Table Of ContentC R
ASE EPORT
Single-Access Transumbilical Laparoscopic Unroofing
of a Giant Hepatic Cyst Using Reusable Instruments
Giovanni Dapri, MD, Matteo Barabino, MD, Pietro Carnevali, MD, Ion Surdeanu, MD,
Jacques Himpens, MD, Guy-Bernard Cadie`re, MD, PhD, Vincent Donckier, MD, PhD
ABSTRACT INTRODUCTION
Introduction: Single-access laparoscopy has garnered Since the advent of laparoscopy, the removal of liver
growing interest in recent years in an attempt to improve lesions using minimally invasive techniques had been
cosmesis, reduce postoperative pain, and minimize ab- reported to be feasible and safe.1–3 Because of laparos-
dominal wall trauma. copy, the postoperative pain, the hospital stay, and the
abdominal trauma can be reduced, besides an improved
Case Description: A female patient suffering from a
comfort of the patient. Furthermore, the laparoscopic
symptomatic giant biliary cyst of the liver segments
techniquehasalsotheadvantageofminimalscarringand
4-7-8 was admitted for transumbilical single-access
fewer adhesions, thereby increasing the feasibility of re-
laparoscopic cyst unroofing. The procedure was per-
peat liver resection.4
formed using a standard 11-mm reusable trocar for a
10-mm, 30°- angled, rigid scope and curved reusable Single-incision, single-port, single-site, or single-access
instruments inserted transumbilically without trocars. laparoscopy(SAL)hasgarneredgrowinginterestinrecent
Operative time was 90 minutes, and the final incision years, in an attempt to minimize the abdominal wall
lengthwas14mm.Theuseofminimalpainmedication trauma, to reduce postoperative pain, and to overall im-
permitteddischargeonthethirdpostoperativeday,and prove the cosmetic outcomes.5
after25months,thepatientremainsasymptomaticwith
Nonparasiticlivercystsareusuallyasymptomatic,butab-
a no visible umbilical scar.
dominal pain due to their enlargement,6 physical signs
Conclusions: Giant biliary cysts can be removed by sin- such as obstructive jaundice,7 complications such as rup-
gle-access laparoscopy. Because of this technique, sur- ture8orintracystichemorrhage,9canoccurduringfollow-
geons work in ergonomic positions, and the cost of the up. Hence, surgical treatment may be recommended
procedure remains similar to that of the multitrocar tech- mainly to relieve symptoms or to prevent potential com-
nique.Theincisionlengthandtheuseofpainmedication plications.However,arelativelylowrateofriskforrecur-
are kept minimal as well. rencehasbeenreported.6,10–12Preoperativeconsideration
basedonpatientage,habitus,cysticsize,aspect,andliver
KeyWords:Livercyst,Unroofing,Single-incision,Single-
segment location is necessary.
port, Single-site, Single-access, Laparoscopy.
Fenestrationorunroofingnonparasiticcystshasbeenfirst
describedinopensurgeryin196813andbylaparoscopyin
1991.14–15 Recently, because of the growing popularity of
other minimally invasive techniques, SAL has been pro-
posed. Cyst unroofing may be a good candidate for SAL
DepartmentofGastrointestinalSurgery,EuropeanSchoolofLaparoscopicSurgery, because no sophisticated laparoscopic maneuvers, such
Saint-PierreUniversityHospital,Brussels,Belgium(Drs.Dapri,Barabino,Carne- asPringlemaneuverorhepaticveinclampsarenecessary,
vali,Surdeanu,Himpens,Cadie`re).
rendering this procedure easier to be performed.
DepartmentofAbdominalSurgery,LiverUnit,ErasmeUniversityHospital,Brus-
sels,Belgium(Dr.Donckier). We report a SAL biliary cyst unroofing performed com-
G.DapriisaconsultantforKarlStorz-Endoskope(Tuttlingen,Germany).Theother pletelythroughtheumbilicus,inapatientpresentingwith
authorshavenoconflictofinterest.
a symptomatic giant cyst of the liver segments 4-7-8.
Addresscorrespondenceto:GiovanniDapri,MD,FACS,FASMBS,FPALES(Hon)
DepartmentofGastrointestinalSurgery,EuropeanSchoolofLaparoscopicSurgery,
Saint-Pierre University Hospital, 322, rue Haute 1000 Brussels, Belgium, E-mail: CASE REPORT
[email protected]
A 53-year-old female with a body mass index of 20.8
DOI:10.4293/108680812X13427982377300
kg/m2 was referred for a symptomatic pain in the right
©2012byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. upper quadrant. The patient had no history of previous
296 JSLS(2012)16:296–300
surgery, and she was undergoing medical therapy for The cystic dome was identified and incised enough to
arterial hypertension. The chest X-ray showed a minimal emptythecysticcavitywiththesuctiondevice.Becauseof
elevation of the right diaphragmatic dome, and the ab- this maneuver, a nonconnection between the biliary cyst
dominalcomputedtomography(CT)scanrevealedasim- andthebiliarytreewasevidenced.Acompleteexcisionof
plebiliarycyst15cmx14cmindiameterintheapexofthe thecysticroofwasperformedusingcoagulatinghookand
liver segments 4-7-8, besides to polycystic liver and kid- bipolarscissors.Becauseofthecurvesoftheinstruments,
neys (Figure 1). the classic working triangulation during laparoscopy was
establishedinsidetheabdomen,andsurgeonwasableto
Transumbilical single-access laparoscopic giant biliary cyst
work in ergonomic positions during the entire procedure
unroofing was proposed to the patient. An incision in the
(Figures 4a and 4b). A custom-made plastic bag was
umbilicus was realized, a 1-cm opening in the fascia was
introduced into the abdomen through the 11-mm trocar,
created,anda1polydiaxone(PDS)purse-stringsuturewas
and the tissue specimen was placed inside and removed
placedinthefascia.An11-mmreusabletrocarwasinserted
transumbilically.Thecysticcavitywasfinallycheckedfor
inside the purse-string suture, and pneumoperitoneum was
bleedingandwasleftopenwithoutanomentalpatch.The
created. A 10-mm, 30°-angled, rigid, standard-length scope
gallbladder was not removed, and the procedure ended
(Karl Storz-Endoskope, Tuttlingen, Germany), and curved
with the removal of the instruments and trocar under
reusable instruments (Karl Storz-Endoskope, Tuttlingen,
view. A meticulous closure of the umbilical fascia and of
Germany) were used. The curved instruments were ad-
the separate window for the grasper was performed, to
vanced transumbilically without trocars. The curved grasp-
avoid development of incisional hernia.
ingforcepsIII(Figure2a),keptinthesurgeon’snondomi-
nanthand,wasinsertedthroughaseparatewindowoutside
thepurse-stringsutureatthe10o’clockposition.Theother
RESULTS
curvedinstrumentsforthesurgeon’sdominanthand,suchas
the coagulating hook (Figure 2b), the bipolar scissors Totaloperativetime(betweenskinincisionandclosureofthe
(Figure2c),andthesuctiondevice,wereinsertedinside fascia)was90minutes,andlaparoscopictime(betweenbegin-
the purse-string suture and besides the 11-mm trocar at ning of pneumoperitoneum and removal of the instruments
the 3 o’clock position (Figure 3). andtrocar)was81minutes.Bloodlosswaslimitedto50mLand
Figure1.PreoperativeabdominalCTscan.
JSLS(2012)16:296–300 297
Single-AccessTransumbilicalLaparoscopicUnroofingofaGiantHepaticCystUsingReusableInstruments,DapriGetal.
Figure 3. Placement of curved instruments, scope, and purse-
stringsuturethroughtheumbilicalincision.
nally and externally (Figure 5a, 5b, and 5c), and the
surgeon maintains ergonomic positions.
No specific ports and only 1 conventional reusable 11-mm
trocarfortheopticalsystemandatransumbilicalinsertionof
theinstrumentswithouttrocarsareusedinthisspecificSAL
technique. Thus, a technique to avoid loss of the pneumo-
Figure2.a,2b,and2c.Curvedreusableinstrumentsaccording peritoneumisadoptedandconsistedintheplacementofa
toDAPRI:graspingforcepsIII(a),coagulatinghook(b),bipolar purse-stringsutureintheumbilicalfasciaandinsertionofthe
scissors (c) (courtesy of Karl Storz-Endoskope, Tuttlingen, Ger- instrument(eg,thegrasper)forthesurgeon’snondominant
many). handoutsidethesuture,throughaseparatefasciawindow.
The grasper is never changed during the entire procedure,
noadditionaltrocarsneededtobeinserted.Thefinalumbilical whereas the other instruments for the surgeon’s dominant
scarwas14mminlength.Pathologicalexaminationshoweda hand (eg, the coagulating hook, bipolar scissors, and the
benign, simple biliary cyst. Use of minimal pain medication suction device) are continuously changed. Hence, they are
permittedthedischargeofthepatientonthethirdpostoperative introduced inside the purse-string suture and alongside the
day.After25months,thepatientremainsasymptomatic,with- 11-mm trocar. The purse-string suture is sufficiently tied to
outrecurrence,andtheumbilicalscarisnotvisible. avoid loss of the pneumoperitoneum and opened only to
allow the instruments to be changed, or to evacuate the
DISCUSSION smokecreatedduringthedissection.
Laparoscopic surgery with the advent of SAL frequently An11-mmtrocarisusedbecauseitallowsthemaintenance
bypassesoneofitsrules,whichisworkingintriangulation ofpneumoperitoneumduringtheentireprocedureandthe
withthescopeatthebisectorofthisangle.16Anoptionfor useofa10-mm30°-angledscope.Anotherpossibilityisthe
obtaining working triangulation inside the abdomen can use of a 5-mm flexible scope (EndoEye camera system,
be offered by the use of articulating instruments, which OlympusMedicalSystems,Tokyo,Japan),whichsimultane-
permit achieving this principle at the usual cost of the ouslypermitsanincreaseinthespacebetweenthehandsof
surgeon crossing either hands or the instruments’ tips. thecameramanandthesurgeonoutsideoftheaccess,17but
Alternatively, the use of curved instruments can establish aremainingproblematicfactoristheconcomitantreduction
the classic laparoscopic working triangulation both inter- ofthemagnifiedqualityoftheimage.
298 JSLS(2012)16:296–300
In the technique described here, the umbilical fascia
openingforthe11-mmtrocarandforthesurgeon’sdom-
inant hand instruments allows the specimen to be re-
moved without enlarging the opening or necessitating
replacementbyalargertrocar.17Furthermore,becauseof
this simple approach, the length of the umbilical scar
remainssimilartotheincisionrealizedforaconventional
12-mm trocar; otherwise, an increased incision length is
required for the insertion of multiple trocars through the
same incision17 or through the same port-device.5,18
Another advantage of the technique reported here is the
cost of the procedure, which appears to be the same as
multitrocar laparoscopy, because all of the materials uti-
lized are reusable.
Here, we have reported a case that was feasible for tran-
sumbilicalSAL,butappropriateselectionbasedonpatient
age,habitus,cysticsize,aspect,andliversegmentlocation
is necessary to decrease the incidence of additional tro-
cars’ insertion or the conversion to laparotomy. Obvi-
ously, if some perioperative complications occur, such as
uncontrolledbleedingorbiliaryspillage,theinsertionof1
or more additional trocars is mandatory. The use of per-
cutaneousstitches19orintroductionofmillimetricwireare
alternative options to help in the cystic dome retraction20
or operative field exposure.21
Technically, we emptied the cyst at the beginning of the
procedure, permitting a precise resection of the cystic
dome margin under simple tissue retraction by the
grasper.Weusetoperformthesetypesofliverresections
Figure 4. a and 4b. Single-access cystic roof excision (a) per- byeithercoagulatinghookorbipolarscissorsalsoduring
formedunderergonomicposition(b). multitrocar laparoscopy, hence we adopted the same
strategy in SAL. However other instruments such as har-
Figure5a,5b,and5c.Theconceptofthecurvedinstrumentsisbasedonthestraightclassicinstruments(a)ofthetriangulationangle,
bothexternally(b)andinsidetheabdominalcavity(c).
JSLS(2012)16:296–300 299
Single-AccessTransumbilicalLaparoscopicUnroofingofaGiantHepaticCystUsingReusableInstruments,DapriGetal.
monic shears (Ethicon Endosurgery, Cincinnati, OH)20,22 7. Eriguchi N, Aoyagi S, Tamae T, et al. Treatments of non-
or a LigaSure device (Covidien New Haven, CT)17 can be parasiticgianthepaticcysts.KurumeMedJ.2001;48:193–195.
used. In contrast to other authors,17 we did not place a
8. MssrouriR,ChicheL.Spontaneousruptureofhepaticbiliary
transumbilicaldrainattheendoftheprocedure,toavoid cysts.JChir.2009;146:294–296.
possible umbilical incisional hernia formation during fol-
9. Takahashi G, Yoshida H, Mamada Y, Taniai N, Bando K,
low-up.Ifadrainhastobeleftinthecavity,betterwould
TajiriT.Intracystichemorrhageofalargesimplehepaticcyst.J
betomakeasecondincisionintheabdomen,whichcan
NipponMedSch.2008;75:302–305.
also be used from the beginning of the procedure for an
additional instrument (eg, needlescopic grasper). 10. DonatiM,StavrouGA,WellmannA,FlemmingP,DonatiA,
Oldhafer KJ. Laparoscopic deroofing of hepatic cysts: the most
Werecordedatotaloperativetimeof90minutes,including effectivetreatmentoption.ClinTer.2010;161:345–348.
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11. MorinoM,GarroneC,FestaV,MigliettaC.Laparoscopictreatment
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final closure of this latter. Our operative time remains in
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13. Lin TY, Chen CC, Wang Sm. Treatment of non-parasitic
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18. CaiXJ,ZhuZY,LiangX,etal.Singleincisionlaparoscopicliver
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