|Year : 2013 | Volume
| Issue : 3 | Page : 122-125
Two-port laparoscopic cholecystectomy with modified suture retraction of the fundus: A practical approach
Ming G Tian, Pei J Zhang, Y Yang, Fan J Shang, J Zhan
Department of Hepatobiliary Surgery, the People's Hospital of Ningxia Autonomous Region, Yinchuan, Ningxia, China
|Date of Submission||24-Jul-2012|
|Date of Acceptance||10-Nov-2012|
|Date of Web Publication||22-Jul-2013|
Ming G Tian
Department of Hepatobiliary Surgery, the People's Hospital of Ningxia Autonomous Region, Yinchuan, Ningxia 750002
Source of Support: None, Conflict of Interest: None
Context: Although transumbilical single incision laparoscopic cholecystectomy (SILC) has been demonstrated to be superior cosmetic, it is only limited to simple cases at present. In complex cases, the standard four- or three-port LC is still the treatment of choice. Aim: To summarize the clinical effect of a modified technique in two-port LC. Settings and Design: A consecutive series of patients with benign gallbladder diseases admitted to the provincial teaching hospital who underwent LC in the past 4 years were included. A modified two-port LC was the first choice except for those requiring laparoscopic common bile duct exploration (LCBDE). Materials and Methods: The operation was done with suture retraction of the fundus by a needle-like retractor. The patients' data, including the operative time, time consumed by gallbladder retraction, operative bleeding, conversion rate, rate of adding trocars, and postoperative complications were recorded. Statistical Analysis: Data were expressed as percentage and mean with standard deviation. Results: Total 107 patients with chronic calculous cholecystitis (N = 61), acute calculous cholecystitis (N = 43), and cholecystic polyps (N = 3) received two-port LC. The procedure was successful in 99 out of 107 cases (success rate, 92.5%), and a third trocar was added in the remaining 8 cases (7.5%) due to severe pathological changes. The operative time was 47.2 (±13.21) min. There was no conversion to open surgery. Conclusion: Two-port LC using a needle-like retractor for suture retraction of the gallbladder fundus is a practical approach when considering the safety, convenience, and indications as well as relatively minimal invasion.
Keywords: Needle-like retractor, suture retraction of the fundus, two-port LC
|How to cite this article:|
Tian MG, Zhang PJ, Yang Y, Shang FJ, Zhan J. Two-port laparoscopic cholecystectomy with modified suture retraction of the fundus: A practical approach. J Min Access Surg 2013;9:122-5
|How to cite this URL:|
Tian MG, Zhang PJ, Yang Y, Shang FJ, Zhan J. Two-port laparoscopic cholecystectomy with modified suture retraction of the fundus: A practical approach. J Min Access Surg [serial online] 2013 [cited 2019 Dec 9];9:122-5. Available from: http://www.journalofmas.com/text.asp?2013/9/3/122/115372
| ¤ Introduction|| |
Since the first laparoscopic cholecystectomy (LC) was reported in 1987, various modifications of LC have been developed, including three-port, two-port and, more recently, one-port or single incision LC (SILC). In most of the modifications, the instrument that holds the gallbladder fundus was omitted. In order to get better exposure without a holding instrument, a method of fundus retraction by thread through the abdominal wall has been reported. ,, However, the exposure is not so satisfactory as that by an instrument because the thread retraction is static and not sufficient. Some special instruments for dynamic retraction of the fundus have been reported recently; these include the mini-loop retractor and the endo-retractor that could adjust retraction strength and direction according to exposure requirement. , By incorporating a number of techniques reported, we have created a simplified technique of two-port LC that has proved to be more practical.
| ¤ Materials and Methods|| |
The inclusion criteria for our modified two-port LC were benign gallbladder diseases that indicated LC under general anesthesia. Patients were excluded if common bile duct stones existed or were suspected preoperatively. A total of 107 patients, adequate to our inclusion criteria, who were admitted to the Department of Hepatobiliary Surgery, People's Hospital of Ningxia Autonomous Region between January 2008 and June 2012 were included in this study. Two-port LC was first attempted for all included patients. A third trocar was added when difficult dissection was encountered.
Instruments and operative technique
The specific instruments in this procedure include a long sewing needle and an assembled needle-like retractor [Figure 1]; Shanghai Medical Instruments (Group) Ltd., Corp. Surgical Instruments Factory, Shanghai, China]. The retractor consists of a needle-like handling rod and a mountable grooved cap for holding sutures. The cap is 5 mm in diameter and has a mounting flange inside the connecting hole, which matches the tip of the handling rod. During the procedure, the surgeon stood at the left side of the patient. An arc incision was made below the upper edge of the umbilicus. After inflation, a 10-mm optical trocar was inserted in the peritoneal cavity through the fascia at the upper left side of the incision. Under a scope, the fascia of the right lower side of the incision was punctured by the stylet of a 5-mm trocar to make a tunnel, through which a 5-mm curved forceps was inserted in the peritoneal cavity. After optical exploration, the serosa at the junction of the gallbladder fundus and the liver was lifted by the curved forceps and punctured by the long sewing needle, which was inserted via the skin incision under the xiphoid process [upper left in [Figure 2]. A length of silk suture left in the gallbladder fundus was tied to make a loop after the needle was retreated, and a 5-mm trocar was inserted via the same skin incision. Then, the handling rod of the retractor was directly inserted through the abdominal wall at the midclavicular line 3-5 cm under the right costal margin and the cap was introduced through the sub-xiphoid trocar and connected to the tip of the rod in the peritoneal cavity [upper right in [Figure 2]. The suture loop of the gallbladder fundus was captured by the groove of the cap and pushed upward [lower left in [Figure 2]. Better exposure was then obtained by a combination of this suture loop retraction with the curved forceps in the operator's left hand. Then, resection of the gallbladder was done from the fundus after division of the cystic artery [lower right in [Figure 2]. The specimen was extracted in a bag through the umbilical optical port.
|Figure 2: Upper left, the serosa of the fundus was punctured by the sewing needle; upper right, the suture was tied to make a loop and the cap was connected to the tip of the handling rod; lower left, the suture loop was hooked by the groove of the cap; lower right, the gallbladder was lifted for fundus-first resection|
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| ¤ Results|| |
A total of 107 patients with chronic calculous cholecystitis (N = 61), acute calculous cholecystitis (N = 43), and cholecystic polyps (N = 3) received the two-port LC. The procedure was successful in 99 out of 107 cases (success rate, 92.5%). A third trocar was added in the remaining 8 cases (7.5%) due to extensive and dense adhesion. The operative time was 47.2 (±13.21) min. The operative bleeding was 11 (±8.15) ml. The time consumed by suture retraction of the gallbladder was 4 (±1.55) min. There was no conversion to open surgery. Postoperative complications including bile leak, bleeding, and biliary injury did not occur. Postoperative scars showed more cosmetic than that of the four or three-port LCs [Figure 3]. Retained common bile duct stone was found in 1 patient and was successfully extracted by retrograde endoscopy.
|Figure 3: Scars created by the needle-like retractor (short arrow) and a 5-mm trocar (long arrow)|
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| ¤ Discussion|| |
Transabdominal suture retraction of the gallbladder was first reported by Navarra et al., who performed a LC via two transumbilical trocars: One for laparoscope and another for electric hook dissector with transabdominal suture retraction (puppeteer technique) of the gallbladder wall.  This retraction technique was subsequently modified and applied to three-port, two-port, and SILC by others. ,, Although innovative, added benefits of this technique were not apparent because the suture retraction could not adjust direction as nimble as a conventional instrument. Yasumitsu et al., reported a "mini-loop retractor" that could hold the fundus during SILC and provide an adequate dynamic exposure.  The exposing effect of this technique seems to be apparent, but it would be difficult to grasp the total wall of the fundus by the loop of the retractor if the gallbladder is distended or has a thickened wall. More recently, Noam et al., reported an "endo-retractor," which was put in the peritoneal cavity through the trocar and anchored the fundus of the gallbladder to any site of the anterior abdominal wall according to exposure requirement.  The benefit of this retraction seems to be more cosmetic. However, it took long operative time (115 min), perhaps due to frequent change of the anchoring site.
In recent years, SILC becomes an attractive technique due to its superior cosmetic results. Although attractive, there are many problems to be solved with this approach. As both the instruments and laparoscope enter the peritoneal cavity via the umbilicus, "sword collision" is unavoidable, and the dissecting hook inside the abdomen constitutes a longer moment arm that prevents precise dissection of tissues around the cystic artery and the duct. As a result, the operative time was much longer than that of the standard LC. , Besides, the fundus-first resection of the gallbladder, which is believed to be a safe procedure in complex cases, is difficult in SILC. Furthermore, the disposable multichannel port, which is widely used in SILC, will make the operation more expensive. Therefore, we believe that SILC cannot replace the standard LC at present.
In our two-port technique, the hook dissector entered the abdominal cavity through the 5-mm trocar under the xiphoid process, while the forceps that served as an assistant instrument for exposure entered through the umbilical incision right lower to the optical trocar. With the help of the fundus retraction, this assistant instrument could provide satisfactory exposure with minor range of movement. By direct insertion of a curved forceps, "sword collision" of the instruments could be prevented to a larger degree. The assembled needle-like retractor can expose a viscus by either pushing away the nearby tissues directly or by holding the suture loop sewed on the viscus. Sewing the serosa rather than the complete walls of the gallbladder can also avoid bile leakage from the gallbladder lumen during manipulation.  In our experience, better exposure of dissection panel for completion of the fundus-first cholecystectomy was obtained by this serosa suture retraction. The exposure was even better than what a grasper provides in the conventional four-port LC, especially in the case that the gallbladder is too distended or the wall is too thick to be grasped. Poon et al., performed a randomized study on 120 patients for comparison of four-port and two-port LC. They found that two-port LC gave less operative time, less port-site pain, similar clinical outcomes, and fewer surgical scars.  Although we did not compare with the standard four- or three-port LC, we believe that the two-port approach using the assembled needle-like retractor would take no more operative time, because acute and chronic cholecystitis with a thickened gallbladder wall and multiple stones accounted for a large proportion of our cases. In these cases, suture retraction of the serosa of the fundus provided better exposure for the fundus-first dissection, and a longer transumbilical incision in this two-port approach made the specimen extraction faster. After resection of the gallbladder, the retractor can also help load the specimen bag by pressing on one side of the opening. Therefore, 4 min consumed by suture retraction is worthwhile to save the total operative time. As the puncturing rod is only 1.5 mm in diameter, the hole left on the abdominal wall was negligible. With the help of this suture retraction, we could complete two-port LC with a success rate of 92.5% in our non-selected patients. The patients who had extensive dense adhesion required a third port in order to save the operative time.
| ¤ Conclusion|| |
Suture retraction of the gallbladder fundus with an assembled needle-like retractor can provide satisfactory exposure for two-port LC. It makes the operation safer, more convenient, and widely indicated, while the cosmetic effect of the two ports is obtained. Therefore, we believe that two-port LC with modified suture retraction of the fundus is a practical approach for benign gallbladder diseases.
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[Figure 1], [Figure 2], [Figure 3]