Single-Operator Multi-Port cholecystectomy (SOMP) - technique, safety, and efficacy.

We thank Garg et al. [1] for their interest in our publication [2]. The meta-analysis was aimed at comparing clinical outcome following single-incision (SILS) vs. multiport laparoscopic cholecystectomy. We demonstrated that SILS cholecystectomy was a safe procedure with a similar clinical outcome to standard multiport laparoscopic cholecystectomy. In their letter Garg et al. [1] raise four points of interest that we wish to deal with in turn. First, we agree that improved cosmesis is one of the major benefits of single-incision surgery. However, with the advent of any new surgical technique, patient safety must be the primary concern before the focus can turn to more subjective outcomes such as cosmesis or pain. This meta-analysis clearly demonstrated that SILS cholecystectomy is a safe procedure for uncomplicated gallstone disease in the hands of experienced laparoscopic surgeons. There was insufficient comparable data to allow the analysis of cosmesis as a primary outcome measure. As part of the discussion in our article we described three studies that reported improved patient wound satisfaction scores (different scoring systems were used making meta-analysis impossible). We also alluded to the need for future highpowered randomized studies to examine patient wound satisfaction associated with these different techniques. Second, the authors suggested that postoperative pain may reflect a function of wound tension. This may be a contributing factor, yet not one of the papers that they cited made any correlation of wound tension with the subjective nature of pain. This makes their conclusions difficult to follow. More importantly, the extent of dissection, the site of the incision, wound infection rates, and the method of closure will also affect the pain response. Therefore, to imply that wound tension is solely responsible is a gross oversimplification. One of the major benefits of laparoscopic cholecystectomy has been the significant reduction in postoperative pain when compared to standard open cholecystectomy. In several institutions across the world, laparoscopic cholecystectomy is performed as a day-case procedure, which directly reflects the benefits in postoperative pain seen with this technique. Thus, as the authors suggest, it may be challenging to demonstrate a significant improvement in pain associated with SILS cholecystectomy as multiport laparoscopic cholecystectomy has already dramatically improved pain associated with open surgery. However, this meta-analysis does demonstrate equivalent short-term pain scores for both techniques. Third, Garg et al. [1] raised concerns regarding the methodology employed in trial selection. In particular, they highlighted the inclusion of the Asakuma et al. [3] study. A method of quasirandomization was used by Asakuma et al. [3], with ‘‘allocation to SILS or conventional multiport cholecystectomy based solely on the day of the week.’’ As Garg et al. [1] mentioned in their correspondence, ‘‘there was no attempt to randomize patients blindly, and patient requests for a particular procedure were honored.’’ While we agree with their statement that this method of treatment allocation is not randomization in its purest sense, Asakuma et al. [3] attempted to randomize patients to each treatment. However, we are happy to acknowledge that differences in opinion may exist regarding the inclusion and exclusion of trials based on the methodology of randomization employed. Fourth, Garg et al. [1] suggested that an error occurred in the Table 5 in reporting the incidence of bile leak in the Lee et al. [4] paper. In their paper Lee et al. [4] described S. Markar (&) J. Kinross Academic Surgical Unit, St. Mary’s Hospital, 10th Floor, Praed Street, London W2 1NY, UK e-mail: sheraz_markar@hotmail.com

Multiport laparoscopy is the gold-standard approach for cholecystectomy, and single-port laparoscopy has been developed to further reduce its invasiveness. A specific robotic single-port platform (da Vinci single-site, Intuitive Surgical Inc., Sunnyvale, CA, USA) has been released in 2011, which could technically facilitate single-site cholecystectomy. Current data show its feasibility; however, detailed short- and long-term analyses of costs and comparisons relative to multiport laparoscopy are not available to date. Patients who underwent robotic single-site cholecystectomy for benign, clinically noninflammatory disease between 2011 and 2015 were matched for disease, age, gender, BMI, ASA classification, diagnosis, and elapsed year of surgery to a cohort of multiport cholecystectomies. Demographic, perioperative, and long-term data were collected retrospectively and analyzed. Perioperative and long-term costs including re-operations due to the primary procedure until February 2017 were compared across both cohorts. 99 patients who underwent robotic single-site cholecystectomy were matched to 99 patients with multiport cholecystectomy. A higher rate of outpatient procedures in the robotic cohort (31.3 vs. 17.2%, p=0.0305) was found, and demographic parameters and perioperative clinical outcomes were similar. Perioperative costs were significantly higher for the robotic single-site patients (6158.0 vs. 4288.0 USD, p<0.0001). With similar follow-up times of 59.0 and 58.9months, respectively (p=0.9552), significantly more patients of the robotic Single-Site cohort underwent follow-up surgery (7.1 vs. 0.0%, p=0.0140), and follow-up costs were significantly higher for the robotic cohort (694.7 vs. 0.0 USD, p=0.0145). With similar early postoperative clinical results and a higher rate of re-operations, perioperative and long-term costs are significantly higher with robotic Single-Site cholecystectomy compared with multiport cholecystectomy. Considering the unclear clinical value of robotic single-site cholecystectomy and the significant short- and long-term costs, a call for further research and a debate as to who should bear the costs beyond the ones of the gold-standard treatment appear reasonable.

This chapter reviews the fundamentals and technology, robotic setup, general operative technique, and adoption considerations for robotic-assisted multiport and single-site cholecystectomy. Basic fundamental knowledge of the robotic system, the procedure setup, and instrumentation is critical prior to performing robotic-assisted cholecystectomy. A graduated training program that includes online education, simulation, direct observation, bedside assistance, and case proctoring is important for the implementation of a safe and effective robotic-assisted cholecystectomy.

Laparoscopy is a constantly evolving field of surgery. New technology, applications, and benefits prompt continual improvement. We have developed a Single Port Access (SPA) surgical technique that allows for the entire cholecystectomy to be performed through a single incision within the umbilicus while maintaining safe standard dissection and retraction techniques of currently performed multiport laparoscopic cholecystectomy. Fifteen consecutive patients underwent SPA cholecystectomy. Indications were cholelithiasis, cholecystitis, CBD stones, and biliary akinesia. The entire procedure was performed through a single umbilical incision measuring <1.8 cm within the umbilicus. Three trocars and a rigid grasper were inserted through separate fascial sites within the same skin incision. The cholecystectomy procedures are then performed in the standard fashion described in multi-port cholecystectomy. Fifteen patients successfully underwent Single Port Access cholecystectomy. One patient required a second 5-mm port site secondary to difficulty with retraction of a large liver. Operative times averaged 107 minutes. Blood loss, patient recovery, and outcomes have been comparable to those of standard multi-port procedures. No umbilical hernias have been seen at 2 years of follow-up. We present the SPA cholecystectomy as an alternative to multi-port cholecystectomy. In the first 2 years, SPA surgery has evolved into a technique easily taught and performed without the restrictions of new equipment or added cost.

Elective cholecystectomy is a high-volume, simple procedure, well suited for the development of a pediatric robotic surgery program. Surgical robot software, by "reversing" the surgeon's hands, simplifies single-site cholecystectomy through a single incision at the umbilicus. Data were reviewed on the first nine children who had robotic cholecystectomy, with the Da Vinci® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) device, at our institution. All cases were performed by a single surgeon, proctored by an experienced robotic general surgeon. There were 9 patients: the first 4 patients had robotic multiport cholecystectomy, and the last 5 had robotic single-site cholecystectomy. Eight were girls. They were 10-18 years of age (median, 14 years). Diagnoses were biliary dyskinesia (n = 5) and symptomatic cholelithiasis (n = 4). Median body mass index was 24.9 (range, 20.2-43.8) kg/m(2). Median anesthesia time for multiport cholecystectomy was 139 (range, 120-162) minutes; median anesthesia time for single-site cholecystectomy was 169 (range 122-180) minutes. Median console time for multiport cholecystectomy was 47 (range, 44-58) minutes; median console time for single-site cholecystectomy was 69 (range, 66-86) minutes. Eight of the 9 patients went home on the day of surgery, and 1 stayed overnight. Patients were seen at 13-20 days after surgery (median, 14 days). There were no complications. There were no conversions to open surgery and none from single-site to multiport surgery. Robotic cholecystectomy is safe and efficacious and is a suitable introductory procedure for pediatric surgeons considering a robotic surgery program. Single-site robotic cholecystectomy is a cosmetically attractive option but takes longer than multiport robotic cholecystectomy.

26 - Robotic multiport cholecystectomy