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A Novel Technique for Fundal Retraction of the Gallbladder in Single-Port Cholecystectomy

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A Novel Technique for Fundal Retraction of the Gallbladder in Single-Port Cholecystectomy
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  Technical Reports A Novel Technique for Fundal Retractionof the Gallbladder in Single-Port Cholecystectomy Joachim Reibetanz, MD, Alexander Wierlemann, MD,Christoph-Thomas Germer, MD, and Katica Krajinovic, MD Abstract Recent reports on the feasibility and safety of single-incision cholecystectomy have challenged the conventionalmultiport access to the gallbladder. Nevertheless, the proximity of different instruments and the laparoscopemay lead to interference that potentially compromises the safety of the operation. This article describes the use of a customary flexible restraint system for the gallbladder fundus to achieve triangulation by means of a three-instrument technique and an optimized view to the Calot’s triangle. Introduction S ingle-incision cholecystectomy  displays substantialprogress in minimally invasive surgery, and recent re-portsonthefeasibilityofthisnoveltechniquehavechallengedtheconventionalmultiportlaparoscopictechniqueasthegoldstandard in cholecystectomy. 1–3 Nevertheless, one majordrawback of single-incision surgery is the proximity of dif-ferent instruments and the laparoscope inserted via the sameport, resulting in extracorporeal interference, which poten-tially compromises the safety of the operation. Concerningsafety aspects, an independent retraction technique of thegallbladder fundus is crucial for an optimal exposition of critical structures in the Calot’s triangle. 4 This techniqueshould also offer maximum range of motion for the appliedinstruments during preparation.We describe a new technique of independent fundal re-traction of the gallbladder using a thin and space-savingcustomary restraint system. Operative Technique The articulated restraint system (DB 2 C; Chirurgical Con-cept, Mery-sur-Cher, France) and its connection to the leftsideoftheoperation tableareshown inFigure1.Theretractoris rigid at its back end, and at its front end it is tridi-mensionally flexible and lockable in any position. The con-nection of the retractor to a straight 3-mm grasper used forgallbladder fundal retraction is shown in Figure 2.Single-port access cholecystectomy is performed usingthe re-usable X-Cone Single-Port Laparoscopic Device (X-Cone TM ; Karl Storz GmbH, Tuttlingen, Germany) (Fig. 3).This metal device is composed of two tapered L-shaped half shells (one with an insufflation tap) and sealed with a siliconerubber cap. After a 20-mm vertical skin incision in the umbi-licus, via an open approach, the port is trocar-like placed intothe abdominal cavity, creating an autostatic X-shaped funnel.For sealing, a rubber cap offering five gas-proof workingchannels is applied. One of the five working channels permitsthe introduction of instruments up to 12.5mm. A 50-cm-long,30  , 5-mm laparoscopic camera (Karl Storz) is introduced viathe right working channel. After the gallbladder is identified,attention is directed to the gallbladder fundus, which is re-tractedupwardusingastraight3-mmgrasperinsertedviathelowest working channel. This technique is comparable tofundal exposition known from standard multiport cholecys-tectomy. For a static fundal retraction, the hand grip of thegrasper is then connected to the flexible retractor and the re-tractor is locked in this position (Fig. 4). For infundibularmanipulation, a curved roticulating grasper (Karl Storz) isused,placedviatheleftworkingchannel.Independentfundalretraction combined with the roticulating function of thecurved (infundibular) grasper enables perpendicular distrac-tion of the cystic duct from the common bile duct and anoptimal exposition of the anterior and dorsolateral view totheCalot’striangle(Figs.5and 6).For dissection andisolationof the cystic duct and the cystic artery, a 5-mm scissors(Karl Storz) is used. The cystic duct and the cystic artery aredoubly clipped using a 10-mm clip applicator (ChallengerTi TM ; Aesculap AG, Tuttlingen, Germany) inserted via themiddle working channel, and then transected. During theseprocedures the fundus is statically retracted with the 3-mmgrasper. Besides optimal exposure, this technique offers Department of General, Visceral, Vascular, and Pediatric Surgery, University Hospital of Wuerzburg, Wuerzburg, Germany. JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUESVolume 21, Number 5, 2011 ª  Mary Ann Liebert, Inc.DOI: 10.1089/lap.2010.0487 427  maximum range of motion for the additionally inserted in-struments, minimizing extracorporeal conflicts of the hands.Further, the assistant can use both hands for optimal camerawork, including radial work with the light cord (Fig. 7). Fordissection of the gallbladder from the liver bed, the restraintsystem may be removed and the 3-mm grasper managed bythe surgical assistant. After complete dissection, the gall- bladder is placed in an endobag (Inzii TM ; Applied Medical,Rancho Santa Margarita, CA) and removed at the port site.The fascial defect at the umbilicus is then closed using inter-rupted absorbable sutures (Vicryl 0; Ethicon GmbH, Nor-derstedt, Germany), and the skin incision is closed with a 4-0absorbable subcuticular suture. Discussion With the development of single-port cholecystectomy asa less invasive access to the gallbladder, surgeons wereforced to become familiar with in-line viewing and a lim-ited ability of triangulation, both resulting in a potentiallycompromised view to critical structures in the Calot’s tri-angle. Given the different techniques that have evolved insingle-port surgery (with versus those without an accessdevice), the use of an access device itself may limit therange of instrument motion, as all instruments need to bepassed through the ‘‘bottleneck’’ of the port. Using the X-Cone, we experienced that this drawback (of any accessdevice) is outweighed by the stable instrument guidanceand the gas-tight sealing.In a recent report, Podolsky and Curcillo clearly demon-strated the superiority of a three-instrument technique inachieving and maintaining an optimal exposure of the hepa-tocystic triangle, when compared with 2-instrument use. 4 However, increasing the number of instruments inserted via asingle incision (in the umbilicus) again confines the ability of unhindered instrument motion. This problem may even in-crease when using an access device, as mentioned above.Consequently, attempts have been made to avoid collision of instruments (and the laparoscope) while achieving the best op-erative exposure, including instruments of different lengths,articulated instruments, flexible-tip cameras, transperitonealsutures, or magnetic aid. 5,6 Nevertheless, some of the reportedtechniques 6 raise concerns regarding bile spillage. 7 The use of a thin, lockable retraction system for the gall- bladder fundus enables (1) good triangulation by means of athree-instrument technique, (2) an increased range of instru-ment motion for the surgeon by eliminating one of the assis-tants’ hands from the limited area of the external instrumenthandles,and(3)superiorcameraworkaffordedbyuseofbothof the assistant’s hands. A safe anterior and dorsolateral viewof the hepatocystic triangle was achieved by the roticulatingfunction of the curved grasper. Further, we were able to FIG. 1.  Restraint system (DB 2 C; Chirurgical Concept) forgallbladder fundus retraction, fixed to the left side of theoperation table. FIG. 2.  Connection of the restraint system to the hand gripof the 3-mm grasper. FIG. 3.  Reusable X-Cone TM Single-Port LaparoscopicDevice (Karl Storz). FIG. 4.  Three-millimeter grasper, inserted via the lowestworking channel, connected to the restraint system for staticgallbladder fundus retraction. 428 REIBETANZ ET AL.  largely use customary equipment for conventional multiportcholecystectomy. The re-usability of the retractor and itsconnectabilitytothehandgripofastandard3-mmgrasperdonot increase costs of the procedure. Finally, the restraint sys-tem introduced here is not prerequisite when using the X-Cone device but has emerged as a practical additional tool inrecent single-port cholecystectomies performed byour group.We anticipate that this might also apply for other single-portaccess techniques. Acknowledgment We thank A. Kellersmann and H. Bergauer for technicalassistance with the graphical material. Disclosure Statement K. Krajinovic and C.-T. Germer received travel grants fromKarlStorz.ForJ.ReibetanzandA.Wierlemann,nocompetingfinancial interests exist. References 1. Curcillo PG II, Wu AS, Podolsky ER, Graybeal C, KatkhoudaN, Saenz A, Dunham R, Fendley S, Neff M, Copper C, BesslerM, Gumbs AA, Norton M, Iannelli A, Mason R, Moazzez A,Cohen L, Mouhlas A, Poor A. Single-port-access (SPA TM )cholecystectomy: A multi-institutional report of the first 297cases. Surg Endosc 2010;24:1854–1860.2. Solomon D, Bell RL, Duffy AJ, Roberts KE. Single-port cho-lecystectomy: Small scar, short learning curve. Surg Endosc2010;24:2954–2957.3. Vidal O, Valentini M, Espert JJ, Ginesta C, Jimeno J, MartinezA, Benarroch G, Garcia-Valdecasas JC. Laparoendoscopicsingle-site cholecystectomy: A safe and reproducible alterna-tive. J Laparoendosc Adv Surg Tech A 2009;19:599–602.4. Podolsky ER, Curcillo PG II. Reduced-port surgery: Pre-servation of the critical view in single-port-access cholecys-tectomy. Surg Endosc 2010;24:3038–3043.5. Dominguez G, Durand L, De Rosa J, Danguise E, ArozamenaC, Ferraina PA. Retraction and triangulation with neodym-ium magnetic forceps for single-port laparoscopic cholecys-tetomy. Surg Endosc 2009;23:1660–1666.6. Rivas H, Varela E, Scott D. Single-incision laparoscopic cho-lecystectomy: Initial evaluation of a large series of patients.Surg Endosc 2010;24:1403–1412.7. Gibbs KE, Kaleya RN. Incidental gallbladder cancer andsingle-incision laparoscopic cholecystectomy. Surg Endosc2009;23:1680. Address correspondence to:  Joachim Reibetanz, MDDepartment of General, Visceral,Vascular, and Pediatric SurgeryUniversity Hospital of WuerzburgZentrum Operative MedizinOberduerrbacher Str. 697080 WuerzburgGermanyE-mail:  reibetanz_j@chirurgie.uni-wuerzburg.de FIG. 5.  Exposition of the gallbladder infundibulum in athree-instrument technique (anterior view). FIG. 6.  Exposition of the gallbladder infundibulum in athree-instrument technique (dorsolateral view). FIG. 7.  Optimal extracorporeal range of motion for theapplied instruments. The assistant can use the free left hand(*) for radial work with the light cord. FUNDAL RETRACTION IN SINGLE-PORT CHOLECYSTECTOMY 429
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