Chapter 33: Single-Incision Cholecystectomy

HISTORY AND INDICATIONS

Laparoscopic cholecystectomy is currently regarded as the procedure of choice for the treatment of symptomatic gallbladder disease. Current techniques include variations on a three- or four-port approach that are generally well tolerated by the vast majority of patients. However, postoperative abdominal, incisional, and shoulder pain still occurs in most patients and persists for a number of days after the procedure. To counter this, laparoscopic techniques continue to evolve in order to minimize scarring and accelerate recovery. Natural-orifice transluminal endoscopic surgery (NOTES), for example, is a technique first introduced in 2005 that attempts to address certain intraabdominal pathology by purely endoscopic techniques. Its application continues to be investigated at this time. Another technique, single-incision laparoscopic surgery (SILS), which was first reported in 1997 and further refined in 2008, has entered into mainstream clinical practice. SILS techniques have now been applied to a number of different procedures, but the most established application for this technique has been for cholecystectomy.

In general, SILS cholecystectomy can be considered in any patient found to be a candidate for the laparoscopic approach. It has been completed successfully in patients with body mass indexes (BMIs) up to 44.6 kg/m². Current data suggest that a small proportion (4%) of patients will need conversion to either a conventional laparoscopic cholecystectomy or open cholecystectomy, principally because of severity of gallbladder disease.

PREOPERATIVE CONSIDERATIONS

Patient Preparation

Symptomatic gallbladder disease is the usual diagnosis prompting cholecystectomy, and suitable preoperative testing and patient preparation should be initiated at the time of diagnosis. The anticipated severity of the disease and other patient factors, such as morbid obesity or prior abdominal surgeries, should be considered before committing to a SILS approach, particularly if the surgeon is still within his or her learning curve. The patient should be consented for SILS, but both laparoscopic and open approaches should be discussed with them, including the more common complications such as bleeding, infection, and damage to intraabdominal structures.

Equipment and Instrumentation

SILS cholecystectomy can be carried out using standard laparoscopic instruments, including atraumatic graspers and a hook electrocautery, with separate port entry at the umbilicus. However, there are now commercially available SILS-specific “all-in-one” ports that incorporate three-port apertures into a molded or low-profile configuration. Use of these commercial SILS ports also mandates a custom roticulating grasper and dissector for the procedure because of the limitations in range of motion dictated by the port design (Figure 1).

A 5- or 10-mm, 30- or 45-degree laparoscope can be used. A bariatric-length 5- or 10-mm, 30-degree laparoscope provides sufficient length for the light stem to be positioned to minimize interference with the handle grips of the working instruments. There are also laparoscopes currently available that ...