Preoperative Training and Planning Methods for a Single-incision Laparoscopic Cholecystectomy for Situs Intrevsus Totalis (sit)

Hisashi Ikoma, PhD, Yukihito Kokuba, PhD, Yusuke Yamamoto, PhD, Ryou Morimura, PhD, Yastutoshi Murayama, PhD, Syuuhei Komatsu, PhD, Atsushi Shiozaki, PhD, Yoshiaki Kuriu, PhD, Masayoshi Nakanishi, PhD, Daisuke Ichikawa, PhD, Hitoshi Fujiwara, PhD, Kazuma Okamoto, PhD, Toshiya Ochiai, PhD, Eigo Otsuji, PhD. Department of Digestive Surgery,Kyoto Prefectural University of Medicine

 

1. Objective of technique: A single-incision laparoscopic cholecystectomy, which is performed by making an incision into the umbilical region, is expected to lead to reduced pain and scarring and a shortened time required for recovery, and this procedure is now becoming more widely used. Although laparoscopic cholecystectomy for situs intrevsus totalis (SIT) has been previously reported, there have been a few previous reports of a single-incision laparoscopic cholecystectomy. We herein introduce the preoperative training and planning methods for a single-incision laparoscopic cholecystectomy for situs intrevsus totalis (SIT). These methods could decrease difficulty, and improve safety.
2. Description of the methods:
1 We made a hepato-billiary model of SIT using wheat clay. When the model was put in a dry box, preoperative simulation was performed.
2. A movie about the mirror image laparoscopic cholecystectomy was made using ‘Quick Time 7’.
3. A Virtual Reality image made using the Work Station and multit-detecter computed tomography.
3. Preliminary results:
A single-incision laparoscopic cholecystectomy in a 49 -year-old female with SIT, who was diagnosed cholelithiasis, was safely performed. Our initial concerns about this procedure were the increased difficulty, and concerns about patient safety. We enhanced our preoperative training and planning to address each of these concerns. In particular, we made a hepato-billiary model of SIT using wheat clay. When the model was put in a dry box, preoperative simulation was performed, and both the multitrocar access using the French technique and the single port access, which were carried out in symmetrical fashion with respect to their situation in orthotopic patients, were tried to estimate the difficulties in performing this procedure using the single port access. During the above simulation, the difficulty using the instruments read to single port access was observed remarding multitrocal access, because it was noticed that the angle crossing by both instruments in the single port access for SIT was similar to that made in orthotopic patients. During the surgical procedure, it was necessary to apply counter-traction between the gallbladder and the adipose tissue surrounding the gallbladder by retracting both instruments either up or down, rather than in the lateral direction, which allowed for good tension.
A movie about the mirror image laparoscopic cholecystectomy was made using ‘Quick Time 7’. The movie allowed us to become used to the mirror image, and made it easier to imagine the actual surgical site. This technique was very easy and inexpensive. This method is also considered to be applicable to another types of endoscopic surgery for SIT.
One more approach was used to familiarize the surgical team to the mirror image, which was a Virtual Reality image made using the Work Station from the voxel data obtained by multit-detecter computed tomography. This image presented the detailed anatomical features of the patient
4. Conclusions:
These three methods of preoperative training allowed for a rapid, successful and safe operation, and allowed the surgeon to maintain a safe dissection and attention to the safety aspects of laparoscopy.
 


Session Number: Poster – Poster Presentations
Program Number: P165
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