Introduction

Laparoscopy has gained widespread recognition in common surgical practice not only for its optimal diagnostic ability but more importantly for the possibility of treating various types of abdominal pathologies [1–3].

Laparoscopic cholecystectomy is the gold standard technique performed in all hospitals, and by every surgeon. It is a challenge that all beginners have to face, gaining expertise and experience in the laparoscopic approach.

Laparoscopy has recently been characterized by the increasing use of smaller laparoscopes, trocars and operative instruments, in order to minimize even more nerve and muscle damage and to optimize aesthetic results [4–11].

As a consequence, minilaparoscopy has been gradually employed in the treatment of several pathologies, such as inguinal hernias, appendectomy and cholecystectomy. However, the feasibility and possible benefits of minilaparoscopy compared to conventional laparoscopy are still not completely clear and controversial. Some investigators have found it to be more expensive due to long operative time in their hands [12].

There is also a considerable confusion regarding terminology.

Minilaparoscopy, micro-laparoscopy, micro-endoscopic surgery, needlescopic surgery and micro-invasive surgery are all synonyms often used.

We prefer the general term minilaparoscopic surgery for any procedure that uses endoscopic instruments—and optics—equal to or less than 5 mm in diameter. This definition of minilaparoscopy surgery must be a strict definition: the equal to or less than 5 mm must be applied to the main trocars used and the total incision being no more than 25 mm [12, 13].

Our institution has routinely used minilaparoscopy since 2000 for the treatment of various abdominal pathologies, such as appendectomy, spermatic vein legations, diagnostic and inguinal hernia repair (in this last one 3 mm instruments diameter are used) and last but not least, colon resection [5, 10, 11].

In 2005 we did a study, although not randomized, of minilaparoscopic cholecystectomy (5 mm MLC) versus conventional laparoscopic cholecystectomy (LC) [14]. Due to the good results we had with the 5 mm MLC, we have since then used 5 mm MLC routinely.

The aim of this case-series study was to prospectively evaluate the patients who underwent 5 mm MLC during a 5-year period, focusing attention on feasibility, safety, and the benefits of having general surgeons carrying out 5 mm MLC. We also want to discuss a few technical aspects such as the site of the trocar insertion.

Materials and methods

Between August 1st 2005 and July 31st 2010, a total of 887 patients at our institution underwent 5 mm-three trocars minilaparoscopic cholecystectomy (5 mm MLC). They represented 40.8% of all the laparoscopic procedures (total 2,170 cases) done in the same period. 123 (13.8%) 5 mm MLC were done as emergency acute cases (of which 29 had a gangrenous component). 25 patients had a preop CPRE while an intraop cholangiography was performed in 11 cases.

Focusing on the demographic data, there were 354 men and 533 women, with a median age of 45 years (range 17–91). The mean BMI ± SD (kg/m2) was 27.1 ± 4.4. Moreover, in 17 patients, suffering from concomitant associated pathologies, the following procedures were performed in the same scheduled setting: 4 appendectomies, 6 adhesiolyses and 7 inguinal hernia repair—TAPP.

During the same period of time in a subgroup of 45 young (median age 28, range 19–42), thin (BMI 22.3 ± 1.1) female patients, a 3 mm MLC was performed (Table 1).

Table 1 Demographic data and summary of the results
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Technical aspects

Three trocars and general anaesthesia plus local anaesthetic injected at the port sites are used, as well as a 30° optic of 5 mm in diameter. No disposable instruments are used. While the surgeon is standing between the legs of the patient and the assistant surgeon on the patient’s left hand side, the first trocar of 5 mm is normally inserted through a left hypochondrium incision at Palmer’s point (direct trocar technique). After total abdominal cavity inspection, the other two trocars are inserted: a 10 mm one in the umbilicus and a 5 mm one in the right hypochondrium. 5 mm titanium clips are applied at the cystic duct and artery. The gallbladder is retrieved through the umbilicus (normally inside an endobag). If needed a drainage is left in situ through the right hypochondrium trocar skin incision. The peritoneum and fascia are usually closed at the umbilicus with a absorbable suture. If needed it is possible to carry out an intraop cholangiography with the introduction of the Olsen catheter through the right hypochondrium trocar.

In the 3-mm approach, the positions of the trocars are similar to those used in the 5-mm procedure with the addition of a 10 mm trocar in the supra-pubic area (which is needed to retrieve the specimen, to apply the clips and if necessary for the drainage. The peritoneum and fascia are usually also closed with absorbable sutures) The optic is a 30°/3 mm in diameter and all the instruments are 3 mm in diameter.

Results

No postoperative deaths were reported. The mean operative time was 47.56 min (±31.2) for both the approaches (while it was 60 min ± 31.4 in the conventional historical one—data already published) [14]. We had two cases (0.2%) of conversion to laparotomy in the 5 mm—emergency group (due to unclear anatomy as a consequence of longstanding severe inflammation) (0.4% in the conventional historical group—data already published) [14]. In two 5 mm cases (0.2%), one in the scheduled and one in the emergency 5 mm group, there was a need for redo-surgery: in the emergency case due to a diffuse bleeding from the gallbladder bed, an attempt to control it by laparoscopy was started and abounded, and as the bleeding was not controlled a laparotomy was necessary. In the scheduled case it was due to a biliary peritonitis, caused by the clips having been applied too loosely at the cystic duct during MLC. This mistake was successfully corrected laparoscopically (0.4% in the conventional historical group—data already published) [14]. In the 5 mm-three trocar group there was the need to add a trocar in the epigastrium—in order to better face the Calot triangle—in 95 cases (10.7%) (of whom 41–33.3% were emergency cases). In none of the cases was it necessary to change the size of the instruments, trocars and optics. There were no intraop complications, no conversions or need to add or change size of trocars in the 3 mm MLC.

The global postoperative hospitalization was 2.0 day (range 0–5.2 days). In 15 cases of the 3 mm-MLC group the procedures was done on a day surgery basis—and this is not the custom in our country. The oral intake was resumed within the first 24 h in all the patients. Minor occurrence ranged as high as 2.1% (19 cases) in the 5 mm MLC and it was nil in the 3 mm group (4.4% in the conventional historical group—data already published) [14]. Regarding analgesic use, during hospital stay, we normally use a standard analgesic regimen of oral paracetamol 1 g/TID. Only 14.2% of the patients (126 cases) needed a further treatment (Khetorolac im) in the 5 mm MLC and 6.6% (3 cases) in the 3 mm MLC (10% in the conventional historical group—data already published) [14]. The mean follow-up of the entire series is 51.4 (±7.1; range 6–60) months. We have registered three cases of hernia (0.3%) at the trocar site of insertion (umbilicus) in the 5 mm group (all scheduled cases), which were treated with a local anaesthesia approach and direct suture of the defect (0.4% in the conventional historical group—data already published) [14]. In the 5 mm group more than 90% of the patients resumed working within 7 days, the remainder within 14 days maximum. We have registered the same percentage in the 3 mm MLC (Table 1).

Discussion

Laparoscopy has gained widespread acceptance in common surgical practice as a diagnostic and therapeutic tool. The natural evolution of this technique are threefold. Number one is the use of robotic for ease of use and precision of surgery [15, 16]. Number two is the use of fewer trocars and the use of miniaturize instruments to reduce invasion to a minimum [17–36] and, number three, the recently reported single port approach [37–39]. Number one is not reproducible in every hospital situations, because of the problem of costs/benefit, while the second one seems to be applicable and feasible almost everywhere. Concerning number three there are several reports about this technique, for the treatment of different pathologies, but there is still as yet lack of evidence about it.

In 2005 we decided, due to the good results of an our early experience with MLC [14], to standardize the technique both scheduled and emergency procedures, using three trocars of which one is of 10 mm diameter in order to take out from the abdomen any specimen and two of 5 mm diameter and all instruments and optic of this last diameter.

Following the standardization of the technique, 887 patients admitted for acute or chronic cholecystopathy have been managed with this standard method by all members of our team. In the same period, an additional 45 young and thin female patients have undergone a 3 mm MLC.

The following is an analysis of the advantages of our experience regarding its indications, morbidity, mortality and also its socio-economic impact.

Indications

The technique has been performed in emergency and scheduled patients and by all the members of our team, experienced and beginner surgeons (under the supervision of a competent laparoscopic surgeon). Our results have been equal to the results we obtained with our use of the conventional laparoscopic approach and the results reported in the international literature—although these present several methodological (study design) and clinical (outcome measures) heterogeneities (Table 2) [17–36]. We have used 3 mm MLC only in a small scheduled group of 45 young and thin patients. In this group, in order to retrieve the specimen, to apply the clips and to leave—if necessary—a drainage, we put a fourth 10 mm trocar in the supra-pubic area. This position was chosen for cosmetic reasons only.

Table 2 Summary of the evidence reported in the two meta-analysis of RCTs of MLC and LC
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Instruments

The 3 mm optic differs from the 5 and 10 mm optic in that it has less depth of vision; however, its resolution and quality of vision is similar. The lack of depth of vision can be easily overcome in these procedures by bringing the optic nearer to the operative theatre. This cannot be done always in LC. The 5 mm optic is equal to the 10 mm one, in its quality of image and as we have already stated, there is never any need to change it during the procedure. Regarding the instruments, all the tools are available in the size of 5 mm (scissors, dissector, needle holder, pick up, hook, clips and so on). They are the same that everyone uses and is so familiar with for all conventional laparoscopic procedures. The 3 mm instruments and optics are smaller and finer and therefore more prone to damage or breakage, which has cost implications.

Treatment options

The 5 mm-three trocars MLC allows the same surgical procedures to be undertaken as for the conventional approach [17–36]. In our experience, the length of surgery is equal if not less than that of our historical LC (47.56 min ± 31.2 min and 60 min ± 31.4), and all the surgeons of our team are able to “reproduce” the technique with no need to “rewrite” the single surgeon’s learning curve. Concerning the number of trocars used, in 10.7% of the patients (95 cases) we had to put in one further trocar (with no related morbidity added), mainly in the acute setting, in order to better see and manage the Calot triangle. The number of trocars is not so important as the basic need to securely complete the procedures [13–40]. The “idea” of performing a minilaparoscopic approach in the treatment of pathologies such as varicoceles and hernia disease avoids the unnecessary removal of any specimen, which would need a bigger trocar and incision (as for cholecystectomy). Moreover, the possibility to utilize a mesh that might be introduced into the abdominal cavity through a 5 mm trocar instead of a 10 mm one, enables the possibility of miniTAPP [10]. For 5 mm MLC the problem is the necessity to remove a specimen normally bigger than 1 cm in diameter. For this reason we prefer to use in the umbilicus one 10 mm trocar in order to retrieve through it the gallbladder with the stones inside, placed inside an endobag. In the 3 mm MLC, a fourth—10 mm trocar is used in the supra-pubic area.

Conversion, morbidity and mortality

Our experience shows the feasibility of 5 mm-three trocars MLC in the treatment of acute and chronic cholecystopathy, with results comparable and equal to those reported for the conventional one [17–36].

Hospital stay

Hospital stay after 5 mm—three trocars—cholecystectomy is the same as the conventional procedure, but patients experience less pain, a faster recovery and return no normal activities [17–21, 26, 27]. It is difficult to say that, in a laparoscopic procedures such as a cholecystectomy, the pain is only or mainly due to the size and number of trocars. We think that pain is more related to the degree of the disease (acute and or chronic setting), the length of the surgery procedures (as a consequence of the experience of the surgeon!), and the individual patient’s medical history (related pathology) and idiosyncratic reaction. But surely the number and size of trocars might play a role regarding possible trocar-related complication (above all, herniation) and, why not, pain. In fact, the area of the wound for a 10 mm trocar is four times greater than for a 5 mm trocar [13, 40]. We have had the same results using the 3 mm MLC. We have used this approach only in selected patients and mainly for cosmetic reasons. Although the results in this group are encouraging, no real evidence has been shown due to the small number of cases.

Costs

The costs are equal to the conventional procedures, due to the use of the same instruments and optics. Further advantages of the proposed technique consist of cosmesis and also in a decrease of operative trauma. The latter might result in a reduced incidence of incisional hernias and possible complications (haemorrhages) at the site of trocars’ insertion.

Patient perception

The technique carries an unquestionably positive patient perception of surgery, thanks to its advantages. As a consequence, there is an ever-growing request from the lay public. Regarding postoperative pain, there are some controversial data in the literature: some authors experienced a decreased use of analgesic therapy in patients approached with minilaparoscopy compared to a laparoscopic group [27–31], while others report different results (without anyway significant drawback concerning hospital stay and return to working activity) [12]. In our experience it appears difficult to really evaluate the impact of mini-skin incision in term of postoperative pain, but it should be noted that less than 15% of our patients required an addition of analgesic therapy to our standard p.o. regimen (since 2005 we no longer use a la demande analgesia).

The surgeon

It still remains a crucial issue. A well-trained and experienced surgeon together with a well-trained team is a necessary requirement for 5 mm MLC (as it should be for the conventional laparoscopic approach). This is especially true in emergency cases. In order to offer patients the same chance of cure, at our Institution the technique of 5 mm-three trocars MLC has become the standard, after an early and confirmed good experience, and as a consequence all members of our team (the experienced and the beginners) have shown comparable results thus showing the technique to be easy, feasible and above all reproducible. In our opinion a minilaparoscopic experience and background should be part of the professional education of every laparoscopic surgeon.

Conclusions

On the basis of our experience all 5 mm-three trocars MLC is feasible, effective and easy to perform (without any increase in technical difficulties). The technique provides acceptable and comparable results concerning the operative time, the postop morbidity and hospitalization as those already reported for conventional laparoscopy. According to our idea and experience, the 3 mm MLC should only be considered in a small group of selected patients (young, thin, scheduled) and mainly for cosmetic reason. Most of the advantages of laparoscopic surgery rely on the minimal access and as a consequence the benefits of this technique will be greater as the access becomes smaller in size and reduced in number. Sparing patients a wider skin incision at the trocar sites might reduce postoperative pain, increase prompt recovery of gastrointestinal functions, shorten hospitalization, help contain health-care costs and increase cosmesis [13–31]. This approach appears to play a crucial role in the laparoscopic treatment of all kinds of cholecystopathy. On these grounds further studies need to be conducted to confirm our encouraging results.