1. 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

2. 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

3. 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)

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

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

6. 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

7. (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.

8. 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

9. 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.

10. 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.

11. 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.

12. 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.

13. 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 | June 2017.

14. 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

15. 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.

16. SILC
Minimaly invasive surgery
Minimaly invasive approach .

17. 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 .

18. 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 .

19. 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) .

20. 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) .

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

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

23. .

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

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

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

27. INSTRUMENTS .

28. Inicinitial experience.
1 citation

29. 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 .

30. 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

31. 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

32. 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

33. 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 Aug;104(9): doi: /bjs 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) Sep 6;22: doi: /j.amsu
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.

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

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

36. FOLLOW THE TREND, THE TREND IS YOUR FRIEND!