Dual trocar laparoscopy improves reduced-port surgery of the distal pancreas.

BACKGROUND: The technical feasibility of transumbilical single-incision surgery (SIL) for pancreatic resections has been demonstrated. However, this technique is hampered by the limited degrees of freedom for instrument handling. Dual-incision laparoscopy (DIL) with an additional trocar may simplify dissection and allow drainage. MATERIAL AND METHODS: Between December 2009 and May 2017, 21 patients were treated with SIL (12/2009 to 01/2014) or DIL (02/2014 to 05/2017) pancreatic resection. All data were collected in a database and retrospectively analysed. RESULTS: Demographic parameters of the patients did not differ significantly in the DIL or the SIL group. No conversion to open surgery was required. No intraoperative complication occurred in either group. The surgical difficulty score was significantly higher in the SIL group (4.4 ± 1.56 vs 2.18 ± 1.95; p = .006). Postoperative serum amylase levels were higher (101.9 U/l ± 50.11 vs 48.91 U/l ± 35.20; p = .01) and return to normal levels (6.4 ± 9.66 days vs 2.09 ± 1.98 days; p = .045) was later in the SIL group. Three complications requiring radiological or surgical intervention were witnessed in the SIL group and one complication in the DIL group (p = .42). CONCLUSION: DIL surgery is a safe and feasible alternative to SIL surgery, facilitating key steps of distal pancreatic tail resection.

Wound complications in 1145 consecutive transumbilical single-incision laparoscopic procedures.

OBJECTIVE: To evaluate the wound complication rate in patients undergoing transumbilical single-incision laparoscopic (SIL) surgery. BACKGROUND: SIL surgery claims to be less invasive than conventional laparoscopy. Small SIL series have raised concerns toward a higher wound complication rate related to the transumbilical incision. METHODS: In a 44-month period, 1145 consecutive SIL procedures were included. The outcomes were assessed according to the intention-to-treat analysis principle. All procedures were followed for a minimum of 6 months postoperatively, and wound complications were recorded as bleeding, infection (superficial/deep), or hernia. Patients were classified as having a wound complication or not. For all comparisons, significance level was set at P<0.05. RESULTS: Pure transumbilical SIL surgery was completed in 92.84%, and additional trocars were used in 7.16%. After a median follow-up of 22.1 (range, 7.67-41.11) months, 29 wound complications (2.53%) had occurred [bleeding 0%/infection 1.05% (superficial 0.9%/deep 0.17%)/early-onset hernia 0.09%/late-onset hernia 1.40%, respectively]. Factors associated with complications were higher patient body mass index (28.16±4.73 vs 26.40±4.68 kg/m; P=0.029), longer skin incisions (3.77±1.62 vs 2.96±1.06 cm; P=0.012), and multiport SIL versus single-port SIL (8.47% vs 2.38%; P=0.019) in complicated versus uncomplicated procedures. Furthermore, a learning curve effect was noted after 500 procedures (P=0.015). CONCLUSIONS: With transumbilical SIL surgery, the incidence of wound complications is acceptable low and is further reduced once the learning curve has been passed.

The Shift from Multiport to Single Port Increases the Amount of Bleeding in Laparoscopic Major Hepatectomy.

BACKGROUND: Bleeding is a negative outcome predictor in liver surgery. Reduction in the abdominal wall trauma in major hepatectomy is challenging but might offer possible benefits for the patient. This study was conducted to assess hemostasis techniques in single-port major hepatectomies (SP-MajH) as compared to multiport major hepatectomies (MP-MajH). METHODS: The non-randomized study comprised 34 SP-MajH in selected patients; 14 MP-MajH served as the control group. Intraoperative blood loss and number of blood units transfused served as the primary endpoints. Secondary endpoints were complications and oncologic five-year outcome. RESULTS: All resections were completed without converting to open surgery. Time for hepatectomy did not differ between SP-MajH and MP-MajH. Blood loss and number of patients with blood loss > 25 mL were significantly larger in MP-MajH (p = 0.001). In contrast, bleeding control was more difficult in SP-MajH, resulting in more transfusions (p = 0.008). One intestinal laceration (SP-MajH) accounted for the only intraoperative complication; 90-day mortality was zero. Postoperative complications were noted in total in 20.6% and 21.4% of patients for SP-MajH and MP-MajH, respectively. No incisional hernia occurred. During a median oncologic follow-up at 61 and 56 months (SP-MajH and MP-MajH), no local tumor recurrence was observed. CONCLUSIONS: SP-MajH requires sophisticated techniques to ensure operative safety. Substantial blood loss requiring transfusion is more likely to occur in SP-MajH than in MP-MajH.

Inline radiofrequency pre-coagulation simplifies single-incision laparoscopic minor liver resection.

BACKGROUND: Single-incision laparoscopy (SIL) has been developed to reduce surgical trauma, whereas technical difficulties in bleeding control limit the broad acceptance for hepatectomy. A novel minimized invasive strategy combining inline radiofrequency pre-coagulation and transumbilical SIL is presented herein. METHODS: A cohort of 21 selected patients underwent transumbilical SIL hepatectomies (segmentectomies II-VI) utilizing inline radiofrequency pre-coagulation for hepatic transection (Habib 4X). Bleeding control, postoperative complications and positive resection margins in malignant diseases served as primary and secondary outcome parameters, respectively. RESULTS: Single-incision laparoscopy was successfully completed in all patients. A total of 33 segments were retrieved: mean resection time was 66 ± 35 min, including 11 anatomical (52.38%) and 10 non-anatomical (47.62%) resections. Sixteen patients (76.19%) underwent concomitant abdominal surgery. No substantial blood loss occurred. Neither additional staplers nor clips were necessary to control any bleeding or bile leakage. One pleural effusion counted for the only postoperative complication. Free margins could be achieved in all but one resection (12/13 patients with malignancies; 92.31%). Ninety-day mortality was zero. CONCLUSIONS: The combination of SIL and inline radiofrequency pre-coagulation proved to be a simple, efficacious and safe technique in minor hepatectomy.

Single port laparoscopy in gastroenterology and hepatology: a fine step forward.

Single incision laparoscopy (SIL) has become an emerging technology aiming at a further reduction of abdominal wall trauma in minimally invasive surgery. Available data is encouraging for the safe application of standardized SIL in a wide range of procedures in gastroenterology and hepatology. Compared to technically simple SIL procedures, the merit of SIL in advanced surgeries, such as liver or colorectal interventions, compared to conventional laparsocopy is self-evident without any doubt. SIL has already passed the learning curve and is routinely utilized in expert centers. This minimized approach has allowed to enter a new era of surgical management that can not be acceded without a fruitful combination of prudent training, consistent day-to-day work and enthusiastic motivation for technical innovations. Both, basic and novel technical specifics as well as particular procedures are described herein. The focus is on the most important surgical interventions in gastroenterology and aims at reviewing the current literature and shares our experience in a high volume center.