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A medical school experience with three port laparoscopic cholecystectomy with a new modification in technique
ORIGINAL RESEARCH International Journal of Surgery 11 (2013) 37e40
Contents lists available at SciVerse ScienceDirect
International Journal of Surgery journal homepage: www.theijs.com
Original research
A medical school experience with three port laparoscopic cholecystectomy with a new modification in technique Mushtaq Chalkoo a, *, Shahnawaz Ahangar a, Aasim Mushtaq Patloo b, Adnan Rashid Matoo b, Faud Sadiq Baqal a, Sikender Iqbal a a b
Department of General Surgery, Government Medical College, Srinagar, J&K, India SKIMS, Srinagar, J&K, India
a r t i c l e i n f o
a b s t r a c t
Article history: Received 13 October 2012 Received in revised form 31 October 2012 Accepted 5 November 2012 Available online 16 November 2012
Introduction: The three port laparoscopic cholecystectomy is a recognized entity in the surgical management of gallstone disease. We report our experience and feasibility of three port laparoscopic cholecystectomy with a new modification in technique. Methods: To assess the feasibility and safety of three-port laparoscopic cholecystectomy with a different port placement, we undertook a prospective study with 50 patients at government medical college, Srinagar, Kashmir, India between Jan 2010 and Jan 2011. Our study offered a benefit of concealed third port designed around umbilicus over the conventional three port laparoscopic cholecystectomy. A single surgeon did all the cases and definite criteria of simple cases of gallstone disease patterned on clinical and radiological grounds. Results: 50 cases of gallstone disease were subjected to the new technique of three port laparoscopic cholecystectomy during a period one year. 34 cases were females and 16 were males. The age range of our patients was between 20 and 55 years with the median age of 33 years. Mean Body mass index 30 (range 25e35). Mean operative time was 30 min (range 15e45 min) and a follow up [period ranged from 9 to 12 months]. No cases were converted to open though two cases required an additional port in the right hypochondrium for retraction. We did not encounter any untoward mishaps during surgery. Conclusion: Three port laparoscopic cholecystectomy with our modification of the third port placement at a different site received good results and patient satisfaction. Moreover the placement of third port at a consealed area around umbilicus apparently gives it an appearance of two port laparoscopic cholecystectomy with an addition of technical ease. Ó 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Laparoscopic cholecystectomy Three port Modification
1. Introduction The aim of the present study was to evaluate the feasibility and safety of three port laparoscopic cholecystectomy with a new site of third port placement around umbilicus. Three port laparoscopic cholecystectomy is a recognized entity accepted by the world literature and reported without any major complications like bile duct injury.3e5 Since the advent of laparoscopic cholecystectomy with the standard four port technique there have been numerous modifications regarding the port number and their placement for patient satisfaction and technical ease of the surgeon.1,2 Recently the published studies have shown that three port technique did not compromise the procedure safety, however, the surgical expertise
* Corresponding author. Tel.: þ91 9419032292. E-mail addresses: [email protected] (M. Chalkoo), Shanz101@ gmail.com (S. Ahangar).
is an important criteria. The conventional three port technique envisages the port placement at umbilicus, a 10 mm optical port and two more working ports at epigastric region, a 10 mm port and a 5 mm port in the right hypochondrium in the midclavicular line. We tried to modify the conventional three port laparoscopic cholecystectomy with an idea that the third port should look concealed in the umbilical scar thereby giving the patient a benefit of apparently a two port laparoscopic cholecystectomy. We strongly feel that the third port placed around the umbilicus technically suits the surgeon as his left hand does not cross the patient and stays in the same plane as the right working port. It is also easy to create a third port around umbilicus as the thrust of making the port is controlled by the dominant hand of the surgeon. It also avoids struggling with the camera-man with an additional benefit of evading the third assistant. Our modification over scores on the two port technique using puppet sutures for gallbladder retraction in many ways and yet retaining the benefit of two port laparoscopic cholecystectomy.
1743-9191/$ e see front matter Ó 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijsu.2012.11.005
ORIGINAL RESEARCH 38
M. Chalkoo et al. / International Journal of Surgery 11 (2013) 37e40
2. Material and methods This study was conducted in the Department of Surgery of Government Medical College, Srinagar, between January 2010 and Jan 2011. Fifty selected patients with cholelithiasis underwent modified three port laparoscopic cholecystectomy in a prospective study. The patients with documented attack of acute cholecystitis, and choledocholithiasis were excluded. A single consultant surgeon carried out the surgeries with an experience of more than 500 laparoscopic cholecystectomy procedures. Informed consent was taken from the patient. The patients were initially evaluated in the out-patient department (OPD) and then admitted for surgery. On admission, a detailed history was asked from the patient including the presenting complaints, duration of the complaints, past history especially with reference to previous operation(s). Investigations performed included routine investigations like complete Haemogram, Kidney Function Tests, Liver function tests, ECG (electrocardiogram), chest radiograph and Ultrasonography (confirmed the presence of gallbladder stones in all patients). All the patients had their blood typed and cross matched. Preanesthetic checkup was done in all patients. Preoperative prophylactic antibiotics were given in all cases.
2.1. Operative technique Our technique involves the placement of ports in a fashion that adds comfort to the operating surgeon and suits to the requirement of the patient. We make the first port on the umbilicus at 4 o’clock position on the left lip of the umbilical scar after creation of pneumoperitoneum by closed technique. It is a 10 mm port for optics. The second working port is placed conventionally at the epigastric region and is again a 10 mm. At this stage of the procedure we introduce the Maryland dissector and study the anatomy of the biliary tract. After being sure that the surgery looks feasible by our modified three port technique we introduce another 5 mm working port designed at 8 o’clock position of the umbilical scar on the right lip of umbilicus, making sure that the distance from the optical port is maximally achieved (Figs. 1 and 2). To facilitate the visual insertion of this port the camera is shifted to the epigastric port. The left working port is very important for the technical aspects of the surgery. It is used as the retraction port and is exploited for safeguarding the dissection at the Calot’s triangle. The gallbladder is held at the infundibulum and pushed up towards the right shoulder of the patient. The Maryland forceps performs the dissection at the Calot’s triangle. After being sure that the anatomy is well displayed, the clips are applied to the cystic artery and the cystic duct and the structures are divided. Much of the art lies in the hands of camera-assistant to allow the surgeon to look at different views of calots triangle while the dissection is being carried there. The gallbladder is dissected off the liver bed using a coordinated effort of both instruments inserted via the non-optical port. The hemostasis is achieved and drain, if required is inserted through the 5 mn working port at the umbilicus. The gallbladder is removed through the epigastric port. The ports are then closed and the dressing applied (Fig. 3). The patients are made ambulatory on the evening of the same day and the liquid orals are given. The drain is removed on the next morning and the patient is discharged subsequently.
Fig. 1. Figure showing port sites.
Fig. 2. Relation between the surgeon and the assistant.
3. Results and analysis 1. Age and sex:d50 patients underwent modified three port laparoscopic cholecystectomy. The median age of patients was 33 years and the range was 20e55 years. There were 34 females and 16 males in the study 2. Body Mass Index (BMI):dMean Body mass index 30 (range 25e35). 3. Previous Interventions/Surgeries:dnone of our patients had a history of previous upper abdominal surgical intervention. 4. Peri-Operative details:dThe operative time, estimated blood loss, requirement of transfusions, intraoperative complications, use of suction/tube drainage, requirement of adding the 4th port and reasons thereof were recorded. The fourth port was required to be inserted in 2 patients only with long comma shaped gallbladder for retraction purposes. There were three complications (6%). All complications were minor in the form of diffuse hemorrhagic ooze from liver bed in two patients and
Fig. 3. Antiseptic dressings applied on the port sites.
ORIGINAL RESEARCH M. Chalkoo et al. / International Journal of Surgery 11 (2013) 37e40
5.
6.
7. 8.
bilious ooze in one patient. Both of these were coming from the gallbladder bed. The complications were managed intraoperatively by securing the proper hemostasis. There was no major bile duct injury in our study. No patient demanded conversion to open cholecystectomy. Post-operative details:d2 of our patients developed postoperative complications. One of the patients developed epigastric port site infection. This was managed by opening up the skin suture and antiseptic dressing twice daily with a short course of antibiotics against staphylococcus. Another patient developed fever due to thrombophlebitis, which was treated with change of intravenous access site and local heparin cream. Hospital stay:dThe mean hospital stay was 1.5 days; the range being 1e2 days. Most of the patients were discharged home on the morning of first postoperative day. The hospital stay got prolonged up to 2 days in patients who developed the above postoperative complications. Return to work:dmost of the patients returned to their normal routine work within one week of surgery. Follow up: All patients were followed strictly after the surgery. The mean follow-up was 6 (range 9e12) months.
4. Discussion Laparoscopic management of gallstone disease has revolutionized the cholecystectomy worldwide. With the advent of video guided surgery the surgeons have started venturing into the previously impossible. Every other day there is a new innovation, modification and refinement in the older techniques used in the surgical arena.1 Laparoscopic cholecystectomy with the four port standard technique is going into abeyance as the new and newer techniques are introduced. The idea behind reducing the number and size of ports is only to alleviate the pain and give the benefits of better cosmesis to the patient.2 In this regard the surgeons have already gone to three port, two port, and single incision laparoscopic surgery. The conventional three port technique is already a recognized modality of treatment for gallstone disease. It envisages placing ports at umbilicus; 10 mm optical port, a 10 mm epigastric port and a 5 mm right hypochondrium port. The safety and feasibility of this procedure is already much talked about in the literature.3e5 In the current study we had an idea to modify the third port placement site in such a way that it gets concealed in the normal physiological scar of umbilicus and gives an apparent look of two port technique.6e9 We felt that the two port puppet technique for gallstone disease has some flaws in completing the procedure uneventfully. Our modified three port laparoscopic cholecystectomy retains the benefit of two port cholecystectomy and accomplishes the procedure without any untoward mishaps that happen in the puppet technique. It is important to mention that there is a possibility of infection dissipating to the parieties while the sutures are taken through he infected bile. The inadvent spillage of stones during cholecystectomy and bleeding is difficult to manage with the puppet technique once the gallbladder is detached from the live bed. The modified three port technique can handle such problems without any trace of difficulty. We are clear in our idea of fashioning the third port around the umbilicus at 8 o’clock position which allows us to retract the gallbladder and perform the dissection safely. Both the hands of the surgeon lie in the same plane and do not cross the body of the patient. Inserting a trocar on the other side of the body is technically difficult for the surgeon and the thrust is not controlled. The modified third port placement is technically easy for insertion and the thrust is also under the control of the surgeon. There is not much of interfering with the camera
39
assistant who otherwise can hold the camera with the right hand and stay away from the surgeon. The insertion of the third port through the optical port has also been reported in the literature. However, there is a lot of struggle between the surgeon and the optical assistant. Recently R-port, single incision multiport, single port laparoscopic cholecystectomy have flooded the literature.10e17 The cost of R-port and single port surgery is quite high and cannot be afforded by many patients, in addition, the surgeon needs a higher learning curve before undertaking such procedures. Our modified three port laparoscopic cholecystectomy can be performed with the conventional instruments and needs lesser surgical expertise and is cost effective especially in developing countries. 5. Conclusion We strongly feel, given the various innovations in laparoscopic cholecystectomy, our three port procedure with a modified approach can prove a better alternative in developing countries visa viz patient satisfaction, the surgeon comfort and the cost incurred on the operative modality. Ethical approval NA. Funding None. Authors contributions Dr Mushtaq chalkoo was the main operating surgeon whileas Dr Shahnawaz ahangar contributed in study design, data collections, analysis and writing. Dr. Aasim Mushtaq Patloo, Dr. Adnan Rashid Matoo, Dr. Faud Sadiq Baqal, and Dr.Sikender Iqbal contributed in data analysis, typesetting and revision. Conflicts of interest None. References 1. Gadacz TR, Talamini MA, Lillemoe KD, Yeo CJ. Laparoscopic cholecystectomy. Surg Clin North Am 1990;70(6):1249e62. 2. Leggett PL, Churchman-Winn R, Miller G. Minimizing ports to improve laparoscopic cholecystectomy. Surg Endosc 2000 Jan;14(1):32e6. 3. Leggett PL, Bissell CD, Churchman-Winn R, Ahn C. Three-port microlaparoscopic cholecystectomy in 159 patients. Surg Endosc 2001 Mar;15(3): 293e6 [Epub 2000 Dec 12]. 4. Saccomani G, Arezzo A, Percivale A, Baldo S, Pellicci R. Laparoscopic cholecystectomy can be performed safely with only three ports in the majority of cases. Chir Ital 2009 SepeDec;61(5e6):613e6. 5. Slim K, Pezet D, Stencl Jr J, Lechner C, Le Roux S, Lointier P, et al. Laparoscopic cholecystectomy: an original three-trocar technique. World J Surg 1995;19(3): 394e7. 6. Leung KF, Lee KW, Cheung TY, Leung LC, Lau KW. Laparoscopic cholecystectomy: two-port technique. Endoscopy 1996 Aug;28(6):505e7. 7. Lee KW, Poon CM, Leung KF, Lee DWH, Ko CW. Two-port needlescopic cholecystectomy: prospective study of 100 cases. Hong Kong Med J 2005 Feb;11(1): 30e5. 8. Cala Z, Niksi c K, Nesek-Adam V, Klapan D, Soldo I. Cosmetic laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A 2006 Dec;16(6): 577e81. 9. Poon C-M, Chan K-W, Ko C-W, Chan K-C, Lee DWH, Cheung H-Y, et al. Two-port laparoscopic cholecystectomy: initial results of a modified technique. J Laparoendosc Adv Surg Tech e Part A 2002;12(4):259e62. 10. Romanelli RJ, Mark L, Omotosho PA. Single port laparoscopic cholecystectomy with the triport system: a case report. Surg Innov 2008 Sep;15(3):223e8. 11. Dominguez G, Durand L, De Rosa J, Danguise E, Arozamena C, Ferraina PA. Retraction and triangulation with neodymium magnetic forceps for single-port laparoscopic cholecystectomy. Surg Endosc 2009 Jul;23(7):1660e6 [Epub 2009 May 5]. 12. Ma J, Cassera MA, Spaun GO, Hammill CW, Hansen PD, Aliabadi-Wahle S. Randomized controlled trial comparing single-port laparoscopic
ORIGINAL RESEARCH 40
M. Chalkoo et al. / International Journal of Surgery 11 (2013) 37e40
cholecystectomy and four-port laparoscopic cholecystectomy. Ann Surg 2011 Jul;254(1):22e7. 13. Solomon D, Bell RL, Duffy AJ, Roberts KE. Single-port cholecystectomy: small scar, short learning curve. Surg Endosc 2010 Dec;24(12):2954e7 [Epub 2010 Apr 17]. 14. Elsey James K, Feliciano David V. Initial experience with single-incision laparoscopic cholecystectomy. J Am Coll Surg 2010 May;210(5):620e4. 624e626.
15. Chandler Nicole M, Danielson Paul D. Single-incision laparoscopic cholecystectomy in children: a retrospective comparison with traditional laparoscopic cholecystectomy. J Pediatr Surg 2011 Sep;46(9):1695e9. 16. Navarra G, Pozza E, Occhionorelli S, Carcoforo P, Donini I. One-wound laparoscopic cholecystectomy. Br J Surg 1997;84(5):695. 17. Kravetz AJ, Iddings D, Basson MD, Kia MA. The learning curve with single-port cholecystectomy. JSLS 2009 JuleSep;13(3):332e6.
Contents lists available at SciVerse ScienceDirect
International Journal of Surgery journal homepage: www.theijs.com
Original research
A medical school experience with three port laparoscopic cholecystectomy with a new modification in technique Mushtaq Chalkoo a, *, Shahnawaz Ahangar a, Aasim Mushtaq Patloo b, Adnan Rashid Matoo b, Faud Sadiq Baqal a, Sikender Iqbal a a b
Department of General Surgery, Government Medical College, Srinagar, J&K, India SKIMS, Srinagar, J&K, India
a r t i c l e i n f o
a b s t r a c t
Article history: Received 13 October 2012 Received in revised form 31 October 2012 Accepted 5 November 2012 Available online 16 November 2012
Introduction: The three port laparoscopic cholecystectomy is a recognized entity in the surgical management of gallstone disease. We report our experience and feasibility of three port laparoscopic cholecystectomy with a new modification in technique. Methods: To assess the feasibility and safety of three-port laparoscopic cholecystectomy with a different port placement, we undertook a prospective study with 50 patients at government medical college, Srinagar, Kashmir, India between Jan 2010 and Jan 2011. Our study offered a benefit of concealed third port designed around umbilicus over the conventional three port laparoscopic cholecystectomy. A single surgeon did all the cases and definite criteria of simple cases of gallstone disease patterned on clinical and radiological grounds. Results: 50 cases of gallstone disease were subjected to the new technique of three port laparoscopic cholecystectomy during a period one year. 34 cases were females and 16 were males. The age range of our patients was between 20 and 55 years with the median age of 33 years. Mean Body mass index 30 (range 25e35). Mean operative time was 30 min (range 15e45 min) and a follow up [period ranged from 9 to 12 months]. No cases were converted to open though two cases required an additional port in the right hypochondrium for retraction. We did not encounter any untoward mishaps during surgery. Conclusion: Three port laparoscopic cholecystectomy with our modification of the third port placement at a different site received good results and patient satisfaction. Moreover the placement of third port at a consealed area around umbilicus apparently gives it an appearance of two port laparoscopic cholecystectomy with an addition of technical ease. Ó 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Laparoscopic cholecystectomy Three port Modification
1. Introduction The aim of the present study was to evaluate the feasibility and safety of three port laparoscopic cholecystectomy with a new site of third port placement around umbilicus. Three port laparoscopic cholecystectomy is a recognized entity accepted by the world literature and reported without any major complications like bile duct injury.3e5 Since the advent of laparoscopic cholecystectomy with the standard four port technique there have been numerous modifications regarding the port number and their placement for patient satisfaction and technical ease of the surgeon.1,2 Recently the published studies have shown that three port technique did not compromise the procedure safety, however, the surgical expertise
* Corresponding author. Tel.: þ91 9419032292. E-mail addresses: [email protected] (M. Chalkoo), Shanz101@ gmail.com (S. Ahangar).
is an important criteria. The conventional three port technique envisages the port placement at umbilicus, a 10 mm optical port and two more working ports at epigastric region, a 10 mm port and a 5 mm port in the right hypochondrium in the midclavicular line. We tried to modify the conventional three port laparoscopic cholecystectomy with an idea that the third port should look concealed in the umbilical scar thereby giving the patient a benefit of apparently a two port laparoscopic cholecystectomy. We strongly feel that the third port placed around the umbilicus technically suits the surgeon as his left hand does not cross the patient and stays in the same plane as the right working port. It is also easy to create a third port around umbilicus as the thrust of making the port is controlled by the dominant hand of the surgeon. It also avoids struggling with the camera-man with an additional benefit of evading the third assistant. Our modification over scores on the two port technique using puppet sutures for gallbladder retraction in many ways and yet retaining the benefit of two port laparoscopic cholecystectomy.
1743-9191/$ e see front matter Ó 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijsu.2012.11.005
ORIGINAL RESEARCH 38
M. Chalkoo et al. / International Journal of Surgery 11 (2013) 37e40
2. Material and methods This study was conducted in the Department of Surgery of Government Medical College, Srinagar, between January 2010 and Jan 2011. Fifty selected patients with cholelithiasis underwent modified three port laparoscopic cholecystectomy in a prospective study. The patients with documented attack of acute cholecystitis, and choledocholithiasis were excluded. A single consultant surgeon carried out the surgeries with an experience of more than 500 laparoscopic cholecystectomy procedures. Informed consent was taken from the patient. The patients were initially evaluated in the out-patient department (OPD) and then admitted for surgery. On admission, a detailed history was asked from the patient including the presenting complaints, duration of the complaints, past history especially with reference to previous operation(s). Investigations performed included routine investigations like complete Haemogram, Kidney Function Tests, Liver function tests, ECG (electrocardiogram), chest radiograph and Ultrasonography (confirmed the presence of gallbladder stones in all patients). All the patients had their blood typed and cross matched. Preanesthetic checkup was done in all patients. Preoperative prophylactic antibiotics were given in all cases.
2.1. Operative technique Our technique involves the placement of ports in a fashion that adds comfort to the operating surgeon and suits to the requirement of the patient. We make the first port on the umbilicus at 4 o’clock position on the left lip of the umbilical scar after creation of pneumoperitoneum by closed technique. It is a 10 mm port for optics. The second working port is placed conventionally at the epigastric region and is again a 10 mm. At this stage of the procedure we introduce the Maryland dissector and study the anatomy of the biliary tract. After being sure that the surgery looks feasible by our modified three port technique we introduce another 5 mm working port designed at 8 o’clock position of the umbilical scar on the right lip of umbilicus, making sure that the distance from the optical port is maximally achieved (Figs. 1 and 2). To facilitate the visual insertion of this port the camera is shifted to the epigastric port. The left working port is very important for the technical aspects of the surgery. It is used as the retraction port and is exploited for safeguarding the dissection at the Calot’s triangle. The gallbladder is held at the infundibulum and pushed up towards the right shoulder of the patient. The Maryland forceps performs the dissection at the Calot’s triangle. After being sure that the anatomy is well displayed, the clips are applied to the cystic artery and the cystic duct and the structures are divided. Much of the art lies in the hands of camera-assistant to allow the surgeon to look at different views of calots triangle while the dissection is being carried there. The gallbladder is dissected off the liver bed using a coordinated effort of both instruments inserted via the non-optical port. The hemostasis is achieved and drain, if required is inserted through the 5 mn working port at the umbilicus. The gallbladder is removed through the epigastric port. The ports are then closed and the dressing applied (Fig. 3). The patients are made ambulatory on the evening of the same day and the liquid orals are given. The drain is removed on the next morning and the patient is discharged subsequently.
Fig. 1. Figure showing port sites.
Fig. 2. Relation between the surgeon and the assistant.
3. Results and analysis 1. Age and sex:d50 patients underwent modified three port laparoscopic cholecystectomy. The median age of patients was 33 years and the range was 20e55 years. There were 34 females and 16 males in the study 2. Body Mass Index (BMI):dMean Body mass index 30 (range 25e35). 3. Previous Interventions/Surgeries:dnone of our patients had a history of previous upper abdominal surgical intervention. 4. Peri-Operative details:dThe operative time, estimated blood loss, requirement of transfusions, intraoperative complications, use of suction/tube drainage, requirement of adding the 4th port and reasons thereof were recorded. The fourth port was required to be inserted in 2 patients only with long comma shaped gallbladder for retraction purposes. There were three complications (6%). All complications were minor in the form of diffuse hemorrhagic ooze from liver bed in two patients and
Fig. 3. Antiseptic dressings applied on the port sites.
ORIGINAL RESEARCH M. Chalkoo et al. / International Journal of Surgery 11 (2013) 37e40
5.
6.
7. 8.
bilious ooze in one patient. Both of these were coming from the gallbladder bed. The complications were managed intraoperatively by securing the proper hemostasis. There was no major bile duct injury in our study. No patient demanded conversion to open cholecystectomy. Post-operative details:d2 of our patients developed postoperative complications. One of the patients developed epigastric port site infection. This was managed by opening up the skin suture and antiseptic dressing twice daily with a short course of antibiotics against staphylococcus. Another patient developed fever due to thrombophlebitis, which was treated with change of intravenous access site and local heparin cream. Hospital stay:dThe mean hospital stay was 1.5 days; the range being 1e2 days. Most of the patients were discharged home on the morning of first postoperative day. The hospital stay got prolonged up to 2 days in patients who developed the above postoperative complications. Return to work:dmost of the patients returned to their normal routine work within one week of surgery. Follow up: All patients were followed strictly after the surgery. The mean follow-up was 6 (range 9e12) months.
4. Discussion Laparoscopic management of gallstone disease has revolutionized the cholecystectomy worldwide. With the advent of video guided surgery the surgeons have started venturing into the previously impossible. Every other day there is a new innovation, modification and refinement in the older techniques used in the surgical arena.1 Laparoscopic cholecystectomy with the four port standard technique is going into abeyance as the new and newer techniques are introduced. The idea behind reducing the number and size of ports is only to alleviate the pain and give the benefits of better cosmesis to the patient.2 In this regard the surgeons have already gone to three port, two port, and single incision laparoscopic surgery. The conventional three port technique is already a recognized modality of treatment for gallstone disease. It envisages placing ports at umbilicus; 10 mm optical port, a 10 mm epigastric port and a 5 mm right hypochondrium port. The safety and feasibility of this procedure is already much talked about in the literature.3e5 In the current study we had an idea to modify the third port placement site in such a way that it gets concealed in the normal physiological scar of umbilicus and gives an apparent look of two port technique.6e9 We felt that the two port puppet technique for gallstone disease has some flaws in completing the procedure uneventfully. Our modified three port laparoscopic cholecystectomy retains the benefit of two port cholecystectomy and accomplishes the procedure without any untoward mishaps that happen in the puppet technique. It is important to mention that there is a possibility of infection dissipating to the parieties while the sutures are taken through he infected bile. The inadvent spillage of stones during cholecystectomy and bleeding is difficult to manage with the puppet technique once the gallbladder is detached from the live bed. The modified three port technique can handle such problems without any trace of difficulty. We are clear in our idea of fashioning the third port around the umbilicus at 8 o’clock position which allows us to retract the gallbladder and perform the dissection safely. Both the hands of the surgeon lie in the same plane and do not cross the body of the patient. Inserting a trocar on the other side of the body is technically difficult for the surgeon and the thrust is not controlled. The modified third port placement is technically easy for insertion and the thrust is also under the control of the surgeon. There is not much of interfering with the camera
39
assistant who otherwise can hold the camera with the right hand and stay away from the surgeon. The insertion of the third port through the optical port has also been reported in the literature. However, there is a lot of struggle between the surgeon and the optical assistant. Recently R-port, single incision multiport, single port laparoscopic cholecystectomy have flooded the literature.10e17 The cost of R-port and single port surgery is quite high and cannot be afforded by many patients, in addition, the surgeon needs a higher learning curve before undertaking such procedures. Our modified three port laparoscopic cholecystectomy can be performed with the conventional instruments and needs lesser surgical expertise and is cost effective especially in developing countries. 5. Conclusion We strongly feel, given the various innovations in laparoscopic cholecystectomy, our three port procedure with a modified approach can prove a better alternative in developing countries visa viz patient satisfaction, the surgeon comfort and the cost incurred on the operative modality. Ethical approval NA. Funding None. Authors contributions Dr Mushtaq chalkoo was the main operating surgeon whileas Dr Shahnawaz ahangar contributed in study design, data collections, analysis and writing. Dr. Aasim Mushtaq Patloo, Dr. Adnan Rashid Matoo, Dr. Faud Sadiq Baqal, and Dr.Sikender Iqbal contributed in data analysis, typesetting and revision. Conflicts of interest None. References 1. Gadacz TR, Talamini MA, Lillemoe KD, Yeo CJ. Laparoscopic cholecystectomy. Surg Clin North Am 1990;70(6):1249e62. 2. Leggett PL, Churchman-Winn R, Miller G. Minimizing ports to improve laparoscopic cholecystectomy. Surg Endosc 2000 Jan;14(1):32e6. 3. Leggett PL, Bissell CD, Churchman-Winn R, Ahn C. Three-port microlaparoscopic cholecystectomy in 159 patients. Surg Endosc 2001 Mar;15(3): 293e6 [Epub 2000 Dec 12]. 4. Saccomani G, Arezzo A, Percivale A, Baldo S, Pellicci R. Laparoscopic cholecystectomy can be performed safely with only three ports in the majority of cases. Chir Ital 2009 SepeDec;61(5e6):613e6. 5. Slim K, Pezet D, Stencl Jr J, Lechner C, Le Roux S, Lointier P, et al. Laparoscopic cholecystectomy: an original three-trocar technique. World J Surg 1995;19(3): 394e7. 6. Leung KF, Lee KW, Cheung TY, Leung LC, Lau KW. Laparoscopic cholecystectomy: two-port technique. Endoscopy 1996 Aug;28(6):505e7. 7. Lee KW, Poon CM, Leung KF, Lee DWH, Ko CW. Two-port needlescopic cholecystectomy: prospective study of 100 cases. Hong Kong Med J 2005 Feb;11(1): 30e5. 8. Cala Z, Niksi c K, Nesek-Adam V, Klapan D, Soldo I. Cosmetic laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A 2006 Dec;16(6): 577e81. 9. Poon C-M, Chan K-W, Ko C-W, Chan K-C, Lee DWH, Cheung H-Y, et al. Two-port laparoscopic cholecystectomy: initial results of a modified technique. J Laparoendosc Adv Surg Tech e Part A 2002;12(4):259e62. 10. Romanelli RJ, Mark L, Omotosho PA. Single port laparoscopic cholecystectomy with the triport system: a case report. Surg Innov 2008 Sep;15(3):223e8. 11. Dominguez G, Durand L, De Rosa J, Danguise E, Arozamena C, Ferraina PA. Retraction and triangulation with neodymium magnetic forceps for single-port laparoscopic cholecystectomy. Surg Endosc 2009 Jul;23(7):1660e6 [Epub 2009 May 5]. 12. Ma J, Cassera MA, Spaun GO, Hammill CW, Hansen PD, Aliabadi-Wahle S. Randomized controlled trial comparing single-port laparoscopic
ORIGINAL RESEARCH 40
M. Chalkoo et al. / International Journal of Surgery 11 (2013) 37e40
cholecystectomy and four-port laparoscopic cholecystectomy. Ann Surg 2011 Jul;254(1):22e7. 13. Solomon D, Bell RL, Duffy AJ, Roberts KE. Single-port cholecystectomy: small scar, short learning curve. Surg Endosc 2010 Dec;24(12):2954e7 [Epub 2010 Apr 17]. 14. Elsey James K, Feliciano David V. Initial experience with single-incision laparoscopic cholecystectomy. J Am Coll Surg 2010 May;210(5):620e4. 624e626.
15. Chandler Nicole M, Danielson Paul D. Single-incision laparoscopic cholecystectomy in children: a retrospective comparison with traditional laparoscopic cholecystectomy. J Pediatr Surg 2011 Sep;46(9):1695e9. 16. Navarra G, Pozza E, Occhionorelli S, Carcoforo P, Donini I. One-wound laparoscopic cholecystectomy. Br J Surg 1997;84(5):695. 17. Kravetz AJ, Iddings D, Basson MD, Kia MA. The learning curve with single-port cholecystectomy. JSLS 2009 JuleSep;13(3):332e6.