Over the last two decades, laparoscopic cholecystectomy has replaced open cholecystectomy as the standard surgical procedure for majority of patients of gall stone disease. Till 1999, laparoscopic Cholecystectomy was being performed using multiple ports usually 3 or 4 ports. Intensive desire of surgeon to reduce the number of ports led invention of two port cholecystectomy and then finally single incision laparoscopic cholecystectomy (SILC) .

1. SINGLE PORT ACCESS CHOLECYSTECTOMY: THE INITIAL
LEARNING CURVE

2. Original Article
SINGLE PORT ACCESS CHOLECYSTECTOMY: THE INITIAL LEARNING CURVE*
Radha Govind Khandelwal, Kirubha Shankar and Prasanna Kumar Reddy
Department of Surgical Gastroenterology and Minimal Access Surgery, Apollo Hospitals, 21Greens Lane,
Off. Greams Road, Chennai 600 006, India.
Correspondence to: Dr Prasanna Kumar Reddy, Head of Department of Surgical Gastroenterology, Apollo Hospitals, 21
Greams Lane, Off Greems Road, Chennai 600 006, India.
e-mail: drpkreddy@hotmail.com
Objective: Single port surgery is a rapidly advancing technique with a lot of enthusiasm among minimal
access surgeons. Single port access cholecystectomy (SPAC) is one of the most commonly performed single
port access surgery all over the world. To establish this technique as standard of care for management of
benign biliary diseases, it needs strong comparison with traditional laparoscopic cholecystectomy. Initial
learning curve, cost effectiveness, post operative pain, post operative recovery and complications rate is yet to
be established. Methods: SPAC was performed on 19 selected patients for symptomatic gall stone disease by
a single surgeon at our institute. The SILSTM port was placed in the umbilicus and combination of articulating
and straight instruments were used. Patient characteristics and outcome were reviewed. Results: The main
selection criteria for SPAC were based on clinical history, body mass index, and ultrasonographic findings. The
SPAC had a mean time of 50 minutes. The first single port cholecystectomy took 120 minutes with sequential
improvement in operating time for further cases. The average patient body mass index was 23. No major
complications or conversion to traditional technique occurred. Conclusion: One of the largest series to date of
SPAC for benign biliary diseases in India, performed by a single surgeon in a single institute is presented. We
conclude that it is a safe and reproducible technique with short learning curve for appropriately trained minimal
access surgeons with a higher cosmetic satisfaction for patients.
Key words: Single port access cholecystectomy (SPAC), SILSTM port, Reproducible, Learning curve.
INTRODUCTION
METHODS
Over the last two decades, laparoscopic cholecystectomy has replaced open cholecystectomy as the
standard surgical procedure for majority of patients of gall
stone disease. Till 1999, laparoscopic Cholecystectomy was
being performed using multiple ports usually 3or 4 ports.
Intensive desire of surgeon to reduce the number of ports led
invention of two port cholecystectomy and then finally
single incision laparoscopic cholecystectomy (SILC) .
Until the beginning of July 2009, traditional multiport
laparoscopic cholecystectomy was the standard of care
for the majority of benign biliary diseases. Before that we
tried SILC occasionally for selected cases but we found it
to be difficult to perform. With the availability of SILSTM
port in india, we started to perform single port access
chole-cystectomy using multichannel SILSTM port in
properly selected cases. We retrospectively reviewed the
effect of this transition on operative times and surgical
complications.
Single incision laparoscopic surgery utilizes three
fascial ports through the single skin incision at umbilicus
[1]. With the introduction of single port with multiple
sleeves, now single port access has become a vital option
for cholecystectomies and other commonly performed
laparo-scopic procedures. Single port access surgery is
being considered as no scar surgery, because the single
port is placed within the umbilical ring that is not visible at
all. We conducted a prospective study to assess learning
curve, reproducibility and advantages of this new
technique at our centre, before offering it to all types of
patients of benign biliary diseases.
*Paper presented in IAGES – 2010 held at Delhi on 21 February 2010.
Apollo Medicine, Vol. 7, No. 2, June 2010
132
All patients of symptomatic benign biliary
diseases were evaluated thoroughly, only those
patients who had history of biliary colic, BMI less
than 23 and normal looking gall bladder with no
evidence of acute or chronic cholecystitis and
choledocholithiasis on ultra sonography were
included in the study. Patients characteristics are
demonstrated in (Table 1).16 patients of symptomatic gall
stone disease and 3 patients of adenomyomatosis of gall
bladder were selected for single port access
cholecystectomy (Fig.1).

3. Original Article
area for retraction because of obstruction of calot’s
triangle by liver.
Table 1. Demonstrating the patient characteristics
Patient characteristics
Number
Male
Female
15
Mean age
32
Mean BMI
28
Coronary artery disease
Nil
Diabetes mellitus
RESULT
4
nil
In first two cases both of symptomatic biliary colic that
were attempted for single port access cholecystectomy, we
required an additional ethilon suture for retracting the
Hartman to expose the calot’s triangle. In initial five cases,
we took long operative time due to poor coordination
between assistant holding the Hartman with articulating
grasper and surgeon doing dissection using straight
instrument. In further cases both surgeon and assistant
were tuned up, so operating time was reduced. In two
cases the liver was enlarged and obstructing the calot’s
triangle. To overcome this problem with exposure, an
ethilon suture was passed around the falciform ligament
from the left subcostal area to pull the liver up.
Instead of anterior and posterior dissection of standard
multiport laparoscopic cholecystectomy, right and left
dissection in calot’s triangle performed to expose the
cystic duct and cystic artery. Meticulous dissection was
done to expose the critical window, as in standard LC.
Fig.1.Preoperative indications for Single port cholcecystectomy
Patients were placed in modified lithotomy position. A
20 mm incision was given entirely within the umbilical
ring and single port deployed. Following access and
placement of port, the surgeon stood in between the legs of
patient with the assistant and camera person on left side of
patient. 5 mm 30 degree scope was used in all cases. The
single port access cholecystectomy was commenced by
passing a straight needle with ethilon suture via right
subcostal region for retraction of gall bladder fundus
cephalad. Articulating grasper was used for lateral
retraction of hartmann’s pouch for exposure of calot’s
triangle. The surgeon held the single operating instrument
for dissection, assisted retracted the Hartman pouch with
articulating grasper. Single handed dissection carried out
in calot triangle by surgeon using Maryland grasper or
harmonic scalpel. After skeletoni-zation of cystic duct and
cystic artery and creation of adequate posterior window,
cystic artery and duct clipped using 5 mm clip applicator
and divided. Harmonic scalpel was then used to remove
the gall bladder from liver bed, and the specimen was
removed along with the port.
Additional traction suture was used for Hartman
retraction in 2 cases. In 2 cases, a second ethilon suture
was passed around the falciform from the left subcostal
Therefore, 19 selected patients underwent SPAC
without the need of additional ports or open conversion.
No gross gallstones or spillage of bile noted with ethillon
sutures. Operative time was reduced from 100-140
minutes (initial 4 cases) to 45-65 minutes (last 4 cases).
None of the cases required placement of drain.
All patients were discharged on the next day of
surgery. The operative time of all successful 19 cases of
single port cholecystectomy is shown in (Fig.2).Mean
operative time for our first four cases was 122.5 minutes
while mean operative time for last 4 cases was 62.5
minutes, that is almost similar to standard laparoscopic
cholecystectomy at our centre.
DISCUSSION
Since 1990’s laparoscopic cholecystectomy using
multiple ports around the abdomen is gold standard
procedure for benign biliary diseases. The constant effort of
surgeons to reduce the number of ports to reduce pain and
higher cosmetic demand from patient led to introduction of
Single port surgery in the field of minimal access surgery. In
single port access cholecystectomy, the incision is placed in
the umbilical ring (not around it). This permits a scar less
operation, because the operative scar is hidden in natural
scar i.e. umbilicus. Any port incision is associated with
some potential complications, although the rate of
incidence varies with the port size and type. Port
complications may include hernias, abdominal wall
133
Apollo Medicine, Vol. 7, No. 2, June 2010

4. Original Article
Like prior published series [4,5], we also
included selected cases in our series to start this
technique at our centre. In our series we found that
this technique is associated with higher cosmetic
satisfaction among patients. Furthermore the learning
curve described is specific to the primary surgeon, a
highly experienced laparoscopic surgeon, and may vary
with the comfort level and technical skills of other
surgeons. However, in our personal experience that after
performing the 10 cases of single port access
cholecystectomy, surgeon reaches an adequate level to
perform single port cholecystectomy independently and
effectively.
CONCLUSION
Fig. 2. Operative times ( x-axis - Patient, y-axis - Operative
Time in minutes).
bleeding , bowel injury and wound infection . Reducing the
port incisions from 3 or 4 to one definitely reduces the
incidence of these morbidities. Furthermore Bresadola,
et al showed that in single incision transumbilical
laparoscopic cholecystectomy, using only the periumbilical
port incision reduces the level of pain engendered by
traditional multiport laparoscopic surgery [2].
Kravetz AJ, et al performed single port access
cholecystectomy on all types of biliary disease, including
acute cholecystitis with inflammation and found that this
form of surgery can be performed in all types of biliary
disease with a short learning curve of approximately five
cases, with an obvious cosmetic benefit [3].
Although initial 4 cases took long operative times, the
last 4 cases were performed with operative times comparable to those with multiport cholecystectomy. Because we
eliminated the additional time in putting the additional
ports and the time in retrieving the gall bladder, we
anticipate that our operative time will continue to diminish
to a level below that of multiport cholecystectomy.
One of the largest series to date of single port
cholecystectomy for benign biliary diseases in India,
performed by a single surgeon in a single institute is
presented. We conclude that this technique can be applied
effectively in selected group of patients with benign
biliary diseases in comparable operative time to traditional
laparoscopic cholecystectomy in a safe manner. It is a
reproducible technique with short learning curve for
appropriately trained minimal access surgeons with a
higher cosmetic satisfaction for patients. The loss of basic
laparo-scopic concept of triangulation, instrumental
cluttering and unfamiliar ergonomics are pitfalls of this
technique. With improvement in articulating instruments,
laparoscope and advance training it may stand the test of
time to become a standard technique for all patients with
benign biliary diseases.
REFERENCES
The learning curve for single port cholecystectomy
primarily reflects the difficulties experienced in understanding the spatial restriction due to instruments cluttering
and the camera. As the traditional concept of laparoscopic
triangulation, anterior and posterior dissection (to some
extent), is lost in single port access surgery, so adoption of
right and left dissection in calot’s triangle and acceptance of
some instrumental cluttering by primary surgeon is crucial
for performance of single port surgery. The use of articulating instrument may aid to manage the spatial conflict
of instruments; however it does not eliminate the technical
challenges associated with single port surgery.
Apollo Medicine, Vol. 7, No. 2, June 2010
134
1. Piskun G, Rajpal S. Transumbilical laparoscopic
cholecystectomy utilizes no incisions outside the
umbilicus. J Laparoendosc Adv Surg Tech. 1999; 9:
361-364.
2. Bresadola F, Pasqualucci A, Donini A, et al. Elective
transumbilical compared with standard laparoscopic
cholecystectomy. Eur J Surg. 1999;165(1) :29-34.
3. Kravetz AJ, Iddings D, Basson MD, Kia MA. The learning
curve with single port cholecystectomy. Journal of
society of laparoendoscopic surgeons 2009;13 (3): 332336.
4. Hong TH, You YK, Lee KH. Transumbilical single-port
laparoscopic cholecystectomy: scarless cholecystectomy. Surg Endosc. 2009;23(6):1393-1397.
5. Kuon Lee S, You YK, Park JH, Kim HJ, Lee KK, Kim DG.
Single-port
transumbilical
laparoscopic
cholecystectomy: a preliminary study in 37 patients with
gallbladder disease. J Laparoendosc Adv Surg Tech A.
2009; 19(4):495-499.

5. A o oh s i l ht:w wa o o o p a . m/
p l o p a : t / w .p l h s i lc
l
ts p /
l
ts o
T ie: t s / ie. m/o p a A o o
wt rht :t t r o H s i l p l
t
p /w t c
ts
l
Y uu e ht:w wy uu ec m/p l h s i ln i
o tb : t / w . tb . a o o o p a i a
p/
o
o
l
ts d
F c b o : t :w wfc b o . m/h A o o o p a
a e o k ht / w . e o k o T e p l H s i l
p/
a
c
l
ts
Si s ae ht:w wsd s aen t p l _ o p a
l e h r: t / w .i h r.e/ o o H s i l
d
p/
le
A l
ts
L k d : t :w wl k d . m/ mp n /p l -o p a
i e i ht / w . e i c c a y o oh s i l
n n p/
i
n no o
a l
ts
Bo : t :w wl s l e l . /
l ht / w . t a h a hi
g p/
e tk t n