Review Article
Laparoscopic Cholecystectomy: What has changed Over the Last Three Decades?
Mustafa Hasbahceci*
Department of General Surgery, Bezmialem Vakif University, Turkey
*Corresponding author: Mustafa Hasbahceci, Department of General Surgery, Bezmialem Vakif University, VatanStr, Fatih, 34093, Istanbul, Turkey
Published: 26 Oct, 2016
Cite this article as: Hasbahceci M. Laparoscopic
Cholecystectomy: What has changed
Over the Last Three Decades?. Clin
Surg. 2016; 1: 1166.
Abstract
The surgical management of gallstone disease has undergone significant changes during the last
three decades starting from open cholecystectomy to laparoscopic cholecystectomy and other
minimally invasive techniques like single incision, robotic or natural orifice transluminal endoscopic
cholecystectomy. Considering all of the outstanding features of laparoscopic cholecystectomy
including less postoperative pain, low incidence of complications, similar rates of biliary injury,
shorter length of hospital stay and more rapid return to full activity, it can be regarded as the gold
standard and it is believed that it will continue to sustain its status until the development of a
superior technique and its widespread clinical use.
Laparoscopic cholecystectomy is a rare and precious example of the surgical techniques which
changed the thinking and operating habits of surgeons. Demand and praise of the patients for
laparoscopic cholecystectomy has been another feature which forced the rapid acceptance of the
technique all over the World.
With regard to find a new innovative technique being more minimally invasive operation than
laparoscopic cholecystectomy with a lesser degree of postoperative pain and better cosmetic
outcomes, even creating an incision less surgery, several modifications and techniques have been
tried. However, due to the fact that safety of the patients is a vital issue, these modifications and
techniques should not be performed with a presumable advantage of better cosmetic outcome or
non-significant lesser degree of postoperative pain. But, the experienced surgeons can perform
these innovative technological approaches due to the patient’s desire or as part of ongoing clinical
trials, preferably in the presence of the ethical committee approval or the institutional review board
approval.
Keywords: Cholecystectomy; Laparoscopic; Minimally invasive surgical procedures; Robotic; endoscopic surgery
Introduction
The surgical management of gallstone disease has undergone significant changes during the
last three decades. A German surgeon, Carl Langenbuch, performed the first open cholecystectomy
(OC) in 1882 [1]. This approach has been shown to be an effective method with low morbidity and
mortality, and was accepted as “the gold standard” for the treatment of gallstone disease [2]. However,
with the advent of “minimally invasive” surgical techniques, removal of the gallbladder without
formal laparotomy via laparoscopically is preferred. This major change of the surgical technique for
cholecystectomy has been the trigger of all subsequent developments and improvements.
Although there is still conflicting opinions about the surgeon who performed the first
laparoscopic cholecystectomy (LC), it has been concluded that Muhe, a German surgeon was the
person who performed the surgery in September 1985 [3,4]. Although the procedure was rejected
by the German Surgical Society initially, Muhe was later officially awarded by SAGES (Society
of American Gastrointestinal Endoscopic Surgeons) and he described the procedure with a
presentation in 1999 entitled “The First Laparoscopic Cholecystectomy: Overcoming Roadblocks
on the Road to the Future”. In addition to Muhe, names of other surgeons including Mouret,
Dubois, Perissat, Reddick, McKernan, Berci and Olsen should be mentioned in this context for their
development and establishment of the technique in France and the Unites States [3,5,6]. Later, LC
became the preferred method in many parts of the world and regarded as the “new” gold standard
for cholecystectomy [1].
Initially, this approach was named laser LC due to the use of laser for the gallbladder dissection
from the liver bed [7-9]. In previous cholecystectomies, argon, KTP
532/YAG (neodymium: yttrium-aluminum-garnet) or potassium
titanyl phosphate laser was used. But, it was shown that electrocautery
is superior to laser use in LC and it has been discarded from the current
practice [10]. After that, the term “laparoscopic cholecystectomy” has
been used throughout the World.
It is believed that LC is a rare and precious technique in the
history of surgery which changed the thinking and operating habits
of surgeons quickly and on a broad scale [6]. It is also thought that
the rapidity with which LC gained acceptance was almost initially
consumer driven as well as its generally accepted advantages;
including early discharge, rapid return to daily life and better cosmetic
outcome [11]. In this respect, it has been mentioned that there is no
operative procedure except LC that has been so highly praised and
demanded by the patients in recent memory [12,13]. However, the
issues with regard to the safety and ethics were also questioned during
the introduction and emergence of the technique [1]. Many surgeons
welcomed this approach with skepticism and total disdain, especially
from academic institutions [6,11]. In a meeting of the German
Surgical Society in 1986, the presentation of Muhe was met with
ridicule and his procedure was described as “Mickey Mouse surgery”
or was remarked as “small brain-small incision” [4]. Several authors
tried to explain the role of this new technique as either a milestone
or a dangerous innovation [14]. However, the younger generation,
especially working in the private arena, displayed more enthusiasm
to develop and refine the technique [6,15]. Due to these drawbacks,
it was recommended that it should be introduced by adequately
trained biliary surgeons with laparoscopic expertise due to morbidity
including common bile duct damage and life threatening intraoperative
bleeding [14]. At least diagnostic laparoscopic expertise,
attending a course for LC or observing an expert on LC at a major
center were regarded as the minimum requirements reported during
the World Congress Symposium in 1990 and by the other authors
[8,14]. Additionally, it was also recommended that it should be
performed only by surgeons who can complete the operation in the
standard open fashion [2].
It is noteworthy that an operation can be regarded as the gold
standard shortly after its clinical use even though it has been met
with skepticism initially. Therefore, surgeons should approach new
technological developments with a more informed approach in the
presence of a well-established effective surgical technique, avoid
adopting total accepting or rejecting behavior and encourage careful
and cautious experience in the light of evidence-based medicine
[16,17].
Surgical Outcome of Laparoscopic Cholecystectomy over the Decades
Early data showed that some complications are more common
after LC which can be attributed to the learning curve of experience
when compared to OC [7,11,18,19]. In Martin’s review in 1994, it
was reported that the incidence of major bile duct injury after OC
was thought to be fairly steady at 0.2% to 0.3% [20]. In accordance
with these findings, Deziel reported the contemporary rates of bile
duct injury during OC as 0.1% to 0.2% [21]. Therefore, the rate of
0.1% to 0.3% was the acceptable range for this complication after OC.
However, in the initial reports, the incidence of common bile duct
injury was found to be ten times more common after LC [2,22]. In
Gadacz’s review, the rates of major complications and common bile
duct injury after LC were shown to be 2% (range 1.3-11.2%) and 0.59
% (range 0-1.0%), respectively [16,23]. Based on Deziel’s large survey
series, the rate of bile duct injury after the advent of laparoscopic
surgery was found to be 0.6%, or about twice that associated with
OC [23]. In Lee’s study, the rates of biliary injury and biliary leak
were reported up to 0.5% and 1%, respectively [15]. Additionally,
major intraoperative bleeding and conversion to open surgery could
be seen in up to 4.3% and 5% of the cases, respectively [16,17]. As
a conclusion, the incidence of major bile duct injury was estimated
approximately as 0.5% (range from 0.1% to 0.6%), based on the large
series published up to 1993 [21]. However, it has been also shown
that these complications were going to decrease with expertise
[11]. In the Southern Surgeons Club’s study, it was found that the
incidence of bile duct injury among the first 13 patients and the
subsequent patients operated on by each surgical group were 2.2%
and 0.1%, respectively [7]. In another study of the same group, they
found that 99% of the biliary injuries were performed within the first
30 cases of each individual surgeon [24]. By using a regression model,
they calculated that a surgeon had a 1.7% and 0.17% chance of a bile
duct injury occurring in the first and 50th cases, respectively. In the
Cochrane review published in 2006, the bile duct injury proportions
were reported as 0.2% for both open and laparoscopic groups [25].
Contrary to the early years of LC in which both lacking of laparoscopic
experience and the learning curve negatively affects the outcomes,
today surgeons who are trained in laparoscopy are more familiar with
both anatomic view laparoscopically and the lack of depth perception
[26,27]. Therefore, it can be accepted that laparoscopy does not
inherently place the common bile duct at greater risk, but rather
experience and critical dissection principles are the most important
considerations [28,29]. Therefore, considering 0.1-0.2% of common
bile duct injury after OC, LC with 0.2% incidence of this type of injury
and low incidence of other complications can be regarded as the gold
standard for the surgical removal of the gallbladder [7,15,25,30].
Additionally, because of the perceived improvement in outcome,
the prospect of conducting a randomized trial of LC as compared
with OC quickly became an unrealistic goal [17]. However, small
randomized studies have shown the superiority of LC over OC with
regard to an earlier consumption of a full diet, more rapid discharge
and a shorter convalescence [31,32]. Besides these issues, LC has been
rapidly adopted by most surgeons worldwide and has been embraced
enthusiastically by the public [5,17,27]. Nowadays, it has been known
that LC causes less postoperative pain, low incidence of complications,
similar rates of biliary injury, shorter length of hospital stay and more
rapid return to full activity based on data taken from retrospective
studies [7,17]. Therefore, considering all these outstanding features,
LC will continue to be the gold standard for the surgical technique of
cholecystectomy until the development of a superior technique and
its widespread clinical use.
Other Minimal Invasive Cholecystectomies
Mini-laparotomy cholecystectomy
If cholecystectomy is performed through smaller incisions
over the abdomen, this type of surgery is called a mini-laparotomy
cholecystectomy (MLC) [33]. Although the length of the incision
varied from one study to another, 3.5 to 6 cm was regarded as the
acceptable range for mini-laparotomy incisions. In selected series,
this approach has been shown to have several advantages like an
improved cosmetic outcome over OC, shorter hospitalization
and no need for sophisticated expensive technology like LC [33].
In Ros’s randomized study, the outcomes of LC and MLC were
almost similar [34]. Although this approach has been used for both
elective and emergent cases, it has been known that obesity has
some negative impact on the success of MLC [35]. Although there
were some reports in which MLC has been recommended due to
several advantages like lower morbidity, shorter operation time and
lower cost, it has been also shown that MLC has similar outcomes
with LC in a meta-analysis of randomized studies [36-39]. Cochrane
reviews showed that MLC has similar surgical outcomes with OC
and LC. However, quicker recovery compared with OC and shorter
operation time and lower cost compared with LC were the important
parameters favoring MLC [40,41]. Therefore, this approach can be a
viable, safe and cheap alternative to laparoscopic surgery in patients
who cannot tolerate laparoscopic procedures as their exposure can be
succeeded with smaller incisions [42]. But, recent review of medical
literature revealed that MLC is performed rarely nowadays. In two
studies in which MLC was performed in 383 patients with chronic
and acute cholecystitis in 2014 and 121 patients with high risk in
2010, respectively, this technique was regarded as a reliable and costeffective
alternative [43,44]. A small randomized study of MLC and
LC to evaluate the effect of ultrasonic dissection also showed similar
results with the previous reports [45]. Due to the lack of experience
with MLC for the last several years and similar outcomes with LC in
the previously published studies, recommendation of the technique
does not appear to be a reasonable and valid approach in the current
surgical practice which is dominated by conventional laparoscopic
and minimally invasive laparoscopic approaches.
Mini- or micro-laparoscopic cholecystectomy (MLSC)
It can be possible to perform LC with similar surgical outcomes
using a 1.2-3mm mini laparoscope and four-ports (an 11 mm subumbilical
working port, a 2-mm sub-xiphoid video port, one 2-mm
mid-clavicular retraction port, and one anterior auxiliary retraction
port) in selected patients [46-50]. The success rate with this approach
was shown to be almost 80%. Although there has been no advantage
with regard to surgical outcomes, there was also a modest increase in
operation time [51]. It has been previously shown that this approach
can be a feasible procedure with nearly scarless wounds, especially
in young female and pediatric patients [46]. Postoperative pain and
patient satisfaction with the cosmetic result have been reported as
the two important issues with regard to using such mini-invasive
techniques [52]. However, studies have failed to show the superiority
of MLSC over LC. In addition, use of thinner instruments than
that of conventional LC has been reported as a limitative factor
for performing the surgery especially in obese patients and in the
acute setting. Several authors recommended MLSC only for special
situations including young and thin patients and in elective, noncomplicated
cases due to the fragility of the instruments and longer
operation times [53]. But more research and technical improvement
are required to recommend mini-laparoscopic surgery routinely to
patients due to the technical limitations [54].
Reduced-port laparoscopic cholecystectomy
Although LC has been performed through four ports (two
10 mm and two 5 mm ports), there have been many studies using
less than four ports for LC [55]. In literature, great variances with
regard to the number and diameter of the trocars have been seen.
In studies using two or three ports, a percutaneous sling or traction
sutures to retract the gallbladder for better visualization of the Calot’s
triangle were also needed [56-58]. Although it could be possible to
perform LC via two or three ports in most of the cases, it has been
recommended to use this approach in simple, uncomplicated cases
due to the demanding nature of the technique. Three-port LC
without any traction suture also has been described [59]. Kagaya’s
study via two ports using the twin-port system may be regarded as
the premise form of single incision laparoscopic surgery (SILS) [60].
In randomized studies comparing two- and three-port methods with
standard four-port LC, it has been shown that these approaches with
similar outcomes cause less pain, are less expensive, and leave fewer
scars [61-63]. In combined studies using needlescopic instruments
via two-port method, it has been shown that two-port needlescopic
cholecystectomy is technically safe and feasible and it can be
considered for routine practice by surgeons who are familiar with the
two-port approach [64]. However, a modified port for both telescope
and grasping instruments, and traction sutures were needed to
perform this operation. In Cochrane analysis, it has been concluded
that there was insufficient data to determine any significant clinical
benefit in using fewer than four ports during LC [65]. In accordance
with these conclusions, it is believed that there is no major advantage
in reducing one 5 mm right lumbar port as it neither reduces pain nor
alters the postoperative recovery and it is cosmetically not superior to
the standard four-port LC [46]. There have been very small statistically
significant differences without clinical benefit with regard to severity
of pain, length of hospital stay and cosmetic outcome in the studies
favoring the reduced port LC [66]. Therefore, reduced port LC cannot
be recommended for routine practice except in a few selected young,
female patients or in patients with a short gallbladder and a floppy
liver or in the presence of adhesions between the liver and the parietal
peritoneum preventing traction of the gallbladder [46,67].
Single port/incision laparoscopic surgery for
cholecystectomy
With the advent of minimally invasive techniques, single wound,
port or incision LC is performed via placement of several trocars at
the umbilicus or using special port systems. In these circumstances,
single skin and sheath incision or single skin and separate sheath
incisions at least 2 mm apart from each other or separate skin and
sheath incisions at least 2 mm apart from each other at the same
umbilical site can be performed [46,68-72]. The main advantage of
single incision technique has been thought as the better cosmetic
outcome and lowered incision risks including incisional hernia
comparing four incisions at LC and one incision at SILS [73,74].
However, the term “lowered incision risks” should be evaluated
in detail with prospective studies due to the necessity of a longer
incision at one point. In Christoffersens´ study, no difference in longterm
incidence of port site hernia after single incision and four-port
LC was found [75]. The incidence of incisional hernia was reported
as 4% and 6% after SILS and four-port LC, respectively. It may be
expected to see lower incidence of incisional hernia in four-port LC
due to the smaller length of the incisions. The surgical techniques
for fascial closures in this study were not mentioned in the text;
therefore, this issue should be taken into consideration before a final
conclusion. In Agaba’s study, the port-site hernia rate was found as
2.9% at 30 to 36 months follow-up after single incision surgery [76].
Marks’s study revealed significant hernia rates after single incision
LC compared with four-port LC at the first year follow-up (8.4% and
1.2%, respectively) [77]. Although scores for cosmetic outcome and
patient preference favor single incision LC, port-site incisional hernia
remains a major setback for patients.
In the initial case series for single incision LC, modified
instruments with angulated shafts, magnetic anchors, traction sutures
and loop retractors have been used for the retraction of the gallbladder
with variable success rates [78-81]. There have also been some
modifications for single incision LC including extra-small wound
retractor and a surgical glove as the single port [82]. It is believed that
all of these modifications seem to be the biggest obstacles to reach a
definitive judgment for the recommendation of SILS routinely for the
patients. Although single incision LC has been reported to be safe,
feasible and a promising alternative method for scarless abdominal
surgery, longer operation times and cost due to the technologically
demanding instruments are the main issues for generally using single
incision techniques. Therefore, it is advisable to use this approach
for patients who have a special cosmetic interest. Additionally, this
technique can be routinely performed by experienced surgeons of
laparoscopy and single incision approach.
In Allemann’s review, the analysis of single incision LC on 895
patients revealed that the feasibility of this approach is lacking due to
the absence of standardization and technical variation [83]. In recent
meta-analyses and systematic reviews of single incision LC, it has been
found that this approach offers only a better cosmetic result. However,
it was associated with higher procedure failure, longer operation
times and additional expensive instruments. Significant benefits in
patient overall satisfaction, postoperative pain and hospital stay have
not been shown [84-88]. With regard to the degree of postoperative
pain after single incision and conventional four-port LC, a significant
difference has been detected in SPOCC trial favoring the former one.
However, the difference in mean visual analog scores was only 1 point
(1 and 2 for single incision and four-port LC, respectively) [89]. With
regard to the safety of single incision LC, although the incidence of
common bile duct injury and the overall biliary complication has
been shown to be higher in single incision LC compared with fourport
LC, these differences were not statistically significant [90]. In
another study, higher bile duct injury rate was shown after single
incision LC [91]. Based on these results, it has been concluded that
this new technology cannot be recommended as a standard technique
for LC [46,55].
It is believed that studies should focus on solving the physical and
technical problems encountered during single incision and reducedport
laparoscopic surgery and to improving technical properties
of the instruments. Achievement of adequate triangulation and
an adequate working space are the main principles for successful
laparoscopic surgery. However, operating through a single incision
with several instruments would be a challenging procedure due to a
parallel positioning of the instruments; conflict between instruments
and camera or a crossing arrangement and the fact that the left hand
of the surgeon controls the right instrument. To overcome these
technical difficulties, flexible, curved or the crossed-over articulating
instruments, and semi-flexible endoscopic camera systems have
been developed [73]. However, use of such instruments with lesser
degrees of strength resulted in longer operation times for careful and
precise dissection. In spite of improvements, problems with regard
to triangulation, ergonomics and range of motion of instruments are
still present, so new instruments should be developed appropriate for
this type of surgery.
Robotic Cholecystectomy
Different types of robotic systems during laparoscopic surgery
have been used since 1998. In the previously published reports, it
has been thought that voice controlled robot or self-guided robotic
camera causes better intraoperative ergonomics and optimal camera
guidance, allows the practice of solo-surgery or tele-mentoring and
help to maintain the surgeon’s concentration [92,93]. The first two
international tele-surgical, tele-mentored, robot-assisted LC’s were the
Johns Hopkins Institute, Baltimore, Maryland, USA and the National
University Hospital, Singapore in 2000 [94]. Initially, this approach
was named as computer assisted surgery using the computer–surgeon
interface of a surgical robotic system [95]. In the first experiences
with this technology, it was concluded that computer-assisted
surgery is safe and feasible although it offers no obvious advantages
to patients. However, it has been mentioned that the ability to convert
the surgical act to digitized data or the transmission over a distance
has the potential for revolution of surgical techniques. Later, with the
advent of robotic-assisted technology, the robotic surgical systems
including ZEUS®, AESOP® and da Vinci® have been developed [95,96].
Each system has some advantages and disadvantages [97]. AESOP
robot replaces the camera person with its voice-controlled property.
The tele-robotic ZEUS and da Vinci systems permit solo surgery by
a surgeon from a remote sight. The main benefits of these systems
are three dimensional imaging, endo-wrist full movement capability,
and superior ergonomic conditions for surgeons and prevention of
tremor [66].
It has been shown that use of robotic camera assistant instead
of human camera assistant has small but significant decrease in
operation times (66 minutes versus 74 minutes respectively) [98].
Robot related tasks including set-up of the equipment, sterile draping
of the system, robotic trocar placement, docking and undocking the
robot leading to time loss have been reported as some of the main
disadvantages of the robotic surgical systems [99]. Early comparative
studies revealed that robot-assisted LC requires significantly more
time than conventional LC [100]. Cochrane analysis showed no
significant differences for morbidity, conversion to OC, total
operating time, or hospital stay [101]. Any significant advantages of
robot-assisted LC over human assisted LC have still not been shown
in an update from the Cochrane review [102]. The cost of robots for
LC has been evaluated in several studies [103]. The results showed
that the costs are high and do not justify the use of robots considering
the lack of benefits for the patients.
Hybrid approaches using a combination of robot assisted surgery
with single port have been described and performed by several
authors [104,105]. Although there was no significant difference in
operating times for both single-port robotic cholecystectomy and
multiport robotic LC, the operation times are still not comparable
to the times for standard LC [66]. In Konstantinidis’ study, a novel
robotic platform has been developed and used to get a potentially
more stable and reliable environment for obese patients or with
difficult cholecystectomies [106]. Therefore, there should be more
research to improve single-port robotic technology for achievement
of widespread applicability and acceptance of the technique.
There have been many limitations of the studies using robotassisted
or single port robot- assisted LC. All the cases in these trials
were usually elective, uncomplicated and non-inflamed cases [66]. The
surgeries in these studies have been performed by a limited number
of experienced surgeons, thereby preventing a wide application of
external validity. The operation times, techniques and instruments
have had great variability. In this way, generalizability of these studies
is going to be limited [107]. Although robot-assisted LC has not been
shown to be inferior for the outcomes of conventional LC, due to
the lack of data with regard to generalizability and external validity,
there is a need to perform long term outcome and financial benefit
studies to reach a decision favoring or against these new technologies.
Therefore, clinical use outside trials cannot be recommended, as its
advantages over LC are not evident [66]. In future, the next generation
robots are expected to be more improved leading to a widespread
acceptability [107].
Natural Orifice Transluminal Endoscopic Cholecystectomy
During the evolution of gallbladder surgery, starting from OC
to single incision robotic cholecystectomy, most technical advances
in this area have been met initially with skepticism [108,109]. At the
convergence point of both the gallbladder surgery and the use of
flexible endoscopy, a novel approach using endo-luminal endoscopic
surgical techniques without a visible scar was developed after the first
experience of trans-gastric peritoneoscopy in an animal [110]. It has
been believed that such incision less techniques named as “Natural
Orifice Transluminal Endoscopic Surgery (NOTES)”could help to
reduce surgical pain, decrease anesthesia, shorten recovery time,
avoid hernia formation and adhesions, and eliminate any surgical site
infection and visible scarring [111-113].
It should be mentioned that NOTES technique shares similar
physical and technical limitations with single incision laparoscopic
surgery. The same principles including achievement of adequate
triangulation and an adequate working space are also valid for NOTES.
The parallel positioning of the instruments and crossing arrangement
have tried to be solved by using flexible, curved or the crossedover
articulating instruments, and semi-flexible endoscopic camera
systems. Nevertheless, the problems with regard to triangulation,
ergonomics and range of motion of instruments are still present.
Following the animal survival studies, cholecystectomy as a
technically challenging procedure has been performed through a
trans-gastric incision or via transvaginal route in animals [114-116].
Before the advent of totally NOTES, transvaginal hybrids including
culdolaparoscopic cholecystectomy via transvaginal route have been
performed in humans [117]. Earliest NOTES cholecystectomy in
humans was reported by Marescaux and Zorrón [118,119]. Beside the
use of NOTES in animals and humans for the last decade, it has been
believed that the technique is still in its infancy [46]. Although various
routes including transvaginal, trans-gastric or trans-colonic have
been used, at least one 3 mm or 5 mm umbilical port is also needed
as an initial guide to puncture the peritoneum and at the end to assist
in closure of the defect [46,120]. Initial case series using transvaginal
and trans-umbilical (laparoscopy assisted) routes revealed that
cholecystectomy with NOTES can be routinely performed to reach
an incision less outcome. But, for the hybrid approaches using both
NOTES and assisted laparoscopy, the incision on the umbilicus was
ignored due to the presence of an invisible scar within the umbilicus.
Another hybrid technique including trans-umbilical flexible
endoscopic cholecystectomy with transcutaneous trocar has been
described. The outcomes of this study were reported to be poor. Four
out of 10 patients were converted to conventional LC due to difficulty
in dissection and uncontrollable hemorrhage. Postoperatively, there
was one hemorrhage from the cystic artery and one cystic duct
leak. The authors concluded that endoscope-based trans-umbilical
cholecystectomy yielded unsatisfactory results in humans. Therefore,
improvement of the instruments and accessories are required for
the success of the technique yielding acceptance and feasibility
[121]. In earlier series, NOTES transvaginal cholecystectomy using
a transvaginal 12 mm and two abdominal trocars (2 mm and 5 mm)
has been regarded as an efficient and safe technique [122,123]. Some
researchers have tried to develop totally NOTES cholecystectomy
using two flexible endoscopes through transvaginal route [124,125].
Although the mean operation time was 210 minutes, postoperative
course was uneventful. In Asakuma’s paper, the authors performed
more than 250 cholecystectomies in pigs before the clinical
application of NOTES technique [126]. They believed that such
stepwise experience is an important step in the development of
methods and devices to enable the evaluation of an incision less
NOTES surgery. Review of the medical literature also revealed that
there were many animal non-survival and survival studies with
regard to NOTES before human use [127-130]. NOTES technique
is a condition in which researchers believe that more experimental
training on animals is needed to validate the technique on humans
due to the presence of ethical and technical questions. Initial large
series concluded that NOTES cholecystectomy and appendectomy
via trans-gastric or transvaginal routes are feasible surgeries although
operation times were longer than that of conventional laparoscopic
surgeries [131]. In a German registry with regard to NOTES, it
has been reported that transvaginal hybrid cholecystectomy is a
practicable and safe alternative to laparoscopic surgery. Among the
572 cases, 488 were operated on for cholelithiasis with a conversion
rate of 4.7%. Complications mostly related to the natural orifice
access occurred in 3.1% of all cases [132]. In the earlier studies
comparing transvaginal LC with conventional LC, it has been found
that transvaginal LC is as successful as conventional LC. Although
it was a more time consuming procedure, it can be regarded as an
ideal surgery due to the absence of a visible scar [133-136]. However,
these conclusions should be evaluated with caution due to the small
number of the patients in each group causing underestimated results
[137].
Some specific issues with regard to patient selection and technical
variability in these studies should be questioned. First, the patients with
uncomplicated gallbladder diseases have been included. Additionally,
there have been several modifications including differences in access
points and instruments. Therefore, it seems to be difficult and
problematic to reach a generalizable conclusion from these findings
even though there was no bile duct injury [138]. Although the reports
published previously suggested a promising future for NOTES, due
to significant ethical, procedural, and technological questions, the
benefit of this innovative technique has not been shown. Larger series
and prospective randomized trials are needed to delineate the exact
risks and the safety of this approach, because the supposed benefits of
better cosmetic outcome should not outweigh the risks of potential
immature application [138,140]. To overcome all of these problems
associated with NOTES, the approach used during the introduction
and emergence of LC can be taken into consideration. Due to the fact
that an increased rate of major bile duct injury and other technical
problems for LC were real issues at the beginning, teaching programs
organized by the surgical scientific community were started all
over the world to adopt the technique [141]. With the help of such
programs, it has been possible to interest the academic communities
in the widespread application of LC with great success.
A Summarized Approach to Modified LC Techniques
After the introduction and emergence of LC, there have been many modifications using different port numbers, variable sized instruments and ports, different combinations of these parameters, and various techniques like NOTES. The idea of all these modifications is to perform a more minimally invasive operation with a lesser degree of postoperative pain and better cosmetic outcomes, even creating an incision less surgery [142]. However, the established and accepted principles of LC should be provided. Safety of the patients especially with regard to the risk of major bile duct injury during LC is a vital issue. These modifications should not be performed with a presumable advantage of better cosmetic outcome only. Additionally, clinically significant difference in the degree of postoperative pain favoring these modified LC approaches has not been shown by previous studies. Therefore, modified LC techniques should be performed only by experienced surgeons in selected circumstances. In cases of any difficulty, the team should not hesitate to place additional trocars or to convert to open surgery.
Conclusion
After its introduction and emergence, LC has been accepted as the gold standard for surgical treatment of gallbladder disease. During the initial period of LC between 1993 and 1994, it was mentioned that surgeons should approach new technological developments in a more attentive manner i.e. LC in the presence of a well-established effective surgical method or OC, avoid adopting total accepting or rejecting behavior and encourage careful and cautious practice in light of evidence-based medicine. However, these phrases didn’t lose their value. It is still possible to state that surgeons should approach new technological developments in a more attentive manner, like single incision laparoscopic surgery, robotic surgery or NOTES in the presence of a well-established effective surgical practice i.e. LC. Therefore, it is believed that LC is the current gold standard technique and surgeons should perform LC routinely for their patients first. However, the experienced surgeons can perform these innovative technological approaches due to the patient’s desire or as part of ongoing clinical trials, preferably in the presence of the ethical committee approval or the institutional review board approval.
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