A Specific Instrument to Facilitate Single-Incision Laparoscopic Cholecystectomy

Patients and Methods

From May 2010 to August 2010, 30 patients underwent cholecystectomy via SILC. Most of our patients were female (female-to-male ratio = 25:5), with an average age of 29.8 years (range = 21-38 years). The mean body mass index was 19.98 (range = 15.3-27.6), and 6 of these patients had a history of abdominal surgery (appendectomy, 4; caesarean section, 2; see Table 1).

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Table 1.

Patient Characteristics and Operative Data

	Age (Years)	Sex	BMI	Technique	Operation Time (Minutes)	Blood Loss (mL)	Hospital Stay (Days)
1	26	Female	23.5	SILC	170	60	4
2	30	Female	19.2	SILC	97	15	3
3	27	Female	22.1	SILC	61	10	2
4	35	Female	15.3	SILC	105	22	4
5	31	Female	20.9	SILC	81	17	2
6	36	Female	18.7	SILC	85	30	2
7	21	Female	17.1	SILC	45	9	1
8	29	Male	24.3	SILC	95	15	5
9	38	Female	18.4	SILC	83	17	3
10	32	Male	25.7	SILC	100	36	2
11	24	Female	16.2	SILC	68	19	2
12	27	Female	21.3	SILC	44	16	4
13	34	Female	23.8	SILC	51	10	2
14	33	Female	17.2	SILC	35	7	3
15	23	Female	16.6	SILC	39	8	3
16	26	Female	17.9	SILC	45	27	1
17	23	Female	20.1	SILC	40	11	2
18	35	Male	22.7	SILC	39	14	3
19	31	Female	18.2	SILC	31	9	4
20	22	Female	19.1	SILC	36	20	2
21	27	Female	20.5	SILC	32	25	3
22	24	Female	22.1	SILC	33	11	3
23	34	Male	27.6	SILC	43	13	2
24	22	Female	16.3	SILC	33	10	4
25	25	Female	17.6	SILC	31	5	1
26	31	Female	18.2	SILC	30	12	2
27	26	Female	20.7	SILC	26	9	2
28	22	Male	19.4	SILC	37	13	3
29	30	Female	17.7	SILC	35	16	2
30	31	Female	21.3	SILC	33	13	3

Abbreviations: BMI, body mass index; SILC, single-incision laparoscopic cholecystectomy.

The inclusion criteria were limited mainly to patients with gallbladder stone, polyp of gallbladder, and chronic cholecystitis; those without a history of recent acute onset of cholecystitis; and those with no suspected anatomic abnormality or complicated conditions such as Mirriz syndrome or serious inflammatory exudates, which were found from magnetic resonance cholangiopancreatography and ultrasonography, which were routinely performed in all the patients. Cases with a history of abdominal surgery or complex biliary disease, including biliary pancreatitis, were excluded.

Surgical Technique

Stage 2: Exploration, Exposure, Dissection of Calot’s Triangle

The grasper with adjustable and rotatable wrist laparoscopic instrument (Liuyedao, Inc, Yuyao, China; Figure 1) was used to grasp the bottom of the gallbladder and pull it cephalically, using the syntropic wrist. The flexible wrist was curved downwards to the extent possible manipulating from outside the abdomen, and Calot’s triangle was clearly visualized (Figure 2). Also, with the extraction, tension was formed on the surrounding peritoneum, which facilitated the dissection using a harmonic scalpel. Then Calot’s triangle was explored and cystic duct and cystic artery were exposed (Figure 3).

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Figure 1.

A, Instrument with the syntropic wrist. B, Instrument with the adverse wrist

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Figure 2.

Grasping the bottom of the gallbladder

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Figure 3.

Exposure of Calot’s triangle

Stage 3: Cystic Duct Clipping and Division

Once the cystic duct has been identified and skeletonized, a clip applier was introduced from the right trocar and the cystic duct was clipped with a 10-mm ham-o-lock. Cystic duct and artery were severed using the harmonic scalpel. Dissection was continued using the harmonic scalpel to detach the gallbladder off the liver bed by pulling it laterally or cephalically as needed by manipulating the outside rotatable wrist (Figure 4).

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Figure 4.

Operation of the instrument wrist outside the abdominal cavity

Results

All the SILC procedures in this group were performed successfully without conversion to conventional laparoscopic cholecystectomy or the introduction of any additional laparoscopic instruments or trocars. No intraoperative adverse events or major perioperative complications occurred. The mean operation time was 56.4 minutes (range = 26-170 minutes). The mean estimated blood loss was 16.6 mL (range = 5-60 mL). No drainage was placed, and no bleeding or bile leakage occurred. The mean hospital stay was 1-5 days, with a mean of 3 days. All the patients were followed up for 10 days to 4 months, and no complication such as bleeding, bile leakage, and wound infection occurred.

Discussion

The advantages of SILC include ideal scarless and cosmetic results, less postoperative pain, and shorter recovery time than with conventional laparoscopic cholecystectomy; it can also decrease operative trauma, incidence of portsite hernia, and infection rate of incision while maintaining patient’s safety.^7-14 However, the single incision constrains the 3 instruments to only 1 axis, and the conflicts among the instruments restrict the freedom of each single instrument, which is described as “chopstick effect” or “linear effect.” Such inborn disadvantages make it difficult to create the necessary operative triangle within limited space, which is however of vital importance during the exploration of Calot’s triangle during SILC, with the rigid movements of the inflexible instruments hardly meeting the requirements when precise dissection is needed; in addition, the loss of the operative triangle extremely complicates routine procedures such as extraction during dissection. Such disadvantages of SILC account for the cumbersome procedure and excessive operative time, which have been bothering the surgeons who perform SILC.

Many attempts have been made to address the above-mentioned problems, not only on the design of specific ports and camera but also on the instruments.^3-8 One typical type of existing instruments is the prebent laparoscopic instrument, which requires the use of crossed-over articulating instruments, and as a result, longer operative times are required for achieving careful and precise dissection and some adjustments in the strategy of exposure, particularly because less strength is applied to tissue than with the standard laparoscopic technique. ² This study was to verify the validity of an innovative instrument that is different from most existing instruments for SILC. The instrument was primarily designed to overcome the limitation by introducing 2 simultaneously rotatable wrists rather than a fixed curved tip. With its adjustable and rotatable wrist, the new instrument transmits the movements of the surgeon’s wrist simultaneously, including instrument with syntropic and adverse wrist, which is illustrated in Figure 1. When the manipulator wrist (outside the abdomen during operation) curves to a curtain direction, the wrist at the tip will curve to the opposite direction simultaneously as in Figure 1A. While for the reverse direction, the wrist at the tip will be curved toward the same direction, as shown in Figure 1B. According to our initial experience, it solves the above-mentioned problems well. This is the first report on the application of this type of instrument, although it is only about SILC.

The wrist of this instrument has 7 degrees of freedom, which includes in-and-out motion, rotation of the wrist, pitch (up-down), and yaw (left-right) at the instrument’s tip, plus the grip at the tip. This simulates the movement of the human wrist inside the abdomen. The flexible wrist increases the space for movements within the limited operative field and fixed angle caused by the single port and restrains from the other 2 instruments, whereas for inflexible instruments, such disadvantages are technically not solvable. For cholecystectomy, Calot’s triangle locates at a limited space, with the vital structures such as cystic artery and cystic duct passing through; also, there are potentially various anatomic abnormalities, such as right accessory hepatic duct.^15-18 A sufficient exposure of Calot’s triangle is important and this is always achieved by retracting the gallbladder more laterally, which is difficult to achieve in SILC because of the “linear effect.” In our experience, this is no longer a problem, we could curve the wrist laterally and cranially to the extent possible by manipulating from outside. Therefore, the cystic artery and cystic duct can be clearly visualized and secured safely. Moreover, the wrist can go in any direction as needed, for example, in complicated cases, when peritoneum covering the cystic artery and cystic duct is thickened due to either edema or adhesion, the wrist can be easily rotated to the left lateral and cranial direction, for the better exposure of the posterior triangle, which is a safe procedure routinely performed in conventional laparoscopic cholecystectomy. In our series, harmonic scalpel has been routinely used for dissection, although it is not considered a routine instrument for laparoscopic cholecystectomy at some centers. The tension created by extracting tissue with the tip of the instrument specifically facilitates the dissection using a harmonic scalpel; nevertheless, such tension is needed when some other instruments are applied also. The conflicts outside the abdomen among instruments are also avoided by manipulating the wrist.

In this study, the mean operation time (56 minutes, range = 26-170 minutes) was longer than that of the conventional laparoscopic cholecystectomy done by a single surgeon (30 minutes on average). Specifically, the operation time decreased considerably with experience in applying this new instrument. The first case took us as long as 170 minutes; for the next 29 cases, the mean operation time was 50 minutes (range = 26-105 minutes). For the last 10 cases, mean operation time was stabilized at an average of 34 minutes.

Despite the above-mentioned advantages for facilitating SILC, this new instrument is incomplete from our single-center experience: the absence of fine-scale maneuverability of the wrist comprising precise and steady manipulation and the lack of electric coagulation and cutting function greatly influences its efficacy.

In our study, we concluded that SILC is a feasible, safe, and reproducible technique with this new instrument. Though large-sample data and long-term follow-up are needed to verify its validity and safety, this new instrument might be potentially more helpful in SILC with further improvement.