Bucher, Pascal

Morel, Philippe

Pugin, François

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From single-port access to laparoendoscopic single-sitecholecystectomyPascal Bucher Æ Franc¸ois Pugin Æ Philippe MorelPublished online: 18 August 2009 Springer Science+Business Media, LLC 2009Dear Sir,We read with interest the report of Langwieler et al. [1]on single-port access (SPA) cholecystectomy. The authorsdescribe their experience with SPA cholecystectomy (14cases) using the newly available multiport trocar (ASCTriport, Advanced Surgical Concepts, Bray, Ireland) andsemiflexible endoscope (Olympus, Hamburg, Germany)with excellent results. We comment on some issues raisedby this report, especially the use of a multiport approachand instrumentation, perception of the transvaginal route,and the importance of intraoperative cholangiography.Whereas Langwieler and colleagues describe theirresults using the multiport trocar, ASC Triport, we confirmtheir report on the important technique of SPA or lapa-roendoscopic single-site surgery (LESS) in terms of thisadjunct’s feasibility and safety.To date, we have completed a series of 34 LESScholecystectomies, with a median follow-up period of8 months. We have reported our preliminary experienceusing two parallel umbilical ports (10 and 5 mm) with asling suture for exposition [2]. The last 16 cases, performedusing the multiport trocar, were associated with a decreasein operative time and a subjective sense of improved fea-sibility and security. Moreover, the use of a single multi-port trocar instead of a multiple 5-mm trocar in theumbilical incision avoided port conflict.Another advantage of the ASC TriPort, not mentioned inthe report, is that it may serve as a wound protector forextraction of the gallbladder at the end of the procedurewith the removal of the valve part of the port. This mayinfluence the cost of LESS cholecystectomy, which has notfavored this approach over standard laparoscopy.Due to the limited space with only a single port, thehands of the operator and assistant may disable each other,as noted by the authors. For this reason, we agree that theuse of instruments differing in length may in part solve thisissue. However, the use of a semiflexible or curvedinstruments could improve this issue and probably willrepresent the solution to this problem in the future.The rate of decline in the vaginal approach to chole-cystectomy reported by Langwieler and colleagues con-firms a previous European report. As noted by Slim et al.[3] in a French survey, the transvaginal approach for cho-lecystectomy is not favored by women, with 94% refusingit. This refusal is retrieved in a survey we conducted inSwitzerland, in which 86% favored transumbilical SPAcholecystectomy, with 9% choosing standard laparoscopyand 5% opting for natural orifice translumenal endoscopicsurgery (NOTES) [4, 5].It should be noted that the transvaginal approachnecessitates a culdotomy, implicating avoidance of inter-course for a nonnegligible period. This delay varies from15 days to 6 weeks depending on the transvaginal NOTESprotocol [6–8]. The sexual abstinence recommended bygynecologists is 3–4 weeks [9–11]. With regard to thisissue, transumbilical SPA laparoscopy may be advanta-geous because no sexual abstinence is needed, and thereturn to normal social life is quicker, especially for theyoung sexually active woman. Furthermore, whereas thetransvaginal approach can be offered only to women,transumbilical SPA may be offered to all patients. This isof importance because the cosmetic issue applies not onlyto female patients [12, 13].Recently, the possible higher rates for umbilical seromaand incisional hernia after transumbilical LESS have beenP. Bucher (&)  F. Pugin  P. MorelDepartment of Surgery, University Hospital Geneva, 24 rueMicheli-du-Crest, 1211 Geneva, Switzerlande-mail: pascal.bucher@hcuge.ch123Surg Endosc (2010) 24:234–235DOI 10.1007/s00464-009-0626-9discussed among experts and opponents to LESS. In ourseries, which admittedly has had only a short follow-uptime (8 months), no umbilical complications (seroma orincisional hernia) have been recorded at this writing. Thismay be due at least in part to the use of a single fascialincision, which is closed during conventional laparoscopy.The avoidance of multiple fascial perforations using mul-tiple parallel umbilical trocars, as described by some teams,creates great traction forces on the fascial layers, weak-ening them [14].It seems that Langwieler et al. [1] did not routinelyperform intraoperative cholangiography in their series. Webelieve that intraoperative cholangiography should beperformed, or at least attempted, in all LESS cholecys-tectomies to exclude the potential for a biliary tract lesion[2]. This is important because the risk of such a lesion maybe higher with this new approach, as noted by Connor [15]in History Should Not Be Allowed to Repeat, referring tothe increase in biliary tract complication and morbidity atthe introduction of laparoscopic cholecystectomy [2, 15].In conclusion, recent instrument and multiport trocardevelopments are improving the feasibility and probablythe safety of transumbilical laparoendoscopic single-siteLESS cholecystectomy, which offers excellent cosmeticresults and shorter postoperative recovery than the trans-vaginal approach, especially in terms of sexuality. The lowrate for acceptance of the transvaginal route in Westerncountries should influence us to pursue the development ofLESS cholecystectomy and to conduct randomized trialscomparing the potential advantage and risk balance of thisapproach with those of standard multiport laparoscopiccholecystectomy.References1. Langwieler T, Nimmesgern T, Back M (2009) Single-port accessin laparoscopic cholecystectomy. Surg Endosc. March 5, [Epubahead of print]2. Bucher P, Pugin F, Buchs N, Ostermann S, Charara F, Morel P(2008) Single-port-access laparoscopic cholecystectomy (withvideo). World J Surg. December 30, [Epub ahead of print]3. Slim K, Launay-Savary M (2008) NOTES: the debates continues.Surg Endosc. July 12, [Epub ahead of print]4. Bucher P, Ostermann S, Pugin F, Morel P (2009) E-NOTESappendectomy versus transvaginal appendectomy: similar cos-metic results but shorter complete recovery? Surg Endosc 23:9165. Bucher P, Pugin F, Morel P, Hagen M (2008) Scarless surgery:myth or reality through NOTES? Rev Med Suisse 4:1550–15526. Palanivelu C, Rajan P, Ranqarajan M, Parthasarathi R, Senthil-nathan P, Praveenraj P (2008) Transumbilical flexible endoscopiccholecystectomy in humans: first feasibility study using hybridtechnique. Endoscopy 40:231–2487. Zorron R, Maggioni L, Pombo L, Oliveira A, Carvalho G, Fil-gueiras M (2008) NOTES transvaginal cholecystectomy: pre-liminary clinical application. Surg Endosc 22:542–5478. Zornig C, Mofid H, Emmermann A, Alm M, Von Waldenfels H,Felixmu¨ller C (2008) Scarless cholecystectomy with combinedtransvaginal and transumbilical approach in a series of 20patients. Surg Endosc. April 9, [Epub ahead of print]9. Palmer R (1984) Why the laparoscopic route for tubal steriliza-tion? Contracept Fertil Sex 12:931–93310. Amias A (1975) Sexual life after gynaecological operation—II.Br Med J 21:680–68111. Newton J, Mc Cormack J (1990) Female sterilization: a review ofmethods, morbidity, failure rates, and medicolegal aspects.Contemp Rev Obstet Gynaecol 2:176–18212. Varadarajulu S, Tamhane A, Drelichman E (2008) Patient per-ception of natural orifice translumenal endoscopic surgery as atechnique for cholecystectomy. Gastrointest Endosc 67:854–86013. Ng W (2006) Optimal cosmetic results without increased oper-ative risk. Surg Endosc 20:1332–133314. Tacchino R, Greco F, Matera D (2008) Single-incision laparo-scopic cholecystectomy: surgery without a visible scar. SurgEndosc. September 25, [Epub ahead of print]15. Connor S (2009) Single-port access cholecystectomy: historyshould not be allowed to repeat. World J Surg. March 6, [Epubahead of print]Surg Endosc (2010) 24:234–235 235123

From single-port access to laparoendoscopic single-site cholecystectomy

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From single-port access to laparoendoscopic single-site cholecystectomy

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