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Invited Critique
August 14, 2009

Single-Incision Laparoscopic Cholecystectomy Using a Flexible Endoscope—Invited Critique

Arch Surg. 2009;144(8):738-739. doi:10.1001/archsurg.2009.130

Laparoscopic cholecystectomy revolutionized not only surgery but all of health care. Its development is also a study in how medicine can be transformed against the best advice of content experts. The first 100 LC operations were performed using rigid cystoscopy instrumentation by Eric Mühe, MD, in Germany. Because of severely limited exposure, the operation was considered dangerous and Dr Mühe was severely criticized by his colleagues. Shortly thereafter, the French developed a videoscopic approach to the operation that was somewhat better but still not well accepted by the surgical community. Experts in biliary surgery were concerned about the lack of exposure and the potential for serious bile duct injuries. They predicted that this new approach was a fad and would disappear once the higher complication rate become evident. The first publications describing the new approach reported a bile duct injury rate that was 10-fold higher than expected, whereupon the experts anticipated the early demise of LC.

It did not happen that way. Patients were intrigued by the notion that they could undergo major abdominal surgery without a large incision. Whereas the quoted complication rates that could occur following a laparoscopic operation were low and, therefore, of remote interest to patients, the prospect of a large, painful scar was very real. Cholecystectomy is common and patients went in droves to those surgeons offering the new approach. Oftentimes, they bypassed traditional, well-respected institutions and surgeons when seeking this new form of treatment.

We learned a great deal from this. Patients pay little attention to the facts and figures that we quibble about in academic meetings. They do care about painful scars. They will go to the practitioners who offer what patients want, irrespective what the experts say. Laparoscopic cholecystectomy also taught us that patients do not need to linger in hospitals for days on end when recovering from surgery. They could eat immediately following major abdominal surgery. The move toward outpatient surgery and shorter hospital stays for all types of operations are a direct extension of the lesson learned from LC. We also learned that the most transformative changes in health care come not necessarily from government-funded research enterprises but from the ideas and operating rooms of individual clinicians interested in finding better ways to take care of patients.

Laparoscopic cholecystectomy revolutionized surgery 2 decades ago. In an era that has witnessed the advent of personal computers, cell phones, wireless communication, and other major engineering advances, the approach to and instrumentation used for LC has remained remarkably stagnant. Progress is made in periodic upheavals rather than by evolutionary change. It is time for another major improvement in the approach to laparoscopic surgery.

Enter single-incision operations. Binenbaum and colleagues describe the use of a flexible endoscope to facilitate cholecystectomy. This article is important in 2 ways. It is one of the first studies to describes a series of SILCs. Given the limitations in exposure and mobility, does the reduction in three 5-mm port sites really improve matters? Our patients' answer will be a resounding “yes.” Whether it is rational or not, the promise of fewer scars will appeal to our patients' imaginations. Perhaps this is fueled by a drive for risk-free living that is pervasive in today's society. Our patients want their medical problems dealt with with the least amount of disfiguring pain and inconvenience possible. The second aspect of this study that is important is that the move toward single-incision surgery will drive the invention of new surgical instrumentation that will facilitate better laparoscopic surgery. Today's tool set for laparoscopic operations looks little different from those that were made available 20 years ago when the field started.

The next generation of laparoscopic instrumentation will be flexible and not rigid. Flexibility overcomes the limitations of current rigid devices that force one to place multiple ports solely to get sufficient angulation and visualization of the structures being operated on. Flexibility of instruments will enable one to approach the abdominal viscera from any angle, facilitating surgery performed through fewer ports. Development of flexible instruments will also make laparoscopic surgery easier for surgeons with less specialized training because a great deal of the skill involved in minimally invasive surgery is in knowing how to place ports and get the most out of a primitive tool box.

The authors point out the difficulties in using a flexible instrument during laparoscopic surgery. The devices are unwieldy and take several people to operate them. This is because there have been few flexible devices built for laparoscopic surgery. The device of the future will be computer controlled, capitalizing on modern technology and its ability to manage complex instrumentation with simple controls. A Microsoft Xbox–type controller is optimal for this purpose. Today's young surgeons are very experienced with this technology and can manipulate complex events via a series of buttons and levers. They will have no need for the very expensive and cumbersome robotic systems used in today's operating rooms. The new generation of surgeons will be able to manage complex laparoscopic tools with video-game controllers as easily as an unskilled construction worker can expertly control a backhoe via a series of hydraulic levers.

We are on the cusp of a revolution in medical instrumentation. Binenbaum and colleagues have taken the first shaky step in a new direction in which we will all be headed within a few years.

Correspondence: Dr Livingston, Gastrointestinal/Endocrine Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Room E7-126, Dallas, TX 75390-9156 (edward.livingston@utsouthwestern.edu).

Financial Disclosure: None reported.