MINILAP CHOLECYSTECTOMY

PROF H KABIR CHOWDHURYDepartment of Surgery

Ibrahim Medical College ampBIRDEM Hospital

DHAKA BANGLADESH

bull Mico-Laparoscopic Cholecystectomybull Mini Laparoscopic Cholecystectomybull Needlescopic Cholecystectomy

A general availability with few access limitations easy applicability with a short learning curve and a superior benefit to cost ratio ensures whether a technique survives for posterity Lastly without direct and substantial benefit to the patient any new technique or technology would ultimately be consigned to the flames of history The final decider obviously is the end consumer or the patient for whose benefit all this is necessitated

GUSTAVO L CARVALHO MD PhD MARCELO P LOUREIRO MD PhD and EDUARDO A BONIN MD MSc Oswaldo Cruz University Hospital and UNIPECLIN Faculty of Medical Sciences University of Pernambuco - Recife and Positivo University - Curitiba Brazil

bull Unlike other new access methods like NOTES and Single port MINI reigns for its simplicity offering increased dexterity delicacy and precision without significantly adding extra costs and at the same time maintains the triangulation that is deemed essential in standard laparoscopy Surgical precision has been always dear to our hearts One wonders whether one should risk losing this for the sake of cosmesis

bull Minilaparoscopy stands out because it uses various diminutive accesses Consequently the potential benefits of MINI would be less volume of parietal injury less total area of tension at the incision and less somatic pain15 16 At the present time Mini instruments are the only ubiquitous instruments that can be used in all current endoscopic techniques including NOTES and single port hybrid techniques Many hybrid techniques are indeed Minilaparoscopy

bull Leonardo Da Vincirsquos quote ldquoSimplicity is the ultimate sophisticationrdquo

Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7Incisions do not simply sum

Blinman T

bull METHODS bull Wounds of various sizes are compared using a simple mathematical model The closing tension perpendicular to any linear incision is a function of the

incisions length varying symmetrically together with a maximum at the midpoint of length If tension rises linearly across an incision integration of the tension relationship demonstrates that the total wound tension actually is proportional to the square of the length In this report incisions of various lengths are modeled and plausible alternative incision scenarios for various procedures (eg Nissen appendectomy) are compared

bull RESULTS bull Total tension rises nonlinearly with increasing wound length Thus total tension across multiple incisions is always less than the total tension for an

incision of the same total length For example an open appendectomy creates 27-fold more wound tension than a laparoscopic appendectomy Similarly two 3-mm trocars create less total tension than a single 5-mm trocar

bull CONCLUSION bull Conventional incisions are subject to more total tension than any combination of trocar incisions of equal total length This inequality yields three

clinically relevant corollaries First it supports the practice of using the smallest effective trocars (or even no-trocar methods) to minimize pain and scar Second addition of a trocar in difficult cases adds relatively little morbidity Finally using two small trocars is better than using a single larger trocar

bull Mico-Laparoscopic Cholecystectomybull Mini Laparoscopic Cholecystectomybull Needlescopic Cholecystectomy

A general availability with few access limitations easy applicability with a short learning curve and a superior benefit to cost ratio ensures whether a technique survives for posterity Lastly without direct and substantial benefit to the patient any new technique or technology would ultimately be consigned to the flames of history The final decider obviously is the end consumer or the patient for whose benefit all this is necessitated

GUSTAVO L CARVALHO MD PhD MARCELO P LOUREIRO MD PhD and EDUARDO A BONIN MD MSc Oswaldo Cruz University Hospital and UNIPECLIN Faculty of Medical Sciences University of Pernambuco - Recife and Positivo University - Curitiba Brazil

bull Unlike other new access methods like NOTES and Single port MINI reigns for its simplicity offering increased dexterity delicacy and precision without significantly adding extra costs and at the same time maintains the triangulation that is deemed essential in standard laparoscopy Surgical precision has been always dear to our hearts One wonders whether one should risk losing this for the sake of cosmesis

bull Minilaparoscopy stands out because it uses various diminutive accesses Consequently the potential benefits of MINI would be less volume of parietal injury less total area of tension at the incision and less somatic pain15 16 At the present time Mini instruments are the only ubiquitous instruments that can be used in all current endoscopic techniques including NOTES and single port hybrid techniques Many hybrid techniques are indeed Minilaparoscopy

bull Leonardo Da Vincirsquos quote ldquoSimplicity is the ultimate sophisticationrdquo

Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7Incisions do not simply sum

Blinman T

bull METHODS bull Wounds of various sizes are compared using a simple mathematical model The closing tension perpendicular to any linear incision is a function of the

incisions length varying symmetrically together with a maximum at the midpoint of length If tension rises linearly across an incision integration of the tension relationship demonstrates that the total wound tension actually is proportional to the square of the length In this report incisions of various lengths are modeled and plausible alternative incision scenarios for various procedures (eg Nissen appendectomy) are compared

bull RESULTS bull Total tension rises nonlinearly with increasing wound length Thus total tension across multiple incisions is always less than the total tension for an

incision of the same total length For example an open appendectomy creates 27-fold more wound tension than a laparoscopic appendectomy Similarly two 3-mm trocars create less total tension than a single 5-mm trocar

bull CONCLUSION bull Conventional incisions are subject to more total tension than any combination of trocar incisions of equal total length This inequality yields three

clinically relevant corollaries First it supports the practice of using the smallest effective trocars (or even no-trocar methods) to minimize pain and scar Second addition of a trocar in difficult cases adds relatively little morbidity Finally using two small trocars is better than using a single larger trocar

A general availability with few access limitations easy applicability with a short learning curve and a superior benefit to cost ratio ensures whether a technique survives for posterity Lastly without direct and substantial benefit to the patient any new technique or technology would ultimately be consigned to the flames of history The final decider obviously is the end consumer or the patient for whose benefit all this is necessitated

GUSTAVO L CARVALHO MD PhD MARCELO P LOUREIRO MD PhD and EDUARDO A BONIN MD MSc Oswaldo Cruz University Hospital and UNIPECLIN Faculty of Medical Sciences University of Pernambuco - Recife and Positivo University - Curitiba Brazil

bull Unlike other new access methods like NOTES and Single port MINI reigns for its simplicity offering increased dexterity delicacy and precision without significantly adding extra costs and at the same time maintains the triangulation that is deemed essential in standard laparoscopy Surgical precision has been always dear to our hearts One wonders whether one should risk losing this for the sake of cosmesis

bull Minilaparoscopy stands out because it uses various diminutive accesses Consequently the potential benefits of MINI would be less volume of parietal injury less total area of tension at the incision and less somatic pain15 16 At the present time Mini instruments are the only ubiquitous instruments that can be used in all current endoscopic techniques including NOTES and single port hybrid techniques Many hybrid techniques are indeed Minilaparoscopy

bull Leonardo Da Vincirsquos quote ldquoSimplicity is the ultimate sophisticationrdquo

Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7Incisions do not simply sum

Blinman T

bull METHODS bull Wounds of various sizes are compared using a simple mathematical model The closing tension perpendicular to any linear incision is a function of the

incisions length varying symmetrically together with a maximum at the midpoint of length If tension rises linearly across an incision integration of the tension relationship demonstrates that the total wound tension actually is proportional to the square of the length In this report incisions of various lengths are modeled and plausible alternative incision scenarios for various procedures (eg Nissen appendectomy) are compared

bull RESULTS bull Total tension rises nonlinearly with increasing wound length Thus total tension across multiple incisions is always less than the total tension for an

incision of the same total length For example an open appendectomy creates 27-fold more wound tension than a laparoscopic appendectomy Similarly two 3-mm trocars create less total tension than a single 5-mm trocar

bull CONCLUSION bull Conventional incisions are subject to more total tension than any combination of trocar incisions of equal total length This inequality yields three

clinically relevant corollaries First it supports the practice of using the smallest effective trocars (or even no-trocar methods) to minimize pain and scar Second addition of a trocar in difficult cases adds relatively little morbidity Finally using two small trocars is better than using a single larger trocar

bull Unlike other new access methods like NOTES and Single port MINI reigns for its simplicity offering increased dexterity delicacy and precision without significantly adding extra costs and at the same time maintains the triangulation that is deemed essential in standard laparoscopy Surgical precision has been always dear to our hearts One wonders whether one should risk losing this for the sake of cosmesis

bull Minilaparoscopy stands out because it uses various diminutive accesses Consequently the potential benefits of MINI would be less volume of parietal injury less total area of tension at the incision and less somatic pain15 16 At the present time Mini instruments are the only ubiquitous instruments that can be used in all current endoscopic techniques including NOTES and single port hybrid techniques Many hybrid techniques are indeed Minilaparoscopy

bull Leonardo Da Vincirsquos quote ldquoSimplicity is the ultimate sophisticationrdquo

Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7Incisions do not simply sum

Blinman T

bull METHODS bull Wounds of various sizes are compared using a simple mathematical model The closing tension perpendicular to any linear incision is a function of the

incisions length varying symmetrically together with a maximum at the midpoint of length If tension rises linearly across an incision integration of the tension relationship demonstrates that the total wound tension actually is proportional to the square of the length In this report incisions of various lengths are modeled and plausible alternative incision scenarios for various procedures (eg Nissen appendectomy) are compared

bull RESULTS bull Total tension rises nonlinearly with increasing wound length Thus total tension across multiple incisions is always less than the total tension for an

incision of the same total length For example an open appendectomy creates 27-fold more wound tension than a laparoscopic appendectomy Similarly two 3-mm trocars create less total tension than a single 5-mm trocar

bull CONCLUSION bull Conventional incisions are subject to more total tension than any combination of trocar incisions of equal total length This inequality yields three

clinically relevant corollaries First it supports the practice of using the smallest effective trocars (or even no-trocar methods) to minimize pain and scar Second addition of a trocar in difficult cases adds relatively little morbidity Finally using two small trocars is better than using a single larger trocar

bull Minilaparoscopy stands out because it uses various diminutive accesses Consequently the potential benefits of MINI would be less volume of parietal injury less total area of tension at the incision and less somatic pain15 16 At the present time Mini instruments are the only ubiquitous instruments that can be used in all current endoscopic techniques including NOTES and single port hybrid techniques Many hybrid techniques are indeed Minilaparoscopy

bull Leonardo Da Vincirsquos quote ldquoSimplicity is the ultimate sophisticationrdquo

Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7Incisions do not simply sum

Blinman T

bull METHODS bull Wounds of various sizes are compared using a simple mathematical model The closing tension perpendicular to any linear incision is a function of the

incisions length varying symmetrically together with a maximum at the midpoint of length If tension rises linearly across an incision integration of the tension relationship demonstrates that the total wound tension actually is proportional to the square of the length In this report incisions of various lengths are modeled and plausible alternative incision scenarios for various procedures (eg Nissen appendectomy) are compared

bull RESULTS bull Total tension rises nonlinearly with increasing wound length Thus total tension across multiple incisions is always less than the total tension for an

incision of the same total length For example an open appendectomy creates 27-fold more wound tension than a laparoscopic appendectomy Similarly two 3-mm trocars create less total tension than a single 5-mm trocar

bull CONCLUSION bull Conventional incisions are subject to more total tension than any combination of trocar incisions of equal total length This inequality yields three

clinically relevant corollaries First it supports the practice of using the smallest effective trocars (or even no-trocar methods) to minimize pain and scar Second addition of a trocar in difficult cases adds relatively little morbidity Finally using two small trocars is better than using a single larger trocar

bull Leonardo Da Vincirsquos quote ldquoSimplicity is the ultimate sophisticationrdquo

Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7Incisions do not simply sum

Blinman T

bull METHODS bull Wounds of various sizes are compared using a simple mathematical model The closing tension perpendicular to any linear incision is a function of the

incisions length varying symmetrically together with a maximum at the midpoint of length If tension rises linearly across an incision integration of the tension relationship demonstrates that the total wound tension actually is proportional to the square of the length In this report incisions of various lengths are modeled and plausible alternative incision scenarios for various procedures (eg Nissen appendectomy) are compared

bull RESULTS bull Total tension rises nonlinearly with increasing wound length Thus total tension across multiple incisions is always less than the total tension for an

incision of the same total length For example an open appendectomy creates 27-fold more wound tension than a laparoscopic appendectomy Similarly two 3-mm trocars create less total tension than a single 5-mm trocar

bull CONCLUSION bull Conventional incisions are subject to more total tension than any combination of trocar incisions of equal total length This inequality yields three

clinically relevant corollaries First it supports the practice of using the smallest effective trocars (or even no-trocar methods) to minimize pain and scar Second addition of a trocar in difficult cases adds relatively little morbidity Finally using two small trocars is better than using a single larger trocar

Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7Incisions do not simply sum

Blinman T

bull METHODS bull Wounds of various sizes are compared using a simple mathematical model The closing tension perpendicular to any linear incision is a function of the

incisions length varying symmetrically together with a maximum at the midpoint of length If tension rises linearly across an incision integration of the tension relationship demonstrates that the total wound tension actually is proportional to the square of the length In this report incisions of various lengths are modeled and plausible alternative incision scenarios for various procedures (eg Nissen appendectomy) are compared

bull RESULTS bull Total tension rises nonlinearly with increasing wound length Thus total tension across multiple incisions is always less than the total tension for an

incision of the same total length For example an open appendectomy creates 27-fold more wound tension than a laparoscopic appendectomy Similarly two 3-mm trocars create less total tension than a single 5-mm trocar

bull CONCLUSION bull Conventional incisions are subject to more total tension than any combination of trocar incisions of equal total length This inequality yields three

clinically relevant corollaries First it supports the practice of using the smallest effective trocars (or even no-trocar methods) to minimize pain and scar Second addition of a trocar in difficult cases adds relatively little morbidity Finally using two small trocars is better than using a single larger trocar

Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site

Surgery (LESS) for Renal SurgeryWeibl P Klingler HC Klatte T Remzi M

SourceDepartment of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria

bull Single port surgery is considered minimally invasive laparoscopy on the other hand when using additional ports it is no more single port but hybrid traditional laparoscopy Whether LESS is a superior or equally technique compared to traditional laparoscopy has to be proven by future prospective randomized trials

bull Like any other new surgical technique MISS surgery will have to pass through two important developmental phases first is the clinical feasibility and safety and the other is suitable technology to perform this technique

bull While media attention may persuade patients to seek out this procedure for an enhanced cosmetic result we must ensure a safe result Although industry will be liked to the development of new procedures and instrumentation surgeons should be the driving force in the development of necessary technology and not vice versa

GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review

Parag W Dhumane Michele Diana Joel Leroy Jacques MarescauxIRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France

bull we believe that the Ultimate form of Minimally Invasive Surgery will be a hybrid form of MISS surgery and Natural Orifice Transluminal Endoscopic Surgery complimented by technological innovations from the fields of robotics and computer-assisted surgery

GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review

Parag W Dhumane Michele Diana Joel Leroy Jacques MarescauxIRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France

bull we believe that the Ultimate form of Minimally Invasive Surgery will be a hybrid form of MISS surgery and Natural Orifice Transluminal Endoscopic Surgery complimented by technological innovations from the fields of robotics and computer-assisted surgery

bull M LOOK SP CHEW YC TAN SE LIEW DMO CHEONG JCH TAN SB WEE CH TEH and CH LOWDepartment of Surgery Tan Tock Seng Hospital Singapore

NC itself is not associated with a higher risk of conversion to open surgery Technical limitations encountered during NC due to the fine instruments can usually be resolved by early conversion to a LC approach rather than struggling with inadequate retraction or exposure In our experience replacement of one or two ports is usually sufficient to complete the operation with little impairment to the postoperative outcome

Two of the three randomised studies from Singapore and Copenhagen found a significant reduction in postoperative pain after needlescopic surgery

However all three trials failed to demonstrate any difference in other objective parameters including operating time hospital stay

The only distinct advantage of adopting needlescopic cholecystectomy is perhaps the better cosmetic results possible and as a result better patient acceptance

M LOOK SP CHEW YC TAN SE LIEW DMO CHEONG JCH TAN SB WEE CH TEH and CH LOWDepartment of Surgery Tan Tock Seng Hospital Singapore

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Patients in the needlescopic group ndash Had less pain (mean visual analogue score 22 versus 36 P lt 0003)

and ndash Had smaller scars (median length 170 versus 250 mm P lt 0001) In

addition patients in the needlescopic group tended to require ndash Fewer intramuscular pethidine injections (P = 005) However ndash Oral analgesic requirements in the two groups were similar ndash There were no complications in either group

ndash Needlescopic cholecystectomy resulted in less postoperative pain and a smaller surgical scar than laparoscopic cholecystectomy in patients with chronic cholecystitis

Cheah WK Department of Surgery National University Hospital

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mini-laparoscopic cholecystectomy was performed in 1009 of 1011 patients

The total operative time was 688 plusmn 319 min

The total hospital stay was 25 plusmn 2 days

One patient (010) underwent conversion hepatic duct laceration

Ten patients (099) major complications including intra-abdominal abscess (1 patient) bile leakage (5 patients) major bile duct injury (2 patients) bowel injury (1 patient) and postoperative hemorrhage (1 patient)

Eleven patients (109) had minor complications including wound infection incisional herniation postoperative ileus and acute urine retention

Minilaparoscopic cholecystectomy is a technically demanding approach Our results indicate that this procedure could be performed successfully and safely by experienced surgical teams

P-C Lee I-R Lai and S-C Yu Department of General Surgery National Taiwan University Hospital and National Taiwan University College of Medicine

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Sixty cholecystectomies were performed using mini-laparoscopy out of a total of 203 video-laparo-cholecystectomies

The benefits of mini-cholecystectomy are potential advantages in improved appearance reduced pain better respiratory function fewer wall complications

Therefore the authors believe that mini-laparoscopy should not be assessed in terms of percentage of use or success but rather considered as a part of the laparoscopic method to be used in selected cases

FAGGIONI A et al Hepato-gastroenterology 1998 vol 45 no22 pp 1014-1015

The operative time ranged from 30 to 256 minutes for the mini-LC group and 25 to 255 minutes for the C-LC group with means of 89 and 82 minutes respectively (P gt 005)

Postoperative length of stay ranged from 0 to 18 days for the mini-LC group and 0 to 21 days for the C-LC group with means of 15 and 19 days respectively (P gt 005)

There were no conversions to open cholecystectomy

These data suggest that a more minimalist approach to laparoscopic cholecystectomy can be accomplished safely and effectively

Reardon PR et al J Laparoendosc Adv Surg Tech A 1999 Aug9(4)373

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

The level of postoperative pain was lower in the MLC group (p lt 0001)

More patients in the MLC group expressed satisfaction with the cosmetic result (p lt 005)

MLC was shown to be feasible in uncomplicated situations

Randomized studies are still needed to confirm these findings

Surgical Endoscopy Volume 15 Number 6 June 2001 614-618L Sarli R Costi G Sansebastiano

Journal of Minimal Access SurgerySingle-incision laparoscopic surgery

Alfred Cuschieri

bull However there are a number of important issues which need to be addressed before we can confirm with good evidence that this variant laparoscopic approach does indeed benefit the patient Thus aside from reduction of visible scars the jury remains out on whether SILS does indeed reduce postoperative pain and adhesion formation Likewise the contraindications to SILS have yet to be clarified and defined There is one potential area of concern and this relates to an increased risk of incisional periumbilical hernia formation The extent of this perceived complication will only be established by prospective cohort or randomised studies and longer follow-up Meantime we need to ensure that these umbilical wounds are closed with a meticulous technique using non-absorbable material

bull Even with the best instrumentation currently available the SILS approach imposes restrictions on instrument manipulation retraction and limits triangulation

Michel GagnerMount Senai Medical center Florida

Journal of Gastrointest SurgeryJuly 2010

bull Needlescopic instruments are often added to complement the surgical task during SILS

bull Needlescopic instruments permits triangulation in surgical complex task during SILS procedure

bull The scar after needlescopic surgery is very negligible and non-existent after 12 months achieving similar cosmetic result to SILS even better

bull Due to higher trauma to the periumbilical are the pain may be more in SILS

bull Long term herniation risk in the peri umbilical area is more n SILS

bull Mesh repair of this hernia will prevent another SILS for the same patient

ANZ J Surg 2009 Jun79(6)437-42Needlescopic versus laparoscopic cholecystectomy a meta-analysis

Sajid MS Khan MA Ray K Cheek E Baig MKDepartment of Colorectal Surgery Worthing Hospital Worthing West Sussex UK

bull Sixteen trials on NC versus LC encompassing 1549 patients were retrieved from electronic databases

bull NC was superior to LC in terms of less post-operative pain and better cosmetic outcomes

Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy

Chow A Purkayastha S Aziz O Pefanis D Paraskeva PSource

Department of Biosurgery and Surgical Technology Imperial College London England

bull Operative time was longer with SILS for cholecystectomy compared with conventional laparoscopic cholecystectomy (P lt 001) A correlation was seen between reducing SILS operative time and increasing experience (Spearman rank correlation coefficient -029) Three patients in the SILS for cholecystectomy group required the addition of extra laparoscopic ports No patients in the SILS for cholecystectomy group required conversion to open surgery compared with 4 patients in the standard laparoscopic cholecystectomy group Patients stayed an average of 076 days following SILS for cholecystectomy and 153 days following conventional laparoscopic cholecystectomy One patient in each group had a postoperative biliary leak

Laparoscopic versus single-incision cholecystectomyKhambaty F Brody F Vaziri K Edwards C

SourceDepartment of Surgery The George Washington University Medical Center 2150 Pennsylvania

Avenue NW Suite 6B Washington DC 20037 USA

bull The data suggests that individuals with a BMI over 33 may not be candidates for single-incision cholecystectomy Those patients that undergo a successful single-incision laparoscopic cholecystectomy require fewer narcotics postoperatively and have a shorter LOS Although this data is intriguing the overall utility of single-incision procedures requires more analysis and potentially randomized trials

Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy

Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S

SourceFrom the Hepatobiliary and Pancreatic Surgery Program Providence Portland

Medical Center Portland ORbull SPLC procedure time was longer and incurred

more complications than CLC without significant benefits in patient satisfaction postoperative pain and QOL SPLC may be offered in carefully selected patients Larger randomized trials performed later in the learning curve with SPLC may identify more subtle advantages of one method over another

bull World J Surg 2011 May35(5)967-72bull

Is Smaller Actually BetterNeedlescopic Surgery mdash A Step

Towards (Virtually)Incisionless Surgery

Andrei Nadu 1Department of Urology Sheba Medical

Center Tel-Hashomer 52621 Israel

bull Needlescopic surgery performed with 2- andbull 3-mm instruments represents a further refinementbull of laparoscopic surgery Several authors havebull demonstrated the feasibility and safety of variousbull needlescopic proceduresbull The 2- and 3-mm ports are virtually incisionless andbull do not necessitate suturing (adhesive tape is sufficient)bull and the consequent scars are almost invisiblebull understandably encouraging surgeons at selectedbull centers to consider needlescopy or minilaparoscopybull as the next logical step in the evolution ofminimallybull invasive surgery

Surgeons Philoshophybull Advancements in laparoscopic surgery is it properly

directedbull Only 15 of the world population live in developed

countriesbull Advancements requiring high skill intensive training and

expensive facilities are for whombull Medical education and training of a surgeon in the

developing and under developed countries needs to be addressed

bull Surgical techniques supply and delivery needs to be cost effective

bull Should only the poor should think about cost effectiveness and developed countries go on wasting the resources

bull We should not run for innovations which do not help the majority

bull Surgeon while working should be comfortable and enjoy what he is doing

bull If only increased noise can increase SSI then a diffifult procedure may cause many problems which need to be addressed

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Since the beginning of lap chole making it more comfortable and more cosmetic never stopped

bull With a little addition to the standard instruments we started mini lap chole in 1995 by making 5 mm port in place of 10 mm epigastric port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Techniquebull Since 1998 we are doing modified Needlescopic Cholecystectomy

where umbilical port is 10 mm and three other ports are 3 mm

bull Clips are used through the umbilical port under the vision of a 2 mm scope from the epigastric port

bull Gallbladder is delivered through the umbilical port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Since 1993 till Sept 2006 about 14000 cases of Laparoscopic Cholecystectomy was done by the author Among which 5600 cases are Needlescopic

Conversion bull to 5 mm port was done in 55 casesbull to standard lap chole was 15bull to open chole was less then 1

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Two of the three randomised studies from Singapore and Copenhagen found a significant reduction in postoperative pain after needlescopic surgery

However all three trials failed to demonstrate any difference in other objective parameters including operating time hospital stay

The only distinct advantage of adopting needlescopic cholecystectomy is perhaps the better cosmetic results possible and as a result better patient acceptance

M LOOK SP CHEW YC TAN SE LIEW DMO CHEONG JCH TAN SB WEE CH TEH and CH LOWDepartment of Surgery Tan Tock Seng Hospital Singapore

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Patients in the needlescopic group ndash Had less pain (mean visual analogue score 22 versus 36 P lt 0003)

and ndash Had smaller scars (median length 170 versus 250 mm P lt 0001) In

addition patients in the needlescopic group tended to require ndash Fewer intramuscular pethidine injections (P = 005) However ndash Oral analgesic requirements in the two groups were similar ndash There were no complications in either group

ndash Needlescopic cholecystectomy resulted in less postoperative pain and a smaller surgical scar than laparoscopic cholecystectomy in patients with chronic cholecystitis

Cheah WK Department of Surgery National University Hospital

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mini-laparoscopic cholecystectomy was performed in 1009 of 1011 patients

The total operative time was 688 plusmn 319 min

The total hospital stay was 25 plusmn 2 days

One patient (010) underwent conversion hepatic duct laceration

Ten patients (099) major complications including intra-abdominal abscess (1 patient) bile leakage (5 patients) major bile duct injury (2 patients) bowel injury (1 patient) and postoperative hemorrhage (1 patient)

Eleven patients (109) had minor complications including wound infection incisional herniation postoperative ileus and acute urine retention

Minilaparoscopic cholecystectomy is a technically demanding approach Our results indicate that this procedure could be performed successfully and safely by experienced surgical teams

P-C Lee I-R Lai and S-C Yu Department of General Surgery National Taiwan University Hospital and National Taiwan University College of Medicine

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Sixty cholecystectomies were performed using mini-laparoscopy out of a total of 203 video-laparo-cholecystectomies

The benefits of mini-cholecystectomy are potential advantages in improved appearance reduced pain better respiratory function fewer wall complications

Therefore the authors believe that mini-laparoscopy should not be assessed in terms of percentage of use or success but rather considered as a part of the laparoscopic method to be used in selected cases

FAGGIONI A et al Hepato-gastroenterology 1998 vol 45 no22 pp 1014-1015

The operative time ranged from 30 to 256 minutes for the mini-LC group and 25 to 255 minutes for the C-LC group with means of 89 and 82 minutes respectively (P gt 005)

Postoperative length of stay ranged from 0 to 18 days for the mini-LC group and 0 to 21 days for the C-LC group with means of 15 and 19 days respectively (P gt 005)

There were no conversions to open cholecystectomy

These data suggest that a more minimalist approach to laparoscopic cholecystectomy can be accomplished safely and effectively

Reardon PR et al J Laparoendosc Adv Surg Tech A 1999 Aug9(4)373

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

The level of postoperative pain was lower in the MLC group (p lt 0001)

More patients in the MLC group expressed satisfaction with the cosmetic result (p lt 005)

MLC was shown to be feasible in uncomplicated situations

Randomized studies are still needed to confirm these findings

Surgical Endoscopy Volume 15 Number 6 June 2001 614-618L Sarli R Costi G Sansebastiano

Journal of Minimal Access SurgerySingle-incision laparoscopic surgery

Alfred Cuschieri

bull However there are a number of important issues which need to be addressed before we can confirm with good evidence that this variant laparoscopic approach does indeed benefit the patient Thus aside from reduction of visible scars the jury remains out on whether SILS does indeed reduce postoperative pain and adhesion formation Likewise the contraindications to SILS have yet to be clarified and defined There is one potential area of concern and this relates to an increased risk of incisional periumbilical hernia formation The extent of this perceived complication will only be established by prospective cohort or randomised studies and longer follow-up Meantime we need to ensure that these umbilical wounds are closed with a meticulous technique using non-absorbable material

bull Even with the best instrumentation currently available the SILS approach imposes restrictions on instrument manipulation retraction and limits triangulation

Michel GagnerMount Senai Medical center Florida

Journal of Gastrointest SurgeryJuly 2010

bull Needlescopic instruments are often added to complement the surgical task during SILS

bull Needlescopic instruments permits triangulation in surgical complex task during SILS procedure

bull The scar after needlescopic surgery is very negligible and non-existent after 12 months achieving similar cosmetic result to SILS even better

bull Due to higher trauma to the periumbilical are the pain may be more in SILS

bull Long term herniation risk in the peri umbilical area is more n SILS

bull Mesh repair of this hernia will prevent another SILS for the same patient

ANZ J Surg 2009 Jun79(6)437-42Needlescopic versus laparoscopic cholecystectomy a meta-analysis

Sajid MS Khan MA Ray K Cheek E Baig MKDepartment of Colorectal Surgery Worthing Hospital Worthing West Sussex UK

bull Sixteen trials on NC versus LC encompassing 1549 patients were retrieved from electronic databases

bull NC was superior to LC in terms of less post-operative pain and better cosmetic outcomes

Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy

Chow A Purkayastha S Aziz O Pefanis D Paraskeva PSource

Department of Biosurgery and Surgical Technology Imperial College London England

bull Operative time was longer with SILS for cholecystectomy compared with conventional laparoscopic cholecystectomy (P lt 001) A correlation was seen between reducing SILS operative time and increasing experience (Spearman rank correlation coefficient -029) Three patients in the SILS for cholecystectomy group required the addition of extra laparoscopic ports No patients in the SILS for cholecystectomy group required conversion to open surgery compared with 4 patients in the standard laparoscopic cholecystectomy group Patients stayed an average of 076 days following SILS for cholecystectomy and 153 days following conventional laparoscopic cholecystectomy One patient in each group had a postoperative biliary leak

Laparoscopic versus single-incision cholecystectomyKhambaty F Brody F Vaziri K Edwards C

SourceDepartment of Surgery The George Washington University Medical Center 2150 Pennsylvania

Avenue NW Suite 6B Washington DC 20037 USA

bull The data suggests that individuals with a BMI over 33 may not be candidates for single-incision cholecystectomy Those patients that undergo a successful single-incision laparoscopic cholecystectomy require fewer narcotics postoperatively and have a shorter LOS Although this data is intriguing the overall utility of single-incision procedures requires more analysis and potentially randomized trials

Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy

Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S

SourceFrom the Hepatobiliary and Pancreatic Surgery Program Providence Portland

Medical Center Portland ORbull SPLC procedure time was longer and incurred

more complications than CLC without significant benefits in patient satisfaction postoperative pain and QOL SPLC may be offered in carefully selected patients Larger randomized trials performed later in the learning curve with SPLC may identify more subtle advantages of one method over another

bull World J Surg 2011 May35(5)967-72bull

Is Smaller Actually BetterNeedlescopic Surgery mdash A Step

Towards (Virtually)Incisionless Surgery

Andrei Nadu 1Department of Urology Sheba Medical

Center Tel-Hashomer 52621 Israel

bull Needlescopic surgery performed with 2- andbull 3-mm instruments represents a further refinementbull of laparoscopic surgery Several authors havebull demonstrated the feasibility and safety of variousbull needlescopic proceduresbull The 2- and 3-mm ports are virtually incisionless andbull do not necessitate suturing (adhesive tape is sufficient)bull and the consequent scars are almost invisiblebull understandably encouraging surgeons at selectedbull centers to consider needlescopy or minilaparoscopybull as the next logical step in the evolution ofminimallybull invasive surgery

Surgeons Philoshophybull Advancements in laparoscopic surgery is it properly

directedbull Only 15 of the world population live in developed

countriesbull Advancements requiring high skill intensive training and

expensive facilities are for whombull Medical education and training of a surgeon in the

developing and under developed countries needs to be addressed

bull Surgical techniques supply and delivery needs to be cost effective

bull Should only the poor should think about cost effectiveness and developed countries go on wasting the resources

bull We should not run for innovations which do not help the majority

bull Surgeon while working should be comfortable and enjoy what he is doing

bull If only increased noise can increase SSI then a diffifult procedure may cause many problems which need to be addressed

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Since the beginning of lap chole making it more comfortable and more cosmetic never stopped

bull With a little addition to the standard instruments we started mini lap chole in 1995 by making 5 mm port in place of 10 mm epigastric port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Techniquebull Since 1998 we are doing modified Needlescopic Cholecystectomy

where umbilical port is 10 mm and three other ports are 3 mm

bull Clips are used through the umbilical port under the vision of a 2 mm scope from the epigastric port

bull Gallbladder is delivered through the umbilical port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Since 1993 till Sept 2006 about 14000 cases of Laparoscopic Cholecystectomy was done by the author Among which 5600 cases are Needlescopic

Conversion bull to 5 mm port was done in 55 casesbull to standard lap chole was 15bull to open chole was less then 1

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Patients in the needlescopic group ndash Had less pain (mean visual analogue score 22 versus 36 P lt 0003)

and ndash Had smaller scars (median length 170 versus 250 mm P lt 0001) In

addition patients in the needlescopic group tended to require ndash Fewer intramuscular pethidine injections (P = 005) However ndash Oral analgesic requirements in the two groups were similar ndash There were no complications in either group

ndash Needlescopic cholecystectomy resulted in less postoperative pain and a smaller surgical scar than laparoscopic cholecystectomy in patients with chronic cholecystitis

Cheah WK Department of Surgery National University Hospital

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mini-laparoscopic cholecystectomy was performed in 1009 of 1011 patients

The total operative time was 688 plusmn 319 min

The total hospital stay was 25 plusmn 2 days

One patient (010) underwent conversion hepatic duct laceration

Ten patients (099) major complications including intra-abdominal abscess (1 patient) bile leakage (5 patients) major bile duct injury (2 patients) bowel injury (1 patient) and postoperative hemorrhage (1 patient)

Eleven patients (109) had minor complications including wound infection incisional herniation postoperative ileus and acute urine retention

Minilaparoscopic cholecystectomy is a technically demanding approach Our results indicate that this procedure could be performed successfully and safely by experienced surgical teams

P-C Lee I-R Lai and S-C Yu Department of General Surgery National Taiwan University Hospital and National Taiwan University College of Medicine

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Sixty cholecystectomies were performed using mini-laparoscopy out of a total of 203 video-laparo-cholecystectomies

The benefits of mini-cholecystectomy are potential advantages in improved appearance reduced pain better respiratory function fewer wall complications

Therefore the authors believe that mini-laparoscopy should not be assessed in terms of percentage of use or success but rather considered as a part of the laparoscopic method to be used in selected cases

FAGGIONI A et al Hepato-gastroenterology 1998 vol 45 no22 pp 1014-1015

The operative time ranged from 30 to 256 minutes for the mini-LC group and 25 to 255 minutes for the C-LC group with means of 89 and 82 minutes respectively (P gt 005)

Postoperative length of stay ranged from 0 to 18 days for the mini-LC group and 0 to 21 days for the C-LC group with means of 15 and 19 days respectively (P gt 005)

There were no conversions to open cholecystectomy

These data suggest that a more minimalist approach to laparoscopic cholecystectomy can be accomplished safely and effectively

Reardon PR et al J Laparoendosc Adv Surg Tech A 1999 Aug9(4)373

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

The level of postoperative pain was lower in the MLC group (p lt 0001)

More patients in the MLC group expressed satisfaction with the cosmetic result (p lt 005)

MLC was shown to be feasible in uncomplicated situations

Randomized studies are still needed to confirm these findings

Surgical Endoscopy Volume 15 Number 6 June 2001 614-618L Sarli R Costi G Sansebastiano

Journal of Minimal Access SurgerySingle-incision laparoscopic surgery

Alfred Cuschieri

bull However there are a number of important issues which need to be addressed before we can confirm with good evidence that this variant laparoscopic approach does indeed benefit the patient Thus aside from reduction of visible scars the jury remains out on whether SILS does indeed reduce postoperative pain and adhesion formation Likewise the contraindications to SILS have yet to be clarified and defined There is one potential area of concern and this relates to an increased risk of incisional periumbilical hernia formation The extent of this perceived complication will only be established by prospective cohort or randomised studies and longer follow-up Meantime we need to ensure that these umbilical wounds are closed with a meticulous technique using non-absorbable material

bull Even with the best instrumentation currently available the SILS approach imposes restrictions on instrument manipulation retraction and limits triangulation

Michel GagnerMount Senai Medical center Florida

Journal of Gastrointest SurgeryJuly 2010

bull Needlescopic instruments are often added to complement the surgical task during SILS

bull Needlescopic instruments permits triangulation in surgical complex task during SILS procedure

bull The scar after needlescopic surgery is very negligible and non-existent after 12 months achieving similar cosmetic result to SILS even better

bull Due to higher trauma to the periumbilical are the pain may be more in SILS

bull Long term herniation risk in the peri umbilical area is more n SILS

bull Mesh repair of this hernia will prevent another SILS for the same patient

ANZ J Surg 2009 Jun79(6)437-42Needlescopic versus laparoscopic cholecystectomy a meta-analysis

Sajid MS Khan MA Ray K Cheek E Baig MKDepartment of Colorectal Surgery Worthing Hospital Worthing West Sussex UK

bull Sixteen trials on NC versus LC encompassing 1549 patients were retrieved from electronic databases

bull NC was superior to LC in terms of less post-operative pain and better cosmetic outcomes

Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy

Chow A Purkayastha S Aziz O Pefanis D Paraskeva PSource

Department of Biosurgery and Surgical Technology Imperial College London England

bull Operative time was longer with SILS for cholecystectomy compared with conventional laparoscopic cholecystectomy (P lt 001) A correlation was seen between reducing SILS operative time and increasing experience (Spearman rank correlation coefficient -029) Three patients in the SILS for cholecystectomy group required the addition of extra laparoscopic ports No patients in the SILS for cholecystectomy group required conversion to open surgery compared with 4 patients in the standard laparoscopic cholecystectomy group Patients stayed an average of 076 days following SILS for cholecystectomy and 153 days following conventional laparoscopic cholecystectomy One patient in each group had a postoperative biliary leak

Laparoscopic versus single-incision cholecystectomyKhambaty F Brody F Vaziri K Edwards C

SourceDepartment of Surgery The George Washington University Medical Center 2150 Pennsylvania

Avenue NW Suite 6B Washington DC 20037 USA

bull The data suggests that individuals with a BMI over 33 may not be candidates for single-incision cholecystectomy Those patients that undergo a successful single-incision laparoscopic cholecystectomy require fewer narcotics postoperatively and have a shorter LOS Although this data is intriguing the overall utility of single-incision procedures requires more analysis and potentially randomized trials

Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy

Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S

SourceFrom the Hepatobiliary and Pancreatic Surgery Program Providence Portland

Medical Center Portland ORbull SPLC procedure time was longer and incurred

more complications than CLC without significant benefits in patient satisfaction postoperative pain and QOL SPLC may be offered in carefully selected patients Larger randomized trials performed later in the learning curve with SPLC may identify more subtle advantages of one method over another

bull World J Surg 2011 May35(5)967-72bull

Is Smaller Actually BetterNeedlescopic Surgery mdash A Step

Towards (Virtually)Incisionless Surgery

Andrei Nadu 1Department of Urology Sheba Medical

Center Tel-Hashomer 52621 Israel

bull Needlescopic surgery performed with 2- andbull 3-mm instruments represents a further refinementbull of laparoscopic surgery Several authors havebull demonstrated the feasibility and safety of variousbull needlescopic proceduresbull The 2- and 3-mm ports are virtually incisionless andbull do not necessitate suturing (adhesive tape is sufficient)bull and the consequent scars are almost invisiblebull understandably encouraging surgeons at selectedbull centers to consider needlescopy or minilaparoscopybull as the next logical step in the evolution ofminimallybull invasive surgery

Surgeons Philoshophybull Advancements in laparoscopic surgery is it properly

directedbull Only 15 of the world population live in developed

countriesbull Advancements requiring high skill intensive training and

expensive facilities are for whombull Medical education and training of a surgeon in the

developing and under developed countries needs to be addressed

bull Surgical techniques supply and delivery needs to be cost effective

bull Should only the poor should think about cost effectiveness and developed countries go on wasting the resources

bull We should not run for innovations which do not help the majority

bull Surgeon while working should be comfortable and enjoy what he is doing

bull If only increased noise can increase SSI then a diffifult procedure may cause many problems which need to be addressed

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Since the beginning of lap chole making it more comfortable and more cosmetic never stopped

bull With a little addition to the standard instruments we started mini lap chole in 1995 by making 5 mm port in place of 10 mm epigastric port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Techniquebull Since 1998 we are doing modified Needlescopic Cholecystectomy

where umbilical port is 10 mm and three other ports are 3 mm

bull Clips are used through the umbilical port under the vision of a 2 mm scope from the epigastric port

bull Gallbladder is delivered through the umbilical port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Since 1993 till Sept 2006 about 14000 cases of Laparoscopic Cholecystectomy was done by the author Among which 5600 cases are Needlescopic

Conversion bull to 5 mm port was done in 55 casesbull to standard lap chole was 15bull to open chole was less then 1

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mini-laparoscopic cholecystectomy was performed in 1009 of 1011 patients

The total operative time was 688 plusmn 319 min

The total hospital stay was 25 plusmn 2 days

One patient (010) underwent conversion hepatic duct laceration

Ten patients (099) major complications including intra-abdominal abscess (1 patient) bile leakage (5 patients) major bile duct injury (2 patients) bowel injury (1 patient) and postoperative hemorrhage (1 patient)

Eleven patients (109) had minor complications including wound infection incisional herniation postoperative ileus and acute urine retention

Minilaparoscopic cholecystectomy is a technically demanding approach Our results indicate that this procedure could be performed successfully and safely by experienced surgical teams

P-C Lee I-R Lai and S-C Yu Department of General Surgery National Taiwan University Hospital and National Taiwan University College of Medicine

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Sixty cholecystectomies were performed using mini-laparoscopy out of a total of 203 video-laparo-cholecystectomies

The benefits of mini-cholecystectomy are potential advantages in improved appearance reduced pain better respiratory function fewer wall complications

Therefore the authors believe that mini-laparoscopy should not be assessed in terms of percentage of use or success but rather considered as a part of the laparoscopic method to be used in selected cases

FAGGIONI A et al Hepato-gastroenterology 1998 vol 45 no22 pp 1014-1015

The operative time ranged from 30 to 256 minutes for the mini-LC group and 25 to 255 minutes for the C-LC group with means of 89 and 82 minutes respectively (P gt 005)

Postoperative length of stay ranged from 0 to 18 days for the mini-LC group and 0 to 21 days for the C-LC group with means of 15 and 19 days respectively (P gt 005)

There were no conversions to open cholecystectomy

These data suggest that a more minimalist approach to laparoscopic cholecystectomy can be accomplished safely and effectively

Reardon PR et al J Laparoendosc Adv Surg Tech A 1999 Aug9(4)373

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

The level of postoperative pain was lower in the MLC group (p lt 0001)

More patients in the MLC group expressed satisfaction with the cosmetic result (p lt 005)

MLC was shown to be feasible in uncomplicated situations

Randomized studies are still needed to confirm these findings

Surgical Endoscopy Volume 15 Number 6 June 2001 614-618L Sarli R Costi G Sansebastiano

Journal of Minimal Access SurgerySingle-incision laparoscopic surgery

Alfred Cuschieri

bull However there are a number of important issues which need to be addressed before we can confirm with good evidence that this variant laparoscopic approach does indeed benefit the patient Thus aside from reduction of visible scars the jury remains out on whether SILS does indeed reduce postoperative pain and adhesion formation Likewise the contraindications to SILS have yet to be clarified and defined There is one potential area of concern and this relates to an increased risk of incisional periumbilical hernia formation The extent of this perceived complication will only be established by prospective cohort or randomised studies and longer follow-up Meantime we need to ensure that these umbilical wounds are closed with a meticulous technique using non-absorbable material

bull Even with the best instrumentation currently available the SILS approach imposes restrictions on instrument manipulation retraction and limits triangulation

Michel GagnerMount Senai Medical center Florida

Journal of Gastrointest SurgeryJuly 2010

bull Needlescopic instruments are often added to complement the surgical task during SILS

bull Needlescopic instruments permits triangulation in surgical complex task during SILS procedure

bull The scar after needlescopic surgery is very negligible and non-existent after 12 months achieving similar cosmetic result to SILS even better

bull Due to higher trauma to the periumbilical are the pain may be more in SILS

bull Long term herniation risk in the peri umbilical area is more n SILS

bull Mesh repair of this hernia will prevent another SILS for the same patient

ANZ J Surg 2009 Jun79(6)437-42Needlescopic versus laparoscopic cholecystectomy a meta-analysis

Sajid MS Khan MA Ray K Cheek E Baig MKDepartment of Colorectal Surgery Worthing Hospital Worthing West Sussex UK

bull Sixteen trials on NC versus LC encompassing 1549 patients were retrieved from electronic databases

bull NC was superior to LC in terms of less post-operative pain and better cosmetic outcomes

Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy

Chow A Purkayastha S Aziz O Pefanis D Paraskeva PSource

Department of Biosurgery and Surgical Technology Imperial College London England

bull Operative time was longer with SILS for cholecystectomy compared with conventional laparoscopic cholecystectomy (P lt 001) A correlation was seen between reducing SILS operative time and increasing experience (Spearman rank correlation coefficient -029) Three patients in the SILS for cholecystectomy group required the addition of extra laparoscopic ports No patients in the SILS for cholecystectomy group required conversion to open surgery compared with 4 patients in the standard laparoscopic cholecystectomy group Patients stayed an average of 076 days following SILS for cholecystectomy and 153 days following conventional laparoscopic cholecystectomy One patient in each group had a postoperative biliary leak

Laparoscopic versus single-incision cholecystectomyKhambaty F Brody F Vaziri K Edwards C

SourceDepartment of Surgery The George Washington University Medical Center 2150 Pennsylvania

Avenue NW Suite 6B Washington DC 20037 USA

bull The data suggests that individuals with a BMI over 33 may not be candidates for single-incision cholecystectomy Those patients that undergo a successful single-incision laparoscopic cholecystectomy require fewer narcotics postoperatively and have a shorter LOS Although this data is intriguing the overall utility of single-incision procedures requires more analysis and potentially randomized trials

Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy

Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S

SourceFrom the Hepatobiliary and Pancreatic Surgery Program Providence Portland

Medical Center Portland ORbull SPLC procedure time was longer and incurred

more complications than CLC without significant benefits in patient satisfaction postoperative pain and QOL SPLC may be offered in carefully selected patients Larger randomized trials performed later in the learning curve with SPLC may identify more subtle advantages of one method over another

bull World J Surg 2011 May35(5)967-72bull

Is Smaller Actually BetterNeedlescopic Surgery mdash A Step

Towards (Virtually)Incisionless Surgery

Andrei Nadu 1Department of Urology Sheba Medical

Center Tel-Hashomer 52621 Israel

bull Needlescopic surgery performed with 2- andbull 3-mm instruments represents a further refinementbull of laparoscopic surgery Several authors havebull demonstrated the feasibility and safety of variousbull needlescopic proceduresbull The 2- and 3-mm ports are virtually incisionless andbull do not necessitate suturing (adhesive tape is sufficient)bull and the consequent scars are almost invisiblebull understandably encouraging surgeons at selectedbull centers to consider needlescopy or minilaparoscopybull as the next logical step in the evolution ofminimallybull invasive surgery

Surgeons Philoshophybull Advancements in laparoscopic surgery is it properly

directedbull Only 15 of the world population live in developed

countriesbull Advancements requiring high skill intensive training and

expensive facilities are for whombull Medical education and training of a surgeon in the

developing and under developed countries needs to be addressed

bull Surgical techniques supply and delivery needs to be cost effective

bull Should only the poor should think about cost effectiveness and developed countries go on wasting the resources

bull We should not run for innovations which do not help the majority

bull Surgeon while working should be comfortable and enjoy what he is doing

bull If only increased noise can increase SSI then a diffifult procedure may cause many problems which need to be addressed

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Since the beginning of lap chole making it more comfortable and more cosmetic never stopped

bull With a little addition to the standard instruments we started mini lap chole in 1995 by making 5 mm port in place of 10 mm epigastric port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Techniquebull Since 1998 we are doing modified Needlescopic Cholecystectomy

where umbilical port is 10 mm and three other ports are 3 mm

bull Clips are used through the umbilical port under the vision of a 2 mm scope from the epigastric port

bull Gallbladder is delivered through the umbilical port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Since 1993 till Sept 2006 about 14000 cases of Laparoscopic Cholecystectomy was done by the author Among which 5600 cases are Needlescopic

Conversion bull to 5 mm port was done in 55 casesbull to standard lap chole was 15bull to open chole was less then 1

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Sixty cholecystectomies were performed using mini-laparoscopy out of a total of 203 video-laparo-cholecystectomies

The benefits of mini-cholecystectomy are potential advantages in improved appearance reduced pain better respiratory function fewer wall complications

Therefore the authors believe that mini-laparoscopy should not be assessed in terms of percentage of use or success but rather considered as a part of the laparoscopic method to be used in selected cases

FAGGIONI A et al Hepato-gastroenterology 1998 vol 45 no22 pp 1014-1015

The operative time ranged from 30 to 256 minutes for the mini-LC group and 25 to 255 minutes for the C-LC group with means of 89 and 82 minutes respectively (P gt 005)

Postoperative length of stay ranged from 0 to 18 days for the mini-LC group and 0 to 21 days for the C-LC group with means of 15 and 19 days respectively (P gt 005)

There were no conversions to open cholecystectomy

These data suggest that a more minimalist approach to laparoscopic cholecystectomy can be accomplished safely and effectively

Reardon PR et al J Laparoendosc Adv Surg Tech A 1999 Aug9(4)373

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

The level of postoperative pain was lower in the MLC group (p lt 0001)

More patients in the MLC group expressed satisfaction with the cosmetic result (p lt 005)

MLC was shown to be feasible in uncomplicated situations

Randomized studies are still needed to confirm these findings

Surgical Endoscopy Volume 15 Number 6 June 2001 614-618L Sarli R Costi G Sansebastiano

Journal of Minimal Access SurgerySingle-incision laparoscopic surgery

Alfred Cuschieri

bull However there are a number of important issues which need to be addressed before we can confirm with good evidence that this variant laparoscopic approach does indeed benefit the patient Thus aside from reduction of visible scars the jury remains out on whether SILS does indeed reduce postoperative pain and adhesion formation Likewise the contraindications to SILS have yet to be clarified and defined There is one potential area of concern and this relates to an increased risk of incisional periumbilical hernia formation The extent of this perceived complication will only be established by prospective cohort or randomised studies and longer follow-up Meantime we need to ensure that these umbilical wounds are closed with a meticulous technique using non-absorbable material

bull Even with the best instrumentation currently available the SILS approach imposes restrictions on instrument manipulation retraction and limits triangulation

Michel GagnerMount Senai Medical center Florida

Journal of Gastrointest SurgeryJuly 2010

bull Needlescopic instruments are often added to complement the surgical task during SILS

bull Needlescopic instruments permits triangulation in surgical complex task during SILS procedure

bull The scar after needlescopic surgery is very negligible and non-existent after 12 months achieving similar cosmetic result to SILS even better

bull Due to higher trauma to the periumbilical are the pain may be more in SILS

bull Long term herniation risk in the peri umbilical area is more n SILS

bull Mesh repair of this hernia will prevent another SILS for the same patient

ANZ J Surg 2009 Jun79(6)437-42Needlescopic versus laparoscopic cholecystectomy a meta-analysis

Sajid MS Khan MA Ray K Cheek E Baig MKDepartment of Colorectal Surgery Worthing Hospital Worthing West Sussex UK

bull Sixteen trials on NC versus LC encompassing 1549 patients were retrieved from electronic databases

bull NC was superior to LC in terms of less post-operative pain and better cosmetic outcomes

Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy

Chow A Purkayastha S Aziz O Pefanis D Paraskeva PSource

Department of Biosurgery and Surgical Technology Imperial College London England

bull Operative time was longer with SILS for cholecystectomy compared with conventional laparoscopic cholecystectomy (P lt 001) A correlation was seen between reducing SILS operative time and increasing experience (Spearman rank correlation coefficient -029) Three patients in the SILS for cholecystectomy group required the addition of extra laparoscopic ports No patients in the SILS for cholecystectomy group required conversion to open surgery compared with 4 patients in the standard laparoscopic cholecystectomy group Patients stayed an average of 076 days following SILS for cholecystectomy and 153 days following conventional laparoscopic cholecystectomy One patient in each group had a postoperative biliary leak

Laparoscopic versus single-incision cholecystectomyKhambaty F Brody F Vaziri K Edwards C

SourceDepartment of Surgery The George Washington University Medical Center 2150 Pennsylvania

Avenue NW Suite 6B Washington DC 20037 USA

bull The data suggests that individuals with a BMI over 33 may not be candidates for single-incision cholecystectomy Those patients that undergo a successful single-incision laparoscopic cholecystectomy require fewer narcotics postoperatively and have a shorter LOS Although this data is intriguing the overall utility of single-incision procedures requires more analysis and potentially randomized trials

Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy

Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S

SourceFrom the Hepatobiliary and Pancreatic Surgery Program Providence Portland

Medical Center Portland ORbull SPLC procedure time was longer and incurred

more complications than CLC without significant benefits in patient satisfaction postoperative pain and QOL SPLC may be offered in carefully selected patients Larger randomized trials performed later in the learning curve with SPLC may identify more subtle advantages of one method over another

bull World J Surg 2011 May35(5)967-72bull

Is Smaller Actually BetterNeedlescopic Surgery mdash A Step

Towards (Virtually)Incisionless Surgery

Andrei Nadu 1Department of Urology Sheba Medical

Center Tel-Hashomer 52621 Israel

bull Needlescopic surgery performed with 2- andbull 3-mm instruments represents a further refinementbull of laparoscopic surgery Several authors havebull demonstrated the feasibility and safety of variousbull needlescopic proceduresbull The 2- and 3-mm ports are virtually incisionless andbull do not necessitate suturing (adhesive tape is sufficient)bull and the consequent scars are almost invisiblebull understandably encouraging surgeons at selectedbull centers to consider needlescopy or minilaparoscopybull as the next logical step in the evolution ofminimallybull invasive surgery

Surgeons Philoshophybull Advancements in laparoscopic surgery is it properly

directedbull Only 15 of the world population live in developed

countriesbull Advancements requiring high skill intensive training and

expensive facilities are for whombull Medical education and training of a surgeon in the

developing and under developed countries needs to be addressed

bull Surgical techniques supply and delivery needs to be cost effective

bull Should only the poor should think about cost effectiveness and developed countries go on wasting the resources

bull We should not run for innovations which do not help the majority

bull Surgeon while working should be comfortable and enjoy what he is doing

bull If only increased noise can increase SSI then a diffifult procedure may cause many problems which need to be addressed

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Since the beginning of lap chole making it more comfortable and more cosmetic never stopped

bull With a little addition to the standard instruments we started mini lap chole in 1995 by making 5 mm port in place of 10 mm epigastric port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Techniquebull Since 1998 we are doing modified Needlescopic Cholecystectomy

where umbilical port is 10 mm and three other ports are 3 mm

bull Clips are used through the umbilical port under the vision of a 2 mm scope from the epigastric port

bull Gallbladder is delivered through the umbilical port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Since 1993 till Sept 2006 about 14000 cases of Laparoscopic Cholecystectomy was done by the author Among which 5600 cases are Needlescopic

Conversion bull to 5 mm port was done in 55 casesbull to standard lap chole was 15bull to open chole was less then 1

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

The operative time ranged from 30 to 256 minutes for the mini-LC group and 25 to 255 minutes for the C-LC group with means of 89 and 82 minutes respectively (P gt 005)

Postoperative length of stay ranged from 0 to 18 days for the mini-LC group and 0 to 21 days for the C-LC group with means of 15 and 19 days respectively (P gt 005)

There were no conversions to open cholecystectomy

These data suggest that a more minimalist approach to laparoscopic cholecystectomy can be accomplished safely and effectively

Reardon PR et al J Laparoendosc Adv Surg Tech A 1999 Aug9(4)373

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

The level of postoperative pain was lower in the MLC group (p lt 0001)

More patients in the MLC group expressed satisfaction with the cosmetic result (p lt 005)

MLC was shown to be feasible in uncomplicated situations

Randomized studies are still needed to confirm these findings

Surgical Endoscopy Volume 15 Number 6 June 2001 614-618L Sarli R Costi G Sansebastiano

Journal of Minimal Access SurgerySingle-incision laparoscopic surgery

Alfred Cuschieri

bull However there are a number of important issues which need to be addressed before we can confirm with good evidence that this variant laparoscopic approach does indeed benefit the patient Thus aside from reduction of visible scars the jury remains out on whether SILS does indeed reduce postoperative pain and adhesion formation Likewise the contraindications to SILS have yet to be clarified and defined There is one potential area of concern and this relates to an increased risk of incisional periumbilical hernia formation The extent of this perceived complication will only be established by prospective cohort or randomised studies and longer follow-up Meantime we need to ensure that these umbilical wounds are closed with a meticulous technique using non-absorbable material

bull Even with the best instrumentation currently available the SILS approach imposes restrictions on instrument manipulation retraction and limits triangulation

Michel GagnerMount Senai Medical center Florida

Journal of Gastrointest SurgeryJuly 2010

bull Needlescopic instruments are often added to complement the surgical task during SILS

bull Needlescopic instruments permits triangulation in surgical complex task during SILS procedure

bull The scar after needlescopic surgery is very negligible and non-existent after 12 months achieving similar cosmetic result to SILS even better

bull Due to higher trauma to the periumbilical are the pain may be more in SILS

bull Long term herniation risk in the peri umbilical area is more n SILS

bull Mesh repair of this hernia will prevent another SILS for the same patient

ANZ J Surg 2009 Jun79(6)437-42Needlescopic versus laparoscopic cholecystectomy a meta-analysis

Sajid MS Khan MA Ray K Cheek E Baig MKDepartment of Colorectal Surgery Worthing Hospital Worthing West Sussex UK

bull Sixteen trials on NC versus LC encompassing 1549 patients were retrieved from electronic databases

bull NC was superior to LC in terms of less post-operative pain and better cosmetic outcomes

Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy

Chow A Purkayastha S Aziz O Pefanis D Paraskeva PSource

Department of Biosurgery and Surgical Technology Imperial College London England

bull Operative time was longer with SILS for cholecystectomy compared with conventional laparoscopic cholecystectomy (P lt 001) A correlation was seen between reducing SILS operative time and increasing experience (Spearman rank correlation coefficient -029) Three patients in the SILS for cholecystectomy group required the addition of extra laparoscopic ports No patients in the SILS for cholecystectomy group required conversion to open surgery compared with 4 patients in the standard laparoscopic cholecystectomy group Patients stayed an average of 076 days following SILS for cholecystectomy and 153 days following conventional laparoscopic cholecystectomy One patient in each group had a postoperative biliary leak

Laparoscopic versus single-incision cholecystectomyKhambaty F Brody F Vaziri K Edwards C

SourceDepartment of Surgery The George Washington University Medical Center 2150 Pennsylvania

Avenue NW Suite 6B Washington DC 20037 USA

bull The data suggests that individuals with a BMI over 33 may not be candidates for single-incision cholecystectomy Those patients that undergo a successful single-incision laparoscopic cholecystectomy require fewer narcotics postoperatively and have a shorter LOS Although this data is intriguing the overall utility of single-incision procedures requires more analysis and potentially randomized trials

Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy

Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S

SourceFrom the Hepatobiliary and Pancreatic Surgery Program Providence Portland

Medical Center Portland ORbull SPLC procedure time was longer and incurred

more complications than CLC without significant benefits in patient satisfaction postoperative pain and QOL SPLC may be offered in carefully selected patients Larger randomized trials performed later in the learning curve with SPLC may identify more subtle advantages of one method over another

bull World J Surg 2011 May35(5)967-72bull

Is Smaller Actually BetterNeedlescopic Surgery mdash A Step

Towards (Virtually)Incisionless Surgery

Andrei Nadu 1Department of Urology Sheba Medical

Center Tel-Hashomer 52621 Israel

bull Needlescopic surgery performed with 2- andbull 3-mm instruments represents a further refinementbull of laparoscopic surgery Several authors havebull demonstrated the feasibility and safety of variousbull needlescopic proceduresbull The 2- and 3-mm ports are virtually incisionless andbull do not necessitate suturing (adhesive tape is sufficient)bull and the consequent scars are almost invisiblebull understandably encouraging surgeons at selectedbull centers to consider needlescopy or minilaparoscopybull as the next logical step in the evolution ofminimallybull invasive surgery

Surgeons Philoshophybull Advancements in laparoscopic surgery is it properly

directedbull Only 15 of the world population live in developed

countriesbull Advancements requiring high skill intensive training and

expensive facilities are for whombull Medical education and training of a surgeon in the

developing and under developed countries needs to be addressed

bull Surgical techniques supply and delivery needs to be cost effective

bull Should only the poor should think about cost effectiveness and developed countries go on wasting the resources

bull We should not run for innovations which do not help the majority

bull Surgeon while working should be comfortable and enjoy what he is doing

bull If only increased noise can increase SSI then a diffifult procedure may cause many problems which need to be addressed

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Since the beginning of lap chole making it more comfortable and more cosmetic never stopped

bull With a little addition to the standard instruments we started mini lap chole in 1995 by making 5 mm port in place of 10 mm epigastric port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Techniquebull Since 1998 we are doing modified Needlescopic Cholecystectomy

where umbilical port is 10 mm and three other ports are 3 mm

bull Clips are used through the umbilical port under the vision of a 2 mm scope from the epigastric port

bull Gallbladder is delivered through the umbilical port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Since 1993 till Sept 2006 about 14000 cases of Laparoscopic Cholecystectomy was done by the author Among which 5600 cases are Needlescopic

Conversion bull to 5 mm port was done in 55 casesbull to standard lap chole was 15bull to open chole was less then 1

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

The level of postoperative pain was lower in the MLC group (p lt 0001)

More patients in the MLC group expressed satisfaction with the cosmetic result (p lt 005)

MLC was shown to be feasible in uncomplicated situations

Randomized studies are still needed to confirm these findings

Surgical Endoscopy Volume 15 Number 6 June 2001 614-618L Sarli R Costi G Sansebastiano

Journal of Minimal Access SurgerySingle-incision laparoscopic surgery

Alfred Cuschieri

bull However there are a number of important issues which need to be addressed before we can confirm with good evidence that this variant laparoscopic approach does indeed benefit the patient Thus aside from reduction of visible scars the jury remains out on whether SILS does indeed reduce postoperative pain and adhesion formation Likewise the contraindications to SILS have yet to be clarified and defined There is one potential area of concern and this relates to an increased risk of incisional periumbilical hernia formation The extent of this perceived complication will only be established by prospective cohort or randomised studies and longer follow-up Meantime we need to ensure that these umbilical wounds are closed with a meticulous technique using non-absorbable material

bull Even with the best instrumentation currently available the SILS approach imposes restrictions on instrument manipulation retraction and limits triangulation

Michel GagnerMount Senai Medical center Florida

Journal of Gastrointest SurgeryJuly 2010

bull Needlescopic instruments are often added to complement the surgical task during SILS

bull Needlescopic instruments permits triangulation in surgical complex task during SILS procedure

bull The scar after needlescopic surgery is very negligible and non-existent after 12 months achieving similar cosmetic result to SILS even better

bull Due to higher trauma to the periumbilical are the pain may be more in SILS

bull Long term herniation risk in the peri umbilical area is more n SILS

bull Mesh repair of this hernia will prevent another SILS for the same patient

ANZ J Surg 2009 Jun79(6)437-42Needlescopic versus laparoscopic cholecystectomy a meta-analysis

Sajid MS Khan MA Ray K Cheek E Baig MKDepartment of Colorectal Surgery Worthing Hospital Worthing West Sussex UK

bull Sixteen trials on NC versus LC encompassing 1549 patients were retrieved from electronic databases

bull NC was superior to LC in terms of less post-operative pain and better cosmetic outcomes

Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy

Chow A Purkayastha S Aziz O Pefanis D Paraskeva PSource

Department of Biosurgery and Surgical Technology Imperial College London England

bull Operative time was longer with SILS for cholecystectomy compared with conventional laparoscopic cholecystectomy (P lt 001) A correlation was seen between reducing SILS operative time and increasing experience (Spearman rank correlation coefficient -029) Three patients in the SILS for cholecystectomy group required the addition of extra laparoscopic ports No patients in the SILS for cholecystectomy group required conversion to open surgery compared with 4 patients in the standard laparoscopic cholecystectomy group Patients stayed an average of 076 days following SILS for cholecystectomy and 153 days following conventional laparoscopic cholecystectomy One patient in each group had a postoperative biliary leak

Laparoscopic versus single-incision cholecystectomyKhambaty F Brody F Vaziri K Edwards C

SourceDepartment of Surgery The George Washington University Medical Center 2150 Pennsylvania

Avenue NW Suite 6B Washington DC 20037 USA

bull The data suggests that individuals with a BMI over 33 may not be candidates for single-incision cholecystectomy Those patients that undergo a successful single-incision laparoscopic cholecystectomy require fewer narcotics postoperatively and have a shorter LOS Although this data is intriguing the overall utility of single-incision procedures requires more analysis and potentially randomized trials

Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy

Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S

SourceFrom the Hepatobiliary and Pancreatic Surgery Program Providence Portland

Medical Center Portland ORbull SPLC procedure time was longer and incurred

more complications than CLC without significant benefits in patient satisfaction postoperative pain and QOL SPLC may be offered in carefully selected patients Larger randomized trials performed later in the learning curve with SPLC may identify more subtle advantages of one method over another

bull World J Surg 2011 May35(5)967-72bull

Is Smaller Actually BetterNeedlescopic Surgery mdash A Step

Towards (Virtually)Incisionless Surgery

Andrei Nadu 1Department of Urology Sheba Medical

Center Tel-Hashomer 52621 Israel

bull Needlescopic surgery performed with 2- andbull 3-mm instruments represents a further refinementbull of laparoscopic surgery Several authors havebull demonstrated the feasibility and safety of variousbull needlescopic proceduresbull The 2- and 3-mm ports are virtually incisionless andbull do not necessitate suturing (adhesive tape is sufficient)bull and the consequent scars are almost invisiblebull understandably encouraging surgeons at selectedbull centers to consider needlescopy or minilaparoscopybull as the next logical step in the evolution ofminimallybull invasive surgery

Surgeons Philoshophybull Advancements in laparoscopic surgery is it properly

directedbull Only 15 of the world population live in developed

countriesbull Advancements requiring high skill intensive training and

expensive facilities are for whombull Medical education and training of a surgeon in the

developing and under developed countries needs to be addressed

bull Surgical techniques supply and delivery needs to be cost effective

bull Should only the poor should think about cost effectiveness and developed countries go on wasting the resources

bull We should not run for innovations which do not help the majority

bull Surgeon while working should be comfortable and enjoy what he is doing

bull If only increased noise can increase SSI then a diffifult procedure may cause many problems which need to be addressed

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Since the beginning of lap chole making it more comfortable and more cosmetic never stopped

bull With a little addition to the standard instruments we started mini lap chole in 1995 by making 5 mm port in place of 10 mm epigastric port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Techniquebull Since 1998 we are doing modified Needlescopic Cholecystectomy

where umbilical port is 10 mm and three other ports are 3 mm

bull Clips are used through the umbilical port under the vision of a 2 mm scope from the epigastric port

bull Gallbladder is delivered through the umbilical port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Since 1993 till Sept 2006 about 14000 cases of Laparoscopic Cholecystectomy was done by the author Among which 5600 cases are Needlescopic

Conversion bull to 5 mm port was done in 55 casesbull to standard lap chole was 15bull to open chole was less then 1

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Journal of Minimal Access SurgerySingle-incision laparoscopic surgery

Alfred Cuschieri

bull However there are a number of important issues which need to be addressed before we can confirm with good evidence that this variant laparoscopic approach does indeed benefit the patient Thus aside from reduction of visible scars the jury remains out on whether SILS does indeed reduce postoperative pain and adhesion formation Likewise the contraindications to SILS have yet to be clarified and defined There is one potential area of concern and this relates to an increased risk of incisional periumbilical hernia formation The extent of this perceived complication will only be established by prospective cohort or randomised studies and longer follow-up Meantime we need to ensure that these umbilical wounds are closed with a meticulous technique using non-absorbable material

bull Even with the best instrumentation currently available the SILS approach imposes restrictions on instrument manipulation retraction and limits triangulation

Michel GagnerMount Senai Medical center Florida

Journal of Gastrointest SurgeryJuly 2010

bull Needlescopic instruments are often added to complement the surgical task during SILS

bull Needlescopic instruments permits triangulation in surgical complex task during SILS procedure

bull The scar after needlescopic surgery is very negligible and non-existent after 12 months achieving similar cosmetic result to SILS even better

bull Due to higher trauma to the periumbilical are the pain may be more in SILS

bull Long term herniation risk in the peri umbilical area is more n SILS

bull Mesh repair of this hernia will prevent another SILS for the same patient

ANZ J Surg 2009 Jun79(6)437-42Needlescopic versus laparoscopic cholecystectomy a meta-analysis

Sajid MS Khan MA Ray K Cheek E Baig MKDepartment of Colorectal Surgery Worthing Hospital Worthing West Sussex UK

bull Sixteen trials on NC versus LC encompassing 1549 patients were retrieved from electronic databases

bull NC was superior to LC in terms of less post-operative pain and better cosmetic outcomes

Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy

Chow A Purkayastha S Aziz O Pefanis D Paraskeva PSource

Department of Biosurgery and Surgical Technology Imperial College London England

bull Operative time was longer with SILS for cholecystectomy compared with conventional laparoscopic cholecystectomy (P lt 001) A correlation was seen between reducing SILS operative time and increasing experience (Spearman rank correlation coefficient -029) Three patients in the SILS for cholecystectomy group required the addition of extra laparoscopic ports No patients in the SILS for cholecystectomy group required conversion to open surgery compared with 4 patients in the standard laparoscopic cholecystectomy group Patients stayed an average of 076 days following SILS for cholecystectomy and 153 days following conventional laparoscopic cholecystectomy One patient in each group had a postoperative biliary leak

Laparoscopic versus single-incision cholecystectomyKhambaty F Brody F Vaziri K Edwards C

SourceDepartment of Surgery The George Washington University Medical Center 2150 Pennsylvania

Avenue NW Suite 6B Washington DC 20037 USA

bull The data suggests that individuals with a BMI over 33 may not be candidates for single-incision cholecystectomy Those patients that undergo a successful single-incision laparoscopic cholecystectomy require fewer narcotics postoperatively and have a shorter LOS Although this data is intriguing the overall utility of single-incision procedures requires more analysis and potentially randomized trials

Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy

Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S

SourceFrom the Hepatobiliary and Pancreatic Surgery Program Providence Portland

Medical Center Portland ORbull SPLC procedure time was longer and incurred

more complications than CLC without significant benefits in patient satisfaction postoperative pain and QOL SPLC may be offered in carefully selected patients Larger randomized trials performed later in the learning curve with SPLC may identify more subtle advantages of one method over another

bull World J Surg 2011 May35(5)967-72bull

Is Smaller Actually BetterNeedlescopic Surgery mdash A Step

Towards (Virtually)Incisionless Surgery

Andrei Nadu 1Department of Urology Sheba Medical

Center Tel-Hashomer 52621 Israel

bull Needlescopic surgery performed with 2- andbull 3-mm instruments represents a further refinementbull of laparoscopic surgery Several authors havebull demonstrated the feasibility and safety of variousbull needlescopic proceduresbull The 2- and 3-mm ports are virtually incisionless andbull do not necessitate suturing (adhesive tape is sufficient)bull and the consequent scars are almost invisiblebull understandably encouraging surgeons at selectedbull centers to consider needlescopy or minilaparoscopybull as the next logical step in the evolution ofminimallybull invasive surgery

Surgeons Philoshophybull Advancements in laparoscopic surgery is it properly

directedbull Only 15 of the world population live in developed

countriesbull Advancements requiring high skill intensive training and

expensive facilities are for whombull Medical education and training of a surgeon in the

developing and under developed countries needs to be addressed

bull Surgical techniques supply and delivery needs to be cost effective

bull Should only the poor should think about cost effectiveness and developed countries go on wasting the resources

bull We should not run for innovations which do not help the majority

bull Surgeon while working should be comfortable and enjoy what he is doing

bull If only increased noise can increase SSI then a diffifult procedure may cause many problems which need to be addressed

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Since the beginning of lap chole making it more comfortable and more cosmetic never stopped

bull With a little addition to the standard instruments we started mini lap chole in 1995 by making 5 mm port in place of 10 mm epigastric port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Techniquebull Since 1998 we are doing modified Needlescopic Cholecystectomy

where umbilical port is 10 mm and three other ports are 3 mm

bull Clips are used through the umbilical port under the vision of a 2 mm scope from the epigastric port

bull Gallbladder is delivered through the umbilical port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Since 1993 till Sept 2006 about 14000 cases of Laparoscopic Cholecystectomy was done by the author Among which 5600 cases are Needlescopic

Conversion bull to 5 mm port was done in 55 casesbull to standard lap chole was 15bull to open chole was less then 1

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Michel GagnerMount Senai Medical center Florida

Journal of Gastrointest SurgeryJuly 2010

bull Needlescopic instruments are often added to complement the surgical task during SILS

bull Needlescopic instruments permits triangulation in surgical complex task during SILS procedure

bull The scar after needlescopic surgery is very negligible and non-existent after 12 months achieving similar cosmetic result to SILS even better

bull Due to higher trauma to the periumbilical are the pain may be more in SILS

bull Long term herniation risk in the peri umbilical area is more n SILS

bull Mesh repair of this hernia will prevent another SILS for the same patient

ANZ J Surg 2009 Jun79(6)437-42Needlescopic versus laparoscopic cholecystectomy a meta-analysis

Sajid MS Khan MA Ray K Cheek E Baig MKDepartment of Colorectal Surgery Worthing Hospital Worthing West Sussex UK

bull Sixteen trials on NC versus LC encompassing 1549 patients were retrieved from electronic databases

bull NC was superior to LC in terms of less post-operative pain and better cosmetic outcomes

Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy

Chow A Purkayastha S Aziz O Pefanis D Paraskeva PSource

Department of Biosurgery and Surgical Technology Imperial College London England

bull Operative time was longer with SILS for cholecystectomy compared with conventional laparoscopic cholecystectomy (P lt 001) A correlation was seen between reducing SILS operative time and increasing experience (Spearman rank correlation coefficient -029) Three patients in the SILS for cholecystectomy group required the addition of extra laparoscopic ports No patients in the SILS for cholecystectomy group required conversion to open surgery compared with 4 patients in the standard laparoscopic cholecystectomy group Patients stayed an average of 076 days following SILS for cholecystectomy and 153 days following conventional laparoscopic cholecystectomy One patient in each group had a postoperative biliary leak

Laparoscopic versus single-incision cholecystectomyKhambaty F Brody F Vaziri K Edwards C

SourceDepartment of Surgery The George Washington University Medical Center 2150 Pennsylvania

Avenue NW Suite 6B Washington DC 20037 USA

bull The data suggests that individuals with a BMI over 33 may not be candidates for single-incision cholecystectomy Those patients that undergo a successful single-incision laparoscopic cholecystectomy require fewer narcotics postoperatively and have a shorter LOS Although this data is intriguing the overall utility of single-incision procedures requires more analysis and potentially randomized trials

Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy

Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S

SourceFrom the Hepatobiliary and Pancreatic Surgery Program Providence Portland

Medical Center Portland ORbull SPLC procedure time was longer and incurred

more complications than CLC without significant benefits in patient satisfaction postoperative pain and QOL SPLC may be offered in carefully selected patients Larger randomized trials performed later in the learning curve with SPLC may identify more subtle advantages of one method over another

bull World J Surg 2011 May35(5)967-72bull

Is Smaller Actually BetterNeedlescopic Surgery mdash A Step

Towards (Virtually)Incisionless Surgery

Andrei Nadu 1Department of Urology Sheba Medical

Center Tel-Hashomer 52621 Israel

bull Needlescopic surgery performed with 2- andbull 3-mm instruments represents a further refinementbull of laparoscopic surgery Several authors havebull demonstrated the feasibility and safety of variousbull needlescopic proceduresbull The 2- and 3-mm ports are virtually incisionless andbull do not necessitate suturing (adhesive tape is sufficient)bull and the consequent scars are almost invisiblebull understandably encouraging surgeons at selectedbull centers to consider needlescopy or minilaparoscopybull as the next logical step in the evolution ofminimallybull invasive surgery

Surgeons Philoshophybull Advancements in laparoscopic surgery is it properly

directedbull Only 15 of the world population live in developed

countriesbull Advancements requiring high skill intensive training and

expensive facilities are for whombull Medical education and training of a surgeon in the

developing and under developed countries needs to be addressed

bull Surgical techniques supply and delivery needs to be cost effective

bull Should only the poor should think about cost effectiveness and developed countries go on wasting the resources

bull We should not run for innovations which do not help the majority

bull Surgeon while working should be comfortable and enjoy what he is doing

bull If only increased noise can increase SSI then a diffifult procedure may cause many problems which need to be addressed

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Since the beginning of lap chole making it more comfortable and more cosmetic never stopped

bull With a little addition to the standard instruments we started mini lap chole in 1995 by making 5 mm port in place of 10 mm epigastric port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Techniquebull Since 1998 we are doing modified Needlescopic Cholecystectomy

where umbilical port is 10 mm and three other ports are 3 mm

bull Clips are used through the umbilical port under the vision of a 2 mm scope from the epigastric port

bull Gallbladder is delivered through the umbilical port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Since 1993 till Sept 2006 about 14000 cases of Laparoscopic Cholecystectomy was done by the author Among which 5600 cases are Needlescopic

Conversion bull to 5 mm port was done in 55 casesbull to standard lap chole was 15bull to open chole was less then 1

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

ANZ J Surg 2009 Jun79(6)437-42Needlescopic versus laparoscopic cholecystectomy a meta-analysis

Sajid MS Khan MA Ray K Cheek E Baig MKDepartment of Colorectal Surgery Worthing Hospital Worthing West Sussex UK

bull Sixteen trials on NC versus LC encompassing 1549 patients were retrieved from electronic databases

bull NC was superior to LC in terms of less post-operative pain and better cosmetic outcomes

Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy

Chow A Purkayastha S Aziz O Pefanis D Paraskeva PSource

Department of Biosurgery and Surgical Technology Imperial College London England

bull Operative time was longer with SILS for cholecystectomy compared with conventional laparoscopic cholecystectomy (P lt 001) A correlation was seen between reducing SILS operative time and increasing experience (Spearman rank correlation coefficient -029) Three patients in the SILS for cholecystectomy group required the addition of extra laparoscopic ports No patients in the SILS for cholecystectomy group required conversion to open surgery compared with 4 patients in the standard laparoscopic cholecystectomy group Patients stayed an average of 076 days following SILS for cholecystectomy and 153 days following conventional laparoscopic cholecystectomy One patient in each group had a postoperative biliary leak

Laparoscopic versus single-incision cholecystectomyKhambaty F Brody F Vaziri K Edwards C

SourceDepartment of Surgery The George Washington University Medical Center 2150 Pennsylvania

Avenue NW Suite 6B Washington DC 20037 USA

bull The data suggests that individuals with a BMI over 33 may not be candidates for single-incision cholecystectomy Those patients that undergo a successful single-incision laparoscopic cholecystectomy require fewer narcotics postoperatively and have a shorter LOS Although this data is intriguing the overall utility of single-incision procedures requires more analysis and potentially randomized trials

Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy

Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S

SourceFrom the Hepatobiliary and Pancreatic Surgery Program Providence Portland

Medical Center Portland ORbull SPLC procedure time was longer and incurred

more complications than CLC without significant benefits in patient satisfaction postoperative pain and QOL SPLC may be offered in carefully selected patients Larger randomized trials performed later in the learning curve with SPLC may identify more subtle advantages of one method over another

bull World J Surg 2011 May35(5)967-72bull

Is Smaller Actually BetterNeedlescopic Surgery mdash A Step

Towards (Virtually)Incisionless Surgery

Andrei Nadu 1Department of Urology Sheba Medical

Center Tel-Hashomer 52621 Israel

bull Needlescopic surgery performed with 2- andbull 3-mm instruments represents a further refinementbull of laparoscopic surgery Several authors havebull demonstrated the feasibility and safety of variousbull needlescopic proceduresbull The 2- and 3-mm ports are virtually incisionless andbull do not necessitate suturing (adhesive tape is sufficient)bull and the consequent scars are almost invisiblebull understandably encouraging surgeons at selectedbull centers to consider needlescopy or minilaparoscopybull as the next logical step in the evolution ofminimallybull invasive surgery

Surgeons Philoshophybull Advancements in laparoscopic surgery is it properly

directedbull Only 15 of the world population live in developed

countriesbull Advancements requiring high skill intensive training and

expensive facilities are for whombull Medical education and training of a surgeon in the

developing and under developed countries needs to be addressed

bull Surgical techniques supply and delivery needs to be cost effective

bull Should only the poor should think about cost effectiveness and developed countries go on wasting the resources

bull We should not run for innovations which do not help the majority

bull Surgeon while working should be comfortable and enjoy what he is doing

bull If only increased noise can increase SSI then a diffifult procedure may cause many problems which need to be addressed

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Since the beginning of lap chole making it more comfortable and more cosmetic never stopped

bull With a little addition to the standard instruments we started mini lap chole in 1995 by making 5 mm port in place of 10 mm epigastric port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Techniquebull Since 1998 we are doing modified Needlescopic Cholecystectomy

where umbilical port is 10 mm and three other ports are 3 mm

bull Clips are used through the umbilical port under the vision of a 2 mm scope from the epigastric port

bull Gallbladder is delivered through the umbilical port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Since 1993 till Sept 2006 about 14000 cases of Laparoscopic Cholecystectomy was done by the author Among which 5600 cases are Needlescopic

Conversion bull to 5 mm port was done in 55 casesbull to standard lap chole was 15bull to open chole was less then 1

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy

Chow A Purkayastha S Aziz O Pefanis D Paraskeva PSource

Department of Biosurgery and Surgical Technology Imperial College London England

bull Operative time was longer with SILS for cholecystectomy compared with conventional laparoscopic cholecystectomy (P lt 001) A correlation was seen between reducing SILS operative time and increasing experience (Spearman rank correlation coefficient -029) Three patients in the SILS for cholecystectomy group required the addition of extra laparoscopic ports No patients in the SILS for cholecystectomy group required conversion to open surgery compared with 4 patients in the standard laparoscopic cholecystectomy group Patients stayed an average of 076 days following SILS for cholecystectomy and 153 days following conventional laparoscopic cholecystectomy One patient in each group had a postoperative biliary leak

Laparoscopic versus single-incision cholecystectomyKhambaty F Brody F Vaziri K Edwards C

SourceDepartment of Surgery The George Washington University Medical Center 2150 Pennsylvania

Avenue NW Suite 6B Washington DC 20037 USA

bull The data suggests that individuals with a BMI over 33 may not be candidates for single-incision cholecystectomy Those patients that undergo a successful single-incision laparoscopic cholecystectomy require fewer narcotics postoperatively and have a shorter LOS Although this data is intriguing the overall utility of single-incision procedures requires more analysis and potentially randomized trials

Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy

Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S

SourceFrom the Hepatobiliary and Pancreatic Surgery Program Providence Portland

Medical Center Portland ORbull SPLC procedure time was longer and incurred

more complications than CLC without significant benefits in patient satisfaction postoperative pain and QOL SPLC may be offered in carefully selected patients Larger randomized trials performed later in the learning curve with SPLC may identify more subtle advantages of one method over another

bull World J Surg 2011 May35(5)967-72bull

Is Smaller Actually BetterNeedlescopic Surgery mdash A Step

Towards (Virtually)Incisionless Surgery

Andrei Nadu 1Department of Urology Sheba Medical

Center Tel-Hashomer 52621 Israel

bull Needlescopic surgery performed with 2- andbull 3-mm instruments represents a further refinementbull of laparoscopic surgery Several authors havebull demonstrated the feasibility and safety of variousbull needlescopic proceduresbull The 2- and 3-mm ports are virtually incisionless andbull do not necessitate suturing (adhesive tape is sufficient)bull and the consequent scars are almost invisiblebull understandably encouraging surgeons at selectedbull centers to consider needlescopy or minilaparoscopybull as the next logical step in the evolution ofminimallybull invasive surgery

Surgeons Philoshophybull Advancements in laparoscopic surgery is it properly

directedbull Only 15 of the world population live in developed

countriesbull Advancements requiring high skill intensive training and

expensive facilities are for whombull Medical education and training of a surgeon in the

developing and under developed countries needs to be addressed

bull Surgical techniques supply and delivery needs to be cost effective

bull Should only the poor should think about cost effectiveness and developed countries go on wasting the resources

bull We should not run for innovations which do not help the majority

bull Surgeon while working should be comfortable and enjoy what he is doing

bull If only increased noise can increase SSI then a diffifult procedure may cause many problems which need to be addressed

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Since the beginning of lap chole making it more comfortable and more cosmetic never stopped

bull With a little addition to the standard instruments we started mini lap chole in 1995 by making 5 mm port in place of 10 mm epigastric port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Techniquebull Since 1998 we are doing modified Needlescopic Cholecystectomy

where umbilical port is 10 mm and three other ports are 3 mm

bull Clips are used through the umbilical port under the vision of a 2 mm scope from the epigastric port

bull Gallbladder is delivered through the umbilical port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Since 1993 till Sept 2006 about 14000 cases of Laparoscopic Cholecystectomy was done by the author Among which 5600 cases are Needlescopic

Conversion bull to 5 mm port was done in 55 casesbull to standard lap chole was 15bull to open chole was less then 1

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Laparoscopic versus single-incision cholecystectomyKhambaty F Brody F Vaziri K Edwards C

SourceDepartment of Surgery The George Washington University Medical Center 2150 Pennsylvania

Avenue NW Suite 6B Washington DC 20037 USA

bull The data suggests that individuals with a BMI over 33 may not be candidates for single-incision cholecystectomy Those patients that undergo a successful single-incision laparoscopic cholecystectomy require fewer narcotics postoperatively and have a shorter LOS Although this data is intriguing the overall utility of single-incision procedures requires more analysis and potentially randomized trials

Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy

Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S

SourceFrom the Hepatobiliary and Pancreatic Surgery Program Providence Portland

Medical Center Portland ORbull SPLC procedure time was longer and incurred

more complications than CLC without significant benefits in patient satisfaction postoperative pain and QOL SPLC may be offered in carefully selected patients Larger randomized trials performed later in the learning curve with SPLC may identify more subtle advantages of one method over another

bull World J Surg 2011 May35(5)967-72bull

Is Smaller Actually BetterNeedlescopic Surgery mdash A Step

Towards (Virtually)Incisionless Surgery

Andrei Nadu 1Department of Urology Sheba Medical

Center Tel-Hashomer 52621 Israel

bull Needlescopic surgery performed with 2- andbull 3-mm instruments represents a further refinementbull of laparoscopic surgery Several authors havebull demonstrated the feasibility and safety of variousbull needlescopic proceduresbull The 2- and 3-mm ports are virtually incisionless andbull do not necessitate suturing (adhesive tape is sufficient)bull and the consequent scars are almost invisiblebull understandably encouraging surgeons at selectedbull centers to consider needlescopy or minilaparoscopybull as the next logical step in the evolution ofminimallybull invasive surgery

Surgeons Philoshophybull Advancements in laparoscopic surgery is it properly

directedbull Only 15 of the world population live in developed

countriesbull Advancements requiring high skill intensive training and

expensive facilities are for whombull Medical education and training of a surgeon in the

developing and under developed countries needs to be addressed

bull Surgical techniques supply and delivery needs to be cost effective

bull Should only the poor should think about cost effectiveness and developed countries go on wasting the resources

bull We should not run for innovations which do not help the majority

bull Surgeon while working should be comfortable and enjoy what he is doing

bull If only increased noise can increase SSI then a diffifult procedure may cause many problems which need to be addressed

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Since the beginning of lap chole making it more comfortable and more cosmetic never stopped

bull With a little addition to the standard instruments we started mini lap chole in 1995 by making 5 mm port in place of 10 mm epigastric port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Techniquebull Since 1998 we are doing modified Needlescopic Cholecystectomy

where umbilical port is 10 mm and three other ports are 3 mm

bull Clips are used through the umbilical port under the vision of a 2 mm scope from the epigastric port

bull Gallbladder is delivered through the umbilical port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Since 1993 till Sept 2006 about 14000 cases of Laparoscopic Cholecystectomy was done by the author Among which 5600 cases are Needlescopic

Conversion bull to 5 mm port was done in 55 casesbull to standard lap chole was 15bull to open chole was less then 1

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy

Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S

SourceFrom the Hepatobiliary and Pancreatic Surgery Program Providence Portland

Medical Center Portland ORbull SPLC procedure time was longer and incurred

more complications than CLC without significant benefits in patient satisfaction postoperative pain and QOL SPLC may be offered in carefully selected patients Larger randomized trials performed later in the learning curve with SPLC may identify more subtle advantages of one method over another

bull World J Surg 2011 May35(5)967-72bull

Is Smaller Actually BetterNeedlescopic Surgery mdash A Step

Towards (Virtually)Incisionless Surgery

Andrei Nadu 1Department of Urology Sheba Medical

Center Tel-Hashomer 52621 Israel

bull Needlescopic surgery performed with 2- andbull 3-mm instruments represents a further refinementbull of laparoscopic surgery Several authors havebull demonstrated the feasibility and safety of variousbull needlescopic proceduresbull The 2- and 3-mm ports are virtually incisionless andbull do not necessitate suturing (adhesive tape is sufficient)bull and the consequent scars are almost invisiblebull understandably encouraging surgeons at selectedbull centers to consider needlescopy or minilaparoscopybull as the next logical step in the evolution ofminimallybull invasive surgery

Surgeons Philoshophybull Advancements in laparoscopic surgery is it properly

directedbull Only 15 of the world population live in developed

countriesbull Advancements requiring high skill intensive training and

expensive facilities are for whombull Medical education and training of a surgeon in the

developing and under developed countries needs to be addressed

bull Surgical techniques supply and delivery needs to be cost effective

bull Should only the poor should think about cost effectiveness and developed countries go on wasting the resources

bull We should not run for innovations which do not help the majority

bull Surgeon while working should be comfortable and enjoy what he is doing

bull If only increased noise can increase SSI then a diffifult procedure may cause many problems which need to be addressed

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Since the beginning of lap chole making it more comfortable and more cosmetic never stopped

bull With a little addition to the standard instruments we started mini lap chole in 1995 by making 5 mm port in place of 10 mm epigastric port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Techniquebull Since 1998 we are doing modified Needlescopic Cholecystectomy

where umbilical port is 10 mm and three other ports are 3 mm

bull Clips are used through the umbilical port under the vision of a 2 mm scope from the epigastric port

bull Gallbladder is delivered through the umbilical port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Since 1993 till Sept 2006 about 14000 cases of Laparoscopic Cholecystectomy was done by the author Among which 5600 cases are Needlescopic

Conversion bull to 5 mm port was done in 55 casesbull to standard lap chole was 15bull to open chole was less then 1

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Is Smaller Actually BetterNeedlescopic Surgery mdash A Step

Towards (Virtually)Incisionless Surgery

Andrei Nadu 1Department of Urology Sheba Medical

Center Tel-Hashomer 52621 Israel

bull Needlescopic surgery performed with 2- andbull 3-mm instruments represents a further refinementbull of laparoscopic surgery Several authors havebull demonstrated the feasibility and safety of variousbull needlescopic proceduresbull The 2- and 3-mm ports are virtually incisionless andbull do not necessitate suturing (adhesive tape is sufficient)bull and the consequent scars are almost invisiblebull understandably encouraging surgeons at selectedbull centers to consider needlescopy or minilaparoscopybull as the next logical step in the evolution ofminimallybull invasive surgery

Surgeons Philoshophybull Advancements in laparoscopic surgery is it properly

directedbull Only 15 of the world population live in developed

countriesbull Advancements requiring high skill intensive training and

expensive facilities are for whombull Medical education and training of a surgeon in the

developing and under developed countries needs to be addressed

bull Surgical techniques supply and delivery needs to be cost effective

bull Should only the poor should think about cost effectiveness and developed countries go on wasting the resources

bull We should not run for innovations which do not help the majority

bull Surgeon while working should be comfortable and enjoy what he is doing

bull If only increased noise can increase SSI then a diffifult procedure may cause many problems which need to be addressed

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Since the beginning of lap chole making it more comfortable and more cosmetic never stopped

bull With a little addition to the standard instruments we started mini lap chole in 1995 by making 5 mm port in place of 10 mm epigastric port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Techniquebull Since 1998 we are doing modified Needlescopic Cholecystectomy

where umbilical port is 10 mm and three other ports are 3 mm

bull Clips are used through the umbilical port under the vision of a 2 mm scope from the epigastric port

bull Gallbladder is delivered through the umbilical port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Since 1993 till Sept 2006 about 14000 cases of Laparoscopic Cholecystectomy was done by the author Among which 5600 cases are Needlescopic

Conversion bull to 5 mm port was done in 55 casesbull to standard lap chole was 15bull to open chole was less then 1

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Surgeons Philoshophybull Advancements in laparoscopic surgery is it properly

directedbull Only 15 of the world population live in developed

countriesbull Advancements requiring high skill intensive training and

expensive facilities are for whombull Medical education and training of a surgeon in the

developing and under developed countries needs to be addressed

bull Surgical techniques supply and delivery needs to be cost effective

bull Should only the poor should think about cost effectiveness and developed countries go on wasting the resources

bull We should not run for innovations which do not help the majority

bull Surgeon while working should be comfortable and enjoy what he is doing

bull If only increased noise can increase SSI then a diffifult procedure may cause many problems which need to be addressed

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Since the beginning of lap chole making it more comfortable and more cosmetic never stopped

bull With a little addition to the standard instruments we started mini lap chole in 1995 by making 5 mm port in place of 10 mm epigastric port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Techniquebull Since 1998 we are doing modified Needlescopic Cholecystectomy

where umbilical port is 10 mm and three other ports are 3 mm

bull Clips are used through the umbilical port under the vision of a 2 mm scope from the epigastric port

bull Gallbladder is delivered through the umbilical port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Since 1993 till Sept 2006 about 14000 cases of Laparoscopic Cholecystectomy was done by the author Among which 5600 cases are Needlescopic

Conversion bull to 5 mm port was done in 55 casesbull to standard lap chole was 15bull to open chole was less then 1

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

bull We should not run for innovations which do not help the majority

bull Surgeon while working should be comfortable and enjoy what he is doing

bull If only increased noise can increase SSI then a diffifult procedure may cause many problems which need to be addressed

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Since the beginning of lap chole making it more comfortable and more cosmetic never stopped

bull With a little addition to the standard instruments we started mini lap chole in 1995 by making 5 mm port in place of 10 mm epigastric port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Techniquebull Since 1998 we are doing modified Needlescopic Cholecystectomy

where umbilical port is 10 mm and three other ports are 3 mm

bull Clips are used through the umbilical port under the vision of a 2 mm scope from the epigastric port

bull Gallbladder is delivered through the umbilical port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Since 1993 till Sept 2006 about 14000 cases of Laparoscopic Cholecystectomy was done by the author Among which 5600 cases are Needlescopic

Conversion bull to 5 mm port was done in 55 casesbull to standard lap chole was 15bull to open chole was less then 1

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Since the beginning of lap chole making it more comfortable and more cosmetic never stopped

bull With a little addition to the standard instruments we started mini lap chole in 1995 by making 5 mm port in place of 10 mm epigastric port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Techniquebull Since 1998 we are doing modified Needlescopic Cholecystectomy

where umbilical port is 10 mm and three other ports are 3 mm

bull Clips are used through the umbilical port under the vision of a 2 mm scope from the epigastric port

bull Gallbladder is delivered through the umbilical port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Since 1993 till Sept 2006 about 14000 cases of Laparoscopic Cholecystectomy was done by the author Among which 5600 cases are Needlescopic

Conversion bull to 5 mm port was done in 55 casesbull to standard lap chole was 15bull to open chole was less then 1

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Techniquebull Since 1998 we are doing modified Needlescopic Cholecystectomy

where umbilical port is 10 mm and three other ports are 3 mm

bull Clips are used through the umbilical port under the vision of a 2 mm scope from the epigastric port

bull Gallbladder is delivered through the umbilical port

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Since 1993 till Sept 2006 about 14000 cases of Laparoscopic Cholecystectomy was done by the author Among which 5600 cases are Needlescopic

Conversion bull to 5 mm port was done in 55 casesbull to standard lap chole was 15bull to open chole was less then 1

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Since 1993 till Sept 2006 about 14000 cases of Laparoscopic Cholecystectomy was done by the author Among which 5600 cases are Needlescopic

Conversion bull to 5 mm port was done in 55 casesbull to standard lap chole was 15bull to open chole was less then 1

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull In this series Acute Cholecyatitis was 12

bull NC was possible in 65 of the acute cases

bull One patient died due to MI 24 hours after surgery

bull Minor umbilical wound infection was reported in 15 cases

bull Minor Bile duct injury 1 case

( Repaired Laparoscopically)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Mean operation time 25 min

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Analgesicsbull Pre-op NSAID Suppository only 35bull + Post ndashop NSAID Inj

60bull + Phthedine 5

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Hospital staybull lt24 hours 98( Average 20 hours where NC completed)

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Cosmetic ndash All patients expressed high satisfaction

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Difficulties

ndash Grasping thick wall with thin instruments

ndash Aspiration of thick pus and debris is difficult

ndash Thin instruments are not good enough for transmitting required force

ndash In inexperienced hands chances of injury may be more

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

bull Our policy was to try all cases except acute cases after 72 hours

bull This helped to gain more experience with acute cases

bull A 10 mm umbilical port allowed to introduce rolled gauze for

dissection and haemostasis

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

Advantages ndash More cosmetic

ndash Slow dissection

ndash More careful dissection

ndash Needs a clean field

ndash Less complications

ndash Patient satisfaction is high

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

Needlescopic Cholecystectomy (NC)Mini Laparoscopic Cholecystectomy

So why not offer the best

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

7th Post Operative day

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44

• MINILAP CHOLECYSTECTOMY
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Surg Endosc 2010 Jul24(7)1746-51 Epub 2010 Jan 7 Incisions do not simply sum Blinman T
• Diagn Ther Endosc 20102010759431 Epub 2010 Feb 14 Current Limitations and Perspectives in Single Port Surgery Pros and Cons Laparo-Endoscopic Single-Site Surgery (LESS) for Renal Surgery Weibl P Klingler HC Klatte T Remzi M Source Department of Urology Medical University of Vienna AKH Waumlhringer Guumlrtel 18-20 1090 Wien Austria
• Slide 10
• GI SURGERY Year 2011 | Volume 7 | Issue 1 | Page 40-51 Minimally invasive single-site surgery for the digestive system A technological review Parag W Dhumane Michele Diana Joel Leroy Jacques Marescaux IRCADEITS Hocircpitaux Universitaires 1 Place de lHocircpital 67091 Strasbourg Cedex France
• Slide 12
• Slide 13
• Needlescopic Cholecystectomy (NC) Mini Laparoscopic Cholecystectomy
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Journal of Minimal Access Surgery Single-incision laparoscopic surgery Alfred Cuschieri
• Michel Gagner Mount Senai Medical center Florida Journal of Gastrointest Surgery July 2010
• ANZ J Surg 2009 Jun79(6)437-42 Needlescopic versus laparoscopic cholecystectomy a meta-analysis Sajid MS Khan MA Ray K Cheek E Baig MK Department of Colorectal Surgery Worthing Hospital Worthing West Sussex UK
• Single-incision laparoscopic surgery for cholecystectomy a retrospective comparison with 4-port laparoscopic cholecystectomy Chow A Purkayastha S Aziz O Pefanis D Paraskeva P Source Department of Biosurgery and Surgical Technology Imperial College London England
• Laparoscopic versus single-incision cholecystectomy Khambaty F Brody F Vaziri K Edwards C Source Department of Surgery The George Washington University Medical Center 2150 Pennsylvania Avenue NW Suite 6B Washington DC 20037 USA
• Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy Ma J Cassera MA Spaun GO Hammill CW Hansen PD Aliabadi-Wahle S Source From the Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland OR
• Is Smaller Actually Better Needlescopic Surgery mdash A Step Towards (Virtually) Incisionless Surgery Andrei Nadu 1 Department of Urology Sheba Medical Center Tel-Hashomer 52621 Israel
• Surgeons Philoshophy
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44