Minimally invasive surgery and its applications continue to progress. New techniques have been introduced to deliver equal surgical results in a less invasive manner. Single-port laparoscopy is an extension of this phenomenon. Advantages have been suggested and these may include less pain, but until more stringent trials are completed, cosmesis and potential complications from additional trocar sites appear to be the main differences. Drawbacks of this technique, unique from standard multitrocar laparoscopy, have also been identified. This is inherent to the single portal of access and may be related to technical considerations including external clashing of instruments, poor visualization of critical structures, and surgeon fatigue. Complications from single-port cholecystectomy have been described, although whether these are the result of the surgical approach or isolated events is unclear, and large-scale comparative trials against standard laparoscopic approaches have not been performed. In addition, the learning curve for these techniques has not been described. Currently, opportunities for training in single-site surgery are limited but include formal and informal fellowship training, continuing medical education courses sponsored by surgical societies, and industry-sponsored events including laboratory work and proctoring.
Planned partial cholecystectomy is a described technique when dissection is inhibited by severe inflammation, and it may prevent biliary injury in the setting of cholecystitis. Incomplete cholecystectomy may also arise inadvertently with incomplete dissection of Calot's triangle, resulting in transection of the gallbladder fundus instead of the cystic duct. Although inadvertent partial cholecystectomy was initially thought to have increased with the widespread adoption of laparoscopy, increased rates have not been seen in the surgical literature.4
Retained gallbladder after cholecystectomy can manifest with symptoms similar to primary gallstone-related disease. Biliary symptoms after cholecystectomy are evaluated with ultrasonography, and typically in these cases this will demonstrate a cystic lesion containing stones.5
MRCP can further delineate biliary anatomy, and it is considered a definitive test for diagnosis. Completion cholecystectomy, by means of laparotomy or laparoscopy, is the definitive treatment.4,6
As with all new technologies, single-port access procedures have inherent limitations. Request for patient consent for single-port techniques should include full disclosure of the risks, benefits, and alternatives to the procedure. Although there are not absolute contraindications to this technique, patient selection should be left to the surgeon's discretion. With the adoption of multitrocar laparoscopic cholecystectomy, there was a significant increase in common bile duct injuries. Although this rate improved with increased surgeon experience, the overall rate is still higher than with the open technique. Standardized techniques for safe laparoscopic cholecystectomy have been developed and have resulted in decreased rates of major biliary complications. Techniques of routine cholangiography to identify aberrant biliary anatomy and demonstration of the critical view of safety have improved the overall conduct of cholecystectomy. If single-port applications are to become widespread for cholecystectomy, the operation must not deviate from these protocols. Cholangiography can and should be used routinely to demonstrate biliary anatomical variants, strictures or stones, or to identify structures for safe gallbladder removal. Dissection in Calot's triangle must be complete to achieve a critical view of safety both to prevent major biliary injury and to perform a complete operation. This visualization may be compromised by a single port of access originating from the umbilicus by not allowing cephalad and lateral retraction of the gallbladder. The result may be biliary injury or, as in this case, incomplete cholecystectomy secondary to failure to remove all adventitial tissue in Calot's triangle.
Using different techniques including improved commercial access devices and instruments, as well as robotics, may improve retraction and/or dissection and may represent an improvement in conduct and safety over current manual single-port techniques.7
Surgeons should also have a low threshold to add additional trocars to recreate relationships seen in standard laparoscopy or convert to open procedures as dictated on an individual patient basis. Recreation of a safe cholecystectomy technique, either laparoscopic or open, must be paramount for single-port procedures, especially in light of the relative improvement over standard laparoscopy. In this particular case, incomplete cholecystectomy resulted in acute gallstone pancreatitis requiring hospitalization and then an additional surgical procedure for definitive care.