Minilaparoscopic CLIPLESS Cholecystectomy: Tips, Tricks and Advanced Maneuvers.

As the world sought the 'Holy Grail' of scarless surgery, minimizing access seemed to be the natural path to follow, and minilaparoscopy (MINI) was considered to be a natural advancement of standard laparoscopy. It aims at minimizing surgical trauma by further reducing the diameter of standard instruments, without compromising range of motion, triangulation or safety. Several different terms have been coined to address this sophisticated reduced-port technique, which is characterized by the use of instruments 3 mm or less in diameter: acuscopic surgery, minilaparoscopy, needlescopic surgery and microlaparoscopy. The early adoption of MINI was mostly inhibited by the limitations of first-generation instruments, especially with respect to functionality, cost and durability. Furthermore, mini cholecystectomy demanded the use of mini optics, which suffered from poor imaging quality and a short lifetime of the scopes. Newer-generation mini instruments have mitigated these issues through the use of improved effector tips, better insulation, strength and durability, and superior optics. During the early MINI years, surgeons clipped most structures, but sturdy mini clip appliers were either unavailable or did not hold the requisite-size clips. Clipping with MINI required the use of a standard clip applier and the scope had to be changed several times during a procedure, making MINI not only more complicated but also boring and time-consuming. The development and popularization of the clipless technique allowed the surgeon to get free from the expensive and cumbersome minilaparoscopic clip appliers, and replace clips with knots. The marked improvements in instrumentation and the development of the clipless technique have occurred simultaneously with the development of NOTES, LESS and Robotic surgery, which may have contributed to a greater push towards MINI. MINI has been proven to offer more than just better cosmesis. Other advantages include better visualization of the surgical field and, with the development of precisely engineered low-friction trocars, which enhance surgical precision during dynamic and delicate tasks (knotting and suturing small structures), less stress and higher efficiency, which makes the procedure easier to perform. Furthermore, transmission of electro cautery through mini instruments has led to less lateral spread of electric current and subsequent less tissue trauma. For more than 20 years, our team has successfully used minilaparoscopy. Even with the rising popularity of robotic surgery, which still uses 8 mm instruments, minilaparoscopy remains an attractive option that is far from becoming obsolete.

The Science Behind Mini-Laparoscopic Cholecystectomy.

BACKGROUND: Mini-laparoscopy (Mini) was pioneered more than 20 years ago. Newer generation mini instruments have recently become available with improved effector tips, a choice of shaft diameters and lengths, better shaft insulation and electrosurgery capability, improved shaft strength and rotation, more ergonomic handles, low-friction trocar options, and improved instrument durability. Whether the use of mini instruments, particularly newer generation instruments, offers advantages for laparoscopic cholecystectomy is the subject of this review. MATERIALS AND METHODS: The literature was searched for level I data comparing mini-laparoscopic cholecystectomy (Mini LC) to standard laparoscopic cholecystectomy (Std LC). Three systematic reviews and 19 randomized clinical trials were identified and these were studied to evaluate the science behind Mini LC. RESULTS: Mini LC requires conversion to Std LC in 12.3% of patients. Mini LC and Std LC require conversion to open cholecystectomy at the same rate (2-3%). As compared to Std LC, Mini LC: (1) takes 3.4-4.9 minutes longer to perform; (2) has the same rate of intraoperative and postoperative complications; (3) may result in slightly less pain in the first 24 hours after surgery; (4) has the same duration of hospital stay, pain scores 1-28 days after surgery, time to return to activity, time to return to work, and postoperative quality of life 10 days after surgery; (5) provides a better early cosmetic result (as graded by patients and by blinded observers); and (6) provides no apparent difference in late cosmesis (as evaluated 6-12 months postop). There are minimal level I data published on the effects of newer mini instruments for laparoscopic cholecystectomy. CONCLUSION: When applied to elective laparoscopic cholecystectomy, the use of mini-laparoscopic instruments results in a slightly longer operative procedure (3-5 minutes), slightly less immediate postoperative pain (in the first 24 hours), and a better early cosmetic result, with no other apparent significant differences. Additional data are needed from large, well-conducted studies of Mini LC to resolve several unanswered questions, including the role of newer mini instruments.

"Big Operations Using Mini Instruments": The Evolution of Mini Laparoscopy in the Surgical Realm.

Laparoscopy using miniature (2-3.5 mm) instruments was introduced in the late 1980s and early 1990s. Though mini laparoscopy (Mini) created new opportunities for surgical diagnosis and therapy, the limitations of early instruments inhibited widespread adoption. This is no longer the case. Mini is enjoying a renaissance, due to several factors: the maturation of minimally invasive surgery (MIS), the failure of laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) platforms to achieve early expectations, and the recent significant improvements in Mini instrument functionality and durability. As a result, Mini is being increasingly applied to pediatric and adult procedures across specialties. To assess the current status of Mini laparoscopy, the Society of Laparoendoscopic Surgeons (SLS) and the Florida Hospital Nicholson Center convened an international symposium in February 2015. This report shares highlights from that symposium, "Big Operations Using Mini Instruments."

Mini-Laparoscopy: Instruments and Economics.

Mini-laparoscopy (Mini) was pioneered more than 20 years ago, initially with instruments borrowed from other specialties and subsequently with tools designed specifically for Mini. Early adoption of Mini was inhibited though by the limitations of these first-generation instruments, especially functionality and durability. Newer generation Mini instruments have recently become available with improved effector tips, a choice of shaft diameters and lengths, better shaft insulation and electrosurgery capability, improved shaft strength and rotation, more ergonomic handles, low-friction trocar options, and improved instrument durability. Improvements are also occurring in imaging and advanced energy for Mini. The current status of mini-laparoscopy instruments and economics are presented.