoscopic procedure, and of extending its indication for other types of surgical pathologies, we propose a simplification of technique, which will help ensure a shorter, and more beneficial, learning curve.

REFERENCES 1. Philipp SR, Miedema BW, Thaler K. Single-incision laparoscopic cholecystectomy using conventional instruments: early experience in comparison with the gold standard. J Am Coll Surg 2009; 209:632–637. 2. Keus F, de Jong J, Gooszen HG, et al. Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev 2006;(4):CD006231. 3. Nguyen NT, Reavis KM, Hinojosa MW, et al. Laparoscopic transumbilical cholecystectomy without visible abdominal scars. J Gastrointest Surg 2009;13:1125–1128. 4. Cuesta MA, Berends F, Veenhof AA. The “invisible cholecystec-

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tomy.” A transumbilical operation without a scar. Surg Endosc 2008;22:1211–1213.

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Reply Scott Reynold Philipp, MD Columbia, MO We greatly appreciate the comments from Dr Pagano and colleagues supporting our recent work in single-incision laparoscopic surgery.1 As mentioned, there truly are many safe and successful ways to perform a minimally invasive cholecystectomy, and our approach appears to be one of them. There are currently several reports of different techniques being used in single-incision laparoscopic surgery and, as experience accrues and technology advances, they will be applied more successfully. It is exciting to read about all the innovative ways that surgeons have devised to safely accomplish operations using single-incision laparoscopic techniques. We agree with the authors that a simplification of technique is necessary to facilitate a shorter and more beneficial learning curve that will ultimately be required for mainstream acceptance. In addition, a clear benefit of single-incision technique over conventional laparoscopy without an increase in complications needs to be established by a prospective randomized trial. We continue to use new products and evaluate new techniques in an attempt to improve outcomes and educate patients about their choices. In our pursuit for improvement, we must not fail to keep patient safety a priority. Using additional ports or making additional incisions should never be considered a failure when done for the benefit of the patient. We agree with Dr Pagano and colleagues that singleincision laparoscopic surgery will prove to be a valuable technique that surgeons will want in their “toolbox.” As more information becomes available, patients will inquire about the possibility of single-incision laparoscopic surgery, which might drive the adoption of these techniques. Future studies are needed to elicit the benefits of single-incision laparoscopy and determine the indications for its use.

REFERENCE 1. Philipp SR, Miedema B, Thaler K. Single-incision laparoscopic cholecystectomy using conventional instruments: early experience in comparison with the gold standard. J Am Coll Surg 2009; 209:632–637.

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