Laparoscopic one-trocar cholecystectomy: the glove technique, tips 'n tricks

The objective of this film is to demonstrate a technique for cholecystectomy using a single port situated in the umbilicus. This home-made system is inexpensive. It has been used a lot in South Korea and Japan. It consists of a surgical glove connected to the Applied Medical Alexis® wound retractor. Different ports are introduced through the finger of the glove. Two 5mm flexible ports will be placed, as well as a rigid 12mm port —a Versaport™ by Covidien, which is beneficial as it allows for the introduction of a 10, 12, or 5mm scope and for abdominal cavity insufflation.

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Laparoscopic one-trocar cholecystectomy: the glove technique, tips 'n tricks

Authors

J Leroy, J Marescaux

Abstract

The objective of this film is to demonstrate a technique for cholecystectomy using a single port situated in the umbilicus. This home-made system is inexpensive. It has been used a lot in South Korea and Japan. It consists of a surgical glove connected to the Applied Medical Alexis® wound retractor. Different ports are introduced through the finger of the glove. Two 5mm flexible ports will be placed, as well as a rigid 12mm port —a Versaport™ by Covidien, which is beneficial as it allows for the introduction of a 10, 12, or 5mm scope and for abdominal cavity insufflation.

Classification

tips and tricks, single port

Keywords

Single port, one trocar, glove technique, SILS, cholecystectomy, cholelithiasis, CBD stone, zero-degree scope

Media type

Surgical video

Duration

10'33''

Publication

2011-01

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E-publication

WeBSurg.com, Jan 2011;11(01).
URL: http://www.websurg.com/doi-vd01en2964.htm

Laparoscopic one-trocar cholecystectomy: the glove technique, tips 'n tricks

1. Introduction and description of technique 00'21''

The objective of this film is to demonstrate a technique for cholecystectomy using a single port situated in the umbilicus. This home-made system is inexpensive. It has been used a lot in South Korea and Japan. It consists of a surgical glove connected to the Applied Medical Alexis® wound retractor. Different ports are introduced through the finger of the glove. Two 5mm flexible ports will be placed, as well as a rigid 12mm port —a Versaport™ by Covidien, which is beneficial as it allows for the introduction of a 10, 12, or 5mm scope and for abdominal cavity insufflation.

2. Abdominal incision 01'07''

The first operative step will consist in performing an abdominal incision through the umbilicus until the aponeurosis is opened under visual control.

3. Plastic drape insertion 01'18''

This incision is large enough to allow for the introduction of the flexible 7cm-diameter ring of the plastic drape. This drape can be pushed down into the abdominal cavity.

4. Glove placement 01'33''

The glove upon which trocars had been placed is then attached. The whole system is put together by tightening the drape, which facilitates the opening of the incision hole, retracting the margins of the aponeurosis.

5. Trocar introduction 01'50''

As can be seen here, trocars have already been placed.

6. Insufflation 01'57''

The insufflation is connected to the 10mm port and the insufflation of the abdominal cavity goes on smoothly. A 0-degree angled Palmer scope is inserted through this 10mm port. The content of the abdominal cavity is made clearly visible in this way. This scope with a 5mm operating channel in line with it could also be used to introduce an instrument.

7. Introduction of double curved instrument 02'35''

A double-curved instrument —S-PORTAL® type— is introduced through the flexible ports for the surgeon’s left hand. It allows access to the abdominal cavity without impairing the operative field. It allows to grasp organs, if necessary, in order to expose them, and without any conflict outside of the abdominal cavity since the surgeon is not forced to cross his/her hands to retract the viscera. A straight instrument is introduced through the other port. It is pushed into the abdominal cavity. It is uneasy to find one’s way at this moment. A hook is used in this case. Here, the exposure is made fairly difficult since the organs tend to come into the operative field. The benefit of using the hook is that it maintains the retraction and offers a very limited area for coagulating and cutting, hence reducing the risk of injury. In reality, vision is not perfect since only one hand can work and the other hand is used to retract.

8. Liver suspension 04'03''

Consequently, a suture is introduced through the abdominal wall. It is placed in a subxiphoid area by means of a needle that is grasped by a forceps placed through the umbilical port. This suture, here a suspension tape, is then passed around the round ligament, and then underneath it to come out in the epigastric region. The round ligament still remains to be brought as high as possible in the subxiphoid region. To do so, the tape is tightened on the abdominal wall, which helps to maintain the liver in a cranial position and to exert both caudal and lateral traction on the gallbladder. As a result, the gallbladder bed and Calot’s triangle are better exposed.

9. Calot’s triangle exposure 05'01''

Dissection is continued by placing traction and by performing division by means of the scissors to pass completely around the cystic duct to achieve its skeletonization.

10. Dissection and division of cystic duct and cystic artery 05'13''

It is obvious that the vision obtained through this 0-degree scope directly in line with the port is not perfect to completely visualize Calot’s triangle. The ideal solution would be to use a 30- or 45-degree angulated scope. Once clips have been positioned, the cystic duct is divided and dissection is carried on by moving closer to the gallbladder bed. Division can be carried out after coagulation by using scissors as in the present case. This is achieved to identify and divide the cystic artery once it has been clipped or coagulated as in this patient. Coagulation should be performed electively distal from the gallbladder bed.

11. Gallbladder dissection 06'40''

The gallbladder bed is then further dissected. Thanks to the suspension of the round ligament, caudal and cranial traction can be placed on the gallbladder. Consequently, the fibrous tracts maintaining the gallbladder on the gallbladder bed are tented. In case of bleeding, coagulation can be achieved either with monopolar scissors, or with a bipolar forceps, which is much more effective as its action is very local and in-depth. Dissection can be continued by placing traction and by perfectly visualizing the operative field. This operative field is perfectly visualized thanks to aspiration connected to instruments. It allows for the aspiration of smoke at the level of the operative field. Here, the wisps of smoke in contact to the operative field are well visible. Contact with the lens should be simply avoided as the lens may be soiled by the secretions. Once the gallbladder has been totally freed, the scope inserted through the 12mm port should be replaced by the bag, which is introduced into the abdominal cavity. A 5mm scope can also be used while the gallbladder is retrieved. The bag can also be pushed into the abdominal cavity, as carried out in this video, and the gallbladder is placed into this bag as regularly performed during surgery with multiple ports.

12. Gallbladder extraction 08'39''

The gallbladder is therefore pushed into the bag, taking care not to perforate the gallbladder and avoid any bile leak that would require a lavage in order to limit the risks of intra-abdominal pain. The bag is then brought outside by pulling along the port’s axis. The extraction is performed through the trans-umbilical incision. The incision remains to be closed now. To do so, the plastic drape should be extracted first. A suture should then be made by leaning on the aponeurosis and not on the umbilical scar. Therefore, the umbilicus should be de-inserted from the margins of the aponeurosis in order to limit the risk of distal internal hernias.