Analysis of post-operative complication in single-port laparoscopic cholecystectomy: A retrospective analysis in 817 cases from a surgeon
Department of Medicine, Graduate School of Medicine Dong-A University, 32 Daesingongwon-Ro, Seo-Gu, Republic of Korea
Department of Surgery, Dong-A University College of Medicine, Busan 49201, Republic of Korea
Address for correspondence: Dr. Younghoon Roh, Department of Surgery, Dong-A University College of Medicine, 26 Daesingongwon-Ro, Seo-Gu, Busan 602715, Republic of Korea. E-mail: gsryh@dau.ac.krAbstract
Background:
Single-port laparoscopic cholecystectomy (SPLC) is a new advanced technique in laparoscopic surgery which has many benefits according to previous reports. The purpose of this study was to present personal experiences with SPLC in >800 cases performed by a surgeon to evaluate the safety and feasibility of this procedure.
Materials and Methods:
A retrospective review of 817 cases of SPLC was conducted. All patients had received elective SPLC by a surgeon in our centre during March 2009–August 2015. Our review suggests patients’ character, peri-operative data and post-operative outcome.
Results:
Three hundred and ninety-eight men (48.7%) and 419 women (51.3%) with an average age of 48.3 years had received SPLC. Their mean body mass index (BMI) was 23.75 kg/m2. The mean operating time took 46.9 min (19–130). Seventy-nine cases (9.7%) needed additional port during operation. BMI, age and previous abdominal surgical history did not affect conversion to multiport surgery. Bile spillage during operation occurred in 73 cases (8.9%). There were 4 cases of open conversion because of bleeding (2 cases, 0.2%) and common bile duct (CBD) injury (2 cases, 0.2%). Mean duration of hospital stay was 2.36 days. We have experienced 38 cases (4.7%) of post-operative complication: 8 cases (1.0%) of major one and 30 cases (3.7%) of minor one. Major complication occurred in 3 cases (0.4%) of retained CBD stone, 3 cases (0.4%) of cystic duct leakage needed endoscopic retrograde cholangiopancreatography and 2 cases (0.2%) of CBD injury needed reoperation. Most minor complications were wound infections that have healed after conservative treatment. There were no post-operative mortalities.
Conclusion:
SPLC is a safe and practicable technique. With surgical experience, criteria and area of SPLC can be broadened. SPLC is occupying a greater domain of a laparoscopic cholecystectomy.
INTRODUCTION
Laparoscopic procedure is the gold standard for cholecystectomy today.[1] The procedure can be performed in different ways.[234] Conventional three-port laparoscopic cholecystectomy (CLC) and single-port laparoscopic cholecystectomy (SPLC) are common. The former was CLC defined as three or sometimes more ports surgery with ports placed at supra- or infra-umbilical areas, epigastrium or left lumber (French position) regions and right lumbar and right hypochondriac regions. The latter was SPLC defined as the laparoscopic surgery conducted through a single intra-umbilical port.[56] In context of minimally invasive surgery, the latter may result in higher satisfaction because of a single wound.[7891011]
This new approach was first introduced in the 1990s.[6] Since then, many studies support results of SPLC that it is theoretically advantageous for improving cosmesis, fast recovery and light intra-abdominal adhesion, so patients prefer minimally invasive surgery instead of CLC.[89101213]
Some studies reveal similar complication rates.[3141516] Others report higher rates on wound-related complications: incisional hernia, wound infection, intraoperative bile leakage and so on.[410111718]
There is controversy about SPLC, because of relatively scant information, short follow-up periods and a limited number of patients involved. Although systemic review has been published, reports were based on data collected from different studies with heterogeneous patients and surgeons. Therefore, further studies are necessary to clearly identify risks and benefits of SPLC. In this study, we present personal experiences with SPLC in >800 cases by a surgeon to evaluate the efficaciousness and feasibility of this procedure as compared to CLC.
MATERIALS AND METHODS
From March 2009 to August 2015, we conducted a retrospective review of 817 patients who had received elective SPLC by a surgeon at Dong-A University Medical Center in Busan, Korea. The selection criteria for SPLC were as follows: symptomatic cholelithiasis, acute cholecystitis and gallbladder (GB) polyps, GB polyps >1 cm or increasing in size (even if <1 cm) on follow-up computed tomography (CT), abdominal ultrasonography (US) or both. The exclusion criteria for SPLC were as follows: pregnancy, suspected prior history of upper abdominal surgery, liver cirrhosis and American Society of Anesthesiologists (ASA) score >3. We excluded patients as follows: highly suspected GB cancer, acute cholecystitis with severe GB wall thickening in CT and US.
The surgical technique
All procedures were performed by an experienced surgeon. Patients underwent standard preparations as the same with CLC. Under general anaesthesia, patients were placed in supine position. The abdomen was prepped and draped in usual sterile manner, carefully cleaning the umbilicus. The trans-umbilical route was established as usual. A trans-umbilical vertical incision (thin patients, BMI <20kg/m2, obese patients, BMI ≥25kg/m2) was made, and a commercial multichannel port was used to make the channel. Then, the laparoscopic camera was inserted through the central passage. Because the surgeon was accustomed to conventional straight laparoscopic instruments, all instruments were the same as those used for CLC, including a 30°-angled rigid laparoscope of 5 mm in diameter. The only flexible hook Bovie (Cambridge Endoscope Devices, Inc., Framingham, MA, USA) was additionally needed. 10 mm and 5 mm Hemo-O-Lok clips (Weck Surgical Instruments; Teleflex Medical, Durham, North Carolina) were used for ligation of dissected cystic duct (CD) and cystic artery, respectively. A GB was retracted in the cephalic direction, dissected from the liver bed and directly extracted through the umbilical incision. In the umbilical port site, peritoneum and fascia were sutured and subcutaneous tissue was sutured.
Outcomes of interest and statistical analysis
We analysed peri-operative data and post-operative outcome comparing with previous data assessed by chart review. We followed up with patients 1 week after discharge in the outpatient department. Six months later, we checked laboratory tests and other elements routinely. We also followed up post-operative complications in the outpatient department and emergency room.
RESULTS
Patients’ character
From March 2009 to August 2015, we conducted a retrospective review of 817 patients who had received elective SPLC by a surgeon at Dong-A University Medical Center in Busan, Korea. Patients’ basic information including age, gender, body mass index (BMI) and previous abdominal surgical history is summarised in Table 1. There were 398 males (48.7%) and 419 females (51.3%) aged 21–82 years (median age, 48.3 years). The median BMI was 23.75 kg/m2. The ASA score was 1 in 257 (31.5%) patients, 2 in 409 (50.1%) patients and 3 in 151 (18.5%) patients. They were 187 (22.9%) patients who had undergone previous abdominal surgical history (including appendectomy, obstetrics and gynaecology and urology).
Peri- and post-operative outcomes
All 817 patients’ SPLC was performed by a surgeon. Table 2 lists peri- and post-operative outcomes of SPLC. The mean operative time was 46.9 min (19–130 min). Intra-operative bile spillage was 73 (8.9%). Because of poor visualization of Calot's triangle in SPLC, 79 cases (9.7%) were converted to multiport laparoscopy. Open conversion was needed for 4 cases (0.5%) due to bleeding in 2 cases (0.2%) and common bile duct (CBD) injury in 2 cases (0.2%). The mean post-operative hospital stay was 2.36 days. Post-operative pathologic findings were 322 patients (39.4%) for cholecystitis with gallstone, 291 (35.6%) patients for GB polyp, 197 patients (24.1%) for adenomatous GB and 7 patients (0.9%) for GB cancer. Nine patients (1.1%) were readmitted and easily recovered with further conservative therapy.
Post-operative complications
Table 3 lists post-operative complications. Overall, 38 (4.7%) patients had post-operative complications including 8 cases (1.0%) for major complications and 30 cases (3.7%) for minor complications. Major complications occurred in five cases for Clavien classification Grade IIIa (retained CBD stone, CD leakage) and three cases for Clavien classification Grade IIIb (CBD injury needed reoperation). Minor complications occurred in 22 cases (2.7%) for wound infection (requiring antibiotics or not), 6 cases (0.7%) for port-site herniation, 1 case (0.1%) for pain and 1 case (0.1%) for wound eversion [Tables 1–3].
DISCUSSION
Since SPLC was first introduced in the 1990s,[619] it has gained attention as an alternative minimally invasive surgery compared to conventional three-port cholecystectomy. Even short learning curve[2021] and many advantages[89101213] are associated with this procedure, SPLC has been prone to higher incidences of post-operative complications. Many systemic reviews of complications have been published[51322] and controversy remains relative to safety and feasibility issues compared to CLC. Most of the reviews’ data were collected from different studies with heterogeneous patients and surgeons. A major strength of our study was to minimize these biases. Our results indicate that SPLC is comparable to CLC in safety and feasibility for a large number of patients in the long term.
The most common reasons for conversion were because of bleeding and CBD injury. In our review, the conversion rate was 0.5% due to bleeding and CBD injury. Some meta-analyses reported the conversion rate in SPLC (2.4%) and CLC (1.4%) and that our conversion incidence rate is acceptable and safe.[23] Other reviews reported the lower (0.2%) rate, but the procedure failure in that report (8.4%) was higher than our study. Furthermore, data were collected from heterogeneous and limited groups.[24] The open conversion rate in SPLC is higher than the CLC. In a considerable number of experiences, bleeding in SPLC could be controlled moderately. There were some treated in the laparoscopic manner, but in two cases, it was necessary to use conversion due to movement restrictions. Bleeding control in laparoscopic manner is difficult compared to CLC. The other two open conversions were due to CBD injury and are mentioned.
One of the major benefits of SPLC over CLC is improved cosmetic result.[891125] In addition, SPLC has similar post-operative complications to those of CLC in meta-analysis. Overall, most post-operative complications were wound infections, incisional hernia and bile duct injuries (leakage) but were not significantly different from others. Other reviews on complications were identical to our study including bile duct injuries, bile leak, biliary collection or abscess, retained choledocholithiasis, port site-related complications and wound site-related complications.[58922252627282930]
In 817 cases, 8 patients (1.0%) had major complications (Clavien IIIa, b) that required intervention or readmission.
In three patients, a bilirubin level was elevated immediately after procedures caused by a retained CBD stone. There is considerable GB manipulation in the initial learning curve of SPLC for those unfamiliar with the technology. All of the complications were caused by small and multiple stones that recovered with endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST). Small and multiple GB stones are retained in CBD. To prevent this, minimize the GB manipulation and treat the CD first.
In two patients, CD leaked due to initial clipping method. The patient complained of abdominal pain the day after surgery and evaluation of fluid collection. Leaks were treated with ERCP, endoscopic retrograde biliary drainage, percutaneous needle aspiration and drainage (PNAD). To reduce leakage, surgical technique evolved. In the first bile leakage, we revised bile clipping number from one to two. After ‘Double hem-o-lock’ revision, bile leakage did not occur. The second bile leakage after the revision due to cutting the bile duct too closely to the clip. After discharge, the patient was readmitted with abdominal pain. The leakage did not need an operation and the patient easily recovered with ERCP, EST and PNAD.
Technical challenges in limited triangulation and movement of instruments are the main issues for SPLC. During the initial period, one patient had an iatrogenic CBD thermal injury that needed additional laparoscopic port to repair the CBD. Another patient had a CBD injury during the procedure that needed conversion and Roux-en-Y hepaticojejunostomy (REY HJstomy). One case of the anomalous right posterior bile duct needed conversion and REY HJstomy.
To prevent these complications, the anatomical structures of CD and CBD should be confirmed as in the conventional method, including adequate dissection of Calot's triangle and accurate identification of the GB-CD junction as well as the CD-CBD junction.[2829] We suggest that CD dissection should be performed completely (360° around there) and the clipping should be performed twice. The possibility of injury due to anomalous duct cannot be prevented 100% even if the CT is carefully checked before surgery. Compared with other reviews, major complications are comparable to or even lower than that published in other research papers.[252627]
In 817 cases, 38 patients (4.7%) had post-operative complications. Most of them were minor complications accounting for 30 cases (3.7%) including wound related, port site related and pain related.
In our study, wound infection occurred in 22 (2.7%) cases. Even though we did carefully dress the site and prescribe prophylactic antibiotic, an anatomical dimpling on the umbilicus may cause more frequent wound infections in SPLC than CLC. It could also be caused by various factors, including residual bacterium at the surgical site or weakened reconstructed umbilicus defence against infections, etc., The SPLC needs more meticulous care of the wound site to prevent infection.[282930] The incidence of wound infection in this study (2.7%) is comparable to or even lower than that published in other research papers (range, 1.05–14.3).[132528]
Five cases of port-site hernia that occurred in the initial period may have been caused by a continuous suture of fascial layer. If any continuous suture is broken, all continuous stitches are vulnerable to be broken. Since we changed continuous suture to interrupt way in 2015, herniation occurred in only one patient (BMI, 27.3). The patient's BMI (27.3 kg/m2) was higher than the average (23.75 kg/m2). High BMI was found to be a risk factor for incisional hernia.[28] With circumspection and awareness of predisposing factors,[25] modification of the suture method and avoidance of excessive exercise after surgery may be helpful in reducing complications.
There was one case (0.1%) of readmission for pain control. The patient was discharged from the ward well after pain treatment. The pain control case was no different than the rate amongst SPLC and CLC.
One case needed cosmetic surgery for the wound eversion. The site was excised under local anaesthesia and sutured by edge alignment with compressive dressing. It is critical to align the wound edge and finish with compressive dressing.
CONCLUSION
The recently published review of SPLC complication rate and other clinical outcomes were not significantly different in our results. Empirically, in this selected case, SPLC is not inferior to CLC on post-operative complications and SPLC has advantage with better cosmetic results, less pain and faster recovery. There was no difference in complication rate and other clinical outcomes amongst SPLC and CLC. Considering all these things, we expect that SPLC will occupy a greater domain in conventional laparoscopic cholecystectomy.
Financial support and sponsorship
This work was supported by the Dong-A University Research Fund.
Conflicts of interest
There are no conflicts of interest.