Introduction: SSL, though promising, introduces ergonomic challenges due to loss of instrument triangulation as obtained in conventional laparoscopy. This limitation makes establishing the critical view during dissection of the Triangle of Calot (TOC) difficult and has resulted in a variety of strategies to overcome the problem. This study investigates use of a novel percutaneous grasper that mimics a standard laparoscopic instrument and MAGS in aiding surgeons to perform SSL cholecystectomy more easily and with a technique that closely mimics four-port cholecystectomy.
Methods: SSL cholecystectomy was performed on four female cadavers by an expert laparoscopic surgeon with limited experience in SSL. A 15–18mm incision was made at the umbilicus and the MAGS introduced into the abdomen. MAGS consists of an oblong (7.8cm × 14mm) magnetic internal effector with a retractable monopolar cautery hook (6.3cm) and is coupled across the abdominal wall to an external hand-held magnet. By sliding the external magnet over the abdominal wall and applying external pressure, subtle motions of the hook can be achieved. Following MAGS introduction, a commercially available port comprised of a foam cuff and three 5mm trocars was placed. Next, the novel grasper was introduced percutaneously in the RUQ. The device’s 3mm transabdominal shaft is mated to a 5mm end effector intra-corporeally and can grasp tissue with the purchase and security of a standard laparoscopic instrument while providing 360° rotation and locking jaws. Retraction was accomplished using the percutaneous grasper to manipulate the fundus and a standard 5mm grasper through the umbilical port for the infundibulum. Dissection was done using a combination of the MAGS and a standard Maryland dissector. Total procedure time, time from procedure start to obtain a critical view of the TOC and clipping and dividing the cystic duct/ artery, time for dissection of the gall bladder from the liver bed, and thickness of the abdominal wall at the umbilicus were measured. A multi-institutional survey was also administered among surgeons having experience with these devices to gauge satisfaction.
Results: The critical view was obtained in each case and all 4 procedures were completed successfully. Both devices performed optimally to allow smooth flow of the procedure. Mean procedure time was 40min (33-51min); time from procedure start to obtaining the critical view and clipping and dividing the cystic duct/ artery was 33 min (28-38min) and time for dissection of the gall bladder from the liver bed was 6.7min (3-13min). The mean abdominal wall thickness was 1.9cm (1.5-2cm). The survey found that MAGS increased surgeon satisfaction in performing SSL cholecystectomy by 73% (18% satisfaction standard SSL, 100% MAGS).
Conclusions: The use of a novel graspers and MAGS overcomes the limitations of SSL cholecystectomy and improves surgeon dexterity. Making SSL feel more like traditional laparoscopy will enable a wider adoption of this procedure in the community.
Session: Podium Presentation
Program Number: S071