Single-Port Cholecystectomy

Laparoscopic cholecystectomy is a widely performed procedure that has been shown to result in less postoperative pain and a shorter hospital stay than the corresponding open procedure. This article describes a newer approach to laparoscopic cholecystectomy that is referred to as single-port cholecystectomy. ^{[1, 2, 3, 4]}

The first laparoscopic cholecystectomy was performed in 1985 by Erich Mühe in the County Hospital of Böblingen, Germany. Mühe's original technique, especially the maintenance of pneumoperitoneum, proved to be so cumbersome that after performing the first six pure laparoscopic cholecystectomies, he abandoned the optically guided transumbilical approach with pneumoperitoneum for a single 3-cm subcostal incision approach in which the gallbladder was removed under direct visualization. ^{[5, 6]}

Since 1985, many competitive approaches have been developed to minimize the invasiveness of laparoscopic cholecystectomies, with surgeons developing new instruments and techniques to reduce postoperative pain and improve cosmesis by decreasing the number and size of necessary ports. ^{[7, 8, 9]}  The most recent developments in laparoscopic surgery have been the combined advances in natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS), as exemplified here by single-port laparoscopic cholecystectomy (SPLC). ^[10]

Despite having been being practiced for more than 25 years, SPLC is still not widely accepted, owing to the ergonomic difficulties brought on by the limited instrument movement and working area. Robotic surgery is seen as a viable alternative by virtue of the additional technical benefits it provides (eg, a three-dimensional [3D] display and a lack of tremors).

Rasa et al analyzed 40 patients (26 female, 40 male; mean age, 49.5 ± 11.6 y) who underwent single-port robotic cholecystectomy, using parameters that included the following ^[11] :

• Demographic data
• American Society of Anesthesiologists (ASA) classification
• Body mass index (BMI)
• Presence of an accompanying umbilical hernia
• Amount of blood loss during procedure
• Requirement for subhepatic drain
• Need to use grafts during the port site's fascial closure
• Hospital stay
• Readmission rates
• Perioperative and postoperative complications
• Clavien-Dindo complication scores
• Postoperative analgesia requirements

Of the 40 patients, 24 (60%) had umbilical hernia. ^[11] Mean BMI was 29.7 ± 5.2 kg/m². With regard to ASA classification, 15 patients were categorized as ASA I, 18 as ASA II, and seven as ASA III. The average amount of bleeding was 58.4 ± 55.8 mL. A drain was placed in 12 patients. Graft reinforcement was performed during fascial closure  in 14 patients. Mean operating time was 101.2 ± 27.0 min. Mean hospital stay was 1.4 ± 0.6 d, after which one patient was readmitted on account of pain. Clavien-Dindo I complications were present in 14 patients (at the wound site in five).

Gasless robotic single-port cholecystectomy has also shown good results. ^[12]  At present, however, only a small percentage of patients may be candidates for this treatment.

Indications for single-port cholecystectomy include the following:

• Biliary colic
• Biliary dyskinesia
• Cholelithiasis (acute cholecystitis is a relative contraindication)
• Gallbladder polyp ^[13]  larger than 1 cm
• Porcelain gallbladder

In any single-port cholecystectomy, it is important to maintain a low threshold for conversion to a standard laparoscopic cholecystectomy or open cholecystectomy.

Absolute contraindications for single-port cholecystectomy are pregnancy and an ASA classification of III or IV. Relative contraindications include acute cholecystitis and previous upper abdominal surgical procedures. These patients should not be considered for single-port cholecystectomy, and a standard four-port laparoscopic cholecystectomy should be performed instead.

Qiu et al reviewed 40 studies of 3711 patients who underwent surgery for benign gallbladder diseases between 1997 and 2012. The study concluded that SPLC is safe and effective and leads to better cosmetic results. ^[14]

In a nonrandomized, age-matched single-center trial comparing the safety of SPLC with that of standard laparoscopic cholecystectomy, ^[15] van der Linden et al found operating time to be significantly shorter in the SPLC group but reported no statistically significant differences between the two groups with respect to complication rate, length of hospital stay, readmission rate, or mortality.

Aprea et al reported successful use of laparoscopic single-site cholecystectomy in the elderly. ^[16] Rosales-Velderrain et al al found single-port robotic laparoscopic cholecystectomy to be feasible and safe in pediatric patients. ^[17]

In a randomized controlled trial by Aktimur et al, single-port cholecystectomy using a facilitating maneuver for better exposure was found to be comparable to four-port cholecystectomy with regard to ease of performance, operating time, reproducibility, and patient safety. ^[18]  Hajong et al reported similar clinical outcomes for the two approaches but noted that operating time was longer for the single-port approach. ^[19]  

In a retrospective study of 70 patients who underwent SPLC, Casaccia et al assessed the following ^[20] :

• Operating time
• Blood loss
• Use of additional trocars
• Conversion to laparotomy
• Intraoperative/postoperative complications
• Hospital stay

Of the 70 patients, 13 had a normal gall bladder (NG), 47 had chronic cholecystitis (CC), and 10 had acute cholecystitis (AC). ^[20] Operating time was 55 ± 22.7 min (NG), 70 ± 33.5 min (CC), and 110.5 ± 50.5 min (AC). Duration of hospital stay was 1.0 ± 0.6 d (NG), 2.0 ± 1.1 d (CC), and 2.0 ± 4.7 d (AC). Postoperative complication rate was 7.6% (NG), 17% (CC) and 30% (AC). The authors found SPLC to be feasible with any pathology but recommended caution with AC. 

A retrospective observational study by Moreno Alfonso et al evaluated 11 patients younger than 15 years who underwent four-port laparoscopic cholecystectomy (LC; n = 6) or SPLC (n = 5) over a 6-year period to determine perioperative outcomes and look for any variations between the two procedures. ^[21]  No appreciable variations were found with respect either to mean hospital stay or to operating time (SPLC, 144 min; LC, 139 min); however, total cost was slightly higher with SPLC (1367 € vs 1322 €). No patients experienced postoperative complications; all were satisfied with the cosmetic outcome.

Jung et al performed a propensity score–matching (PSM) analysis (N = 2507; 20 institutions) to determine whether SPLC (n = 331) had advantages over multiport laparoscopic cholecystectomy (MPLC; n = 2176) with respect to the following ^[22] :

• Perioperative outcomes
• Pain assessed by the numeric rating scale (NRS) score
• Quality of life (QoL) evaluated by the gastrointestinal QoL index (GIQLI) questionnaire

PSM was employed to select 912 patients from the MPLC group and 329 from the SPLC group. ^[22] For the majority of the outcomes, including biliary problems, the two groups showed no significant differences, aside from the longer operating time and reduced surgical difficulty noted with SPLC. However, SPLC was significantly superior to MPLC with respect to duration of hospitalization, NRS score, and results on the GIQLI questionnaire (ie, lower morbidity and better postoperative QoL).