Jonathan D Svahn, MD FACS, Austin L Spitzer, MD, Christine Henneberg, BS, Matthew R Dixon, MD. Kaiser Permanente East Bay, Oakland Campus
Over the last two decades minimally invasive surgery has become more prevalent in digestive surgery. The feasibility of advanced hepato-biliary procedures using minimally invasive techniques has been well documented. More recently there have been reports of single incision laparoscopic surgery undertaken in individuals with both benign and malignant liver disease. We report our experience with single incision laparoscopic surgery in four patients with surgical liver disease.
Three individuals (age range: 62 – 81, two female, one male) were referred to the surgical department for management of suspected benign simple liver cysts. Lesions were located in the left lobe in two patients and in the right lobe in one patient. They ranged in size from 9 cm to 25 centimeters in maximum dimension. A fourth patient (59 year old female) with advanced cirrhosis was referred for management of a single peripheral hepatocellular carcinoma (HCC) in immediate proximity to her gallbladder. In each patient, CT imaging was used to establish the extent, character, and surrounding architecture of the lesion(s).
Our technique has been previously reported and involves the use of a home made single port device. Our "gloveport" is created using a small latex free glove and one 12 mm trocar. The trocar is placed through the thumb of the glove and secured with steri-strips. Similarly, a five mm 30 degree laparoscope and a five mm atraumatic grasper are secured through alternating fingers of the glove. A vertical incision is made through the base of the umbilicus and the fascia is divided sharply under direct vision. A small wound protector is introduced into the abdomen and rolled until it is secure. The gloveport is then secured around the external portion of the wound protector.
In each of the cyst resections the cyst was aspirated and then unroofed using a Ligasure device (Covidien. Norwalk , CT). The cyst wall was removed and sent for pathologic examination to confirm the benign nature of the cyst. The exposed intrahepatic surface of the cyst was then coagulated with argon beam energy source. For the HCC, the gallbladder was first removed with the assistance of transabdominal retraction sutures. Ablation of the nearby HCC was accomplished under laparoscopic ultrasound guidance with real time imaging. In each case, after homeostasis was confirmed, the gloveport and wound protector were removed. The fascia was closed with interrupted sutures and a running subcutaneous stitch was used for the skin. The patients all did well and were discharged without event. At follow up, the three patients status post cyst resection are all symptom free and have had no evidence of recurrence based on ultrasound evaluation. The fourth patient continues to do well and is currently being followed for HCC recurrence.
Our initial experience will single incision laparoscopic surgery for surgical liver disease has been promising. Larger scale studies are warranted to determine if this application of single incision laparoscopic surgery is truly safe and provides similar or improved outcomes compared to open and standard laparoscopic liver surgery.
Session Number: Poster – Poster Presentations
Program Number: P263