Minimizing the Minimally Invasive: the Yale SILS Cholecystectomy Experience

Amir H Shariff, MD, Shohan Shetty, MD, Heather L Yeo, MD MHSR, Andrew J Duffy, MD, Robert L Bell, MD, Kurt E Roberts, MD. Yale University School of Medicine

BACKGROUND: Single incision laparoscopic surgery (SILS) is arising as a novel technique for performing various general surgical procedures. We describe one surgeon’s experience with SILS cholecystectomy through his first 100 cases.

METHODS & PROCEDURES: Between November 2007 and September 2010, 100 patients were scheduled for SILS cholecystectomy. Through a 2-cm vertical transumbilical incision, three 5-mm ports or, subsequently, a SILS^(TM) Port (Covidien Ltd, Norwalk, CT, USA) was placed using the Veress technique. One extracorporeal stay suture was utilized to provide cephalad retraction of the gallbladder fundus, and a roticulating instrument was used at the infundibulum for lateral retraction. The hilum was dissected and the cystic duct and artery were clipped and divided. One 5-mm port was removed and another upgraded to one 10-mm port to allow the introduction of a retrieval bag for gallbladder extraction. Patient demographic data, operative time, length of stay, surgical pathology, and complications were recorded. These factors were analyzed using SPSS 19. Chi squares and t-tests were used where appropriate.

RESULTS: 98 of 100 patients successfully underwent single-port cholecystectomy. Two patients required conversion to either a conventional laparoscopic or open cholecystectomy. One patient underwent a simultaneous appendectomy and was excluded from analysis. The average patient age was 41.4±14 years and average BMI was 29.9±6 kg/m². Mean operative time was 64.9±25 mins. Length of stay was 0.3±0.6 days. The complication rate was 7%. Patients were divided into sequential quantiles (n=10-11) and all quantiles were found to be comparable for age and BMI. Mean OR time decreased after the first 10 procedures performed (p=0.01). Following the next 20 procedures performed, operative times decreased further and then plateaued for the remaining cases (71 vs 53 mins; p<0.0001). Although increasing BMI showed a trend towards a longer operative time, only class III obesity (BMI >40) was statistically significant (p=0.006).

CONCLUSIONS: Single-incision laparoscopic cholecystectomy is a safe and effective alternative to conventional four-port laparoscopic cholecystectomy. The initial learning curve for this procedure is approximately 10 cases, with a subsequent 20 cases required to hone one’s skills. BMI of >40 is associated with longer operative times.

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