Single incision laparoscopic approach in hepatopancreatobiliary surgeries
Year: 2025
Type: article
Abstract: 1. Introduction Many abdominopelvic surgeries are now performed laparoscopically rather than through open approaches. This trend continued despite reports of increased rates of unintended complications, such as bile duct injuries during cholecystectomy, in the early phase of laparoscopic adoption [1,2]. Although the “learning curve period” may largely explain these complications, it remains difficult to determine how much was due to more enthusiastic reporting or heightened awareness, compared to complication reporting in open procedures. We believe a similar pattern applies to the single-incision laparoscopic surgery (SILS) approach. Interest in this technique for cholecystectomy began in 1997, when Navarra et al.[3] published their “one-wound” laparoscopic cholecystectomy technique. With the introduction of new access ports—including the SILS device from Covidien, the TriPort+, TriPort15, and QuadPort+ from Olympus, and the GelPOINT system from Applied Medical—interest in single-incision laparoscopic cholecystectomy (SILC) was renewed. Early results were promising [4–7], and SILS was soon adopted for other hepatopancreatobiliary procedures [8] including cholangiography [8], bile duct exploration [9], liver cyst deroofing [10], pancreatic pseudocystogastrostomy [11], liver resection [12], and distal pancreatectomy [13]. These procedures were supported by feasibility and safety studies, as well as largely driven by patient satisfaction [14]. More recent comparative studies have also shown that hepatopancreatobiliary surgeries can be performed using the SILS approach with satisfactory outcomes [15–18]. However, interest declined after higher rates of bile duct injury were reported compared to historical data on conventional laparoscopic cholecystectomy. In a review of 76 studies, Joseph et al. [19] reported a bile duct injury rate of 0.72%. In an editorial, Le Roy and Slim [20] stated that SILC carried a 4.5-fold increased risk of bile duct injury, a 3-fold increased risk of biliary complications, and a 2.5-fold increased risk of incisional hernia. One systematic review and meta-analysis also found SILC to be associated with greater blood loss compared to conventional cholecystectomy [21]. These findings, along with the technical challenges of the SILS approach, further limited its adoption in hepatobiliary surgery. Since 2014, there have been fewer reports on the use of SILS for hepatobiliary procedures (Figure 1).Figure 1: Number of publications on SILS cholecystectomy.2. Interest in other specialties Although the use of the SILS approach has “lost its shine” in hepatobiliary surgery, it began to gain traction in other surgical fields, and this interest appears to be more sustained (Figure 2). For instance, even in the most recent 2 years, there have still been publications on SILS colectomy [22], gastric surgery [23], gynecological procedures [24], adrenalectomy [25], thoracic surgery [26], and even breast surgery [27].Figure 2: Number of publications on SILS surgeries.3. Use of robotics More recently, with the introduction of the Da Vinci SP system from Intuitive—despite the increased costs—surgeons have revisited the single-port approach, accompanied by a corresponding increase in publications (Figure 3). Single-site robotic cholecystectomy (SSRC) has also received more “lenient” acceptance among surgeons. In a meta-analysis comparing SILC and SSRC, Rudiman et al. [28] found no statistical difference in hospital stay, blood loss, conversion rate, postoperative complication rate, or immediate postoperative pain scores between the 2 groups. However, the authors claimed superiority in SSRC owing to a lower incidence of intraoperative complications as well as reduced pain experienced at hospital discharge. They concluded that the better pain score result could be a decisive point for adopting SSRC over SILC, despite significantly higher operative costs and longer operation times.Figure 3: Number of publications on single-port robotic surgeries.However, the analysis only included one single-blind randomized controlled trial. The remaining studies consisted of nine retrospective cohorts and three prospective cohort studies. There were no double-blind randomized trials included. In the setting of a pain score analysis, a superiority outcome based on a subjective parameter without double-blinding may not be very conclusive. Interestingly, the study showed no difference in postoperative complication rates. If the incisional hernia rate is higher for SILC, then SSRC should be even higher, given the need for a larger incision of 2.7 cm (the newer disposable devices for SILC typically require an incision of 1.5 cm or less). Perhaps surgeons have mastered the technique of closing a larger incision to avoid incisional hernia. The study also reported a lower incidence of intraoperative complications in SSRC. In our own experience, there have been no intraoperative complications in SILC, which makes it difficult to appreciate the validity of this finding [29]. Some may argue that with SSRC, it is easier and safer to scale the learning curve. However, it is our belief that, through proper proctorship and by adopting certain unique instrument-handling techniques, it is just as easy and safe to master SILC, at a markedly lower cost. 4. Technical tips 4.1. Limitations and challenges faced during SILS procedures In performing SILS procedures, the surgeon faces a few limitations and challenges compared to the conventional multiple-port approach. Firstly, there is a loss of the “usual” triangulation between surgical instruments, as the instruments enter the abdomen almost parallel to each other. In addition, with all working instruments entering through the same port, the operating field can only be approached from one direction, which limits the range of dissecting angles. Moreover, having all instruments enter the abdomen at the same point places all the instrument handles near each other. This inevitably increases the chance of hand clashing and further restricts the range of motion. Finally, the number of instruments that can be introduced into the abdomen is limited depending on the type of device used. To circumvent the above challenges, we recommend the following technical modifications. 4.2. Intentional “crisscrossing” of instruments for adequate retraction In conventional laparoscopic surgery, retraction is provided by opposing instruments introduced into the abdominal cavity, each pulling one side of the tissue to be divided in opposite directions (triangulation) (Figure 4). In single-port surgery, retraction is achieved by grasping instruments pivoting at the abdominal wall pivot point (usually just deep to the single-port device), each grasping the opposite side of the tissue to be divided. Instead of pulling, the instruments pivot at the entry point, and the instrument handles are moved in the direction opposite to the intended direction of tissue retraction (Figure 5).Figure 4: Retraction force in conventional laparoscopic surgeries.Figure 5: Retraction force in SILS.4.3. “Reverse hand grip” and “snooker-cue-guide” positions In conventional laparoscopy, the laparoscope is usually introduced through a port placed at a site away from the working instrument ports. Its range of movement is relatively free. In SILS, the laparoscope and instruments are introduced through the abdomen in a confined location. Even with a 30-degree telescope, to visualize the tip of a straight working instrument, the laparoscope needs to be almost in the same plane and parallel to the working instrument. This often restricts its range of movement and may jeopardize the field of vision. To overcome this, 2 technical adjustments are needed while manipulating the laparoscope and the instrument performing critical functions such as cutting, dividing, coagulating, or clipping. First, when holding instruments with a pistol grip handle, it is recommended to hold the handles in a reverse hand grip position (Figure 6). This prevents the handles from knocking against the laparoscope-holding hand and allows more freedom of movement.Figure 6: Reverse hand grip and “snooker-cue-guide” positions.Second, the surgeon should be the one holding the laparoscope, usually with the nondominant hand. The dominant hand should hold the instrument performing the critical function. One hand is positioned on top of the other, mimicking the snooker cue stick guided by a cue rest position—“snooker-cue-guide” (Figure 6). In this manner, the surgeon can coordinate the movements of the laparoscope and the working instrument at the same time, minimizing interference between the 2. With these technical tips, SILS procedures can be safely performed, as they allow for adequate retraction, an uncompromised laparoscopic view, and unhindered execution of the working instrument. 5. Selection of cases Inherently, the SILS approach is technically more challenging than the conventional laparoscopic approach and demands a new learning curve for surgeons attempting to adopt it. As such, careful patient selection is paramount for safe adoption and confidence-building at the beginning of the learning phase. More specifically, intracorporeal suturing and knot tying in SILS is technically more demanding. Thus, during the early learning phase, surgeries that may require suturing or knot tying should be avoided. Instead, simpler excisional procedures such as liver cyst deroofing, straightforward cholecystectomies, and excision of small peripheral liver tumors should be considered. In a recent review by Karabicak et al. [30], the authors analyzed 27 published manuscripts on SILS hepatectomies since 2010. They recommended that patients with Child-Pugh Class A liver function and a solitary tumor in the left lateral section or in anterior and inferior liver segments are ideal candidates for single-incision laparoscopic liver resections during the early phase of adoption. The authors also advised against selecting patients with a history of upper abdominal surgery—although, interestingly, there are advantages to employing SILS in such cases, as a larger first-port incision allows for a safer primary entry and reduces the risk of bowel injury [31]. 6. Conclusion We believe that the SILS approach in selected HPB surgeries should continue to be learned and adopted with appropriate proctorship, refined techniques, and careful case selection.
Authors: Stephen K.Y. Chang, Olivia J.J. Guo
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4411260351