First Congress of Serbian Association of Endoscopic Surgery with international participation, October 12-14th, Belgrade under the auspices of European Association for Endoscopic Surgery (EAES) One thousand plus (1,000+) consecutive laparoscopic cholecystectomy (LC) and initial experience on single incision laparoscopic cholecystectomy (SILC)   Vladimir Djordjevic MD General surgeon Clinic for Digestive Surgery, First Surgical Clinic, Clinical Center of Serbia

Kirurgisk avdeling, Arendal. Sorlandet Sykehus, Norge  Vladimir Djordjevic, Nemanja Zaric, Zeljko Radojkovic, Aleksandar Ninic, Nebojsa Lekic, Slavenko Ostojic, Mirko Kerkez First Department Clinic for Digestive Surgery-First Surgical Clinic, Clinical Center of Serbia, Belgrade, Serbia Zoran Raznatovic Kirurgisk avdeling, Arendal. Sorlandet Sykehus, Norge

Single-incision laparoscopic cholecystectomy (SILC)  Laparoscopic cholecystectomy (LC) “golden standard" in the treatment of gallbladder disease introduced in 1987 widely accepted among surgeons worldwide *Kalloo A, Kantsevoy S (2001) Gallstones and biliary diseases. Primary Care 28:591–606 Single-incision laparoscopic cholecystectomy (SILC) relatively new minimally invasive surgical technique in the treatment of benign gallbladder diseases the bridge technique between LC and natural orifice transluminal endoscopic surgery (NOTES)

Data collected between January 2009- Jun 2017   Data collected between January 2009- Jun 2017 Total 1060 surgical procedures were performed 1033 LC 17 SILC 10 conversions

Following outcomes were analyzed: pain during the further postsurgical course, rescue analgesia, complications, satisfaction with the cosmetic result

one postoperative hemorrhage was noted   one postoperative hemorrhage was noted Laparoscopic cholecystectomy is a surgical procedure of choice for benign gallbladder diseases. In about 1-2% of cases histopathological examination demonstrate incidental gallbladder cancer (GBCA). 6 citations

(TNM:T3 Nx Mx L1V1), grade III.  one incidental gallbladder cancer (61-year-old woman who developed port site metastases after LC for adenocarcinoma of the gallbladder) CEA and CA 19-9 serum levels-normal laparoscopic cholecystectomy (gallbladder was removed via umbilical port without using the retrieval bag; abdominal drain was placed through right lateral port) uneventful postoperative course first postoperative day: the drain was removed the second postoperative day: the patient was discharged from the hospital one month follow up: no signs and symptoms of postoperative complications Histopathology finding of the gallbladder was infiltrative adenocarcinoma of gallbladder (TNM:T3 Nx Mx L1V1), grade III. Raznatović ZJ, Zarić ND, Galun DA, Lekić NS, Micev M, Djordjevic VR, Djurasic LM, Kerkez MD. Multiple port-site metastasis of incidental gallbladder carcinoma after laparoscopic cholecystectomy. Acta Chir Iugosl. 2012;59(1):105-9.

Eleven months after the surgery: Raznatović ZJ, Zarić ND, Galun DA, Lekić NS, Micev M, Djordjevic VR, Djurasic LM, Kerkez MD. Multiple port-site metastasis of incidental gallbladder carcinoma after laparoscopic cholecystectomy. Acta Chir Iugosl. 2012;59(1):105-9. Eleven months after the surgery: tumor like lump in the area of umbilical port the patient was readmitted

CEA, CA 19-9, AFP serum levels and laboratory analysis-in normal range Surgical procedure included biopsy of the liver bed (histopathology benign) excision of metastatic lump and round ligament of the liver and excision of lig. Teres Raznatović ZJ, Zarić ND, Galun DA, Lekić NS, Micev M, Djordjevic VR, Djurasic LM, Kerkez MD. Multiple port-site metastasis of incidental gallbladder carcinoma after laparoscopic cholecystectomy. Acta Chir Iugosl. 2012;59(1):105-9.

Histopathology of the tumor of the anterior abdominal wall was metastatic adenocarcinoma originating from the gallbladder. Raznatović ZJ, Zarić ND, Galun DA, Lekić NS, Micev M, Djordjevic VR, Djurasic LM, Kerkez MD. Multiple port-site metastasis of incidental gallbladder carcinoma after laparoscopic cholecystectomy. Acta Chir Iugosl. 2012;59(1):105-9.

The operation was completed by the reconstruction of the front abdominal wall defect (component separation technique, modification according to Maas) Raznatović ZJ, Zarić ND, Galun DA, Lekić NS, Micev M, Djordjevic VR, Djurasic LM, Kerkez MD. Multiple port-site metastasis of incidental gallbladder carcinoma after laparoscopic cholecystectomy. Acta Chir Iugosl. 2012;59(1):105-9.

eighteen months after LC: - patient was readmitted (lump in the area of right lateral port, used for abdominal drainage) -serum levels of the tumor markers- in normal range -patient was operated (lump was removed) -histopathology examination: metastatic adenocarcinoma originating from the gallbladder 24 months after LC: -patient was presented with metastasis in the area of epigastric port site. -patient refused further surgical treatmen -patient died 28 months after LC. Raznatović ZJ, Zarić ND, Galun DA, Lekić NS, Micev M, Djordjevic VR, Djurasic LM, Kerkez MD. Multiple port-site metastasis of incidental gallbladder carcinoma after laparoscopic cholecystectomy. Acta Chir Iugosl. 2012;59(1):105-9.

  300/1033 LC patients included in the prospective study LAPAROSCOPIC ELECTIVE CHOLECYSTECTOMY IN CHRONIC CHOLECYSTITIS-DRAINAGE YES OR NO? Djordjevic et al. 25th International EAES Congress, At Frankfurt am Main, Germany | 14 - 17 June 2017.

group 1 (patients with drainage) group 2 (patients without drainage)   Prospective study 300 consecutive patients who underwent LC were randomized in two groups: group 1 (patients with drainage) group 2 (patients without drainage) Data collected, analyzed and compared: subhepatic fluid collections (ultrasound verification), postoperative pain (abdominal and shoulder pain after 12h, 24h and 7 days), postoperative nausea vomiting (PNV) after 12h, 24h and 7 days hospital stay wound infection

  No statistically significant advantages in using a drain after LC in terms of: wound infections, PNV, abdominal collections, postoperative pain (in line with many randomized studies and meta analyses that also showed no differences in postoperative complications after LC with or without drainage) Hospital stay was significantly shorter in patients without drainage! Conclusion: Drainage should be introduced only in selected patients based on the surgeons’ judgment.

SILC   Minimaly invasive surgery Minimaly invasive approach .

Progress in Surgical Treatment Laparoscopic cholecystectomy - LC “Reduced port” LC Mini- laparoscopic cholecystectomy Single port LC Transvaginal Hybrid NOTES holecistektomija NOTES- natural orifice transluminal endoscopic surgery .

What is single port surgery?   A new technique of minimally invasive laparoscopic surgery Implies an incision of the front abdominal wall Special multi-channel ports and instruments .

Synonyms . SPA – single port access SSL – single site laparoscopy   SPA – single port access SSL – single site laparoscopy S-PORTAL – single portal laparoscopy SPL – single port laparoscopy SSA – single site access TUES – transumbilical endoscopic surgery TULA – trans umbilical laparoscopic assisted NOTUS – natural orifice transumbilical surgery OPUS – one port umbilicus surgery SPLS – single port laparoscopic surgery LESS* – laparo-endoscopic single site surgery (Olympus) SILS* - single incision laparoscopic surgery (Covidien) .

History 2005. – Dr Eylul, Izmir, Turska   2005. – Dr Eylul, Izmir, Turska - First single port apendectomy 2007. – Dr Curcillo, Philadelphia, SAD - First single port cholecystectomy (SPA – single port access) .

Single port procedures   Appendectomy Cholecystectomy Splenectomy Colorectal procedures Nissen’s fundoplication Adrenalectomy inguinal hernia, etc. .

PROS Cosmetic effect Less postoperative pain   Cosmetic effect Less postoperative pain Minor percentage of wound infections Faster recovery Simple conversion to conventional LC .

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CONS SAFETY? Inability to triangulate   Inability to triangulate Complex and technically more comprehensive procedure More time consuming High price of ports and instruments SAFETY? .

OCTOTM PORT- Dalim surgnet corp. PORTS   . SILSTM PORT - Covidien OCTOTM PORT- Dalim surgnet corp.

TRIPORT – Advanced Surgical Concepts PORTS   . TRIPORT – Advanced Surgical Concepts ENDOCONER – Karl Storz

INSTRUMENTS   .

Inicinitial experience   . 1 citation

Inicinitial experience   August 2010 – February 2012 17 patients (11 women and 6 men) Mean BMI score - 29,4 kg/m2 Mean operative time - 93,5 minutes. Average age - 43 .

OCTOTMPort – DalimSurgnet Inicinitial experience   Postoperative VAS pain - 2,00 (after 8h), and 1,58 (after 24h) Wound infections – 0% Conversions to conventional LC in two cases (11,6%) . OCTOTMPort – DalimSurgnet

X-CONE port– Karl Storz Inicinitial experience   All patients were discharged on first postoperative day All patients expressed satisfaction with achieved cosmetic effect. . X-CONE port– Karl Storz

Safety and efficacy confirmation SILC-What is next? Standardisation of the surgical procedure Selection of patients and adopting of strict criteria Prospective studies Safety and efficacy confirmation Minimaly invasive procedure Surgical trend

SILC-What does the literature say? Meta-analysis of single-port versus conventional laparoscopic cholecystectomy comparing body image and cosmesis. Haueter R, Schütz T, Raptis DA, Clavien PA, Zuber M. Br J Surg. 2017 Aug;104(9):1141-1159. doi: 10.1002/bjs.10574. Epub 2017 Jun 1 CONCLUSION: SILC is associated with better outcomes in terms of cosmesis, body image and postoperative pain. The risk of incisional hernia is, however, four times higher after SILC than after LC. Feasibility and safety of single-incision laparoscopic cholecystectomy in elderly patients: A single institution, retrospective case series. Wakasugi M, Tanemura M, Furukawa K, Tei M, Suzuki Y, Masuzawa T, Kishi K, Akamatsu H. Ann Med Surg (Lond). 2017 Sep 6;22:30-33. doi: 10.1016/j.amsu.2017.08.024. SILC for uncomplicated gallbladder could be performed for patients ≥ 80 years with acceptable morbidity and mortality as compared with the previous reports, though the complication rate of patients ≥ 80 years was higher than that of patients < 80 years.

Special thanks to Zoran Raznatovic, MD Kirurgisk avdeling, Arendal. Sorlandet Sykehus, Norge

TAKE AWAY MESSAGE   Having in mind high incidence of gallbladder disease and consequently the frequency of these surgical procedures, further evolvement is essential. .

FOLLOW THE TREND, THE TREND IS YOUR FRIEND!