SILS Single port cholecystectomy

Laparoscopic techniques have allowed surgeons to perform complicated intra-abdominal surgery with minimal trauma. Recently, the use of single incision laparoscopic surgery (SILS) has increased the potential of further reducing the trauma of surgical access respecting the basic principles of cholecystectomy.

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SILS Single port cholecystectomy

Authors

D Mutter, J Marescaux

Abstract

Laparoscopic techniques have allowed surgeons to perform complicated intra-abdominal surgery with minimal trauma. Recently, the use of single incision laparoscopic surgery (SILS) has increased the potential of further reducing the trauma of surgical access respecting the basic principles of cholecystectomy.

Classification

new techniques, single port

Keywords

SILS Single port cholecystectomy

Media type

Surgical video

Duration

05'50''

Publication

2009-09

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E-publication

WeBSurg.com, Sept 2009;9(09).
URL: http://www.websurg.com/doi-vd01en2722.htm

SILS Single port cholecystectomy

1. Introduction 00'09''

A patient presenting with a symptomatic choledocholithiasis benefits from a single trocar cholecystectomy.

2. SILS system introduction 00'18''

The port used is a SILS one. The incision is strictly intra-umbilical in order to avoid any operative pain. A 2cm incision is carried out under direct visual control. The SILS port is introduced into the abdomen. It has three operating channels and another channel for insufflation. The position of the port is controlled after introduction of a sheath. The optical system is a 5mm one with a 30 degree angulation. The good positioning of the port into the abdominal cavity is checked. Then insufflation is performed using the insufflation cannula. Three 5mm cannulas are placed. One cannula is used for the introduction of a 5mm camera. The two other cannulas are used for the introduction of instruments. The procedure is started conventionally by the placement of two straight instruments: one grasper to expose the gallbladder, and one hook to progressively dissect the Calot’s triangle.

3. Dissection of Calot\'s triangle 01'28''

The dissection may turn out to be difficult owing to the permanent contact between the scope, the graspers and the hook. The use of a 30 degree scope is essential. The leftward or rightward orientation of the scope allows to ensure a free view and to control the dissection using the coagulating hook. The basic principles of cholecystectomy should be respected with progressive opening of the peritoneum posteriorly, then anteriorly to the Calot’s triangle in order to completely identify it.

4. Introduction of articulated forceps 02'14''

It is sometimes necessary to replace the rigid instrument used to expose the gallbladder with an articulated instrument. A 5mm articulated forceps is used to retract the instrument’s axis outside of the visual field and free the space required to handle the hook. A better exposure of the cystic duct is obtained, which allows for the safe placement of clips. We do not usually perform a routine intraoperative cholangiography.

5. Division of cystic duct and artery 02'55''

The cystic duct may be divided safely after identification of the cystic artery and duct. The cystic artery is dissected entirely. It is then controlled by clip application. The basic principles of laparoscopic cholecystectomy are respected here. It is essential not to alter anything because of this one trocar approach.

6. Cholecystectomy 03'29''

Once the cystic artery and duct have been freed, the cholecystectomy may be carried out progressively through monopolar cautery by using either the divide or coagulate mode. The peritoneum is opened first. The fibrous adhesions between the liver and the gallbladder are progressively taken down. Here again, the rightward, then leftward change of direction of the scope’s axis provides us with the benefits of using the 30 degree camera; indeed, the anterior portion, then the posterior portion of the adhesions are successively exposed. In most cases, the three-trocar technique as described here allows to perform a single port cholecystectomy safely.

7. Control of gallbladder\'s bed and specimen extraction 04'20''

Since the gallbladder is totally freed, the gallbladder’s bed may be controlled. Complementary coagulations at the level of the liver’s bed may be carried out using either a monopolar or a bipolar forceps. A 5mm cannula is replaced by a 10mm one in order to allow for the introduction of an extraction bag. This bag allows for a safe removal of the gallbladder. The gallbladder and the trocar are removed simultaneously. The umbilical access is removed after extraction of the cannulas, which diminishes its diameter. The gallbladder is extracted with the bag safely.