Laparoscopic Bikini Line Cholecystectomy

Abstract

Laparoscopic cholecystectomy (LC) approach is accepted as the gold standard in gallbladder surgeries in the world. However, today, cosmetic expectations of patients have led surgeons to define new surgical techniques that do not create visible scar on the abdominal wall. Two common and well-known techniques for this purpose are natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SİLS). These techniques have long-learning curve and difficulty of implementation, so that have not become widespread. Alternatively, the placement of laparoscopic ports in less visible areas of the body such as the bikini line, termed alternative port site selection (APSS), may result in further improved cosmesis. Laparoscopic Bikini Line Cholecystectomy (LBLC) can be classified into two main groups as Full Bikini Line Cholecystectomy (FBLC) and Modified Bikini Line Cholecystectomy (MBLC), depending on inputs of the ports.

1. Introduction

The cosmesis is very important topic nowadays. Surgeons try to hide and minimalized visible scar that they try to found new techniques which has less visible scar and better cosmesis. Laparoscopic cholecystectomy is the most commonly performed procedure for gallbladder operations. However, it causes visible scars due to trocar entry sites on the abdominal wall [1]. New alternative surgical techniques are tried to be defined in order to hide scars. NOTES and SİLS are the best known methods [2, 3, 4].

İn the NOTES technique, the abdominal cavity is reached by entering through natural orifices such as the vagina, urethra, stomach, and colon [5, 6, 7]. But this technique doesn’t seem cost-effective, require long learning period and has complications due to unsafe closure of the orifices.

İn the SİLS technique, LC is performed with a single umbilical port. İn this technique, proximity between the hand tools creates difficulty in working, and the need for extra tools creates a serious cost [8, 9, 10].

For these reasons, NOTES and SILS could not be a widely used method for gallbladder surgery.

There is a need for new techniques for cosmetic results, easy application and low risk of complications for frequently applied LC surgery. The placement of laparoscopic ports in less visible areas of the body such as the bikini line, termed alternative port site selection (APSS), may result in further improved cosmesis [11].

Different option of bikini line cholecystectomy has been defined by surgeons [12, 13, 14, 15, 16, 17, 18, 19, 20]. These techniques may combine two main titles that Full Bikini Line Cholecystectomies (FBLC) and Modified Bikini Line Cholecystectomies (MBLC).

The trocars insert on pfannenstiel line in this technique which hides the trocar scar on bikini line area.

These technics and modifications can be easier to learn and can perform easily and safely. These techniques hide the trocar scar behind bikini and the one of natural orifice umbilicus. The cosmesis of this procedures are best then classical approach.

2. The Pfannenstiel or so called “bikini line incision”

Pfannenstiel incision, which is especially used in gynecology was described by a German Gynecologist Herman Johannes Pfannensteil in 1900. It has excellent cosmetic result, rare incisional hernia complication rate and low rate nerve damage complication [21].

3. Full bikini line cholecystectomies

İn this technique, all trocars are inserted into the bikini line. This technique was described to using 1, 3 and 4 port by researchers (Figure 1). Degano et al. firstly described video-laparoscopic cholecystectomy with suprapubic approach which used tree port on full bikini line 12. Twenty-nine cholecystectomy were performed using this personal technique of which only 2 had to be converted to open surgery. Monika E. Hegan, et al. described a new single port technique (SILS) for cholecystectomy. They have carried the umbilical single port into the bikini line 16.

Figure 1.

a-1, b-3 and c-4 port Full Bikini Line Cholecystectomies and port replacement.

F Ersöz et al. aimed to provide maximal cosmesis by placing 4 ports in the bikini area (Figure 2). While this technique provides success in cosmesis, it can cause organ injuries in patients who have undergone operations in the pelvic area. These techniques do not require extra instruments and can be performed with normal laparoscopic tools.

Figure 2.

Four port full bikini line cholecystectomy.

4. Modified bikini line cholecystectomies

These methods aim to provide safety and convenience in surgery practice.

İn this techniques, surgeons start the procedure by inserting a 10 mm or 5 mm trocar from the umbilicus and other trocars enter through the bikini line by seeing (Figures 3 and 4). İn this technique, 2, 3 or 4 port options were described by surgeons [13, 14, 15, 17, 19, 20].

Figure 3.

a-2, b,c-3 and d,e-4 port Modified Bikini Line Cholecystectomies and port replacement.

Figure 4.

The view of four port replacement.

Two port technique need a traction for bladder with by outside structure [14]. There were only two operation performed by two port technique. Tree and four port techniques are the most preferred because they are safe and easy. İn these techniques camera port and work port can change that this is an advantage of the easy work. Surgeons working with the 3 port technique suggest inserting an extra 3 mm or 5 mm port if needed [17, 20]. İn one study, a mixed method was preferred by entering a 3 mm trocar from xiphoid or right hypocondrium for the traction of the gallbladder [19, 22].

Modifications to Bikini Line Cholecystectomy provide an easier and safer surgery while preserving cosmesis.

For this reason, frequency of MBLC techniques and randomized studies are significantly more numerous.

4.1 Patient selection

İn the selection of the patient, previous abdominal and pelvic operations, age, obesity, general condition of the patient and cosmetic expectations should be taken into consideration.

4.2 İnclusion criteria

• All group of adult age of women and man (15–65).

• Symptomatic gallbladder diseases (cholecystolithiasis and bilayer colic attacks, acute and chronic cholecystitis, polyp).

• BMI (Body mass index) ≤ 40 patients.

4.3 Exclusion criteria

• Gynecologic conditions such as endometriosis, inflammatory pelvic disease, myomatosis and may keep from operation.

• Adhesions which developed after pelvic and abdominal operations such as hysterectomy, bladder operations.

• BMI of >40 kg/m² and advanced abdominal obesity.

• Pregnancy.

• ASA ≥ III patients.

• >65 age.

• Patients taller than 1.85 cm.

4.4 Operation position

Patients are operated under general anesthesia with reverse Trendelenburg position and open legs (Figure 5). The operation area is disinfected with povidone iodine. A urinary catheter is necessary. Prophylactic 1g cefazolin iv is administered. A nasogastric tube may place in the stomach during the operation.

Figure 5.

Operation position.

5. Modified Bikini Line Cholecystectomy (MBLC) procedure

In our 4 port modified technique, we entered the first 10 mm trocar from the incision site we made into the belly with an open technique and placed the other three ports in the bikini area under camera view (Figure 6). In this way, we are trying to place other trocars safely [23].

Figure 6.

Port entry points.

5.1 Four port operation technique

First, an 11 mm midline incision is made into belly button by working on the right of the patient in a straight position.

The pnömoperitoneum is performed by opening technique with a 1 cm median umbilical incision.

Hasson trocar is placed in the abdomen with a 0 no vicryl U suture passed through the fascia.

The abdomen is insufflated with CO₂ at a pressure of 14 mm Hg. While the surgeon is working between both legs, first assistant checks the laparoscope on the left side. The second assistant provides to retraction of the gallbladder on the right side of the patient. One 10 mm trocar is placed on midline and two 5 mm trocars placed on the right side of bikini line by protecting epigastric vessels (Figure 7). Then the operating table is tilted 30° in reverse Trendelenburg and 15–20° to the left. The laparoscope works through a 10 mm trocar on the bikini line. The lateral 5 mm trocar is used for gallbladder traction, while the medial 5 mm trocar is used as a working port.

Figure 7.

İntraabdominal view of port entry points and epigastric vessels.

However, all ports could be used as working ports depending on the intraabdominal features. Standard laparoscopic cholecystectomy equipment is used, but sometimes may need long instrument (Figure 8). Dissection and clipping of artery and ductus cysticus is performed from the 10 mm umbilical trocar.

Figure 8.

Operation instruments.

The gallbladder is separated from the bed with a hook or other devices, it is worked retrograde. The gallbladder is visually removed from umbilicus. The laparoscope is entered from the umbilicus and observes any bleeding during the removing trocars and intervention when necessary. Drain is placed through the right 5 mm trocar of the patient. Fascial opening in the umbilicus is closed with 0 vicryl. Skin openings are closed with 3/0 absorbable sutures subcutaneously (Figure 9).

Figure 9.

Post-operation view.

Between March 2019 and March 2020 MBLC was applied to a total of 38 patients in our clinic. They were 35 women and 3 men. The age of patients ranged from 15 to 65 years [23].

5.2 Advantages of four port MBL technique

While the umbilical trocar leaves no visible scar, it provides important guidance on the evaluation of pelvic area and the patient’s suitability of the technique.

The umbilical port can be used both as a camera and a working port.

While the sufficient angle formed between the working ports provides ease of dissection, clipping can be done easily from umbilical port.

This technique is cost-effective as no extra working tool is required. But rarely long hand tools may be preferred in patients with a long distance between the gall bladder and the bikini area.

Epigastric vessels could be seen and after that the trocars could be entered.

The gallbladder is preferably visually removed from the umbilicus. In this way, it can be protected from possible strain, perforations, bile leakage and abdominal stone falling.

Learning time and ease of application are easier than NOTES and SILS.

The fact that all of the patients expressed significant satisfaction with the cosmetic result showed that the esthetic results of the technique were satisfactory (Figure 10).

Figure 10.

Postoperative six months view.

6. Discussion

BLK, which was defined by Degano et al. in 1995, was applied to more than 750 patients with different modifications. In generally, biliary colic, acute and chronic cholecystitis, gallbladder polyp are indications. Advanced age (>65), advanced obesity (BMI > 40) and abdominal obesity, ≥ ASAIII patients had previous pelvic region surgeries, myomatosis, pregnancy, height >1.85 cm are the exclusion criteria stated in the publications [17, 24, 25, 26, 27, 28]. Although this criteria differ in publications, the common emphasis is that potential difficulties should be considered in patient selection. It should be known that the difficulty of surgery may increase significantly in the presence of a large distance between the bikini line and the gallbladder, severe abdominal obesity, adhesions around the gallbladder, advanced inflamed and gangrenous gallbladder [23].

The entrance of the first umbilical trocar is preferred after the pneumoperitoneum with Veress or from the umbilicus with the open technique. This approach allows to be placed other trocar by evaluation of pelvic area, it prevents possible injury to the epigastric vessels and other important structures. İf the single port technique is left aside, the procedures can be performed with 2, 3 or 4 ports.

In all studies, standard hand tools were used, but it was emphasized that long tools may be needed in limited cases.

These surgical procedures are the same as classical laparoscopic cholecystectomy and do not require additional training.

During the procedures, the functions of the ports can be changed according to the needs. For example, depending on the surgeon’s request, the umbilical port can be used both for optics and as a working port.

Operation times vary in studies. However in most of the studies, no significant difference was found with classical LC.

İn tree same studies in the literature with 4 ports technique, average operation times are 53.3, 28.65, 54.65 minute respectively [17, 23, 29]. It can be thought that surgical experience is effective in operation time.

In an analysis of before 2013, the total 275 cases was determined and found that the rate of conversion was % 1,04 (n = 20). This is similar to the CLC.

These surgical procedures are a little more difficult but the similar to CLC and do not require special training.

One coleperitoneum was reported in a patient in Degano’ series in 1995, and then no serious mortality or morbidity was reported in any subsequent study. After that, one intraabdominal hematoma, five seroma in the trocar side and one intraabdominal abscess were reported up to 2023. All complication could be treated conservatively [17, 20, 27].

Patients were generally discharged on 1st or 2nd day.

İn most of the studies, it was emphasized that the technique was safe in the conclusion section.

Cosmetic results stand out as an important factor in patient satisfaction.

There is a limited number of randomized studies on MBLK, outcomes were measured patients characteristics, operative time, operative and postoperative complications, recovery, hospital length of stay, cost, analgesia required after surgery, and cosmetic results. The Visual Analog Score (VAS)and The Patient Satisfaction Score (PSS) also were evaluated in two group.

İn 2013, Lei Zhang et al. randomized 75 patients into CLC (n = 35), MBLC (n = 40) groups. They used 3 port. No patient was converted open procedure in two groups. There were no operative complications within 30 days in either two group. The Visual Analog Score (VAS) for pain was significantly lower in the MBLK group on post-operative day 3 compared with the CLK group (P = 0.01). The Patient Satisfaction Score (PSS) of 7 and 30 days after surgery were significantly higher into MBLK group then in the CLC group (p = 0.02). İn conclusion they said that MBLK is a safe and feasible alternative compared with CLC in experienced hands, and it is superior for outcomes regarding pain control and cosmesis.

İn 2022 Sieda, et al. randomized 416 patients into CLC (n = 216), MBLK (n = 200) groups. There were no differences between both groups about the baseline (age, gender, BMI) characteristics. Operative time was nearly same, one day case surgery better, recovery time faster and length of stay better than CLC group. They found that postoperative pain was significantly lower, and cosmesis was better in MBLK group. İn this study, it was concluded that it can be applied safety in patients up to a BMI of 40.

7. Conclusion

Laparoscopic Bikini Line Cholecystectomy technique provides a satisfactory cosmetic result for patients by hiding the trocar entry sites in the umbilicus and bikini line area. The important advantages of this technique are that it does not require special training and extra tools.