Background: The development of a purely NOTES cholecystectomy will be limited by the safety profile of access techniques and the sophistication of flexible instrumentation. Although NOTES cholecystectomy in humans has been reported, in all cases some form of percutaneous transperitoneal assistance has been required. We report our experience with 8 cases performing a laparoscopic cholecystectomy through a single periumbilical incision using flexible endoscopy.
Method: From August to October 2007, a total of 8 patients (7 women, 1 man) underwent elective single incision laparoscopic cholecystectomy (SILC) using flexible endoscopic instruments. The patients’ ages ranged from 19 to 67 years old. Access was obtained through a 1.5 cm periumbilical incision. A dual-channel flexible endoscope (Olympus) was inserted into the peritoneal cavity. A 5mm trocar was inserted through the same incision. In all but one case, dissection of the gallbladder and hilum was performed in a retrograde fashion using flexible endoscopic instruments, while ligation of the cystic duct and artery was accomplished with a standard laparoscopic clip applier.
Results: All procedures were completed through the single incision. There were no conversions to either traditional laparoscopic or open technique. Operative time ranged from 1 hour 50 minutes to 4 hours. Six of eight patients were discharged home on the same day of surgery; the other two were kept for observation overnight and were discharged the next morning. There were no complications.
Conclusion: SILC is a technically challenging though feasible option in select patients requiring laparoscopic cholecystectomy. With fewer incisions, improved cosmetic outcome is an obvious advantage over traditional laparoscopic cholecystectomy. However, further studies are needed to establish its overall safety as well as to evaluate other potential benefits. Additionally, this approach avoids the potential risks of transgastric and transvaginal access while affording surgeons the opportunity to develop advanced endoscopic skills.