Single-Port Cholecystectomy 

Updated: Apr 16, 2018
Author: Kurt E Roberts, MD; Chief Editor: Vikram Kate, MBBS, MS, PhD, FRCS, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS, FFST(Ed) 

Overview

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:

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]  

 

Periprocedural Care

Equipment

Equipment required for single-port cholecystectomy includes the following:

Patient Preparation

General anesthesia is required because of the need for gaseous insufflation of the abdominal cavity to provide adequate visualization. The patient should be placed in a reverse Trendelenburg position with the right side up.

 

Technique

Laparoscopic Cholecystectomy via Single Port

In a single-port cholecystectomy, three working ports are placed through a single incision (see the video below). One extracorporeal stay suture is used to achieve the standard cephalad retraction of the gallbladder fundus. Lateral retraction of the infundibulum is accomplished with a roticulating instrument, allowing optimal exposure of the gallbladder hilum.

Laparoscopic cholecystectomy. Video courtesy of SAGES.

A 2-cm vertical incision is made through the center of the umbilicus. Access to the abdominal cavity is gained either with a Veress needle or by means of the Hasson technique. Carbon dioxide is insufflated into the abdomen to a pressure of 15 mm Hg. Three 5-mm ports are placed through the same umbilical incision but through three separate fascial incisions (see the image below).

External view of single-port access through umbili External view of single-port access through umbilicus.

A Keith needle is used to pass a 2-0 glycolide-lactide suture extracorporeally through the right upper quadrant close to the lowest rib and through the body of the gallbladder for cephalad retraction (see the first image below). A roticulating grasper is applied to the infundibulum for lateral retraction (see the second image below).

Suture being placed for cephalad retraction. Suture being placed for cephalad retraction.
Typical intra-abdominal view of gallbladder retrac Typical intra-abdominal view of gallbladder retraction.

The gallbladder hilum is dissected with a Maryland dissector to expose the cystic duct and the cystic artery (see the image below). The cystic duct and artery are clipped with a 5-mm clip, then divided with scissors.

Critical view of cystic duct and cystic artery. Critical view of cystic duct and cystic artery.

A hook electrocautery is used to dissect the gallbladder from the gallbladder fossa. At this point, one of the 5-mm ports is removed, and another is exchanged for an 11-mm port to facilitate placement of a retrieval bag. The bag is positioned beneath the gallbladder, and the retraction sutures are cut to permit removal of the gallbladder (see the image below).

Gallbladder placed in retrieval bag. Gallbladder placed in retrieval bag.

The fascial defect is repaired with a 0 glycolide-lactide suture in a figure-eight configuration, and the skin is reapproximated.

Complications

Complications seen after single-port cholecystectomy are similar to those seen after traditional laparoscopic cholecystectomy, including bile duct injury, port-site hernia formation, wound infection, bleeding, and bowel injury.[18, 19, 20, 21]