LC rapidly replaced open cholecystectomy (OC) 20 y ago as the procedure of choice when cholecystectomy is indicated.2
Few randomized trials were performed comparing LC to OC given the significant difference between the 2 procedures with regard to pain, hospital length of stay, and postoperative recovery. Some investigators felt it would be unethical to subject patients to OC in a randomized trial given the benefits seen with LC.3
However, as the number of laparoscopic cholecystectomies increased, it became evident that certain complications rarely seen with OC were more frequent when LC was performed. These complications included intestinal and vascular injuries from trocar or Veress needle insertion and major bile duct injuries.4–6
Currently, novel new techniques for gallbladder removal, such as natural orifice transluminal endoscopic surgery (NOTES) and single incision laparoscopic cholecystectomy (SILC), are being investigated as an alternative to the traditional 4-port LC. While neither technique has been widely adopted, there is growing enthusiasm for SILC despite lack of data showing a distinct advantage over the traditional laparoscopic approach. Also unknown is how this increase in SILC will affect the currently low complication rate of LC, particularly as it pertains to bile duct injury.
One major difference between 4-port laparoscopic cholecystectomy and its less invasive counterparts, NOTES and SILC, is the technique to gain entry into the peritoneal cavity. In the traditional 4-port technique, access to the peritoneal cavity can be performed using either a closed or open technique. Complications related to initial trocar insertion include vascular and intestinal injury, with rate of injury reported in large series from 0% to 0.23%.4,7
The vast majority of trocar insertion-related injuries occur with the Veress needle technique. In an analysis of trocar-related injuries reported to the FDA in the mid 1990s, there were 182 visceral and 408 vascular injuries, all using the closed technique.8
In a review by Hasson totaling close to 560,000 laparoscopic procedures, the rate of injury for closed technique was vascular 0.2%, visceral 0.1%, and open technique 0.0% and 0.1%, respectively.9
Though extremely rare, major vascular injury using the open technique has been reported.10
Complications related to peritoneal access for SILC are likely to be similar to those seen with the 4-port technique. Like the 4-port LC, there is no consensus regarding the ideal method to gain access to the peritoneal cavity as reported series use both open11,12
techniques. The number (12 to 150) of patients in these studies is too small to evaluate the incidence of vascular or intestinal complications from Veress needle or trocar insertion. However, there is no reason to believe that the frequency of these complications would be any different in SILC than in 4-port LC, because the entry techniques are identical. When choosing the technique to gain peritoneal access during either LC or SILC, one must remember that major vascular injury never occurs with open cholecystectomy. Using only an open technique, the injury rate was 0% for both vascular and intestinal injury in the author's personal series.
Peritoneal access is of a radically different nature with NOTES. Three primary access sites, stomach, vagina, and rectum, are currently being investigated for NOTES procedures. Of these, cholecystectomy has been performed most frequently through the vagina.15–17
Although NOTES has been studied for over 6 y, it has yet to achieve widespread use in the surgical community, unlike laparoscopic cholecystectomy, which virtually replaced the open technique in just 2 y to 3 y. The main limitations of NOTES are the lack of advanced instrumentation and closure techniques, particularly for the transgastric approach. Also, NOTES is not applicable to all patients. In the German registry for NOTES, 99.2% of patients were women and a transvaginal approach was used in almost all of these patients.17
Of the 1000 patients presented herein, over 50% would not be eligible for NOTES due the prior pelvic surgery or male sex. These patients would be candidates for the transgastric route; however, contamination of the peritoneal cavity is also much more likely with NOTES if the transgastric route is used versus the transvaginal approach. Studies looking at bacterial counts and cultures of the peritoneal cavity following gastrotomy show that bacterial counts are higher after gastrotomy18
and may result in peritonitis.19
Although this has not translated into increased incidence of peritonitis in the cases reported thus far,15,17
the potential exists should NOTES become more widely utilized.
Biliary injury continues to be a significant complication seen with all forms of minimally invasive cholecystectomy. Although rare, injury to the common bile duct often results in additional surgical procedures and increased risk of morbidity and mortality. Bile duct injury is also a leading cause of litigation against general surgeons.20
An increase in the rate of major ductal injury was seen with the advent of LC; however, several reports with a large series of patients demonstrates that LC can be performed with a biliary injury rate comparable to that of OC.2,21,22
Key components in minimizing ductal injury include surgeon experience,2
adherence to well-defined dissection principals (critical view of safety),23
Cholangiography remains controversial as a means to reduce biliary injury during laparoscopic cholecystectomy. While increased cost and operative time have been cited as reasons not to perform routine IOC, several large population-based studies have shown a substantial reduction of >50% in CBD injury when routine IOC is performed.20,24
Additional benefits to cholangiography include identification of occult choledocholithiasis ()
and precise delineation of biliary anatomy ( and )
. Despite these potential advantages, IOC continues to be utilized in a minority of cases.20,25
Anatomic variation: cystic duct draining into right hepatic duct.
Anatomic variation: accessory right hepatic duct.
Biliary injury statistics are difficult to assess with SILC and NOTES, because many of the reports involve a relatively small number of patients. In a recent collective review of all types of single incision laparoscopic surgery, 73% of all reviewed studies contained 20 or fewer patients.26
In 3 articles published after the publication of this collective review, a total of 4 patients who underwent SILC experienced a major biliary injury; 3 required hepaticojejunostomy.27–29
In another published series of SILC,13
cholangiography was utilized in only 10% of patients. It is curious to see that IOCG is not used more liberally when SILS or NOTES is performed, especially if it could lead to reduced biliary tract injuries. Given the changes in visualization and difficulties in dissection due to loss of triangulation in SILC and NOTES, if these less-invasive procedures become more widespread among surgeons without adequate training and supervision, will we again see an increase in biliary injury similar to that seen with the adoption of LC?
Although rare, port-site hernias are a well-known, though late, complication of laparoscopic surgery. In a recent review,30
the overall incidence was 1.7%. Determining the true incidence is difficult, because follow-up is often limited after LC. In the current series, a port-site hernia was diagnosed only after the patient presented with a bulge. All were at the umbilicus, and time from laparoscopic cholecystectomy to surgical repair of the hernia averaged 28 mo (range, 11 to 73). Similar incidence of hernia is likely with SILC, given the similar incision at the umbilicus, though data are lacking as this complication is rarely seen. Incisional hernia is unlikely to be seen after a NOTES procedure, as the site of access is often not in the abdominal wall.