A Simple Technical Option for Single-Port Cholecystectomy

Health Link Europe, Tilburg, The Netherlands) has indeed a proven track record as a means of robust abdominal access and could be used to allow multiple trocars provide access to the peritoneum by their placement through the gel in a single incision. We recently used this system as a single umbilical access to perform a laparoscopic cholecystectomy in a 30-year-old woman with symptomatic cholelithisais. For the operation, a 2-cm incision was performed into the umbilicus. The plastic ring of the wound retractor was inserted into the abdomen allowing the wound to be retracted but the retractor was not entirely rolled. The GelSeal cap paper protection was removed and, after the port’s fixation, three 10-mm trocars were inserted at a distance of 5 cm each. A CO2 pneumoperitoneum was induced and, thanks to the wide deployment of the intraabdominal ring, an excellent seal ensured no gas leakage. A 10-mm lateral view laparoscope, including a 6-mm working channel (ref 26034 AA, Karl Storz Company, Tuttlingen, Germany) was used allowing both a good-quality view of the operative field and an added operative channel for the introduction of a grasper. Exposure and dissection were performed using single use articulated instruments (Endo Grasp, Endo Dissect, Endo Shears, Covidien, Mansfield, MA) that enabled triangulation as well as a safe dissection of the Calot’s triangle. Arteries as well as the cystic duct were controlled by clip application and the gallbladder was removed after its freeing and introduction into a bag (Endocatch, Covidien) inserted through the umbilical access. No additional stitches or retraction devices were required. The main advantage of this technique lies in the fact that all instrumentation used is immediately commercially available and is already familiar to many surgeons. The use of a wound retractor that has no rigid part in contrast to standard trocars or indeed several single-access ports allows easy mobilization The evolution of surgery today is toward less and less invasiveness. If the NOTES (natural orifice translumenal endoscopic surgery) approach is taken to constitute the peak of this trend, 1-trocar surgery may be viewed as an intermediary development that is gaining increasing support. Its main inherent difficulties, however, remain the lack of readily available, sophisticated trocars that can allow safe introduction of multiple surgical instruments simultaneously and the limited facility for high-quality exposure of the entire operative field through a single, small incision. These constraints mean that the instrumentation used does not easily realize the ideals of triangulation for dissection while providing effective traction/countertraction remains difficult. To overcome these challenges, several surgical teams are employing varying means of suspension off the inner abdominal wall, including sutures or wires. Although initial reports are promising, such techniques add risk, including potential complications such as bile leaks when they are employed for cholecystectomy. Furthermore, in this procedure, dissection and cystic duct control require multiple differing instruments. Although their concurrent insertion could be obtained by means of a flexible endoscope, multiple ports, or recently developed multiaccess single trocars (Uni-X Single Port Access Laparoscopic System, Pnavel System, Cleveland, OH), TriPort system (Advanced Surgical Concept, Wicklow, Ireland) equally, the adaptation of surgical devices that have been already validated on the market may offer significant advantages. One such product (GelPort Hand Access System, Applied Medical, Surgical Innovation Volume 15 Number 4 December 2008 332-333 © 2008 SAGE Publications 10.1177/1553350608327575 http://sri.sagepub. com hosted at http://online.sagepub. com Letter to the Editor