Many surgeons attempting Laparo-Endoscopic Single Site (LESS) cholecystectomy have found the operation difficult, which is inconsistent with our experience. This article is an attempt to promote a standardized approach that we feel surgeons with laparoscopic skills can perform safely and efficiently. This is a four-trocar approach consistent with the four incisions utilized in conventional laparoscopic cholecystectomy. After administration of general anesthesia, marcaine is injected at the umbilicus and a 12-mm vertical incision is made through the already existing anatomical scar of the umbilicus. A single four-trocar port is inserted. A 5-mm deflectable-tip laparoscope is placed through the trocar at the 8 o'clock position, a bariatric length rigid grasper is inserted through the trocar at the 4 o'clock position (to grasp the fundus), and a rigid bent grasper is placed through the 10-mm port (to grasp the infundibulum). This arrangement of the instruments promotes minimal internal and external instrument clashing with simultaneous optimization of the operative view. This orientation allows retraction of the gallbladder in a cephalad and lateral direction, development of a window between the gallbladder and the liver which promotes the "critical view" of the cystic duct and artery, and provides triangulation with excellent visualization of the operative field. The operation is concluded with diaphragmatic irrigation of marcaine solution to minimize postoperative pain. Standardization of LESS cholecystectomy will speed adoption, reduce intraoperative complications, and improve the efficiency and safety of the approach.
Surgeons can now perform operations on their patients while sitting at a remote site. During telerobotic operations, the surgeon sits at a computer console. The computer translates the motions of the surgeon's hands into motions of the robotic instruments. Introduction of telerobotics into clinical practice raises issues comparable to those generated by the rapid introduction of laparoscopic cholecystectomy in the late 1980s. As a result, we have instituted processes in our hospitals for the granting of clinical privileges for telerobotic surgery. These processes are derived from the guidelines of the Society of American Gastrointestinal Endoscopic Surgeons for granting clinical privileges for laparoscopic general surgery. Our hospitals require the following: (1) board certification or board eligibility for the appropriate surgical board; (2) clinical privileges for the open and laparoscopic operations that will be performed telerobotically; (3) satisfactory completion of the Food and Drug Administration-mandated training course in the safe use of the robotic surgical system; (4) performance of telerobotic operations in animate models; (5) observation of clinical cases of telerobotic surgery by an expert surgeon; (6) acting as bedside assistant surgeon in telerobotic operations or supervision by a preceptor during the surgeon's initial operations; (7) observation by a proctor of the surgeon's initial clinical telerobotic operations; and (8) ongoing monitoring of surgical outcomes of telerobotic operations. This process has facilitated the safe and orderly introduction of telerobotics operations into clinical practice in our hospitals.
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