SURG INNOV OnlineFirst, published on December 22, 2009 as doi:10.1177/1553350609353422
Cholecystectomy by Single Trocar Access
(SITRACC): The First Multicenter Study
Surgical Innovation
XX(X) 1–4
© The Author(s) 2009
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DOI: 10.1177/1553350609353422
http://sri.sagepub.com
Marcus Vinicius Dantas de Campos Martins, PhD,1
James Skinovsky, PhD,2 Djalma Ernesto Coelho, PhD,1
Almino Ramos, PhD,3 Manoel P. Galvão Neto, PhD,3
José Rodrigues, PhD,4 Luiz de Carli, PhD,5 Leandro Totti
Cavazolla, PhD,6 Josemberg Campos, PhD,7 Fábio Thuller, PhD,8
and Adriano Brunetti, PhD9
Abstract
Background: The advent of endoscopic surgery has radically changed surgery worldwide.The concept of minimally invasive
procedures has spread quickly, allowing less pain and more rapid recovery for patients. The authors have developed a
device for a new surgical approach, the so-called single trocar access (SITRACC). This study report the first multicenter
study of cholecystectomies performed with SITRACC. Methods: Between December 2008 and June 2009, 81 single trocar
cholecystectomies were performed in 9 Brazilian surgery centers. Results: The average operative time was 68 minutes. In
all, 10 surgeries required 1 additional trocar because of technical problems, and 3 cholecystectomies were converted to
standard video laparoscopies. Conclusion: A cholecystectomy using the SITRACC method is feasible and safe.
Keywords
minimally invasive surgery, cholecystectomy, SITRACC
Introduction
The development of endoscopic surgery, which began in
1987 in the hands of the French surgeons Mouret and
Perissat, represented the beginning of a new concept in
surgery and allowed for surgical procedures that were
minimally invasive and could reduce physiopathologic
changes, cause less pain, lead to a faster recovery, and
generally result in more satisfactory cosmetic outcomes.
The fast and continuous technologic improvements in
the optical system, as well as of the instruments used in
endoscopic surgery, have permitted more and more complex operations to be performed via the minimally invasive method with worldwide acceptance.
Several brand-new technologies and approaches have
been developed concurrently, such as telesurgery, robotic
surgery, the use of virtual reality in the surgical learning,
natural orifice translumenal endoscopic surgery (NOTES),
and transumbilical endoscopic surgery (TUES).
Since Kalloo et al1 reported their first experience with
NOTES using transgastric access in a porcine model,
many clinicians have been searching for new technologies to complement this approach, as well as to determine
the feasibility of NOTES in various settings. In 2005,
New York City hosted members of the American Society
of Gastrointestinal Endoscopy (ASGE) and the Society
of American Gastrointestinal and Endoscopic Surgeons
(SAGES), the working group of which (Natural Orifices
Surgery Consortium for Assessment and Research
[NOSCAR]) produced a document titled “White Paper,”
to define research guidelines, potential benefits, and
priorities.2
Our group initially published our experience with
NOTES in 20063 using a porcine model and concluded
that some barriers need to be overcome for the adequate
development of this new technology.
1
Estácio de Sá University, Rio de Janeiro, Brazil
Positivo University, Curitiba, Brazil
3
Gastrobeso, São Paulo, Brazil
4
Hospital de Clínicas de Teresina, Piauí, Brazil
5
Santa Casa, Porto Alegre, Brazil
6
Hospital Mãe de Deus, Porto Alegre, Brazil
7
Universidade Federal de Pernambuco, Recife, Brazil
8
Americana, Brazil
9
Hospital Especializado, Ribeirão Preto, Brazil
2
Corresponding Author:
Marcus Vinicius Dantas de Campos Martins, Medical Course of the
Estácio de Sá University, Av. das Americas 505/209, Rio de Janeiro
22631000, Brazil
Email: [email protected]
2
Surgical Innovation XX(X)
Table 1. SITRACC Cholecystectomies
Head Staff
Figure 1. Trocar
James Skinovsky/
Marcus V Dantas
Almino Ramos/
Manuel Galvão
Paulo Amaral
José Rodrigues
Luiz De Carli
Leandro Totti Cavazolla
Josemberg Campos
Fábio Thuller
Adriano Brunetti
Total
Brazilian City
No. of Patients
Curitiba, PR
41
São Paulo, SP
9
Salvador, BA
Teresina, PI
Porto Alegre, RS
Porto Alegre, RS
Recife, PE
Americana, SP
Ribeirão Preto, SP
9
7
6
5
4
4
3
2
81
Figure 3. External view of the procedure
Figure 2. Working station with flexible instruments
In 2007, Zhu4 published his first experience accessing
the abdominal cavity via the umbilicus performing a
hepatic cyst fenestration and appendectomy. This new
approach was called transumbilical endoscopic surgery
(TUES). Many names came later: single access surgery,
single port access, single trocar access, and so on. Two
years later, Zhu et al5 reported 6 cholecystectomies and 9
appendectomies using a trichannel trocar via the umbilicus. In the same year, Palanivelu et al6 reported 8 transumbilical appendectomies using a regular flexible
endoscope. In 2009, Zhu et al5 published a paper describing 10 appendectomies and 26 cholecystectomies using
the trichannel trocar. To further develop this approach by
adding a new device to the TUES arsenal, the SITRACC
device was created. The experimental study was accomplished in 2008,7 with 10 cholecystectomies being performed in pigs.
This report represents the first multicenter study of
cholecystectomies performed by SITRACC. This new
device has Brazilian government approval for human use
since early 2009.
Patients and Methods
In the beginning of the research process, a single trocar
access system named SITRACC (Edlo Company, Porto
Alegre, Brazil) was developed. This disposable new
device consists of a 4-channel trocar, through which special reusable articulated instruments and a 5-mm optical
device are introduced (Figures 1 and 2). Articulated
graspers, scissors, hook, and clip appliers were developed especially for this approach.
The surgeons, all of them with laparoscopic expertise,
were chosen for training by Edlo. Training over 1 weekend was then conducted. Two groups came later and had
no training.
After approval of the standard protocol in the local
ethics committees in all participating institutions, the
study began in December 2008 and continued until June
2009. During that period, 81 single trocar access cholecystectomies were performed in 9 different surgical services in Brazil, as listed in Table 1.
There were 52 women and 29 men, and the average
age was 48 years (range = 17-87 years). The surgical
steps were the same as for laparoscopic cholecystectomy
3
Martins et al.
Figure 4. Cosmetic result 7 days following the procedure
except for the use of articulated instruments. No cholangiographies were done. Figure 3 shows an external view
of the procedure.
Results
The average surgical time was 68 minutes (range =
25-205 minutes). In all, 10 surgeries required an additional trocar placed in the right upper quadrant of the
abdomen because of technical difficulties. Three cholecystectomies were converted to standard video laparoscopies, 3 of which were because of acute cholecystitis,
and in 1 because the trocar placement was difficult secondary to morbid obesity.
All patients were discharged from the hospital between
24 and 35 hours postoperatively, and returned for appointments within 7 to 30 days. There were no major complications; only 3 cases developed wound infections, and 8
cases developed small seromas, all of which were
successfully treated with conservative measures. Figure 4
shows the cosmetic results 7 days following the
procedure.
Discussion
In recent years, interest in performing new minimally
invasive approaches has increased worldwide. The
SITRACC is one new option for use in minimally invasive procedure. The advantages of the transumbilical surgical path are similar to NOTES, and include a potential
faster recovery, and a scarless procedure, without the disadvantages of endolumenal surgery. The main difficulty
with single trocar access surgery is the challenge of working in a single movement axis and using the instruments
in parallel where the goal is to develop flexible and articulated instruments, creating triangulation, but still
limited compared with standard video laparoscopy
procedures.
Because of the limitations with NOTES (access, orientation, infection, and visceral closure), TUES may be
an excellent option to perform scarless abdominal surgery. We still do not have large comparative surgical
series between similar procedures using the single access
and the standard endoscopic surgery method. Some
groups have also published their single incision transumbilical cholecystectomies series.8,9 Urological procedures
have been also described.10
This is the first multicenter study that allows us to suggest that a cholecystectomy with a single trocar access is
an excellent option and has all the advantages of a minimally invasive procedure. Prior training is desirable. Procedures by the 2 groups that did not undergo training took
longer times.
The TUES procedures must be viewed as part of the
surgical techniques that begins with open operations,
bypasses videosurgery, and in the future may be performed by NOTES. It is ultimately up to the surgeon to
determine the best procedure to achieve a mix of safety,
efficacy, and the best cosmetic results.
Conclusion
Cholecystecomy by the SITRACC approach is feasible
and safe, representing a new important option in minimally invasive surgery. Because this is a new technique,
SITRACC needs to be compared with conventional
laparoscopy.
Declaration of Conflicting Interests
The authors wish to acknowledge the help rendered by ELDO,
a brazilian industry which produces the SITRACC and donated
the instruments for this research.
Funding
The authors received no financial support for the research and/
or authorship of this article.
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Surgical Innovation XX(X)
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