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UCSF Surgeons Perform First Single-Incision Gallbladder Removal

Ruzanna Harutyunyan's picture

Surgeons at UCSF have taken a major step down the path toward less invasive procedures, performing San Franciscos first gallbladder removal using only a single, small incision hidden within the navel.

The procedure, which took place in May, is a significant advance in the field of minimally invasive surgery, said UCSF Medical Center gastrointestinal surgeon Dr. Jonathan Carter, who led the surgical team. "Over the last 20 years, many of the big surgical innovations have involved doing operations using less invasive techniques," Carter said. "Our ultimate goal is bloodless, incisionless and painless surgery. With the single-incision laparoscopic surgery, we've moved another step in that direction."

Carter's team performed the surgery using a new device called the SILS Port, an instrument manufactured by Covidien that received Food and Drug Administration clearance in January. SILS stands for "single-incision laparoscopic surgery."

The SILS Port is a flexible plug that can be placed within a small incision in the navel. The surgeon can then insert up to three laparoscopic instruments — such as scissors or forceps — through holes in the plug. This design feature eliminates the need for multiple incisions to accommodate multiple instruments operating simultaneously. Conventional gallbladder removal, for example, requires four separate incisions.

To date, only several hundred patients in the United States have undergone single-incision gallbladder removal, Carter said. But the potential market is huge: more than 500,000 Americans undergo conventional gallbladder removal every year.

Single-incision surgery takes roughly the same amount of time as multiple-incision surgery, and the technique is similar to — albeit more demanding than — conventional laparoscopic gallbladder surgery, Carter said. The main benefit is cosmetic, he said, but other potential benefits are less pain, less scarring, less risk of infection, and a faster recovery.

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"I think this is something the market will drive, as people seek to avoid visible scars on the abdomen, he said. That potential benefit was one of the things that convinced Carter's inaugural gallbladder patient to agree to try the SILS procedure.

The patient began having pain in her upper abdomen in April 2008, but doctors initially had trouble identifying the source of the problem, she said. "I would have these episodes where I couldn't sit up, couldn't stand," she said. "I wouldn't stop throwing up until I got to the emergency room."

Although one scan of her gallbladder showed no signs of gallstones — a condition that affects 10 percent of Americans — another scan showed abnormal gallbladder function. The patient chose to undergo surgery rather than wait for the next episode to occur, she said. "I was referred to Dr. Carter, and he mentioned single-incision surgery," she recalled. "I was definitely interested in hearing more."

After discussing her options at length with Carter and watching an online video of a procedure using a SILS Port, the patient agreed to give it a try. On May 4, she underwent San Francisco's first single-incision gallbladder removal. She was back at home the next day and back to work two weeks later, she said.

As of late May, the patient was recovering well, but said her abdomen was still slightly tender and the surgical incision was still quite visible — something Carter said was normal at that stage in the healing process, which could take up to six months.

Eleven days after the inaugural surgery, Carter performed another successful operation using the SILS Port, this time to remove the appendix of a 20-year-old woman with acute appendicitis.

Carter said that he chose his initial two patients carefully, and that not everyone is a good candidate for single-incision surgery. Patients who are obese, have had prior major abdominal operations or present with severe inflammatory disease should opt for the conventional approach, he said. In addition, Carter cautions that the benefits of single-incision over multiple-incision surgery are still being evaluated. "We dont know if there is a significant improvement in recovery time, hospitalization time, use of pain medications or return-to-work time," he said.