Needlescopic clipless cholecystectomy as an efficient, safe, and cost-effective alternative with diminutive scars: the first 1000 cases.
BACKGROUND
The advent of natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS), surgery without skin scarring, is now challenging every surgeon to improve the esthetic results for patients. Minilaparoscopic cholecystectomy (MLC) represents a refinement in laparoscopic surgery, potentially as cosmetically effective as NOTES. Nevertheless, because of the increased cost and difficulty in managing the equipment, it has not been widely accepted among surgeons.


OBJECTIVE
To report modifications of the minilaparoscopic technique that make it possible to conduct needlescopic procedures safely and effectively, thereby, considerably reducing costs and promoting the dissemination of this operation.


METHODS
One thousand consecutive patients who underwent MLC were analyzed, from January 2000 to May 2009 (78.7% women; average age 45.9 y).


METHODS
after performing the pneumoperitoneum at the umbilical site, 4 trocars were inserted; 2 of 2 mm, 1 of 3 mm, and 1 of 10 mm in diameter, through which a laparoscope was inserted. Neither the 3-mm laparoscope, nor clips, nor manufactured endobags were used. The cystic artery was safely sealed by electrocautery near the gallbladder neck and the cystic duct was sealed with surgical knots. Removal of the gallbladder was carried out, in an adapted bag made with a glove wrist, through the 10-mm umbilical site.


RESULTS
The operative time was 43 minutes. The average hospital stay was 16 hours. There was no conversion to open surgery; 2.8% of patients underwent conversion to standard (5 mm) laparoscopic cholecystectomy because of difficulties with the procedure; there were 1.9% minor umbilical site infections and 1.0% umbilical herniations. There was no mortality; no bowel injury, no bile duct injury, and no postoperative hemorrhage, only 1 patient with Luschka's duct bile leakage needed a reoperation.


CONCLUSIONS
The MLC technique shows no differences in risks as compared with other laparoscopic cholecystectomy procedures. It also entails a considerable reduction in cost, and, as it does not use the 3-mm laparoscope or disposable materials, it is possible to perform MLC on a larger number of patients. Owing to the near invisibility of scars, MLC may also be considered as cosmetically effective as NOTES and SILS.
Clínica Cirúrgica, Videolaparoscópica Gustavo Carvalho, Department of Surgery, Faculdade de Ciências Médicas (FCM), Member of SAGES, SOBRACIL, ELSA and Brazilian College of Surgeons (CBC), Universidade de Pernambuco (UPE), Recife, Brazil. glcmd1@gmail.com
Gustavo L
GL
Carvalho
Frederico W
FW
Silva
José Sérgio N
JS
Silva
Pedro Paulo C
PP
de Albuquerque
Raphael de Macedo C
Rde M
Coelho
Thiago G
TG
Vilaça
Cláudio M
CM
Lacerda
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000191:economics / Q000295:instrumentation / Q000379:methods*; D041881:Cholecystitis, Acute / Q000601:surgery*; D002921:Cicatrix / Q000517:prevention & control*; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D012449:Safety; D014481:United States; D055815:Young Adult