Minilaparoscopy-assisted transumbilical laparoscopic cholecystectomy

The role of laparoscopy in the modern surgery era is well established. With the prospect of being able to improve the already privileged current situation, new alternatives have been proposed, such as natural orifice endoscopic surgery (NOTES), the method for single transumbilical access (LESS - Laparo-endoscopic single-site surgery) and minilaparoscopy (MINI). The technique proposed by the authors uses a laparoscope with an operative channel like the flexible endoscope used in NOTES. All operative times are carried out through the umbilical trocar as in LESS, and assisted by a minilaparoscopy grasper. This new technic combines, and results from, the rationalization of technical particularities and synergy of these three approaches, seeking to join their advantages and minimize their disadvantages. RESUMO O papel da videolaparoscopia na era moderna da cirurgia encontra-se bem estabelecido. Com a perspectiva de ser possível melhorar a já privilegiada situação atual, novas alternativas têm sido propostas, como a cirurgia por orifícios naturais (NOTES), o método por acesso único transumbilical (LESS - Laparo-endoscopic single-site surgery) e a minilaparoscopia (MINI). A técnica proposta pelos autores utiliza-se de óptica com canal de trabalho como o endoscópio flexível do NOTES, executa-se todos os tempos operatórios pelo trocarte umbilical, como no LESS, e é assistido por pinça de minilaparoscopia. Esta nova técnica combina e resulta da racionalização de particularidades técnicas e do sinergismo destas três abordagens, buscando agregar suas vantagens e minimizar as suas desvantagens.


INTRODUCTION
T he role of laparoscopic surgery in the modern age is well established.With the prospect of improving the already privileged current situation, new alternatives have been proposed, such as surgery through natural orifices (NOTES) and the Laparo-endoscopic single-site surgery (LESS).At the same time, minilaparoscopy (MINI) returned to the agenda with the advent of greater resistance miniaturized grippers.
Among the main indications for minimally invasive techniques, there is cholecystectomy, the most commonly performed surgical procedure in the West 1 .The available literature shows no consensus on the best technical alternative to classic laparoscopic cholecystectomy (LC).In the literature review conducted by Gaillard et al.,   comparing the single-access approaches NOTES with minilaparoscopy, they found that none of these procedures showed benefits superior to LC 1 .Sulu et al. compared the cholecystectomies performed by the four-trocar classic laparoscopic access with those carried out by LESS and found no significant advantages of the latter technique 2 .

Sinha et al. compared LC with LESS cholecystectomy
using multiple transumbilical portals and conventional instruments 3 .LESS showed results comparable to LC, but with longer operative time 3 .In a randomized study, Dabbagh et al. compared cholecystectomies performed by LESS and MINI techniques.Despite displaying the same postoperative complications rates, the minilaparoscopy approach had lower operative time and hospital stay 4 .
In this context, and taking into account the experience of our group in single-access surgery with an endoscope with an operative channel, we set up a fertile environment to the introduction of Laparoscopic Umbilical Monomini Assisted Surgery (LUMAS).In general, this proposed surgical therapy rests on the argument of combining technical features and the synergism of NOTES, LESS and MINI.

Patient, surgical team and equipment positions
We place the patient in supine with the legs separated.The surgeon stands between the legs of the patient and his assistant is on his left (patient's right), facing the laparoscopy equipment, positioned to the patient's right at the level of shoulder.

Operative technique
We conducted a single curvilinear incision of 12mm in the lower umbilical fold.We instilled the pneumoperitoneum through a Veress needle and introduced a 12mm trocar, maintaining the insufflation pressure at

Bucher et al., when comparing C-LESS with LC
in a randomized study, concluded that the single-access route promotes better cosmetic results, less pain and ear-lier return to normal activities 8 .However, other studies reported higher incidence of parietal and biliary complications related to C-LESS 9,10 .
NOTES proposes new accesses and ways to perform minimally invasive operations, in an attempt to reduce surgical trauma and eliminate the complications and parietal scarring.However, it requires knowledge and experience in advanced endoscopy and the use of flexible endoscopic equipment and instruments, which hinders their incorporation by most surgeons.Moreover, these procedures generate some degree of contamination of the peritoneal cavity and closing of the viscera still lacks effective known techniques 11,12 .
These alternative procedures to LC provide better cosmetic results, but do not cause significant advantages over the reduction of postoperative pain, shorter hospital stay, earlier return to normal activities and lower immune response 13,14 .
In this context, it seems logical to search for less invasive alternatives to achieve objectives other than the aesthetic ones.Our group proposed this tactical option when using the endoscope with an operative chan- By consulting the literature using the Pubmed platform, we found the description of cholecystectomy performed with an endoscope with an operative channel and single umbilical access, aided by extracorporeal suture manipulated by crochet needles.We believe that when we use the minilaparoscopy forceps we achieved a more effective traction and exposure of the gallbladder, with greater dynamism and comfort 6,16 .
We believe that the future of minimally invasive surgery is the combination of NOTES, LESS and minilaparoscopy.The micromini uses an endoscope with a working channel, such as the NOTES flexible endoscope, carries out all operative times through the umbilical trocar, as in LESS, and is assisted by a minilaparoscopy clamp.We can therefore say that the technique herein proposed combines, and results from, the rationalization of technical features and the synergism of these three approaches, seeking to aggregate their advantages and minimize their disadvantages, hoping to achieve less invasiveness.
15mmHg.Next, was inserted the Palmer endoscope into the cavity through the umbilical trocar with the Maryland forceps within its working channel.The minilaparoscopy forceps was introduced directly through a 3mm incision at the mid-axillary line level in the right flank under vision and without the need of a trocar (Figure 2).We then percutaneously introduced a 0 multifilament suture with straight needle in the right costal margin, lateral to the midclavicular line.Once inside the cavity, the needle transfixed the gallbladder fundus guided by the Maryland forceps inside the Palmer endoscope, and then exteriorized near the point of its introduction, exerting the required traction to approach the gallbladder to the abdominal wall and facilitate the exposure of the gallbladder pedicle.We performed the dissection of the cystic duct and cystic artery in the usual way with the Maryland forceps, associated with counter-traction of the gallbladder infundibulum exerted by the minilaparoscopy clamp.We ligated the cystic structures with the hem-lok-type clip deployed by a clip applier entered through the operative channel of the Palmer endoscope.Once ligated, the pedicle elements were cut by curved scissors and we proceeded to release the gallbladder from the liver bed with cautery through the hook (both instruments introduced by the endoscope's working channel) with sustained traction by the minilaparoscopy clamp.Before completing the separation of the gallbladder and liver, we took the advantage of the exhibition to double-check the clips andhemostasis of the bloody area.We extracted the gallbladder through the umbilical trocar, by grasping its neck with the Maryland forceps, after releasing the extracorporeal suture from the gallbladder fundus.We proceeded to the aponeurotic suture of the umbilical trocar orifice with a 0 Vicryl® "X" stich or continuous suture, depending on the
nel (Palmer), with minimization of C-MINI, to perform the procedure only with an 11mm umbilical access and another 3mm incision on the right flank.In the proposed laparoscopic technique (micromini cholecystectomy), the forceps introduced through the endoscope operative channel replaces the subxiphoid trocar, the transmural suture replaces the gallbladder fundus tweezers, and minilaparoscopy forceps replaces the gallbladder infundibulum grasper.The Palmer endoscope is manipulated by the surgeon, who performs the main operative times and handles the camera.The control of gallbladder pedicle elements is made by means of the hem-o-lok clip applier.The advantages of this clips type compared with the metal ones are: a) they are radiolucent; b) they provide greater security in ligation, since they have a closing system by lock, which is only triggered if the structure is smaller than the clip range; c) they allow to undo a ligation without damaging the structure; d) they withstand higher pressures; e) and one may safely use monopolar cautery near them.The disadvantage of the higher cost of this device is overcome 209-213 Lima Minilaparoscopy-assisted transumbilical laparoscopic cholecystectomy by the replacement of the disposable trocar, reimbursed by health insurance plans, by the reusable one.Micromini cholecystectomy, as the C-MINI, is attractive when compared with C-LESS and C-NOTES, since it: a) keeps triangulation and proper trine of the Callot's triangle; b) allows the non-static lateral traction of the gallbladder infundibulum; c) Traction is more accessible from the training point of view; avoids intra and extra-abdominal instruments collisions and reversed hands motion.The initial investment in the acquisition of an endoscope with an operative channel is offset by the significant number, in our service, of single-access transumbilical video-assisted appendectomies, laparoscopies for diagnosis and lysis of adhesions in gynecological interventions, and for performing classical laparoscopic cholecystectomies and appendectomies, subtracting one of the trocars.In our experience in LESS cholecystectomy, this endoscope minimizes the collision of instruments, since only two trocars are necessary in the umbilical incision, helping to overcome this limiting factor inherent to this method.Carvalho et al. demonstrated, by means of a mathematical model, that the miniaturization of the gras-pers results in considerable reduction of parietal trauma, compared with the usual 10mm and 5mm trocars 15 .Thus, the micromini cholecystectomy justifies its designation, for it dispenses the subxiphoid 3mm and the midclavicular line 2mm portals of the classic C-MINI.