Single-Incision Laparoscopic Cholecystectomy Using a Set of Novel Needle Instruments.

BACKGROUND: Although the technique of single-incision laparoscopic cholecystectomy (SILC) has improved remarkably, problems such as limited exposure and instrument collision persist. We describe a new SILC technique that uses a set of specially-designed needle instruments. METHODS: Fifty-six patients with benign gallbladder disease underwent SILC using the newly-designed needle assembly instruments (NAIs). The NAIs comprise an needle assembly exposing hook for operative field exposure and an needle assembly electrocoagulation hook for dissection. During the operation, the NAIs were assembled and disassembled before and after gallbladder removal within the abdominal cavity. The operative efficacy and postoperative complications of this procedure were evaluated. RESULTS: SILC was completed successfully in 52 cases, and four cases (7.14%) required an additional trocar. There were no conversions to open surgery. The mean operative time was 48.2 ± 21.8 min, and the mean operative bleeding volume was 10.5 ± 12.5 mL. Minor postoperative complications occurred in 3 cases, including 2 cases of localized fluid accumulation in the abdominal cavity and 1 case of pulmonary infection, and all of them recovered after conservative treatment. There was no occurrence of bile leak, abdominal bleeding, bile duct injury and incisional hernia. The medical cost of each case was saved by approximately $200. The abdominal scars produced by the needle instruments were negligible. CONCLUSION: NAIs can make SILC safer, more convenient, and less expensive.

Port-sharing techniques for laparoscopic cholecystectomy and sleeve gastrectomy.

In Japan, the number of bariatric surgeries performed has remained low. Thus, concomitant laparoscopic cholecystectomy (LC) with laparoscopic sleeve gastrectomy (LSG) is still relatively uncommon, but is increasing. We developed new port-sharing techniques for LC and LSG, which we performed on 26 obese Japanese patients with gall bladder (GB) diseases, using the LSG trocar arrangement and one additional trocar. We performed LC first, and after exchanging a port for a liver retractor in the epigastrium, we then completed LSG. One patient with an anomalous extrahepatic bile duct required one additional port. The mean LC time was 55 min, and the transition to LSG just after LC was smooth in all the patients. One patient suffered postoperative intraperitoneal hemorrhage, which was managed conservatively. Concomitant LC with LSG using port-sharing techniques is feasible and safe for obese Japanese patients with GB diseases.

True single-port cholecystectomy with ICG cholangiography through a single 15-mm trocar using the new surgical platform "symphonX": first human case study with a commercially available device.

BACKGROUND: Minimally invasive single-port surgery is often associated with large incisions up to 2-3 cm, complicated handling due to the lack of triangulation, and instrument crossing. Aim of this prospective study was to perform true single-port surgery (cholecystectomy) without the use of assisting trocars using a new surgical platform that allows for triangulation incorporating robotic features, and to measure the perioperative outcome and cosmetic results. METHODS: As the first European site after FDA and CE-mark approval, the new device has been introduced to our academic center. In patients with cholecystitis and cholecystolithiasis, the operation was performed through only one 15-mm trocar. For patients safety, intraoperative cholangiography using intravenous ICG and a standard Stryker 1588 system was routinely performed. RESULTS: Symphonx was used in n = 12 patients for abdominal surgery (6 females, mean age 42.5 [30-77], mean BMI 26.2 [19.3-38.9]. A total of 8 patients underwent surgery using no additional ports besides the 15-mm trocar; in the remaining patients, one assisting instrument (3-5 mm) was used. Mean OR time was 107 [72-221] minutes. The postoperative course was uneventful in 11 patients; in one patient, a seroma at the surgical site required interventional drainage 1 month postoperatively. No intraoperative complications occurred. CONCLUSION: This is the first human case series using the commercially available symphonX platform for abdominal laparoscopic surgery and the first series using the system without assisting instruments. Laparoscopic cholecystectomy in patients with cholecystitis and cholecystolithiasis using the symphonX platform through only one 15-mm trocar is feasible, safe, and more cost-efficient compared to robotic platforms.

Laparoscopic Cholecystectomy with Single Port Access System in 15 Dogs.

OBJECTIVE: To evaluate the outcome of laparoscopic cholecystectomy performed with a single port access system (SPAS) in dogs. STUDY DESIGN: Retrospective study. ANIMALS: Fifteen client-owned dogs with nonobstructive gallbladder disease. METHODS: Medical records were reviewed for signalment, clinical signs, diagnostic imaging, surgical findings, and outcome until suture removal. RESULTS: The SPAS was placed 1 cm caudal to the umbilicus. The procedure was completed with the SPAS alone in two cases. An additional cannula was added in 12 cases. In the last 10 cases, the additional cannula was placed at the beginning of the procedure. Dissection began at the cystic duct in 11 dogs (73%). In three cases (20%), the SPAS procedure was converted to a laparotomy; two of these conversions were elective, and one was emergent. The risk of conversion was affected by the experience of the surgeon (odds ratio = 0.53; P = .0105), and the rate of conversion was reduced when a cannula was added at the beginning of the procedure (P = .022). Fourteen dogs were discharged from the hospital. One dog died after being discharged due to severe cholangiohepatitis, and another dog died due to leakage of a gastrostomy tube. CONCLUSIONS: The use of SPAS for cholecystectomy in dogs has an acceptable outcome. The experience gained by the surgeon and the addition of a cannula reduced the risk of conversion. CLINICAL RELEVANCE/IMPACT: Laparoscopic cholecystectomy can be performed with a SPAS. The placement of an additional cannula at the beginning of the procedure is highly recommended.

Achieving Surgical Supply Savings through Preference Card Standardization.

Among high volume procedures considerable variation exists in the average cost per case (ACPC) of surgical supplies used between surgeons. A contributing factor to these cost differences are divergences in surgeons' preference cards, which act as a guide to hospital staff for the supplies a surgeon requires to successfully perform a procedure. This article documents efforts and results of an initiative to standardize preference cards for Laparoscopic Cholecystectomies. Data collected for this project outlined differences between surgeon's preference card composition, utilization of selected supplies and associated procedure costs. Reports were developed that grouped surgical supplies based on United Nations Standard Products and Services Code (UNSPC) product classes and highlighted classes with the highest per case standard deviations. Based on these findings and feedback from clinical partners, a composite set of supplies for use across all preference cards was developed in conjunction with the Chief of General Surgery. The net result of moving to a standardized set of supplies was an estimated $21,650 in annual supply expenses associated with Laparoscopic Cholecystectomies. Results suggest that standard deviation-based reports organized by product class facilitate effective surgeon-to-surgeon comparisons and make apparent readily available supply substitutes that are less expensive.

Obstructive Jaundice Secondary to Clip Migration in the Common Bile Duct 9 Years after Laparoscopic Cholecystectomy.

Surgical clip migration in the common bile duct with consecutive stone formation is a rare occurrence after laparoscopic cholecystectomy, less than 100 cases being reported so far. We report a case of a 55-year-old woman with obstructive jaundice due to bile duct stone formed around a migrated surgical clip 9 years after laparoscopic cholecystectomy. The patient presented with pain in the upper abdomen and jaundice. Abdominal ultrasound diagnosed dilation of the common bile duct and intrahepatic bile ducts. The diagnosis was confirmed by computed tomography which revealed a metal clip in the distal part of the common bile duct. The patient was managed successfully by endoscopic retrograde cholangiopancreatography (ERCP) and the surgical clip was retrieved using the Dormia basket. The exact mechanism of clip migration is not fully understood but may be explained by local inflammation and ineffective clipping. Although a rare occurrence, clip migration should not be excluded when considering the differential diagnosis of patients presenting with obstructive jaundice or cholangitis after laparoscopic cholecystectomy. Minimally invasive management by ERCP is the procedure of choice for migrated clips related complications but surgical common bile duct exploration may be necessary.

10-mm Laparo-Endoscopic Single-Site Cholecystectomy Using Multiple Magnetically Anchored and Controlled Instruments.

BACKGROUND: To study the feasibility of laparo-endoscopic single-site (LESS) cholecystectomy through a 10-mm incision using a miniature magnetically anchored and controlled laparoscopy system and a grasper system. METHODS: The miniature magnetically anchored and controlled laparoscopy system consisted of a miniature magnetically anchored camera (MMAC), an external magnetic anchoring unit, and a vision output device. The camera weighed 9.8 g and measured Φ10 mm × 50 mm. The magnetically anchored and controlled grasper system consisted of a magnetically anchored grasper (MAG), an external magnetic anchoring unit, and a push-pull device. The MAG had a titanium alloy clip head and a magnetic tail. The laparoscopy system and grasper system were used simultaneously to perform LESS cholecystectomy through a single 10-mm incision in model canines. RESULTS: LESS cholecystectomy through a 10-mm incision using the MMAC and MAG was attempted in six dogs. The mean operative time was 85.75 ± 7.14 min. The operation was completed successfully in four cases, with failure occurring in one case due to gallbladder rupture and in another due to bile duct injury. The MMAC provided clear imaging, and the MAG provided sufficient exposure to perform the cholecystectomy. The use of multiple magnetically anchored and controlled instruments did not result in notable collisions. CONCLUSIONS: The designed MMAC and MAG system could be easily maneuvered. LESS cholecystectomy may be feasible through a single 10-mm incision with the simultaneous use of multiple magnetically anchored and controlled instruments.

Regional cost analysis for laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is the most common procedure performed by general surgeons in the United States, with approximately 600,000 procedures performed annually. As the cost of care rises, there is increasing emphasis on utilization and quality. Our objective was to evaluate the cost of laparoscopic cholecystectomy in our health system and to compare the operative times and outcomes at high- and low-cost centers. METHODS: We evaluated all laparoscopic cholecystectomies performed in our system over a 1-year period. The operating room supply costs and procedure durations were obtained for each of the hospitals. The American College of Surgeons National Surgical Quality Improvement Program outcomes and demographics were compared to the costs for each hospital. RESULTS: During the study period, 7601 laparoscopic cholecystectomies were performed at 20 hospitals (170-759/hospital) by 227 surgeons. The average cost per case ranged from $296 at the lowest cost center to $658 at the highest cost center. The average operative time varied between sites from 46 to 95 min. There was no association between cost and operative time or case volume. There was a slight trend toward increased cost with higher number of emergency procedures, but this was not well correlated (R2 = 0.03). The patient demographics and comorbidities were similar between sites. There were no significant differences in postoperative complications between high- and low-cost centers. The items with the greatest increase in cost were disposable trocars, disposable hook cautery, disposable endoscissors, and disposable clip appliers. We estimate that a savings of over $300/case is possible by using reusable instruments, which would result in an annual savings of $1.3 million for our health system, and $285 million nationwide. CONCLUSION: Performing laparoscopic cholecystectomy with reusable instruments can significantly decrease costs and does not increase operative time or postoperative complications.

Innovation in surgery/operating room driven by Internet of Things on medical devices.

BACKGROUND: With the improvement of sensor technology, the trend of Internet of Things (IoT) is affecting the medical devices. The aim of this study is to verify whether it is possible to "visualize instrument usage in specific procedures" by automatically accumulating the digital data related to the behavior of surgical instruments/forceps in laparoscopic surgery. METHODS: Five board-certified surgeons (PGY 9-24 years) performed laparoscopic cholecystectomy on 35-kg porcine (n = 5). Radio frequency identifier (RFID) was attached to each forceps with RFID readers installed on the left/right of the operating table. We automatically recorded the behavior by tracking the operator's right/left hands' forceps with RFID. The output sensor was installed in the electrocautery circuit for automatic recordings of the ON/OFF times and the activation time. All data were collected in dedicated software and used for analysis. RESULTS: In all cases, the behaviors of forceps and electrocautery were successfully recorded. The median operation time was 1828 s (range 1159-2962 s), of which the electrocautery probe was the longest held on the right hand (1179 s, 75%), followed by Maryland dissectors (149 s, 10%), then clip appliers (91 s, 2%). In contrast, grasping forceps were mainly used in the left hand (1780 s, 93%). The activation time of electrocautery was only 8% of the total use and the remaining was mainly used for dissection. These situations were seen in common by all operators, but as a mentor surgeon, there was a tendency to change the right hand's instruments more frequently. The median activation time of electrocautery was 0.41 s, and these were confirmed to be 0.14-0.57 s among the operators. CONCLUSION: By utilization of IoT for surgery, surgical procedure could be "visualized." This will improve the safety on surgery such as optimal usage of surgical devices, proper use of electrocautery, and standardization of the surgical procedures.

Clinical outcomes of single-incision robotic cholecystectomy versus conventional 3-port laparoscopic cholecystectomy

Background: Few studies have compared the surgical results of single-incision robotic cholecystectomy (SIRC) with those of conventional laparoscopic cholecystectomy (CLC). The purpose of this study was to evaluate the relative clinical efficacy of SIRC by comparing the number of postoperative days, pain level and complications between the 2 surgical methods. Methods: We retrospectively collected demographic, perioperative and postoperative data for all patients who underwent SIRC or CLC performed by a single surgeon from June 2016 to May 2017. Operative time was recorded, divided into anesthesia time, docking time, console time and total operation time. Postoperative pain was measured with the Numerical Pain Rating Scale. Results: A total of 121 patients underwent cholecystectomy during the study period, of whom 61 had SIRC and 60 had CLC. The mean total operation time of SIRC and CLC was 93.52 (SD 20.27) minutes and 37.67 (SD 19.73) minutes, respectively (p < 0.001). The total operation time excluding console time of SIRC was significantly longer than that of CLC (82.77 [SD 18.27] min v. 37.67 [SD 19.73] min) (p < 0.001). The mean Numerical Pain Rating Scale score was 4.73 (SD 1.23) (SIRC: 4.75 [SD 1.24]; CLC: 4.70 [SD 1.22]) (p = 0.8) within 1 hour after the operation; scores after 6 hours and 1 day decreased in a similar manner in the 2 groups (p = 0.1). Conclusion: Postoperative pain, use of an additional port, complication rates, operation time and cost of SIRC were similar to or greater than those of CLC. Large randomized controlled trials are needed to examine the true benefits of SIRC.

Contexte: Peu d'études ont comparé les résultats chirurgicaux de la cholécystectomie robotique par incision unique (CRIU) à ceux de la cholécystectomie laparoscopique classique (CLC). Le but de la présente étude était d'évaluer l'efficacité clinique relative de la CRIU en comparant le nombre de jours postopératoires, l'intensité de la douleur et les complications avec les 2 méthodes chirurgicales. Méthodes: Nous avons recueilli de manière rétrospective les données démographiques, périopératoires et postopératoires de tous les patients soumis à une CRIU ou à une CLC effectuée par un seul chirurgien entre juin 2016 et mai 2017. Le temps opératoire a été enregistré, subdivisé entre anesthésie, temps d'installation, temps à la console et durée totale de l'intervention. La douleur postopératoire a été mesurée au moyen d'une échelle numérique d'évaluation de la douleur. Résultats: En tout, 121 patients ont subi une cholécystectomie durant la période de l'étude, dont 61, une CRIU et 60, une CLC. La durée opératoire totale moyenne des CRIU et des CLC a été de 93,52 (É.-T. 20,27) minutes et de 37,67 (É.-T. 19,73) minutes, respectivement (p < 0,001). La durée opératoire totale excluant le temps à la console a été significativement plus longue avec la CRIU qu'avec la CLC (82,77 [É.-T. 18,27] minutes c. 37,67 [É.-T. 19,73] minutes) (p < 0,001). Le score moyen à l'échelle numérique d'évaluation de la douleur a été de 4,73 (É.-T. 1,23) (CRIU : 4,75 [É.-T. 1,24]; CLC : 4,70 [É.-T. 1,22]) (p = 0,8) 1 heure suivant l'intervention; après 6 heures et après 1 jour, les scores avaient diminué de façon similaire dans les 2 groupes (p = 0,1). Conclusion: La douleur postopératoire, l'utilisation d'un port additionnel, les taux de complication, le temps opératoire et le coût de la CRIU ont été similaires ou supérieurs à ceux de la CLC. Il faudra réaliser de plus grands essais randomisés et contrôlés pour analyser les bénéfices réels de la CRIU.

Is Needlescopic Cholecystectomy a Safe Way to Improve Mininvasiveness and Cosmesis in Young Female Patients?

INTRODUCTION: Needlescopic cholecystectomy (NC) was introduced in the late 1990s. It uses a reduced trocar caliber in an otherwise standard four-port laparoscopic cholecystectomy (LC) and seeks to achieve "scarless" surgery without compromising patient safety. MATERIALS AND METHODS: Between May 2016 and November 2017, 29 patients underwent elective NC at the Department of General Surgery of Sant'Andrea Hospital (La Spezia, Italy). Inclusion criteria were female sex, age between 18 and 45 years, good performance status (ASA 1-2) and BMI lower than 25. Twenty-one patients underwent a standard 4-port technique: 12mm port in the supraumbilical area, 5mm port in the subxiphoid position, 3mm port in the mid-epigastric area and another 3 mm port in the right mid-clavicular position. In 8 patients, 3mm ports were replaced by 2mm angiocath. A Critical View of Safety (CVS) was achieved in all procedures. Intra-operative cholangiography (IOC) via the cystic duct before any transection of the structures was routinely performed in selected cases, such as those with an unclear biliary anatomy or risk factors for main-duct stones. In our institution, laparoscopic transcystic common bile duct (CBD) exploration is routinely performed in CBD lithiasis. RESULTS: The mean operative time was 66.79 min (range 25-120 min). IOC was performed in 12 patients (41.4%) with suspected choledocolythiasis. There was no conversion to conventional laparoscopic cholecystectomy or open cholecystectomy. The mean hospital stay was 1.48 days (1-7 days). A Clavien-Dindo IIIB complication occurred in one patient on the third postoperative day. The mean VAS pain score was 3 (0-7). Closure of the skin with primary intention was achieved in all patients. Mean return to work was 6.76 days (3-15 days) and the mean return to previous physical activity was 12.17 days (4-30 days). All of the patients completed the Scar Satisfaction Questionnaire: 26 (89.7% ) and 3 patients (10.3%) were very satisfied and satisfied, respectively. CONCLUSION: Any effort to reduce invasiveness and improve cosmesis must not jeopardize safety. Our case series demonstrates that needlescopy can be safely associated with intraoperative cholangiography to recognize CBD stones. This technique offers the advantage of minor postoperative pain, better cosmesis results, early return to routine life activities and great satisfaction for the patient. Needlescopy is a valuable and safe alternative that is suitable for elective cholecystectomy in properly selected patients, such as young female patients.

Cost effectiveness of Glove Endobag in Laparoscopic Cholecystectomy: Review of the available literature.

Laparoscopic cholecystectomy is the most common procedure performed worldwide and remains the gold standard for symptomatic gallstones. The most common complication obser ved during this procedure is gallbladder perforation resulting in spillage of stones and bile into peritoneal cavity. In order to avoid such complications, gallbladder is commonly extracted in an endobag. The current literature review was conducted to assess the efficacy and cost-effectiveness of glove endobags. PubMed and Google Scholar databses were searched to find relevant studies from January 1990 to December 2017. Search terms used were 'glove endobag' and 'laparoscopic cholecystectomy'. Literature suggests glove endobag is an effective and comparatively inexpensive compared to commercially prepared endobags.

Magnetic Surgery: Results From First Prospective Clinical Trial in 50 Patients.

OBJECTIVE: To evaluate a new magnetic surgical system during reduced-port laparoscopic cholecystectomy in a prospective, multicenter clinical trial. BACKGROUND: Laparoscopic instrumentation coupled by magnetic fields may enhance surgeon performance by allowing for shaft-less retraction and mobilization. The movements can be performed under direct visualization, generating different angles of traction and reducing the number of trocars to perform the procedure. This may reduce well-known associated complications of trocars, including incisional pain, scarring, infection, bowel, and vascular injuries, among others. METHODS: A prospective, multicenter, single-arm, open-label study was performed to assess the safety and performance of a magnetic surgical system (Levita Magnetics' Surgical System). The investigational device was used during a 3-port laparoscopic technique. The primary endpoints evaluated were safety and feasibility of the device to adequately mobilize the gallbladder to achieve effective exposure of the targeted surgical site. Patients were followed for 30 days postprocedure. RESULTS: Between January 2014 and March 2015, 50 patients presenting with benign gallbladder disease were recruited. Forty-five women and 5 men with an average age of 39 years (18-59), average body mass index of 27 kg/m (20.4-34.1) and an average abdominal wall thickness of 2.6 cm (1.8-4.6). The procedures were successfully performed in all 50 patients. No device-related serious adverse events were reported. Surgeons rated as "excellent" (90%) or "sufficient" (10%) the exposure of the surgical site. CONCLUSIONS: This clinical trial shows that this new magnetic surgical system is safe and effective in reduced-port laparoscopic cholecystectomy.

Magnetic surgery: first U.S. experience with a novel device.

INTRODUCTION: Magnet-assisted surgery is a new platform within minimally invasive surgery. The Levita™ Magnetic Surgical System, the first magnetic surgical system to receive Food and Drug Administration (FDA) approval, includes a deployable, magnetic grasper and an external magnet that is used to manipulate the grasper within the peritoneal cavity. This system is currently approved for patients undergoing laparoscopic cholecystectomy with a body mass index (BMI) between 21 and 34 kg/m2. Herein, we detail the first United States experience with the Levita™ Magnetic Surgical System during laparoscopic cholecystectomy. METHODS: The Levita™ Magnetic Surgical System was used on consecutive patients undergoing laparoscopic cholecystectomy at our institution from June 2016 through November 2016. Only patients undergoing elective surgery and those with a body mass index (BMI) between 21 and 34 kg/m2 were included. Baseline patient characteristics, operative time, and perioperative details were collected. RESULTS: A total of ten patients underwent laparoscopic cholecystectomy with the Levita™ Magnetic Surgical System during the defined study period. The mean age at the time of surgery was 49.0 years and the average BMI of the cohort was 27.6 kg/m2. The average operative time was 64.4 min. There were no perioperative complications. Seven (70.0%) patients were discharged to home on the day of surgery, while the remaining three (30.0%) patients were discharged to home on postoperative day number one. Surgeons reported that the magnetic grasper was easy to use and provided adequate tissue retraction and exposure. CONCLUSIONS: The Levita™ Magnetic Surgical System is safe and feasible to use in patients undergoing laparoscopic cholecystectomy. Routine use of this system may facilitate a reduction in the total number of laparoscopic trocars used, leading to less tissue trauma and improved cosmesis. Additional studies are needed to determine the applicability and utility of this system for other general surgery cases.

Low-impact laparoscopic cholecystectomy is associated with decreased postoperative morbidity in patients with sickle cell disease.

BACKGROUND: Laparoscopic cholecystectomy (LC) is one of the most frequent surgeries performed in patients with sickle cell disease (SCD). LC in SCD patients is associated with a particularly high postoperative morbidity. The aim of the present study is to assess the safety and feasibility of cholecystectomy performed by mini-laparoscopy with low- and stable-pressure pneumoperitoneum (MLC + LSPP) and to compare the rate of postoperative SCD-related morbidity with standard LC. METHODS: Thirty-five consecutive SCD patients admitted between November 2015 and March 2017 for cholelithiasis requiring surgery were compared with an historical cohort of 126 SCD patients who underwent LC for the same indication. Operative variables, postoperative outcomes, patient and surgeon satisfaction, and costs were evaluated. RESULTS: MLC + LSPP exhibited a mean operative time comparable to LC (p = 0.169). Operative blood loss was significantly reduced in the MLC + LSPP group, and the suction device was rarely used (p = 0.036). SCD-related morbidity (including acute chest syndrome) was significantly higher in the LC group compared with the MLC + LSPP group (18.3 vs. 2.9%; p = 0.029). The mean times to resume ambulation (p = 0.018) and regular diet (p = 0.045) were significantly reduced in the MLC + LSPP group. The mean incision length (all trocars combined) was 28.22 mm for MLC + LSPP and 49.64 mm for LC patients (p < 0.0001). Multivariate regression analysis demonstrated that the only significant predictor of postoperative SCD-related morbidity was the surgical approach (odds ratio: 9.24). Patient and surgeon satisfaction were very high for MLC + LSPP. The mean total cost per patient (surgery and hospitalization) was not different between groups (p = 0.084). CONCLUSION: MLC + LSPP in SCD patients appears to be safe and feasible. Compared with LC, MLC + LSPP in SCD patients is associated with a significantly reduced incidence of postoperative SCD-related morbidity and more rapid ambulation and return to regular diet without increasing the total costs per patient.

Three-trocar laparoscopic cholecystectomy under spinal anesthesia in a patient with asthma.

INTRODUCTION: Laparoscopy is perceived as the state-of-the-art technique for a wide variety of operations but is contraindicated by comorbidities such as respiratory diseases. We present the case of a patient affected by asthma who underwent a successful three-trocar low-pressure pneumoperitoneum under spinal anesthesia. CASE REPORT: A 58 year-old male with symptomatic gallstones had partly-controlled asthma and respiratory allergies. Potential bronchospasm was avoided by a less invasive laparoscopic technique. Under spinal anesthesia open pneumoperitoneum was achieved at the umbilicus. Two more trocars were inserted. A cholecystectomy was performed in 90 minutes keeping the patient in a supine position and the pneumopneumoperitoneum at 8 mmHg. The post-operative course was uneventful. Discharge to home occurred on day two. DISCUSSION: Laparoscopy is contraindicated in the presence of hemodynamic instability and inability of the patient to tolerate laparoscopic surgery. Asthma is caused by bronchoconstriction from a myriad possible stimuli requiring a specific anesthetic plan. Spinal anesthesia under low pressure pneumoperitoneum is a safe alternative to general anesthesia in high risk candidates. In experienced hand, a three-trocar cholecystectomy is safe and feasible. CONCLUSION: Our patient represented a challenging case due to a partly-controlled asthma. Bronchospasm under general anesthesia was prevented by spinal anesthesia to keep a spontaneous physiologic respiration, irrigation of the right subdiaphragmatic surface with lidocaine to control right shoulder pain, safe dissection by three trocars, a pneumoperitoneum at 8 mmHg, the supine position to prevent significant physiologic changes and minimize diaphragmatic irritation.

A magnetic levitation robotic camera for minimally invasive surgery: Useful for NOTES?

BACKGROUND: Minimally invasive surgery (MIS) is rising in popularity generating a revolution in operative medicine during the past few decades. Although laparoscopic techniques have not significantly changed in the last 10 years, several advances have been made in visualization devices and instrumentation. METHODS: Our team, composed of surgeons and biomedical engineers, developed a magnetic levitation camera (MLC) with a magnetic internal mechanism dedicated to MIS. Three animal trials were performed. Porcine acute model has been chosen after animal ethical committee approval, and laparoscopic cholecystectomy, nephrectomy and hernioplastic repair have been performed. RESULTS: MLC permits to complete efficiently several two-port laparoscopy surgeries reducing patients' invasiveness and at the same time saving surgeon's dexterity. CONCLUSIONS: We strongly believe that insertable and softly tethered devices like MLS camera will be an integral part of future surgical systems, thus improving procedures efficiency, minimizing invasiveness and enhancing surgeon dexterity and versatility of visions angles.

Multi-port versus single-port cholecystectomy: results of a multi-centre, randomised controlled trial (MUSIC trial).

BACKGROUND: Single-port laparoscopic surgery as an alternative to conventional laparoscopic cholecystectomy for benign disease has not yet been accepted as a standard procedure. The aim of the multi-port versus single-port cholecystectomy trial was to compare morbidity rates after single-access (SPC) and standard laparoscopy (MPC). METHODS: This non-inferiority phase 3 trial was conducted at 20 hospital surgical departments in six countries. At each centre, patients were randomly assigned to undergo either SPC or MPC. The primary outcome was overall morbidity within 60 days after surgery. Analysis was by intention to treat. The study was registered with ClinicalTrials.gov (NCT01104727). RESULTS: The study was conducted between April 2011 and May 2015. A total of 600 patients were randomly assigned to receive either SPC (n = 297) or MPC (n = 303) and were eligible for data analysis. Postsurgical complications within 60 days were recorded in 13 patients (4.7 %) in the SPC group and in 16 (6.1 %) in the MPC group (P = 0.468); however, single-access procedures took longer [70 min (range 25-265) vs. 55 min (range 22-185); P < 0.001]. There were no significant differences in hospital length of stay or pain VAS scores between the two groups. An incisional hernia developed within 1 year in six patients in the SPC group and in three in the MPC group (P = 0.331). Patients were more satisfied with aesthetic results after SPC, whereas surgeons rated the aesthetic results higher after MPC. No difference in quality of life scores, as measured by the gastrointestinal quality of life index at 60 days after surgery, was observed between the two groups. CONCLUSIONS: In selected patients undergoing cholecystectomy for benign gallbladder disease, SPC is non-inferior to MPC in terms of safety but it entails a longer operative time. Possible concerns about a higher risk of incisional hernia following SPC do not appear to be justified. Patient satisfaction with aesthetic results was greater after SPC than after MPC.

'The other right': control strategies and the role of language use in laparoscopic training.

CONTEXT: Laparoscopic techniques present a particular challenge to the academic surgeon in maintaining control and patient safety. The authors explored the use of verbal and physical control strategies including deixis, language used to locate subject in spatio-temporal, social and discoursal contexts, in this setting. METHODS: Forty cases of laparoscopic cholecystectomy at an academic centre were video and audio-recorded. Surgeon and trainee discourses and physical gestures during the crucial anatomical steps of the operation were qualitatively analysed using a hybrid inductive and deductive technique with explicit attention to the use of deixis. RESULTS: Laparoscopic surgeon educators use verbal and physical strategies and engage in bidirectional communication to maintain indirect control of an operation where direct control is not possible. Among verbal strategies, deictic language predominates. DISCUSSION: As in open surgery, laparoscopic surgical educators attempt to exert control over surgical procedures when the instruments are in the hands of a trainee. One dominant strategy is the use of deictic language, which may be ambiguous. In addition to the physical manoeuvres and bidirectional communication used to disambiguate, instructors must attend to potential uncertainties and explicitly clarify frames of reference in order to enhance educational experiences and maximise patient safety.