Surgical Endoscopy

, Volume 24, Issue 12, pp 3038–3043

Reduced-port surgery: preservation of the critical view in single-port-access cholecystectomy


  • Erica R. Podolsky
    • Department of SurgeryDrexel University College of Medicine
    • Department of SurgeryDrexel University College of Medicine

DOI: 10.1007/s00464-010-1081-3

Cite this article as:
Podolsky, E.R. & Curcillo, P.G. Surg Endosc (2010) 24: 3038. doi:10.1007/s00464-010-1081-3



Over the past 3 years, minimal-access surgery has seen movement toward single-port-access (SPA) surgery. Since its inception in the spring of 2007, a number of differing approaches and technologies for reduced-port surgery have become available to move the field toward “scarless” surgery. As with any advance, a cautious eye needs to observe changes with respect to the risks and benefits of new procedures or devices. Although the adoption of reduced-port techniques in cholecystectomy may move the field of surgery forward, there is a need to ensure that basic tenets of safety are not left behind. In cholecystectomy, one of the gold standards for safety is preservation of the critical view of safety during cystic duct dissection and transection.


Early in the development of SPA surgery, a standardized procedure was sought that could be extended safely to laparoscopic surgeons. With this ideal in mind, the technique of SPA cholecystectomy was evaluated early. Deeming exposure to be critical, specifically the view of the cystic-to-common duct relationship beneath the liver, the authors aimed to evaluate whether this critical view of safety can be maintained during the procedure and before the cystic port is clipped and transected. To determine reproducibility, the authors did a simple comparison of their initial 10 two-instrument SPA cholecystectomies with their subsequent 10 three-instrument cholecystectomies by reviewing the videos of each case.


The authors’ review confirmed that the critical view of safety was obtained in all the three-instrument cases but was difficult to obtain in the two-instrument procedures. In addition, they were able to demonstrate the critical angle of clip placement in all three-instrument cases.


The authors present their initial results in an attempt to demonstrate that as new procedures develop, there is a need to ascertain their safety and adherence to underlying principles already established before advancing them further at the risk of compromise and complication.


CholecystectomyTechnicalSingle port access surgeryComplicationsSingle incision laparoscopic surgeryCommon bile duct

The field of minimally invasive surgery is dynamic. Introduced more than a century ago with diagnostic peritonoscopy [1], a series of technological advances enabled therapeutic interventions. In the late 1980s, general surgeons turned the laparoscope to the right upper quadrant and performed the laparoscopic cholecystectomy (LC) [2], initiating a radical change in the practice of general abdominal surgery. Since then, both the breadth and complexity of laparoscopic procedures have continued to expand rapidly. The benefits of this advancement have included decreased postoperative pain, resulting in decreased hospital stays and quicker return to daily activities [1] and revolutionizing the practice of surgery. This desire to improve outcomes seems never-ending.

Almost contradictory to the basics of surgery itself, natural orifice transluminal surgery (NOTES) was introduced with the potential of eliminating surgical incisions [36]. This platform, a radical change from current minimally invasive procedures, will require new access and technology. In addition, we may see changes in the technical approach to dissection that will differ from standard laparoscopic techniques and define new safe standards of dissection. Perhaps this is why we have seen NOTES advance slowly.

Conversely, 3 years ago, single-port-access (SPA) laparoscopic surgery emerged as a novel technique of abdominal entry via a single incision for laparoscopic procedures. Subsequently, it was applied to multiple organs and across specialties [711]. Since then, we have seen various techniques and access devices introduced [1216] as this new approach grows. Its adoption has been widespread. The corporate marketing of this new technology may be the driving force, perhaps altering the goals of surgical advancement.

It must be considered that reduced-port techniques may be a steppingstone toward scarless surgery, or these procedures may simply emerge as an alternative access technique for traditional multiport laparoscopy. In either case, SPA surgery has gained popularity, and the safety of this new approach needs to be weighed and measured. Probably due to the large number of cases managed, LC again appears to be the lead procedure as reduced-port techniques are reported [1215, 17, 18].

Although initially met with skepticism almost two decades ago, LC became the most common procedure performed, with open cholecystectomy currently reserved for conversion. Interestingly, we are again seeing similar skepticism and concerns as surgeons migrate toward reduced-port techniques. One of the primary concerns previously was and currently is the possible deviation from safe standards and whether these new approaches truly offer any benefits.

In LC, the incidence of common bile duct (CBD) injuries compared with that in open cholecystectomy has been followed. A rise in the incidence of CBD injury was observed initially, almost halting the progression of LC. In reaction to this observation, the American College of Surgeons reviewed possible causes of this complication and made suggestions regarding safer outcomes [19]. As a hallmark of safety, the relation of the cystic duct to the CBD and liver during dissection was defined by Strasberg et al. [19]. This “critical view of safety” offered a technique to help prevent an increase in CBD injuries. This has been adopted as a crucial step in laparoscopic removal of the gallbladder that avoids injury to surrounding structures.

To obtain and maintain this critical view of safety, a four-port technique (1 port for visualization, 2 ports for independent retraction of the gallbladder and liver, and 1 port for dissection) for cholecystectomy was used. Given the small area of entry with the reduced-port, single-access techniques and devices, many clinicians abandon one of these trocars, resulting in a three-trocar technique. We recognized this alteration in technique and hypothesized that this may alter safety and could result in increased complication rates. Although our first SPA cases were managed with two instruments, our technique evolved to include a third instrument. Subsequently, this allowed us to compare the two approaches.

We aimed to evaluate the safety of our technique with the addition of a third instrument. We retrospectively reviewed video recordings of 20 early SPA cholecystectomies: 10 performed with the two-instrument technique and 10 performed with the three-instrument technique. In each case, we specifically evaluated for exposure and maintenance of the critical view of safety. We present our early reconciling of a new technique and safety standards already established in both open and multiport cholecystectomy.


The videos of 20 SPA cholecystectomies performed by a single surgeon were retrospectively reviewed by an independent reviewer not present during the procedures. These procedures were 20 of the first SPA cholecystectomies performed by the primary surgeon (P.G.C.) from May 2007 through October 2007.

All 20 procedures were performed via a 1.5- to 2-cm incision within the umbilicus using the SPA technique already described [20, 21]. A 5-mm trocar was inserted in the center of the incision under direct visualization (Optiview; Ethicon, Cincinnati, OH, USA). Lateral skin and soft tissure flaps then were raised from the fascia. Two very-low-profile 5-mm trocars (Hunt Cannula; Apple Medical, Marlborough, MA, USA) were placed superolaterally within the incision.

In the first 10 cases, a two-instrument technique was used. One trocar was placed for the scope, and two very-low-profile trocars were placed for the two operative instruments (Fig. 1A). Articulating Maryland dissectors and graspers (Realhand; Novare Surgical, Cupertino, CA, USA) were used in early cases. The right-sided instrument was used for cystic duct and artery dissection, clipping, and cutting. The left instrument was used to retract the gallbladder and liver (Fig. 1B).
Fig. 1

A Two-instrument setup (schematic). B Internal picture of the two-instrument technique

In the second set of 10 patients, a second rigid grasper was placed transfascially without a trocar in the inferior position within the single incision. This allowed a three-instrument technique, mimicking multiport cholecystectomy (Fig. 2A). One rigid grasper was placed directly through the fascia to provide independent fundal retraction of the gallbladder and support for the liver, whereas the other grasper provided independent infundibular manipulation (Fig. 2B).
Fig. 2

A Three-instrument setup (schematic). B Internal picture of the three-instrument technique

The initial SPA procedures were video recorded. These videos were reviewed by a surgeon not present for the cases specifically to evaluate adequate exposure of the cystic duct, cystic artery, and CBD relationship. It was noted in each case whether the critical view of safety was clearly obtained. In addition, the extent of the angle of separation of the cystic duct and CBD was evaluated.


A comparison was made between 10 procedures performed with the two-instrument technique and 10 procedures using the three-instrument technique. The indications varied from acute to chronic pathology (Table 1). The review of the 10 videos showing the cholecystectomies performed with the two-instrument technique demonstrated that the critical view of safety could be obtained but not maintained or consistently reproduced for dissection, clipping, and transection because both operative instruments were required to expose this view. We could not maintain opposing upward retraction of the fundus (and liver) and outward and lateral retraction of the infundibulum with a single instrument (Fig. 1B).
Table 1

Demographics for 20 single-port-access cholecystectomies: Two- versus three-instrument procedures




Biliary akinesia












In 1 of the 10 patients, a subxypoid trocar was added to provide additional retraction. In this case, the critical view could be obtained after addition of the instrument but not before.

With the three-instrument technique, we were able to maintain independent retraction of the fundus and the infundibulum of the gallbladder as we do in multiport cholecystectomy (Fig. 2B). This allowed us to obtain the critical view in the technique described by Strasberg et al. [19] with independent retraction upward on the fundus. The infundibulum then could be pulled laterally and inferiorly with the second retracting instrument. The third instrument was used to dissect the cystic duct. In addition, the second retracting instrument allowed us to expand the angle of separation of the CBD and cystic duct to 90°.

No intra- or postoperative complications occurred in either group. The incision sizes were equal in the two groups. In the two-instrument group, one patient required an additional port site to aid in retraction.


As we move forward in any surgical endeavor, techniques certainly will change, as will the procedures. In advancing our field, we need to maintain, or even improve, the safe principles that have already been established and proven without increasing or creating new complications.

After the initial introduction and adoption of LC, an increase in CBD injury was noted, almost preventing its expansion [19, 22, 23]. Recognition of this complication prompted the development of safety guidelines. Basic tenets were developed including proper exposure, retraction, and dissection. Obtaining the critical view of safety defined by the clear separation of the cystic duct and the common duct beneath the liver became an essential step in performing a safe procedure.

As we move forward with reduced-port surgery, we are seeing an increasing number of case reports and series for reduced-port cholecystectomy in the literature [1115, 17, 18]. Although SPA may not be as radical a shift as the laparoscopic procedure was compared with open surgery, we still must maintain a cautious eye as it develops, ensuring that we adhere to strict safety standards so as not to offer the benefit of a perhaps more cosmetic result at the expense of an increase in CBD injury. The similarity of SPA to multiport procedures is both a benefit and a risk. It affords us a familiar procedure while offering a more readily performed procedure as well.

Perhaps the most concerning change we are seeing compared with multiport cholecystectomy, and the one with the greatest potential for complication, is the reduction of operative instruments. This may lead to a reduction in optimal exposure as well.

In multiport LC, a scope and three instruments are traditionally used: two independent retracting instruments, one for fundal retraction over the liver and one for infundibular manipulation, and a third instrument to dissect the cystic duct. With some reduced-port techniques, the desire to use a single small opening caused one of these critical instruments to be sacrificed. Only two operative instruments are used alongside the camera and scope. This can provide a suboptimal view for safe dissection and oftentimes may lead to use of the infundibular technique [24].

With the infundibular technique, dissection is performed on the neck of the gallbladder toward the cystic duct. Although we may think the cystic duct has been clearly identified, there may be a parallel or adherent common duct, leading to CBD injury [19] (Fig. 3). Avoiding this infundibular technique and distracting the cystic duct from its parallel position to the CBD are an important safety measure. To do this, we need to see clearly behind the cystic duct, exposing the liver surface. We also need to distract the cystic duct as far from the CBD as possible (Fig. 4).
Fig. 3

Two-instrument technique. The white arrow illustrates the single retraction of the gallbladder over the liver. The black arrows indicate the cystic duct (CD) and the common bile duct (CBD) in parallel
Fig. 4

Three-instrument technique demonstrating the critical view. The white arrow illustrates cranial retraction of the gallbladder fundus above the liver. The gray arrow illustrates independent lateral retraction of the infundibulum, resulting in the black arrows of the cystic duct (CD) and the common bile duct (CBD) at a perpendicular angle

In a review of our two-instrument cases, the single retracting instrument was used to retract the gallbladder over the liver with an attempt at also pulling the organ laterally to provide exposure of the triangle of Calot. Our review of the videos demonstrated difficulty maintaining optimal exposure throughout the procedures. To combat this, grasping the gallbladder more proximally toward the mid-body may provide better exposure and manipulation than grasping traditionally at the fundus. This technique seems to work in select cases, but unfortunately, in many cases with a large or lax gallbladder or a large liver, this technique fails to provide adequate exposure.

Another alternative put forth is the suture technique [15, 25]. The suture technique certainly allows for independent retraction of the gallbladder parts. However, multiple sutures are needed for manipulation and rotation of the infundibulm. In addition, a large liver or gallbladder cannot be retracted as cephalad as with a straight push of a rigid instrument. This technique also requires the placement of a needle into the gallbladder and not only requires more advanced skill, but also adds a new element to the standard multiport procedure, raising a question regarding routine placement of needles through the gallbladder [26, 27].

Although CBD injuries with the two-instrument technique in reduced-port surgery have not been reported in the literature to date, we still are early in its applications, and it has been used for a select group of patients in many cases. As more cases are performed and more surgeons apply this technique, this critical view of safety may play a more important role.

Another pitfall we recognized in comparing the two techniques was regarding optimal exposure as it relates to the angle of the cystic duct at clip placement, potentially lending itself to more minor complications such as duct leaks. In multiport cholecystectomy, the clip applier is placed perpendicular to the cystic duct through the subxyphoid port position. This allows a perpendicular placement of the clip.

In reduced-port surgery, the clips currently are placed “in line” with the camera (Fig. 5A). Inadequate visualization of the clip across the entire duct may lead to incomplete control of the lumen, resulting in minor leaks. These clips may be placed in a tangential direction instead of the perpendicular position obtained with adequate retraction and the exposure provided by the three-instrument technique (Fig. 5B). Without proven benefits of the reduced-port techniques, these concerns could hinder the progression of this platform before advantages or advances are realized.
Fig. 5

In-line clipping of the cystic duct. A Two-instrument technique demonstrating tangential placement of clip. B Three-instrument technique demonstrating perpendicular placement of the clip

We believe the standard multiport LC comprises a series of crucial steps. Optimal exposure is provided by a fundal grasper, which retracts the gallbladder superiorly toward the liver edge. This not only retracts the liver from the field of surgery but also exposes the entire gallbladder down to the neck–duct junction. To dissect and remove the gallbladder, a separate infundibular manipulator must be placed. This infundibular grasper allows manipulation of the infundibulum laterally and inferiorly, providing clear separation from the common duct and liver, exposing the critical view of safety.

This critical view of safety described by Strasberg and Soper is one of the hallmarks by which we measure the success of LC. Although described in the era of laparoscopy, the independent retraction of the fundus and infundibulum of the gallbladder to maintain the cystic duct at a right angle to the common duct and visualize posterior to the gallbladder is very similar to the open surgical technique that uses two Kelley clamps in similar positions to dissect the cystic duct free and avoid CBD injury. The ability to separate the cystic duct and the common duct has thus proved to be crucial in performing safe dissection. It is this view that ultimately allows safe transection of the cystic duct. We have found that this can be maintained with dissection during SPA cholecystectomy using three instruments.

We have demonstrated that the critical view can be obtained in SPA cholecystectomy using the three-instrument technique that mimics multiport cholecystectomy. In addition, we are able to continue opening the cystic duct–CBD angle to the “critical angle of separation” of 90º. This allows not only a clear separation of the two structures and removal of the cystic duct from any parallel position to the CBD, but also allows for perpendicular clip placement as is also necessary in multiport cholecystectomy. This angle may not be as important in multiport procedures, given that we are clipping from above. Currently, we are clipping “in line” with the camera, and the 90º angle becomes a crucial step in this dissection. Given the access technique that allows us to put three instruments and a camera through one opening, we have been able to maintain the safe standards of multiport cholecystectomy as we transition to SPA surgery.

Although this new platform of reduced-port surgery is a shift within the field of minimally invasive surgery, it must be used with caution to ensure safe outcomes. Differences from multiport procedures exist and must be recognized. Basic, reliable, reproducible principles of laparoscopy should not be skewed for the wrong goals if they compromise safe principles.

As we developed SPA surgery during its initial months in 2007, we quickly saw the possible “sacrifice” of the critical view of safety. In addition, we also noted that we could not achieve or maintain the proper angle of separation of the common and cystic ducts. It was decided early in its development, that SPA cholecystectomy would revolve around the safe dissection and maintenance of a familiar procedure rather than around instrumentation or access devices. This maintenance of safety was done so a technique could be developed that could be safely reproducible by large numbers of surgeons and offered to more patients.


Paul G. Curcillo has spoken about single-port-access surgery for Storz Endoscopy, Ethicon Inc., Olympus Inc., and Microline. Erica R Podolsky has no conflicts of interest or financial ties to disclose.

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© Springer Science+Business Media, LLC 2010