Minilaparoscopic Approach With Hidden Scars for Usual Laparoscopic Procedures.

Isaac Baley Spindel, MD, Karla Susana Martin Tellez, MD, Angel Martinez Munive, MD, Jorge Cueto Garcia, MD, Fernando Quijano Orvañanos, MD. American British Cowdray Medical Center, Mexico City.

Introduction
About 25 years ago laparoscopic surgery emerged as a novel, minimally invasive technique for treatment of common surgical pathologies. In the last 5 years, techniques and instruments evolved looking to reduce morbidity while improving cosmetic outcomes. Such techniques include single incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES), however equipment is usually expensive and a new learning curve required for most surgeons. We propose a 3 or 4 port minilaparoscopic approach with hidden scars for usual laparoscopic procedures using standard laparoscopic instrumentation and techniques.

Methods
All appendectomies since 1998 and all cholecystectomies since 2005 were reviewed in terms of complications, postoperative pain, and cosmetic results, with a mean follow of at least 1 month.
Results were compared against data published in international literature.

Appendectomy is performed with a 10 mm umbilical port and two 3 or 5 mm suprapubic ports. A 10mm scope is introduced through the umbilical port and, working from the suprapubic ports, dissection is carried out in the usual fashion. A 5 mm harmonic scalpel or 3 mm pulsated bipolar coagulator is used to ligate the appendicular artery. The appendix is tied with Endoloop sutures and transected with scissors. We then switch to a 3 or 5mm scope and extract the appendix with a laparoscopic retrieval bag.
For cholecystectomy, ports are placed in the same manner and an additional 3mm port is introduced in subxiphoideal position. The right suprapubic port is used for fundus retraction, left suprapubic and subxiphoideal ports for dissection. The cystic duct is ligated either with intracorporeal suture or with clips (introduced through the 10mm port and switching to 3 or 5mm optics), a 3mm pulsated bipolar electrocautery is used for cystic artery ligation, again, this can be performed with other methods. The gallbladder is extracted through the umbilical port using a laparoscopic retrieval bag.

Results
No statistically significant difference in complications was found as compared to rates reported in worldwide literature, nor was operative time increased. Postoperative stay was 12- 24 hours. For cholecystectomies, five transcystic cholangiographies and 2 common bile duct explorations were performed; mean operative time was 45 minutes. No conversion to open surgery or extra trocars were needed.

Discussion
Back in 1998 we started to perform a hidden scar appendectomy using a 10mm umbilical port and two 3 or 5 mm suprapubic ports. In 2005, upon realization that the gallbladder could be reached from the suprapubic ports, we added a 3mm subxiphoideal trocar and began to perform cholecystectomies, at first on selected patients, today we do it standard, including complicated gallbladder disease. The tecnique is suitable for all kind of patients, including the very tall and obese.
We have found no increase in complication rates or operative time. Moreover, postoperative pain is decreased, ergonomics improved, there is practically no learning curve for laparoscopic surgeons and costs are not increased.
Lately we performed 10 gynecologic procedures using the same approach and a laparoscopic fundoplication with only one 5mm and one 10mm visible ports.

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