Single incision laparoscopic cholecystectomy: for what benefit?

BACKGROUND: A single-incision laparoscopic cholecystectomy (SILC) was developed to improve outcomes as compared with the four-port classic laparoscopic cholecystectomy (CLC). Any potential benefits associated with a SILC have been suggested by previous studies reporting few patients with different surgical techniques. The aim of this study was to describe the experience with a standardized SILC as compared with CLC. METHODS: From June 2010 to January 2012, 40 patients underwent a SILC [median age: 47.5 years (25-92)] and operative and peri-operative data were prospectively collected. Over the same period, 37 patients underwent a CLC. A 10-point visual analogue scale (VAS) was used for qualitative data. The costs of SILC and CLC were also compared. RESULTS: For those patients undergoing a SILC the median operating time was 70 min (24-110). There were no conversions. An additional trocar was necessary in 16 patients. Four patients developed post-operative complications. The median immediate post-operative pain score was 5 (0-10). The median quality of life and cosmetic satisfaction at the initial post-operative visit were 10 (6-10) and 10 (5-10), respectively (VAS). Although the surgical results of both groups were similar, post-operative complications were exclusively reported in the SILC group (two incisional hernias). CONCLUSION: Standardization of SILC is possible but associated with an important rate of additional trocar placement and a disturbing rate of incisional hernias.

Left Hypochondrium or Transumbilical Single-Incision Laparoscopic Sleeve Gastrectomy for the Treatment of Severe Obesity: Surgical Technique and Results of a Tertiary Referral Bariatric Center.

BACKGROUND: Technical aspects of single-incision laparoscopic sleeve gastrectomy (SILSG) vary depending on surgeon's experience and availability of surgical equipment. We have performed more than 3000 SILSGs using standardized technique with left hypochondrium or transumbilical access. The aim of this study is to describe the SILSG technique in a stepwise manner providing technical tips and pitfalls for a left hypochondrium or transumbilical approach and report results of SILSG experience in a tertiary referral bariatric center. METHODS: A detailed description of left hypochondrium and transumbilical SILSG is provided. Data from all consecutive patients who underwent SILSG between August 2010 and August 2017 were prospectively collected and retrospectively analyzed and reported. RESULTS: One thousand eight hundred patients underwent SILSG, from which 384 (21.3%) using a transumbilical approach. Mean age was 42.3 years, median BMI 45.3 kg/m2, and median operative time 88 min. An additional port was required in 89 patients (4.9%). Postoperative mortality and morbidity rates were 0.05% and 7.5%, respectively. Relaparoscopy and/or endoscopic treatment were required for intra-abdominal bleeding in 27 patients (1.5%) and staple-line leakage in 35 patients (1.9%). Mean excess weight losses were 71.1%, 73.7%, and 70.4% at 1, 2, and 4 years after SILSG, respectively. Two years after SILSG, sustained statistical significant remission of major obesity-related comorbidities was noted. Incisional hernia occurred in 39 patients (2.1%). CONCLUSIONS: The use of specific instruments allows standardization of left hypochondrium SILSG, which can be routinely performed for the treatment of severe obesity. Transumbilical approach for SILSG should be reserved for well-selected patients and experienced bariatric surgeons.

Single-port Laparoscopic Surgery for the Treatment of Severe Obesity: Review and Perspectives.

This report aims to review current data on single-incision (single-port) laparoscopic surgery (SILS) for bariatric surgery. A comprehensive research of Pubmed database and Cochrane library on SILS bariatric surgery was conducted. Twenty-eight articles met inclusion criteria (3611 patients). Intraoperative and clinical outcomes for SILS sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and adjustable gastric banding (AGB) seem comparable to conventional laparoscopy. SILS for SG was safe and feasible with good outcomes. The same stands for RYGB but more studies are necessary for safe conclusions, while additional trocars are necessary to perform the procedure. AGB is feasible and safe by SILS but the declining number of annual procedures will probably limit the use of SILS. Major studies are unavailable for SILS and other bariatric procedures.

Reducing medication errors at admission: 3 cycles to implement, improve and sustain medication reconciliation.

BACKGROUND: In France, medication errors are the third leading cause of serious adverse events. Many studies have shown the positive impact of medication reconciliation (MR) on reducing medication errors at admission but this practice is still rarely implemented in French hospitals. OBJECTIVE: Implement and sustain a MR process at admission in two surgery units. The quality improvement approach used to meet this objective is described. SETTING: The gastrointestinal surgery and orthopedic surgery departments of a 407 inpatient bed French teaching hospital. METHODS: A step by step collaborative approach based on plan-do-study-act (PDSA) cycles. Three cycles were successively performed with regular feedback during multidisciplinary meetings. MAIN OUTCOME MEASURE: mean unintended medication discrepancies (UMDs) per patients at admission. RESULTS: The three PDSA cycles and the monitoring phase allowed to implement, optimize and sustain a MR process in the two surgery units. Cycle 1, by showing a rate of 0.65 UMDs at admission (95 % CI 0.39-0.91), underlined the need for a MR process; cycle 2 showed how the close-collaboration between pharmacy and surgery units could help to reduce mean UMDs per patients at admission (0.18; 95 % CI 0.09-0.27) (p < 0.001); finally, cycle 3 allowed the optimization of the MR process by reducing the delays of the best possible medication history availability. CONCLUSIONS: This work highlights how a collaborative quality-improvement approach based on PDSA cycles can meet the challenge of implementing MR to improve medication management at admission.

Atypical as well as anatomical liver resections are feasible by laparoendoscopic single-site surgery.

INTRODUCTION: Liver surgery was one of the last fields to be conquered by laparoscopy, which has become safe and effective, especially for left lateral sectionectomy (LLS) and limited peripheral resections. However, major hepatectomies remain challenging. Laparoendoscopic single-site (LESS) surgery is being employed for an increasing variety of surgical sites and indications. PRESENTATION OF CASE: Three patients underwent LESS hepatectomy. A 36-year-old woman had LLS for a 38-mm adenoma, an 85-year-old woman an atypical resection of segment VI for a 12-mm hepatocellular carcinoma and a 41-year-old woman an atypical right anterior resection for a 9cm symptomatic FNH. Procedures were performed transperitoneally with a single-port device, via a 20-mm or 30-mm incision. Operative times were 110min for LLS, 100min for the atypical segment VI resection and 120min for the atypical right anterior liver resection. Blood loss was less than 50ml in the first two patients and 150ml in the third. Postoperative courses were uneventful. The first two patients were discharged on postoperative day 3 and the third on postoperative day 1. DISCUSSION: To date, some case reports and series of LESS liver surgery have been published. We performed the reported hepatectomies after a considerable experience in laparoscopic hepatic surgery and after applying the LESS approach to other procedures. Our hepatectomy technique was not modified by the use of the single-port and results were very encouraging. CONCLUSION: We believe that in selected patients, both peripheral resections and LLS are feasible by LESS surgery, with good intra-operative and post-operative results.

Laparoscopic liver resection with selective prior vascular control.

BACKGROUND: Selective control of vascular inflow can reduce blood loss and transfusion rates and may be particularly efficient in laparoscopic liver resection (LLR). The aim of this study was to evaluate the efficacy of selective prior vascular control (PVC) in patients undergoing laparoscopic or open liver resections (OLR). METHODS: Between 1999 and 2008, 52 patients underwent LLR with PVC with prospective data collection and were compared with patients undergoing OLR with PVC. RESULTS: There was no difference in the operative time between the 2 groups. Blood loss and transfusion rates were lower in patients who underwent LLR (367 vs 589 mL, P = .001; 3.8% vs 17.3%, P = .05, respectively). Morbidity did not differ significantly between the 2 groups. Hospital stay was longer in the OLR group (11.0 vs 7.4 days, P = .001). CONCLUSIONS: PVC during LLR was feasible and improved intraoperative and postoperative results. Selective PVC should be obtained in LLR whenever possible.