Introduction: Single Incision Laparoscopic Cholecystectomy (SILC) is emerging as a potentially less invasive alternative to both standard laparoscopic cholecystectomy (LC) and NOTES cholecystectomy. However, as this technique becomes more widely employed, it is important to maintain the ability to perform the critical view (CV) dissection and intraoperative cholangiography (IOC). We present our initial experience with SILC using the CV dissection and routine IOC.
Methods: Fourteen patients with biliary colic were offered SILC. Exclusions were acute cholecystitis, morbid obesity, and prior upper midline abdominal surgery. The SILC approach was performed via the umbilicus and critical view dissection (with photo documentation) was attained prior to clipping or transection of any ductal structures. IOC was done using various needle puncture techniques. Assessment of CV was carried out retrospectively by independent surgeon (SMS) review of operative still photos in 15 of 16 cases using a three point grading scale under IRB approval. One point was given for each of the following: visualization of only two ductal structures entering the gallbladder, a clear hepatocystic triangle, and separation of the base of gallbladder from the liver.
Results: SILC was performed in 16 patients (6M, 10F). Average BMI was 28±4.6. Mean OR time was 125 ±31.4min. Fourteen of 16 cases were performed as single incision and two cases required one supplementary 3 or 5mm subcostal port. Complete IOC was successful in 14/16 cases (87.5%). One attempted IOC was unsuccessful and a 2nd IOC showed incomplete filling of the proximal ductal system due to contrast extravasation at the cystic duct. Critical view was achieved at the time of operation in all 16 cases. Photo documentation review confirmed CV by all 3 criteria in 10 cases, 2 of 3 in 2 cases, and 1 of 3 in two. In only one case was photo documentation inadequate to verify any of the three CV criteria.
Conclusions: As laparoscopic cholecystectomy becomes less invasive, proven safe dissection techniques must be maintained. Dissection to obtain the critical view should be the goal of every single incision case and routine IOC can be done in a high percentage of cases. These measures should help ensure that patient safety considerations are foremost in the evolution of minimally invasive approaches to cholecystectomy.
Program Number: P516