Autor: Dr. Miguel Nácul | Publicado: 2013-03-11T04:33:00-07:00

POLÊMICA NA VIDEOCIRURGIA - COLECISTECTOMIA MINI VERSUS CONVENCIONAL LAPAROSCÓPICA

O artigo original publicado no Journal of Laparoendoscopic &amp; Advanced Surgical Techniques:
Mini-Laparoscopic Versus Conventional Laparoscopic Cholecystectomy: A Randomized Controlled Trial
na edição de fevereiro 2013 (doi:10.1089/lap.2012.0349).

Autores do Departmento de Cirurgia Geral do Hospital Sint-Lucas, Ghent,&nbsp;Bélgica.
Luís Filipe Abreu de Carvalho, MD, Kjell Fierens, MD, and Marc Kint, MD
ABSTRACT
Background: Several studies have reported faster recoveries, lower pain scores, and superior cosmetic results after mini-laparoscopic cholecystectomy (MLC). The purpose of this study was to perform a randomized controlled trial, comparing MLC with conventional laparoscopic cholecystectomy (LC).

Subjects and Methods: Forty-one patients with symptomatic cholecystolithiasis were randomized between the two groups: 23 having undergone LC and 18 MLC. The primary end point was postoperative pain, which was evaluated during the first 24 hours postoperatively, using the numerical rating scale. Patient satisfaction with the cosmetic result was evaluated after 1 month.

Results: The two groups were comparable concerning age, sex, and body mass index. The median operating time (42 minutes versus 45 minutes; P=.386), complication rate, and duration of hospital stay (2 days; P=.611) were similar in both groups. The level of postoperative pain was analogous at every time. There was no difference in the analgesic requirements or cosmesis.

Conclusions: MLC showed similar results concerning postoperative pain and did not lead to a greater patient satisfaction with the cosmetic result, compared with LC. MLC did not take longer to perform, nor was it associated with major complications or a high conversion rate. MLC is a safe and feasible technique for the treatment of gallbladder disease in elective patients.

Resposta Dr. Gustavo Carvalho, "Papa" da minilap

Minilaparoscopic Surgery – Not Just a Pretty Face! - What can be found beyond the aesthetics reasons? – Letter to Editor

Authors:
Gustavo L. Carvalho MD, PhD. [1] - glcmd1@gmail.com
Leandro Totti Cavazzola [2] - cavazzola@hotmail.com
Prashant Rao [3] - pprao2@mac.com

Institutes:
[1] Oswaldo Cruz University Hospital and UNIPECLIN, Faculty of Medical Sciences, University of Pernambuco – Recife, Brazil
[2] Universidade Federal do Rio Grande do Sul - Porto Alegre, Brazil
[3] RAO Institute

&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; We read with careful interest the paper entitled Mini-Laparoscopic Versus Conventional Laparoscopic Cholecystectomy: A Randomized Controlled Trial by Carvalho and cols. Although we can no more than agree with most of the ideas, several missing points still needs to be addressed.
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; The authors conclude, with a very small sample size and using a nonstandard &nbsp;technique for mini-chole, that there is no difference between laparoscopic (LC) and mini cholecistectomy (MLC). The authors used systematically a 5mm trocar and a drain, something that really runs out from the scope of minimalizing trauma. There are two main standard techniques for MLC, with over 1000 cases, and none of them use trocars with a diameter greater than 3mm outside the umbilical site. The proposed technique can be suggested as an hybrid between mini and Lap technique since the author used in a routine basis a 5mm port outside the umbilicus. In most MLC series, the use of a 5mm out of the umbilicus was considered a conversion to LC.
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Most of the published works were inefficient to prove differences between LC e MLC, but none were performed with the new Low Friction equipment which can improve dexterity and cosmesis. Another issue to be adressed in this paper is the routine use of prophylactic drains, that usually are unnecessary and in fact can be responsible by an increase in costs, postoperative pain and worsen the cosmetic result, especially if a 5mm port is used.
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; The advent of Natural Orifice Translumenal Endoscopic Surgery (NOTES) and subsetquently Laparoendoscopic Single Site Surgery (LESS) has called the attention of the surgeons to look for even less invasive modalities of surgical access. Minilaparoscopy (MINI) is a natural advancement of laparoscopy, which proposes to diminish surgical trauma by reducing the diameter of the standard laparoscopic instruments, without loosing range of motion na triangulation, important aspects that can be a major issue in NOTES and LESS. Minilaparosocpy what was first described more than 12 years ago is not really a new modality of access, but really needs to be carefully revisited because several aspect have changed over this period of time:
- New instruments were developed, much well designed and with more resistant materials, which are now giving a totally new face to MINI,
- In procedures that enhanced visualization in a restritcted space is necessary, MINI offers advantages over regular LAP (for example, for mini TEP inguinal hernia repair, mini lumbar or thorax sypmpatectomies, mini common bile duct exploration and reconstructions) When it’s necessary to suture or even just to tie a knot the enhanced precision of the new low friction MINI equipments can have advantages in their handling over the conventional 5mm equipment that uses rubber sealings and valves that can preclude some amplitude of movement.
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; MINI is no longer na experimental procedure, and it’s here to stay. As a matter of fact, one may say the MINI has returned to stay. The same MINI that Michel Gagner and Peter Goh described on the 90s,5,6 that did not become popular because the instruments deemed too flimsy and surgeons were not used to work with very thin, fragile, and expensive scopes. Moreover, surgeons insisted on clipping every structure from the umbilical port, which resulted in changing the scope several times in a single procedure, making MINI not only complicated but also boring and time consuming.7 Stigmatized as an expensive and complicated surgery, at that time MINI seemed to have no major advantages and did not progress the way industry had imagined.
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; With some minor adjustments in the technique, what we have named Clipless technique, we could overcome the problem of the MINI optics simply by tying knots to the cystic duct. This technique is detailed described in recent publication of 1000 cases (in a series that now surpases 1700), without mortality, conversion to open surgery or common bile duct injuries. Using the new MINI instruments we could safely complete more than 97% of cases only with mini instruments. In the case of placement one 5mm trocars (what is standard by the author of the present paper), we consider it to be a conversion to laparoscopic cholecistectomy. In order to avoid the use of mini-scopes, all gallbladders are removed in a bag, and most of our cases are discharged in less than 24h with virtually no pain. Currently, MINI Clipless is a 1-day surgery, safe, with all the advantages of laparoscopy, highly reproducible, cost effective, and with great aesthetic appeal.
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Another great advantage of the MINI that usually is forgotten by many authors (who are really wanting to address the cosmetic issue) is the enhanced view. A surgeon that uses MINI can work much closer to the subject without being disturbed by the 5mm fórceps. &nbsp;Mathematically speaking, we can find gains up to 2.7x in magnification when using MINI equipments.
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; In endoscopic surgery, peripheral vision is limited by the visual field of the laparoscope. In this tunnel vision, thinner instruments occupy less space, and a much better view can be obtained. MINI instruments fit well into the concept of amplified vision provided by laparoscopes. The increase in vision scale seen in laparoscopy does not find a perfect partnership with conventional 5-mm instruments, and they become a coarse instrument for dealing with more delicate situations, such as biliary anastomosis, resection of a sympathetic ganglion adherent to the vena cava, or dissection of the deferens duct from the hernia sac during hernia surgery. This is especially important in retroperitoneal surgeries, where the space is naturally restricted and inadvertent movements may result in peritoneal perforations thus causing gas escape and further space reduction. More delicate surgeries should be preferably done by minilaparoscopy, because you can get closer vision and work with more precision due to the size of the instruments.
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Current technical limitations of MINI are being resolved by the efforts of the industry in crafting more resistant and higher performance instruments. Even though MINI instruments are more delicate, when properly used they do not need much more maintenance then 5-mm laparoscopy instruments. Current Low Friction MINI trocars (unlike their ancestors from the 90s) do not have a sealing membrane (what can be called as “mo rubber trocars”). They have very low friction and therefore almost no force is needed to move the instruments inside the trocars, which prevents the undesirable movement (and eventually the total displacement) of the trocars. Another important achievement of the new MINI trocars is that they have a ball shaped dilating tip with smooth transition between tip and cannul, allowing for minimal skin incision by radially dilating the skin, muscle layers and fascia. Adding this with the abscence of friction with rubber, there is no dislocation of trocar during operation and improved cosmesis at the site of penetration of the trocar.
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; The ball shaped tip introducer helps to minimize injuries to vessels and nerves when gently introducing the trocar, by dissecting instead of cutting. There is an extra-precise fit between instrument and cannula, resulting in extremely reduced friction and minimal gas leak (<0 .1l="" a="" and="" any="" as="" being="" by="" co2="" consequence="" corrected="" criticism="" for="" formerly="" in="" increase="" is="" leak="" min="" models.="" new="" of="" p="" performance="" procedure="" real="" reason="" regarded="" resultant="" successfully="" the="" these="" trocar="" without="">WE PLACE HERE TWO or 3 figures !!!

The author (Carvalho) declares to have a possible conflict of interest. He is a consultant, without financial interest, for Karl Storz for the development of the new minilaparoscopic low friction trocars. The other authors have no relevant disclosures to this article.
References:

1.Abreu de Carvalho LF, Fierens K, Kint M. Mini-Laparoscopic Versus Conventional
Laparoscopic Cholecystectomy: A Randomized Controlled Trial. J Laparoend Adv Surg Tech 2013; 23(2): 109-116.
&nbsp;2. Rao PP, Rao PP, Bhagwat S. Single-incision laparoscopic surgery - current status and controversies. J Minim Access Surg. 2011;7(1):6-16.
3.. Zorron R, Maggioni LC, Pombo L, et al. NOTES transvaginal cholecystectomy: preliminary clinical application. Surg endosc 2008;22:542-547
4/ Gagner M, Garcia-Ruiz A. Technical aspects of minimally invasive abdominal surgery performed with needlescopic instruments. Surg Laparosc Endosc. 1998; 8(3):171-179.
5. Cheah WK, Goh P, Gagner M, So J. Needlescopic retrograde cholecystectomy. Surg Laparosc Endosc. 1998;8(3):237-238.
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9. Carvalho GL, Chaves EFC, Gouveia RLP, et al. Cystic artery Electrocauterization as an efficient, safe and cost-effective alternative in the minilaparoscopic cholecystectomy. Poster Presented at the Society of American Gastrointestinal and Endoscopic Surgeons Congress (SAGES), 2011, Abstract P379.
10. Carvalho GL, Lima DL, Sales AC, Silva JSN, Fernandes Junior FAM. A new very low friction trocar to increase surgical precision and improve aesthetics in minilaparoscopy. Poster presented at the Society of American Gastrointestinal and Endoscopic Surgeons Congress (SAGES), 2011, Abstract ETP077.
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