1. Dr Lam Shek Ming Sherman Kwong Wah Hospital

2.  Introduction  Review of literature  Conclusion

3.  In 1882, first open cholecystectomy was performed by Carl Langenbach on a 42-year- old man with gallstones.

4.  In 1985, the first laparoscopic cholecystectomy was performed by Prof Dr Med Erich Mühe

5.  Since 1990s, laparoscopic cholecystectomy had been the gold standard for removal of gallbladder  Laparoscopic cholecystectomy. The new 'gold standard'? Soper NJ et. al. Arch Surg. 1992 Aug;127(8):917-21; discussion 921-3.  Laparoscopic cholecystectomy: an analysis of 777 cases. Perissat J et. al. Baillieres Clin Gastroenterol. 1992 Nov;6(4):727-42.  Laparoscopic cholecystectomy as standard intervention in symptomatic cholecystolithiasis. Experiences with 1,277 patients Faust H et. al. Chirurg. 1994 Mar;65(3):194-9.

6.  Reduce size of incisions ◦ Needlescopic surgery (2-3mm ports)  Reduce number of incisions ◦ Single incision laparoscopic surgery

7.  Single incision laparoscopic surgery  Single port access surgery  Laparoscopic endoscopic single-port surgery

8.  In 1997, Navarra G and his colleague performed the first single incision laparoscopic cholecystectomy One-wound laparoscopic cholecystectomy. Navarra G et. al. Br J Surg. 1997 May; 84(5):695

9.  3 methods ◦ special, purpose-made access devices or ports for introducing the laparoscope and instruments ◦ passing three trocars side-by-side through the fascia after exposing a wide area via a single umbilical incision ◦ using two trocars at the umbilicus along with suspension sutures to retract the gallbladder. Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et. al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23. Single incision laparoscopic cholecystectomy

10.  3 methods ◦ special, purpose-made access devices or ports for introducing the laparoscope and instruments ◦ passing three trocars side-by-side through the fascia after exposing a wide area via a single umbilical incision ◦ using two trocars at the umbilicus along with suspension sutures to retract the gallbladder. Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et. al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23.

12.  3 methods ◦ special, purpose-made access devices or ports for introducing the laparoscope and instruments ◦ passing three trocars side-by-side through the fascia after exposing a wide area via a single umbilical incision ◦ using two trocars at the umbilicus along with suspension sutures to retract the gallbladder. Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et. al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23.

14.  3 methods ◦ special, purpose-made access devices or ports for introducing the laparoscope and instruments ◦ passing three trocars side-by-side through the fascia after exposing a wide area via a single umbilical incision ◦ using two trocars at the umbilicus along with suspension sutures to retract the gallbladder Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et. al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23.

16.  length of incision: 1.5-2 cm  remaining steps are similar to the conventional laparoscopic cholecystectomy Single-incision laparoscopic cholecystectomy: How I do it? Deepraj Bhandarkar et. al. J Minim Access Surg. 2011 Jan-Mar; 7(1): 17–23.

17.  The primary technical obstacles: ◦ Collision of instruments both within and outside the abdomen as a result of their common entry point (“sword fighting”) ◦ Inadequate triangulation ◦ Compromised field of view due to obstruction by instruments entering the common port ◦ Inadequate exposure and retraction.  Single-incision laparoscopic cholecystectomy: lessons learned for success. Noam Shussman et. al. Surg Endosc. 2011 February; 25(2): 404–407.

19.  Potential advantages: ◦ Better cosmesis ◦ Less pain  Potential disadvantages: ◦ Steep learning curve ◦ Compromised safety

21. ◦ Single-incision laparoscopic cholecystectomy: a systematic review. Antoniou SA et. al. Surg Endosc. 2011 Feb;25(2):367-77. Epub 2010 Jul 7.

22.  29 case series  1,166 patients  many studies excluded acute cholecystitis  conversion to conventional laparoscopic cholecystectomy: 9.3% ◦ obscure anatomy at Calot’s triangle (5.2%) ◦ inadequate exposure of the Calot’s triangle due to insufficient gallbladder retraction (2.6%) ◦ inability to maintain pneumoperitoneum (1.4%)  conversion to open cholecystectomy 0.4%  intraoperative complication rates: 0-20% (cumulative rate: 2.7%) ◦ gallbladder perforation/bile spillage (2.2%) ◦ haemorrhage (0.3%) ◦ bile duct injury (0.09%)  mortality: 0%

23. SILC [1]Needlescopic LC [2] Conventional LC [3] Conversion to open 0.4%0.1%5-7% Complication rate 2.7%2.08%4% Bile duct injury0.09%0.19%0.3% Gallbadder perforation 2.2%0.5%0.4%  [1] Single-incision laparoscopic cholecystectomy: a systematic review. Antoniou SA et. al. Surg Endosc. 2011 Feb;25(2):367-77. Epub 2010 Jul 7.  [2] Minilaparoscopic (needlescopic) cholecystectomy: a study of 1,011 cases. Lee PC et. al. Surg Endosc. 2004 Oct;18(10):1480-4. Epub 2004 Aug 24.  [3] Laparoscopic cholecystectomy: a review of 12,397 patients. Scott TR et. al. Surg Laparosc Endosc. 1992 Sep;2(3):191-8.

24.  3 randomized control trials ◦ Randomized clinical trial of single-incision laparoscopic cholecystectomy versus minilaparoscopic cholecystectomy. Lee PC at. el. Br J Surg. 2010 Jul;97(7):1007-12. ◦ Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial. Tsimoyiannis EC et. al. Surg Endosc. 2010 Aug;24(8):1842-8. Epub 2010 Feb 20. ◦ Prospective randomized comparative study of single incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy. Lai EC et. al. Am J Surg. 2011 Sep;202(3):254-8.

25.  70 patients  35 single-incision laparoscopic cholecystectomy vs 35 minilaparoscopic cholecystectomy

26.  70 patients  35 single-incision laparoscopic cholecystectomy vs 35 minilaparoscopic cholecystectomy

27.  70 patients  35 single-incision laparoscopic cholecystectomy vs 35 minilaparoscopic cholecystectomy

28.  40 patients  20 single-incision laparoscopic cholecystectomy vs 20 minilaparoscopic cholecystectomy

31.  51 patients  24 single incision laparoscopic cholecystectomy vs 27 four-ports laparoscopic cholecystectomy SILC4-port LCP value Hospital stay (days)1.5 +/-.61.8 +/- 1.2.20 Total wound length (cm)1.76 +/-.292.25 +/-.05.001 Time to return to usual physical activity (days) 5.6 +/- 1.65.0 +/- 1.6.193 VAS pain score 6 hours after surgery 4.5 (2-8)4.0 (2-7).203 7 days after surgery1 (0-3)0 (0-2).048 Cosmetic score 3 months after surgery 7 (4-8)6 (3-8).023

32.  51 patients  24 single incision laparoscopic cholecystectomy vs 27 four-ports laparoscopic cholecystectomy SILC4-port LCP value Hospital stay (days)1.5 +/-.61.8 +/- 1.2.20 Total wound length (cm)1.76 +/-.292.25 +/-.05.001 Time to return to usual physical activity (days) 5.6 +/- 1.65.0 +/- 1.6.193 VAS pain score 6 hours after surgery 4.5 (2-8)4.0 (2-7).203 7 days after surgery1 (0-3)0 (0-2).048 Cosmetic score 3 months after surgery 7 (4-8)6 (3-8).023

33.  The Learning Curve for Single-Port Laparoscopic Cholecystectomy by Experienced Laparoscopic Surgeon. Soon Hwa Youn et. al. J Korean Surg Soc 2011;80:119-124

34.  Single-incision laparoscopic cholecystectomy: lessons learned for success. Noam Shussman et.al. Surg Endosc. 2011 February; 25(2): 404–407.

35.  A specialized course of basic skills training for single-port laparoscopic surgery. Yang et. al. Surgery Volume 149, Number 6

37.  Single incision laparoscopic cholecystectomy is a safe option for treatment of symptomatic gallstone in early studies  Published RCTs so far support the advantage of better cosmesis, yet controversial in reduction of pain and shortening of hospital stay  It requires 20-30 to master the technique for experienced laparoscopic surgeons  Structured specialized training may be helpful in overcoming the learning curve