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

Background 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. Methods 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. Results 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. Conclusion 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.