Hepatobiliary Surgery

Abstract

Carl Langenbuch first reported the procedure of cholecystectomy in 1882. He used an open approach then which remained unchanged for more than 100 years (Bittner, Langenbecks Arch Surg 389:157–163, 2004). In 1987, Philippe Mouret performed the first video-assisted laparoscopic cholecystectomy (LC) in Lyon, France (Kaiser and Corman, Surg Oncol Clin N Am 10:483–492, 2001). LC was a significant advancement, removing many of the objections that patients had to go under open cholecystectomy. It is now considered world-wide as the “golden standard” because of its unquestionable advantages in terms of smaller incision, reduced postoperative pain, shorter hospital stay, and faster return to normal activities when compared to the traditional open approach (Soper et al., Arch Surg 127:917–921, 1992; Schirmer et al., Ann Surg 213:665–676, 1991; Johansson et al., Br J Surg 92:44–49, 2005). Laparoendoscopic single-site cholecystectomy (SILSC), which emerged as a form of natural orifice surgery, was first described in 1995 (Navarra et al., Br J Surg 84:695, 1997). Hypothetically, the benefits of laparoendoscopic single-site surgery (SILS) would include those of the conventional multiport laparoscopic procedures in association with improved cosmetic results and patient satisfaction as the operation is performed through just one incision.

The application of SILSC is in its infancy, but gaining significant momentum. Experience with single incision laparoscopic technique, is growing rapidly. With advancements in laparoscopic techniques and the development of new instruments, more complex operations are being approached laparoscopically, including resection of malignant intestinal tumors (Lai et al., Arch Surg 144:143–147, 2009; Adani et al., Surgery 145:452, 2009; Sarpel et al., Ann Surg Oncol 16:1572–1577, 2009; Choh and Madura, Surg Clin North Am 89:53–77, 2009). Laparoscopic biliary-enteric anastomosis has been reported for benign biliary tract disease (O’Rourke et al., Am J Surg 187:621–624, 2004; Chokshi et al., J Laparoendosc Adv Surg Tech A 19:87–91, 2009). All of these have made it possible to perform laparoscopic bile duct exploration, bile duct reconstruction, biliary bypass, and resection of congenital choledochal cyst and high cholangiocarcinomas, all through a single incision. Besides that, some complex hepatic procedures such as liver resection has been reported using the SILS technique (Binenbaum et al., Arch Surg 144:734–738, 2009; Hodgett et al., J Gastrointest Surg 13:188–192, 2009; Hong et al., J Laparoendosc Adv Surg Tech A 19:75–78, 2009; Fagotti et al., Fertil Steril 92:1168.e13–1168.e16, 2009; Fader and Escobar, Gynecol Oncol 114:157–161, 2009).

Evidence to support routine use of single incision laparoscopic hepatobiliary surgery is still lacking, but this approach can be considered an alternative and may be applied in a selected group of patients. Despite the rapid uptake of SILS techniques, it has become increasingly clear that there still remain issues that need to be addressed; among which, safety is of utmost importance. SILS hepatobiliary surgery requires a unique technical skill set, with ergonomic and technical demands that are different from conventional laparoscopic skills, exhibiting a learning curve even for expert laparoscopic surgeons. Only through a fully implemented system of proficiency-based progression can competent laparoscopic surgeons be ensured to further advance the technique. It is the intention of this section to detail our current techniques for SILS hepatobiliary surgery.