How to perform the most minimal invasive cholecystectomy?

Twenty years ago, laparoscopy has totally transformed the surgical approach of the gallbladder. For those who were not in surgery at that time, it has to be reminded that most open cholecystectomies performed in the 80’s required nasogastric tube for several days, surgical drain, and 5 to 8 days of hospitalisation. For these obvious advantages, laparoscopic cholecystectomy has become the “Gold Standard” without evidence by a randomised controlled study comparing open and laparoscopic techniques.

These last years, some groups proposed variations of laparoscopic cholecystectomies that they presented as less invasive. In robotic surgery, the Da-Vinci device has been proposed without significant improvement since more than 10 years. To date, no interest of this Da-Vinci robot has been demonstrated in abdominal surgery. Its cost for acquisition, its yearly fee and the cost for each use render its use without proof of results totally inappropriate.

Single-Incision Laparoscopic Surgery (SILS) has also been described to perform cholecystectomy with only one larger umbilical incision. Until now, no superiority of SILS on classical cholecystectomy has been demonstrated. The Natural Orifice Transluminal Endoscopic Surgery (NOTES) proposes to use the vagina, the stomach or the colon to remove the gallbladder. No prospective controlled comparison has proved the superiority of these approaches that sometimes do not reach common sense or usual surgical principles.

What is a minimal invasive cholecystectomy? A safe and un expensive cholecystectomy, with a good anatomical exposure, a cholangiography, and a good surgical comfort allowing to perform several procedures in the same day; a cholecystectomy that can be performed as a day-case without complications; a cholecystectomy that can be performed laparoscopically in acute settings; a cholecystectomy without the risk of postoperative incisional hernia. In necessary, in young and thin woman, laparoscopic cholecystectomy may be performed using 2 mm trocars that allow a good triangulation but with minimal scars.