Yasuhiro Miyazaki, MD, Kiyokazu Nakajima, MD, Makoto Yamasaki, MD, Hiroshi Miyata, MD, Shuji Takiguchi, MD, Yukinori Kurokawa, MD, Yoshiyuki Fujiwara, MD, Masaki Mori, MD, Yuichiro Doki, MD. Osaka university graduate school of medicine
Introduction: Laparoscopic fundoplication (LF) has been generally performed using 4- or 5- port technique. LF is considered to be potentially suitable for single port access, since this procedure requires no organ resection, anastomosis, and specimen retrieval. However, its feasibility and safety have not been fully established. The objective of this study was to evaluate the feasibility and safety of single port LF, with specific considerations of accessibility to the esophageal hiatus via the umbilical access.
Methods and Procedure: Single port LF was introduced in our institution in August 2009 and attempted in 10 patients (2 males, 8 females). Median age at surgery was 63.5 (29-77) years with morbidity period of 5(4-24) years. The series included 4 GERD (including 3 sliding type hernias) and 6 achalasia patients. Approximately 2.5cm umbilical incision was made and a dedicated single port access device (SILS port, Covidien and X-CONE, Karl Storz) was used in 8 patients. In the remaining 2 patients, subcutaneous dissection was added beneath the umbilical incision and three 5mm trocars were manually placed. Two loop retracting devices (Mini Loop Retractor, Covidien, USA) were inserted one at the subxyphoid and the other on the left lateral abdomen, to gain exposure of the esophageal hiatus and downward traction of the stomach. The similar surgical techniques (full esophageal mobilization, sutured crural repair and Nissen/Dor fundoplication with/without fundic mobilization) were employed as in conventional multi-port LF.
Results: Single port LF was completed in 3 patients without addition of any surgical ports. The remaining 7 patients required addition of 1 – 3 ports to complete LF, for the following reasons: 1) insufficient hiatal exposure due to large left hepatic lobe (n=3), 2) lack of working length of conventional laparoscopic instruments (n=3), 3) sword fighting of cramps/forceps due to extreme “in-line” motion (n=5), 4) giant hiatal hernia with severe peri-esophageal inflammation (n=1). The problems 2) and 3) were encountered to a certain extent in every patient, mainly due to deep location of the esophageal hiatus and consequently long distance between the esophageal hiatus and the umbilicus. The addition of surgical ports greatly facilitated the exposure and maneuverability by improving retraction of the surrounding organs and optimizing tissue triangulation. One case required conversion to conventional 4-port technique, because of insufficient exposure even after addition of 1 -2 ports. Median operating time was 219.5 (115-303) min and estimated blood loss was 15 (5-50) ml (intention-to-treat basis). No major postoperative complications directly related to the introduction of single port surgery were noted. All patients showed uneventful postoperative recovery, with their oral intake resumed in 2-4 days and hospital stay of 10 days. They showed clinical improvement of their preoperative symptoms with satisfactory cosmetic outcome.
Conclusion: Still technically challenging, single port LF is feasible and safe. Further clinical experiences, with improvement of instrumentation, are necessary to establish this technique as attractive choice of treatment.
Program Number: P243