Single incision laparoscopic cholecystectomy with two umbilical ports and thin forceps

Hidenori Fujii, MD, PhD, Yoshiyuki Kawakami, MD, PhD, Toshiharu Aotake, MD, PhD, Koji Doi, MD, PhD, Riki Ganeko, MD, Yuki Hirose, MD, PhD

Department of Surgery, Japanese Red Cross Fukui Hospital

Recently single incision laparoscopic cholecystectomy has become popular. Various techniques and devices are employed in this procedure. We have performed single incision laparoscopic cholecystectomy with three umbilical ports by the multiple trocar method. Recently high-performance thin forceps has become available and we have used this as an auxiliary forceps in difficult cases. Using two umbilical ports, we devised a technique to insert the thin forceps via the right abdomen from the beginning . In this technique, a 1-cm incision is made at the umbilicus and a puncture scar measuring a few millimeters is created for the thin forceps, which results in better preservation of the umbilicus and better cosmetic presentation compared with the conventional method.

Surgical technique: A 1-cm skin incision made from the center of the umbilicus to the cranial side and the fascial defect was grasped with Kocher’s forceps at the center of the umbilical incision. A pneumoperitoneum needle was inserted into the fascial defect and a pneumoperitoneum was created. An Optical trocar (5 mm in diameter and 10 cm in length; Covidien) containing a direct vision camera (5 mm in diameter; manufactured by LARL STORZ) was inserted through the incision into the abdominal cavity by an optical insertion technique. After ports were inserted, the camera was exchanged with a 50-cm long oblique viewing camera (30?; KARL STORZ).

Subsequently, a 6-mm Endo Tip Cannula (ETC) was screwed into the left side and a thin forceps 2.1 mm in diameter was inserted in the right lateral abdomen. No skin incision was required for either procedure. A 2-0 proline thread (90 cm) was then inserted into the peritoneal cavity via the ETC and the fundus of the gallbladder was grasped by extracorporeal sutures with the modified Roeder knot. A 4-0 nylon thread was inserted to a 22-G needle and a loop was made at the tip, the skin was punctured with the needle. Then, a 2-0 proline thread was inserted to the loop of the 4-0 nylon thread and the 4-0 nylon thread was pulled out of the body to extract the fundus of the gallbladder to the abdominal wall. With these procedures a setting for cholecystectomy with two umbilical ports and thin forceps was accomplished.

The forceps could be controlled via the umbilical and the right lateral abdominal ports and triangulation was easy to perform. This technique was economical because a regular straight forceps was used without an additional access port. In the peritoneal cavity, the gallbladder was stowed in a plastic bag inserted via the ETC and extracted through the umbilical port. A minimum fascial incision was made to aid in this extraction procedure.

Results: The technique was employed in 21 patients and intraoperative cholangiography was done in all cases. There were no intraoperative or postoperative complications. The operation time was 125±30 min and the bleeding was minimal.

Session: Poster Presentation

Program Number: P480

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