Laparoendoscopic Single Site Cholecystectomy Using a Novel Oval-shaped Port Device

Kazunori Shibao, MD PhD, Aiichiro Higure, MD PhD, Noritaka Minagawa, MD PhD, Koji Yamaguchi, MD PhD. Dept of Surgery I, University of Occupational and Environmental Health

OBJECTIVE: 

To evaluate the usefulness of oval-shaped port devices compared to round-shaped port devices in laparoendoscopic single site (LESS) surgery, and to report an initial clinical case series of LESS cholecystectomy using this oval-shaped port device.
METHODS:
The LAPPROTECTOR series (Hakko, Japan) is a wound retractor/protector made from a silicon rubber membrane with a flexible shape-memory frame. The EZ ACCESS Round type (Hakko, Japan) is a silicon rubber cap that is designed for the LAPPROTECTOR Round type device to create a tight seal, and was introduced for LESS surgery. As the EZ ACCESS Round type device has no fixed channel, surgeons can select the best trocar placement to maintain maximum trocar separation for each surgery. We recently developed an oval-shaped EZ ACCESS device, which we named the EZ ACCESS Oval type, which is designed exclusively for the LAPPROTECTOR Oval type device, and compared the trocar separation to procedures using the conventional round-shaped EZ ACCESS/LAPPROTECTOR in five patients with cholecystolithiasis.
Both devices were placed through a single 25 mm umbilical incision. The scope trocar was introduced at the caudal side of the device center. Two other trocars for working instruments were inserted through both sides of the device. The lengths between the working-ports were measured and compared. After measuring the trocar separation for both devices, the LESS cholecystectomy with the oval-shaped device was performed. Another 3 mm grasper was directly inserted into the peritoneal cavity through the device for cephalad retraction of the gallbladder. Only standard straight instruments were used throughout the procedures.

RESULTS:
The average distance between the right and left trocars for the oval- and round –shaped devices with a 2.5 cm umbilical incision were 34±0.67 mm and 27±1 mm, respectively. The wider trocar separation achieved using the oval-shaped device made the surgical procedures easier. Frequent instrument changes during the surgery did not affect the seal.
Conversion from 5 mm to 12 mm trocars, and replacement of trocars were performed easily without air leakage. The direct insertion of a 3 mm grasper through the device for cephalad retraction of the gallbladder allowed a good surgical view to be maintained without air leakage or touching of instruments. The novel port cap allowed for safe and quick retrieval of the gallbladder with the cap off the device. Re-pneumoperitoneum was easily achieved by recapping the device.
All procedures were completed uneventfully. The total length of the operation was 70±12.3 minutes, and intraoperative blood loss was less than 5 grams in all five patients. There were no perioperative port-related or surgical complications.

CONCLUSIONS:
LESS cholecystectomy using the EZ ACCESS Oval type device was found to be technically feasible. The oval type device appears to provide wider trocar separation, thereby reducing the surgeon’s stress, and ensuring patient safety with cosmetic benefits. Further investigations will need to be performed to confirm the efficacy and safety of using such oval-shaped LESS port devices.
 

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