J Gastrointest Surg (2009) 13:533–534 DOI 10.1007/s11605-008-0614-8
MULTIMEDIA ARTICLE
Totally Transumbilical Laparoscopic Cholecystectomy Andrew A. Gumbs & Luca Milone & Prashant Sinha & Marc Bessler
Published online: 16 August 2008 # 2008 The Society for Surgery of the Alimentary Tract
Abstract A recently convened Consortium at the Cleveland Clinic agreed on the term Laparo-Endoscopic Single-Site (LESS) surgery to describe minimally invasive techniques that use a single incision to accomplish laparoscopic procedures. These procedures are done by using either a single port through one fascial incision or multiple ports placed through separate fascial incisions. Because of cost containment issues and the lack of widespread availability of a single port, we currently use multiple reusable ports placed through three separate fascial incisions via a transumbilical incision. As opposed to standard laparoscopic cholecystectomy, a deflecting laparoscope and one articulating instrument are utilized to improve the safety and ease of this procedure. Presented in this video are the steps necessary to perform a LESS cholecystectomy via a transumbilical incision with commercially available instruments. Keywords Single port surgery . SPA . Transumbilical endoscopic surgery . TUES . Single incision surgery
erative pain.6,7 Presented here are the steps necessary to perform totally transumbilical laparoscopic cholecystectomy (TTLC) with the use of commercially available technology.
Introduction Material and Methods With the advent of natural orifice transluminal endoscopic surgery (NOTES), and the acknowledged limitations of the current technology, single port access (SPA) has emerged as a viable and more widely applicable minimally invasive technique.1–3 Unfortunately, access to a single port that allows for SPA has been limited to small numbers of academic centers.4,5 In an effort to exploit the benefits of single-incision laparoscopic surgery, some centers have begun performing minimally invasive surgery in this manner to further improve cosmesis and potentially reduce postopElectronic supplementary material The online version of this article (doi:10.1007/s11605-008-0614-8) contains supplementary material, which is available to authorized users. A. A. Gumbs (*) : L. Milone : P. Sinha : M. Bessler Department of Surgery, Division of Upper GI and Endocrine Surgery, Columbia University College of Physicians and Surgeons/New York Presbyterian Hospital, 161 Fort Washington Ave, 8th Floor, New York, NY 10032, USA e-mail:
[email protected]
As with all new technology, patient selection is paramount during the initial period of one’s experience. To perform TTLC we make a 2-cm incision through the umbilicus until the fascia is identified. Using three separate fascial sites, three 5-mm reusable trocars are placed after pneumoperitoneum to 15 Torr is obtained using the Veress needle. Intra-abdominal visualization should be obtained with a 5-mm deflecting laparoscope (LTF-VP Deflectable Tip Video Laparoscope, Olympus Surgical America, Orangeburg, NY, USA). The deflecting scope is necessary to minimize external interference of the instrument handles. Because only two other instruments are used, it is imperative to grasp the gallbladder in the “sweet spot,” to enable the exposure of both the Triangle of Calot and retract the cystic duct off of the common bile duct. Because all instruments are transumbilical, at least one articulating instrument (Realhand, Novare Surgical Systems, Cupertino, CA, USA) will be necessary to accomplish this and stay out of the line of view of the optic port. A straight laparoscopic instrument can then used to perform the dissection just as in a standard laparoscopic cholecystectomy.
534
J Gastrointest Surg (2009) 13:533–534
Conclusion Totally transumbilical minimally invasive surgery (TTMIS) is feasible. Although single ports are coming on the market, enabling so-called SPA surgery, the TT technique obviates the need for this device and may help reduce costs. The use of a deflecting scope and an articulating instrument greatly reduces the “learning curve” of this procedure. More complex procedures may require two articulating instruments. Robotic assistance may further reduce operating room times and allow for the successful performance of more complex procedures with TT minimally invasive techniques in humans. Figure 1 Image of robotically assisted single incision surgery. The robotically controlled camera holder, ViKY (Vision Kontrol for endoscopY; ViKY Ste Endocontrol-Medical SAS 38000, Grenoble, France) is holding a 5-mm deflecting scope (LTF-VP Deflectable Tip Video Laparoscope, Olympus Surgical America, Orangeburg, NY, USA). Two articulating 5-mm laparoscopic instruments (Realhand, Novare Surgical Systems, Cupertino, CA, USA) are being used.
Results At our institution, two patients have been enrolled in an Institutional Review Board (IRB)-approved study to evaluate the safety and efficacy of this technique. Both procedures took less than 60 minutes and both patients were discharged home in less than 20 hours. To date, no wound infections or hernias have developed. We have recently begun performing totally transumbilical procedures with a robotically controlled camera holder in an animal model (Fig. 1) (Vision Kontrol for endoscopY; ViKY Ste Endocontrol-Medical SAS 38000, Grenoble, France).8 To date, we have successfully performed a partial hepatectomy, distal pancreatectomy, and sleeve gastrectomy with robotic assistance in animals.
References 1. Bessler M, Stevens PD, Milone L, Parikh M, Fowler D. Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery. Gastrointest Endosc 2007;66(6):1243–1245. 2. Inoue H, Takeshita K, Endo M. Single-port laparoscopy assisted appendectomy under local pneumoperitoneum condition. Surg Endosc 1994;8(6):714–716. 3. Rao MM, Rao RK. Two-port and single port laparoscopic appendicectomy. J Indian Med Assoc 2004;102(7):360, 362, 364. 4. Saad M. Fisherman’s technique, introducing a novel method for using the umbilical port for removal of appendix during laparoscopic appendectomy. Surg Laparosc Endosc Percutan Tech 2007;17 (5):422–424. 5. Zhu JF. Scarless endoscopic surgery: NOTES or TUES. Surg Endosc. 2007;21(10):1898–1899. Oct. 6. Piskun G, Rajpal S. Transumbilical laparoscopic cholecystectomy utilizes no incisions outside the umbilicus. J Laparoendosc Adv Surg Tech Part A 1999;9(4):361–364. 7. Allam M, Piskun G, Kothuru R, Fogler R. A three-trocar midline approach to laparoscopic-assisted colectomy. J Laparoendosc Adv Surg Tech A 1998;8(3):151–155. 8. Gumbs AA, Crovari F, Vidal C, Henri P, Gayet B. Modified robotic lightweight endoscope (ViKY) validation in vivo in a porcine model. Surg Innov 2007;14(4):261–264.
