Single-fulcrum Laparoscopic Cholecystectomy: A Variant Single-Incision and Multiport Technique

Abstract

Background: Single-port laparoscopic surgery using a natural wound, the umbilicus, has been developed based on accumulated laparoscopic experiences and technique. Because working instruments need different fulcrum points in a narrow incision (umblicus), various types of specialized instruments are generally necessary for performing single-port surgery.1–8

Methods: This technique is a kind of single-incision and multiport technique. However, by using two main working instruments in a single fulcrum point, we can perform single-incision laparoscopic cholecystectomy more effectively without expensive and specialized equipments. After making an incision on the umbilicus, a 10-mm port for the laparoscope was introduced through the upper portion of the wound. A commercialized miniature 5-mm port was inserted through the lower part of incision, and the usual 2-mm port was inserted just below the 5-mm trocar insertion site (these two working ports use the same fulcrum point). Upward and lateral traction of gallbladder was done by applying 2-0 monofilament suture to the fundus percutaneously. With right lateral traction of the gallbladder by a 2-mm grasper, the anterior aspect of Calot's triangle was dissected. After changing the vector of the working port at the single fulcrum, gallbladder was retracted to the left lateral portion to expose the posterior part of Calot's triangle. After isolating and dividing both cystic artery and cystic duct, cholecystectomy was done.

Results: From March 2009 to May 2010, seventy patients underwent this single-fulcrum laparoscopic cholecystectomy. The general characteristics and perioperative outcomes of the patients were summarized. There was no conversion case to conventional laparoscopic cholecystectomy or open surgery. There was no case of drain insertion, complication, or death, even though about 16% of bile spillage was occurred. Cosmetic effect of this single-fulcrum laparoscopic cholecystectomy was similar to the usual one-port technique.

Conclusion: This single-fulcrum laparoscopic cholecystectomy is regarded feasible, safe, and cost effective. Further comparative study between current single-fulcrum laparoscopic cholecystectomy and conventional technique will address the potential benefits of this technique.

The authors would like to express special thanks to Dong-Su Jang (Medical Illustrator, Medical Research Support Section, Yonsei University College of Medicine, Seoul, Korea) for his help with the figures and to Anthony Thomas Milliken (English Editor, Medical Research Support Section, Yonsei University College of Medicine, Seoul, Korea) for comprehensive narration of this multimedia article.