Pedro E Garcia-Quintero, MD, Christian A Hernandez-Murcia, MD, Juan-Carlos Verdeja, MD, FACS. Baptist Health South Florida
Introduction: Single incision laparoscopic cholecystectomy (SILC) is emerging as an alternative to conventional laparoscopic cholecystectomy (CLC), offering satisfactory outcomes with improved aesthetic results. Other potential benefits are still being explored. A concern of every abdominal surgical intervention is the risk of subsequent incisional herniation. Incisional hernia (IH) rates are reported between 0.14% and 5.8% depending on the port site. Single site technique results in a larger incision at the umbilical port than CLC, and there are multiple operative techniques for SILC, including those via multi-trocar single incision, robotic single site and SPIDER systems. This study reviews a series of cholecystectomies performed by CLC (12mm trocar at umbilicus) and SPIDER (18mm incision at umbilicus) techniques by a single surgeon (J-CV) and reports on the incidence of IH identified in this patient population.
Material and Methods: Under Institutional Review Board (IRB) approval, medical records of patients that had a laparoscopic cholecystectomy by either CLC or SPIDER technique, between January, 2010 and September, 2013 were retrospectively reviewed. Follow-up ranged between 9 and 30 months. Selection criteria, demographics and outcomes, including incisional hernia were evaluated.
Results: A total of 698 cases were evaluated in this study, 366 by CLC and 332 by SPIDER system. Patients with existing primary umbilical or incisional herniation at the time of the cholecystectomy (86 cases) were excluded from this study, since their rate of re-herniation may be expected to be higher. No absolute contraindications were established for inclusion into either group. Experience gained after an initial 50 consecutive case use of the SPIDER, resulted in increased selectivity in its use. Evaluation of the demographics reveals that the SPIDER group was younger with proportionately more women, less obese patients and less ASA class 3-4. A higher rate of acute cholecystitis was observed in the CLC group, also. No hernias were reported in 279 SPIDER cases, yielding a 95% confidence interval, upper bound of 1.3% for the true IH rate. No IH were identified in 333 CLC cases, giving a 95% confidence interval, upper bound of 1.1% in this group.
Conclusion: The technique used in both approaches had excellent results with no incisional hernias observed in either group. There were identified differences in the composition of the two groups, therefore ongoing study is warranted. In selective use, the incidence of incisional hernia of SILC by the SPIDER system appears to be acceptable and similar to that of CLC.