Background
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 cholecystectomy. [10]
Indications
Indications for single-port cholecystectomy include the following:
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Biliary dyskinesia
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Cholelithiasis (acute cholecystitis is a relative contraindication)
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Gallbladder polyp [11] larger than 1 cm
In any single-port cholecystectomy, it is important to maintain a low threshold for conversion to a standard laparoscopic cholecystectomy or open cholecystectomy.
Contraindications
Absolute contraindications for single-port cholecystectomy are pregnancy and an American Society of Anesthesiologists (ASA) classification of 3 or 4. 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.
Outcomes
Qiu et al reviewed 40 studies of 3711 patients who underwent surgery for benign gallbladder diseases between 1997 and 2012. The study concluded that single-port laparoscopic cholecystectomy is safe and effective and leads to better cosmetic results. [12]
In a nonrandomized, age-matched single-center trial comparing the safety of single-port laparoscopic cholecystectomy with that of standard laparoscopic cholecystectomy, [13] van der Linden et al found operating time to be significantly shorter in the single-port 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. [14] Rosales-Velderrain et al al found single-port robotic laparoscopic cholecystectomy to be feasible and safe in pediatric patients. [15]
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. [16] Hajong et al reported similar clinical outcomes for the two approaches but noted that operating time was longer for the single-port approach. [17]
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External view of single-port access through umbilicus.
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Suture being placed for cephalad retraction.
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Typical intra-abdominal view of gallbladder retraction.
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Critical view of cystic duct and cystic artery.
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Gallbladder placed in retrieval bag.
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Laparoscopic cholecystectomy. Video courtesy of SAGES.
