In recent years, many surgical subspecialties have experienced a paradigm shift from open to minimally invasive surgery. This evolution has progressed to the development of different promising single-port and single-site laparoscopic procedures that are in strong demand by the public.
1,2 Commercial single-port devices like the SILS Port (Covidien, Norwalk, CT) or the TriPort Access System (Advanced Surgical Concepts, Wicklow, Ireland) seal the umbilical incision and allow bundled umbilical introduction of the endoscope and working instruments without loss of the pneumoperitoneum. In children, laparoscopic single-site cholecystectomy is a viable alternative to the conventional 4-port technique. These techniques have been shown to be safe and effective with similar outcomes as the traditional multiport laparoscopy.
3–6The disadvantage of single-site surgeries with sealing devices or placement of multiple instruments through the same incision is the obligatory size of 20mm to 25mm for the main incision, which is comparatively large for a pediatric patient. The single-port devices are large enough to produce significant dilation of the umbilical ring in children. This not only creates more postoperative discomfort, but also often results in an unnatural abdominal wall appearance after umbilical closure. The use of a 10-mm operating laparoscope allows the use of a standard access port and results in a predictably excellent cosmetic outcome.
Single-incision multiport techniques demand considerable practice and advanced laparoscopic skills from the surgeon. They provide a limited degree of instrument range and compromised ergonomics. Furthermore, triangulation with mirror-inverted view of the working instruments violates traditional basic principles of laparoscopic surgery. The use of the 10-mm Storz telescope with inbuilt 6-mm working channel obviates some of the disadvantages of the described single-site techniques. It combines the benefits of minimally invasive single-port surgery with traditional exposure and in-line ergonomics of conventional laparoscopic surgery. The learning curve is comparatively shallow compared to the standard single-port technique. Khosla et al.
7 and Rothenberg et al.
8 described a comparable laparoscopic technique with a modified Frazee endoscope, accommodating a 4-mm 6-degree optic and a 5-mm working channel. Unlike the Storz telescope, it is not commercially available.
The 27-cm length and 0-degree optic are the main shortcomings of the Storz telescope; 43-cm instruments are required, which makes its use in very small patients more demanding. The in-line relationship of the operating channel and the 0-degree optic can create parallax view problems, but these are partially compensated by the excellent maneuverability of the gallbladder with the portless graspers.
The described technique provides adequate view and exposure of the cystic duct to perform a traditional cholangiography with a 48-cm Kumar cholangiography clamp (Nashville Surgical Instruments, Springfield, TN). This was successfully performed on 2 patients.
In the first 6 patients, we sealed the cystic artery and duct, and performed the dissection of the gallbladder from the fossa, with the laparoscopic Harmonic scalpel (Ethicon EndoSurgery). Numerous reports have documented the safety of ultrasonic devices for the gallbladder dissection and ligation of the cystic duct and artery.
9,10,11 Although technically satisfactory, the use of the Harmonic scalpel for this limited purpose resulted in an unfavorable cost-per-case metric. For reasons of cost-containment, we adopted the use of self-locking polymer clips (Hem-o-lok, Weck Closure Systems, Research Triangle Park, NC) to control the cystic duct and larger cystic arteries in most our patients. Hem-o-lok clips are self-locking polymer clips with outstanding tissue sealing properties that provide secure closure of tubular structures, such as blood vessels, appendiceal stumps, or ureters.
12,13The gallbladder is removed directly through the umbilical port site. The fascial defect can be widened to remove a large gallbladder.
There are some limitations to this procedure. Severe cholelithiasis or tense adhesions can reduce the maneuverability of the gallbladder with the 2.3-mm graspers; hence, placement of more rigid 5-mm graspers is necessary. Anatomical variations or postinflammatory changes may demand an angulated optic for optimal view. In these cases, conversion to the traditional laparoscopic cholecystectomy is advised.
José R. Ramirez, MD, and David K. Magnuson, MD
