Bucher, Pascal

Buchs, Nicolas

Morel, Philippe

Ostermann, Sandrine

Pugin, François

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Single Port Access Laparoscopic Cholecystectomy (with Video):ReplyPascal Bucher • Nicolas Buchs • Franc¸ois Pugin •Sandrine Ostermann • Philippe MorelPublished online: 26 February 2011 Socie´te´ Internationale de Chirurgie 2011We read with interest the letter of Papagoras et al. [1]which pointed out several important issues regarding singleport access cholecystectomy as described in our article [2].They raised a question about exposing the gallbladder andhepatoduodenal ligament during single access cholecys-tectomy, essentially referring to the presented video [2].We first stress that we agree with them regarding the3-year-old technique illustrated. It does not fulfill therequirements of the critical view of safety for laparoscopiccholecystectomy. The technique has since been modifiedbased on our growing experience and by using differentports and instrumentation [3–5]. However, we do not wantto discuss any specific instrumentation as we wish to avoidwhat could be seen as marketing and because many toolscan be used instead others. Moreover, although the industryand others can argue about the need for new tools, manysingle access endoscopic surgeries can be performedusing conventional laparoscopic, reusable, or ‘‘low cost’’instruments.Exposure is no longer achieved with transparietal stit-ches, which are static and, moreover, may be associatedwith accidental puncture of the gallbladder, with its asso-ciated oncological risk [6]. We now use either an intra-corporeal grasper or additional instruments. The firstapproach implies use of a quite expensive instrument, butdoes safety have a cost? The second may be less expensivebut invites increased conflict. Regardless, improvements inthe armentarium of laparoendoscopic single-site surgeryare needed to allow safer, but mainly more reproducible,techniques for cholecystectomy. Finally, before starting asingle access endoscopic surgery program, one shouldattend training courses as proposed by surgical societies.Such attention can, if nothing else, help avoid repeating themistakes that the pioneers in the field (and we) have made[7–9].Regarding the critical need for safety during cholecys-tectomy, we completely agree that it should be achievedduring all cases of minimally invasive cholecystectomy,including single access endoscopic surgery (SAES) [4, 10,11], as we are now achieving with the progress made withSAES cholecystectomy (Fig. 1) [3, 10]. Although intra-operative cholangiography can certainly help avoid acommon bile duct lesion, it also allows detection of anaccessory or sectorial duct lesion; and eventually a bileduct stone can be mobilized during gallbladder manipula-tion. Thus, we believe that recommending cholangiographyfor SAES cholangiography is not untoward. It is a ‘‘lowcost’’ quality and safety control that may decease the dra-matic consequences of a biliary tract accident [3, 12, 13].Paragoras et al. commented on the introduction of thisnew technique with references to the laparoscopic revolu-tion. As they probably know, the introduction of laparos-copy was driven by patient interest and industry marketing,followed by surgeons’ interest [14]. Thus, taking intoaccount what could be patient perception and preference isnow simply alerting surgeons to continue work in this area[8, 15]. In fact, the introduction of new technologiesincreases costs. However, as already noted, along withinnovation being costly, safety too may be related to costincreases [16].In conclusion, while running the risk of being viewed as‘‘aficionados’’ of surgical innovation, we want to stress thatthrough our work, in close collaboration with others, we tryto foresee how future surgery innovation can offer lessP. Bucher (&)  N. Buchs  F. Pugin  S. Ostermann  P. MorelDepartment of Surgery, Visceral and Transplantation Surgery,University Hospital Geneva, 24 Rue Micheli-du-Crest,1211 Geneva, Switzerlande-mail: pascal.bucher@hcuge.ch123World J Surg (2011) 35:1150–1151DOI 10.1007/s00268-011-1011-0traumatic surgery. In this regard, SAES, as ‘‘needlescopic’’laparoscopy, or NOTES, are simply ways to explore thepossibility of reduced port access surgery, which allows usto offer what our patients are seeking: a safe, curative, lessmutilating solution to their problem [8, 17].References1. Papagoras D, Kanara M, Argiropoulos-Rakas C, Tsianos G(2011) Single port access laparoscopic cholecystectomy (withvideo). World J Surg 35(1):235–2362. Bucher P, Pugin F, Buchs N et al (2009) Single port accesslaparoscopic cholecystectomy (with video). World J Surg 33:1015–10183. Bucher P, Pugin F, Morel P (2010) From single-port access tolaparoendoscopic single-site cholecystectomy. Surg Endosc24:234–2354. Podolsky ER, Curcillo PG 2nd (2010) Reduced-port surgery:preservation of the critical view in single-port-access cholecys-tectomy. Surg Endosc 24:3038–30435. Curcillo PG 2nd, Wu AS, Podolsky ER et al (2010) Single-port-access (SPATM) cholecystectomy: a multi-institutional report ofthe first 297 cases. Surg Endosc 24:1854–18606. Bucher P, Pugin F, Morel P (2010) Laparoscoendoscopic single-site cholecystectomy and occult gallbladder cancer. Surg Endosc24:17017. Gill IS, Advincula AP, Aron M et al (2010) Consensus statementof the consortium for laparoendoscopic single-site surgery. SurgEndosc 24:762–7688. Bucher P, Pugin F, Ostermann S et al (2010) Patient’s point ofview on surgical innovations: for less traumatic surgery andenhanced recovery. Rev Med Suisse 5:1292–12979. Neugebauer EA, Becker M, Buess GF et al (2010) EAES rec-ommendations on methodology of innovation management inendoscopic surgery. Surg Endosc 24:1594–161510. Wijsmuller AR, Leegwater M, Tseng L et al (2007) Optimizingthe critical view of safety in laparoscopic cholecystectomy byclipping and transecting the cystic artery before the cystic duct.Br J Surg 94:473–47411. Emous M, Westerterp M, Wind J et al (2010) Registering thecritical view of safety: photo or video? Surg Endosc 24:2527–253012. Sanjay P, Fulke JL, Exon DJ (2010) ‘Critical view of safety’ asan alternative to routine intraoperative cholangiography duringlaparoscopic cholecystectomy for acute biliary pathology. J Gas-trointest Surg 14:1280–128413. Gigot J (2007) Bile duct injury during laparoscopic cholecys-tectomy. J Chir 144:383–38414. Pe´rissat J (1999) Laparoscopic surgery: a pioneer’s point of view.World J Surg 23:863–86815. Swanstrom L, Volkmann E, Hungness E et al (2009) Patientattitudes and expectations regarding natural orifice translumenalendoscopic surgery. Surg Endosc 23:1519–152516. Winter D (2009) The cost of laparoscopic surgery is the price ofprogress. Br J Surg 96:327–32817. Bucher P, Pugin F, Ostermann S et al (2011) Population per-ception of surgical safety and body image trauma: a plea forscarless surgery? Surg Endosc 25:408–415Fig. 1 Critical view of safety during laparoendoscopic single-sitecholecystectomy. Note the anterior cystic artery originating from aright hepatic arteryWorld J Surg (2011) 35:1150–1151 1151123

Single Port Access Laparoscopic Cholecystectomy (with Video): Reply

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Single Port Access Laparoscopic Cholecystectomy (with Video): Reply

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