ISSN: 2320-5407 Int. J. Adv. Res.

12(05), 325-332

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/18719
DOI URL: http://dx.doi.org/10.21474/IJAR01/18719

RESEARCH ARTICLE
SAFETY AND FEASIBILITY OF THE THREE PORT TECHNIQUE FOR CONCOMITANT
CHOLECYSTECTOMY DURING SLEEVE GASTRECTOMY: A COMPREHENSIVE ANALYSIS AND
CLINICAL IMPLICATIONS

Owaid M. Almalki1,2
1. Department of Surgery, College of Medicine, Taif University, Taif, Saudi Arabia.
2. Department of Surgery, Alhada Military Hospital, Taif, Saudi Arabia.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Introduction:Obesity, a prevalent global health issue, has led to an
Received: 15 March 2024 increased demand for bariatric surgeries, with laparoscopic sleeve
Final Accepted: 18 April 2024 gastrectomy (LSG) being a preferred option due to its efficacy and
Published: May 2024 minimal invasiveness. Concomitant cholecystectomy (CC) during LSG
has gained traction among patients with obesity and gallstones. While
Key words:-
Obesity, Bariatric Surgery, Laparoscopic various techniques have been explored, concerns persist regarding
Sleeve Gastrectomy, Three-Port safety and efficacy. Our study aims to evaluate the feasibility and
Technique, Cholecystectomy, outcomes of a three-port laparoscopic technique for this combined
Concomitant Cholecystectomy
procedure.
Methodology:Ahigh-volume bariatric center in Saudi Arabia
conducted a retrospective cohort study involving patients who
underwent three-port sleeve gastrectomy (3PSG) with CC between
January 2022 and January 2024. We collected and analyzed data on
demographics, preoperative evaluation, intraoperative details, and
postoperative outcomes using descriptive statistics.
Results:Out of 360 LSG patients, 76 underwent CC with the three-port
technique. The mean age was 42.18 years, with a female predominance
(71.0%) and a mean BMI of 44.67 kg/m2. Intraoperatively, the mean
operative time was 109.8 minutes, with minimal blood loss and no
complications or conversions to open surgery. The average hospital
stay was 2.1 days. Postoperatively, the complication rate was 4%,
primarily consisting of early bleeding, port-site infection, and
atelectasis, all of which were managed conservatively. No severe
complications, mortalities, or thrombotic events occurred during the 3-
month follow-up.
Conclusion:Thethree-port laparoscopic technique for concomitant
cholecystectomy during sleeve gastrectomy appears safe and feasible,
offering favorable outcomes in terms of operative time, blood loss, and
postoperative complications. This approach presents a promising option
for minimizing surgical trauma and enhancing recovery in obese
patients who require both procedures.

Copy Right, IJAR, 2024,. All rights reserved.

……………………………………………………………………………………………………....

Corresponding Author:- Owaid M. Almalki

Address:- Department of Surgery, College of Medicine, Taif University, Taif, Saudi 325
Arabia.
ISSN: 2320-5407 Int. J. Adv. Res. 12(05), 325-332

Introduction:-
Obesity is an escalating worldwide health issue, affecting millions of people and leading to various health
complications such as type 2 diabetes, hypertension, and sleep apnea. Bariatric surgery has become a potent method
for achieving long-term weight loss and enhancing the circumstances related to it [1, 2].

Bariatric surgery (BS) is increasingly acknowledged as an effective approach, with laparoscopic sleeve gastrectomy
(LSG) being preferred because to its relative ease and positive results in comparison to more intricate procedures
[3]. The minimally invasive method has several advantages, including less blood loss, low rates of complications,
and shorter hospital stays [4].

LSG, which was traditionally performed with several access points (ports), usually four to six ports, has seen
advancements aimed at minimizing surgical trauma and improving patient comfort. One such innovation is the
single-port approach, utilizing fewer instruments for a potentially smoother recovery and better cosmetic results [5].
However, some concerns remain regarding its feasibility, safety, and effectiveness compared to the standard
technique [6, 7].

In addition to obesity, gallstone prevalence is heightened, particularly amongindividuals with obesity [8].
Laparoscopic cholecystectomy (LC) stands as the gold standard treatment for symptomatic gallstones [9].

Due to the minimally invasive nature of both LSG and LC, there has been a growing interest in doing both jointly in
a single surgery [10]. There is no proof that performing concomitant cholecystectomy (CC) during LSG leads to an
increase in complications in severely obese patients with other health conditions and symptomatic gallstones. This
indicates that it is a secure and efficient surgery for high-risk severely obese individuals [8].

Although numerous reports demonstrate the safe performance of the combined procedure, it is not devoid of
complications. Reports indicate the need for additional ports, an increase in surgical time and hospital stay duration,
and the occurrence of certain adverse events, such as gastrointestinal leaks, wound infections, renal failure, and
pneumonia [11, 12].

Barakat et al. and Hsu et al. recently published studies on a four-port laparoscopic technique that suggests it might
be able to reduce the number and size of trocars, leading to better cosmetic results and less pain after surgery [13,
14].

Building on these advancements, the current study aims to investigate the safety and efficacy of a three-port
laparoscopic technique for this combined procedure. We believe this approach holds promise for further reducing
surgical trauma and enhancing recovery outcomes.

Methodology:-
Study Design:
We conducted a retrospective cohort study from our prospective database between January 2022 and January 2024
to investigate the safety and efficacy of combined three-port sleeve gastrectomy (3PSG) and concomitant
cholecystectomy (CC).

Study Setting:
The study was conducted in a high-volume bariatric center at Alhada Military Hospital, Taif, Saudi Arabia. One
experienced bariatric surgeon with expertise inlaparoscopic techniques performed the surgical procedures.

Participants:
The study included patients who fulfilled the following criteria: We performed a combination 3PSG and CC
procedure at our facility. The study included participants who were 18 years of age or older and had complete
medical records throughout the whole study period. We specifically excluded individuals who had undergone gastric
or biliary surgery in the past, as well as those whose medical records were insufficient.

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Data Collection:
We collected data from electronic medical records and operative reports. The data collection period spanned from
the procedure's initiation until the last follow-up appointment or documented encounter.

Ethical Considerations:
This study was approved by the Research Ethics Committee of Alhada Military Hospital, Taif, Saudi Arabia.
Informed consent was waived due to the retrospective nature of the study, and patient confidentiality was ensured
through anonymization and de-identification of all data.

Demographic Characteristics:
Demographic data, including age, gender, body mass index (BMI) at the time of surgery, and comorbidities were
collected.

Preoperative Evaluation:
Preoperative evaluation details were extracted from the medical records, includinglaboratory investigations (e.g.,
complete blood count, liver function tests); Endoscopic findings (if available); Imaging studies (e.g., upper
GIcontrast, abdominal ultrasound); nutritional assessment.

Conversion to open surgery criteria:

Conversion to open surgery during combined laparoscopic sleeve gastrectomy and cholecystectomy may occur due
to intraoperative complications, technical challenges, poor visualization, hemodynamic instability, or surgeon's
judgment based on case complexity.

Intraoperative Data:
Intraoperative data will include operative times for LSG and cholecystectomy, estimated blood loss, any
intraoperative complications and any conversion to open surgery.

Postoperative Data:
Postoperative data will encompass length of hospital stay, development of complications (e.g., bleeding, infection,
leak and bile duct injury), need for additional interventions, and readmission rates within 30 days.

Statistical Analysis:
Descriptive statistics were employed to summarize demographic and clinical characteristics. Categorical variables
were presented as frequencies and percentages, while continuous variables were expressed as means with standard
deviations or medians with interquartile ranges, depending on the distribution. IBM SPSS Statistics software
(version 25; IBM Corp., Armonk, NY, USA) was used for conducting statistical analysis.

Results:-
Among the 360 patients who underwent laparoscopic sleeve gastrectomy (LSG) over a two-year period, 76
presented withcholelithiasis and underwent concomitant cholecystectomy (CC) with three-port technique.

The mean age of patients undergoing 3PSGwith CC was 42.18 years and gender distribution showed a female
predominance (71.0%). Mean BMI was 44.67 kg/m2.

Sixty-eight patients (80.5%) had type 2 diabetes mellitus (T2DM), thirty two patients (30.2%) had hypertension and
hyperlipidemia and five patients had moderate to severe obstructive sleep apnea (6.5%). (Table 1).
Table 1:- Demographic characteristics of the study patients.
Patient characteristic Total (n = 76)
Age (y) mean ± SD 42.18 ± 9.44
Gender Male 22 (28.9%)
Female 54 (71.0%)
BMI (kg/m2), mean ± SD 44.67 ± 4.472
Gall bladder stones Multiple 66 (86.9%)
Single 10 (13.1%)
Comorbidities DiabetesT2DM 68 (80.5%)

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Hypertension 23 (30.2%)
Hyperlipidemia 23 (30.2%)
Obstructive sleep apnea 5 (6.5%)

In our study, the mean operation times were 109.8 minutes for 3PSG with CC, with minimal blood loss (12 mL) and
no intraoperative complications or conversions to open surgery observed. The mean hospital length of stay was 2.1
days, reflecting a favourable perioperative course (Table 2).
Table (2):- Operative details in the studied groups.
Variable Total (n = 76)
Operative time (min) mean ± SD 109.8 ± 7.35
Intraoperative complication Blood loss (mL), mean ± SD 12± 13.61
Gall bladder bed bleeding 0 (0%)
Gall stone spillage 0 (0%)
Conversions to open surgery 0 (0%)
Length of stay (d), mean ± SD 2.1 ± 2.32

During the 30-day follow-up period, the total postoperative complication rate was 4% (3/76 patients). One patient
experienced early post-operative bleeding within the first 24 hours post-operatively, managed conservatively with a
blood transfusion, and discharged on day four post-operatively. Another patient developed a port-site infection with
abscess formation at the first week post-operative visit, and we treated it with drainage and antibiotics. We removed
the patient's gall bladder using an endobag but did not remove the stomach specimen. Later, we adopted the method
of extracting both specimens using an endobag. The third patient developed atelectasis on postoperative day two; he
was a smoker, not adherent to incentive spirometry, and treated conservatively with aggressive chest physiotherapy.

On the other hand, we registered no postoperative complications such as staple leakage, bile leakage, post-operative
paralytic ileus, or post-operative pelvic collection, indicating a favorable postoperative course. Additionally, there
were no reported mortalities or occurrences of post-operative venous thrombosis in the 3-month follow-up period,
underscoring the safety and efficacy of the procedures. (Table 3).
Table 3:- Postoperative complications.
Complication Patient (3=76)
Post-operative bleeding 1 (1.3%)
staple leakage 0 (0%)
bile leakage 0 (0%)
Post-operative atelectasis 1(1.3%)
Post-operative wound complications 1 (1.3%)
Post-operative paralytic ileus 0 (0%)
Post-operative pelvic collection 0 (0%)
Post-operative venous thrombosis 0 (0%)
Post-operative at 30 days mortality 0 (0%)

Discussion:-
Recent studies show that cholelithiasis is very common in individuals with obesity, affecting anywhere from 19% to
45% [15]. Therefore, knowing how to treat these patients surgically is very important.

The literature on the feasibility ofCC during LSGcurrently exhibits notable disparities. While some authors advocate
for the safety of concurrent procedures based on research findings [16], others highlight heightened postoperative
complications and prolonged hospital stays [17].

A more widely accepted and selective approach involves exclusively performing CC during LSG for morbidly
obesity individuals with confirmed gallbladder pathology on preoperative imaging. In line with this approach, our
study protocol mandated CC for all patients with documented gallbladder disease on imaging, regardless of
symptomatology, mirroring the protocol employed in a study by [13].

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In our evaluation of the feasibility of the Three-Port Sleeve Gastrectomy (3PSG) with concomitant cholecystectomy
(CC) technique, we found favorable perioperative outcomes. Crucially, there were few or non-existent postoperative
complications observed throughout the 30-day follow-up, underscoring the safety of these treatments.

Furthermore, using a single approach for both surgeries simplifies the process, enhances operative efficiency, and
improves the patient's experience.

Simultaneous procedures in laparoscopic surgery may need the use of extra ports. Typically, simultaneous
laparoscopic procedures necessitate the use of 6 to 7 ports, consisting of three 12-mm trocars and three or more 5-
mm trocars [18, 19]. Ohta et al. introduced a method for sharing ports in laparoscopic sleeve gastrectomy (LSG) that
used a total of 7 trocars, with 3 of them having a diameter more than 10 mm [20].

The Fang-Chin research determined that using four trocars was sufficient for performing CC during LSG. There are
only two trocars that are 10 mm or greater in size. These include the umbilical trocar, which is 12 mm, and the left
abdominal trocar, which is 10 mm. The use of these trocars offers several benefits, such as the ability to change the
trocar sites, resulting in improved esthetic outcomes and a more extensive surgical field [21].

In our protocol, the integration of a three-port approach presents several potential benefits. By reducing the number
of ports and instruments utilized, this technique reduces surgical trauma, improves cosmetic outcomes, and
potentially accelerates recovery times.

Our center protocol for performing the 3PSG with CC included a three-port laparoscopic sleeve gastrectomy,
followed by a cholecystectomy using the same three-port laparoscopic approach. We performed all procedures under
general anesthesia. We administered prophylactic antibiotics during the induction of anesthesia. In reverse
Trendelenburg, patients lie supine with adducted legs. We set up the laparoscopic equipment to the left of the
patient's head. During the sleeve gastrectomy, the surgeon positioned himself on the right side of the patient, then
shifted to the left side to perform the cholecystectomy.

To get into the abdomen, a 5-mm optical view trocar (ENDOPATH XCEL™) is placed 1 hand's breath below the
left costal margin in the midclavicular line in the left upper quadrant. The next step involves insufflating the
abdomen and creating a pneumoperitoneum. Next, insert a 45-degree 5-mm camera, and place two additional ports
under direct vision. A 5-mm trocar (ENDOPATH XCEL™) is placed 15 cm below the xiphoid process. Place the
third 12-mm port (Versaport Bladeless; Covidien, Mansfield, MA) in the right upper quadrant, just below the right
costal margin in the anterior axillary line. Dissection is performed through the right and left upper quadrant ports,
and the field view is maintained with a 5-mm, 45-degree camera through the supraumbilical 5-mm port.

We devascularized the great curve up to the left crus using a sealing device to perform the sleeve procedure. An
endoscopic stapler through the right port transected the stomach after calibration with a 36-Fr orogastric suction
bougie. After sleeve construction, we routinely fixed the remnant stomach to the prepancreatic fascia using
interrupted 2-0 vicryl sutures to prevent axial twisting.

CC started by shifting the surgeon's position to the patient's left side. Using the same two working ports, the left
hand will retract the gall bladder cephalic at the Hartman pouch, while the right hand's sealing device will dissect the
cystic triangle to reach the critical view for safety, after which the cystic artery will be sealed, and the duct clipped.

Both specimens were retrieved using endo-bag. We usually did not place abdominal drains after surgery. In all
cases, port 12-mm fascia closure was routinely performed.Ourfindings suggest that this approach is a promising
option with several potential benefits.

Our study observed a mean operative time of 109.8 minutes, extending the duration by approximately 12–40
minutes compared to LSG performed alone. Previous literature reports have indicated varying degrees of operative
time extension when performing CC with obesity surgery, ranging from 18–49 minutes [22, 23] to up to 15–110
minutes [22]. Another study found this extension to be within the range of 15–45 minutes [13].

We used harmonic shears to dissect the Calot triangle and cauterize the cystic artery, which resulted in a
comparatively shorter operative time for CC in our study. Unlike in other studies, we conducted CC through the

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same three ports used for LSG without requiring additional trocar insertion for either procedure. We attribute this
efficiency to our experience with the three-port LSG technique.

Our research found no substantial difference in the duration of hospitalization between patients who had CC during
LSG and those who underwent LSG alone at our facility. The short duration of hospitalization, typically lasting 2.1
days, suggests rapid recuperation, irrespective of the particular medical intervention. This conclusion aligns with the
observations made by Aridi et al. and Wood et al., who also reported no substantial increase in the duration of
hospital stays [24, 25]. On the other hand, Habeeb et al. found in their study that the duration of hospitalization after
surgery was extended for the 222 patients who received CC [26].

The current study reported a single incidence of post-operative bleeding (1.3%), which necessitated hospitalization
in the intensive care unit (ICU) and a blood transfusion. The patient was hospitalized for a duration of 4 days and
was discharged without encountering any complication.

In the current study, intraoperative cholecystectomy complications were notably absent, with no instances of
gallbladder bed bleeding or gallstone spillage observed. This contrasts with findings from a study by Gamal Osman
et al., where 2 (11.1%) patients experienced gallstone spillage, and another 2 (11.1%) individuals encountered
complications related to gallbladder bed bleeding [27].

We successfully performed all procedures in our study laparoscopically, without any instances requiring conversion
to open surgery. These results are consistent with prior research [27, 28]. Another study, on the other hand, found
two cases of open conversion during gallbladder removal. One was needed because of uncontrolled bile leakage
caused by a partial tear in the common bile duct that had to be fixed with simple interrupted sutures using Vicryl 4/0
sutures, and the other was needed because of extensive adhesions that required an open partial cholecystectomy
[26].

A subsequent study reaffirmed that CC during LSG increased the risk of surgical site infection by 0.6% [29]. Our
findings indicated a higher incidence, with wound infection complications reaching 1.3%.

Limitations:
The study has some limitations. It was retrospective, which makes it harder to prove cause and effect and account
for possible confounding factors. Additionally, the sample size was relatively small (n = 76), which limits the
generalizability of the results. Finally, the follow-up period was only three months, which makes it hard to see if
there were any long-term complications.

Although our study did not document any intraoperative complications or instances requiring conversion to open
surgery, it's imperative to maintain vigilance for such occurrences, especially in patients with complex anatomical
considerations or comorbidities.

Conclusion:-
Our study suggests that the 3PSG with CC is a safe and effective approach for patients with cholelithiasis who are
undergoing LSG. This minimally invasive technique offers potential benefits, including reduced surgical trauma,
favorable perioperative outcomes, and potentially lower healthcare costs.

This study offers crucial information on the safety and effectiveness of combining 3PSG with CC in individuals with
cholelithiasis. The favorable perioperative outcomes observed underscore the feasibility of this approach in
appropriately selected patients.

It is necessary to persist in research endeavors to improve surgical procedures, enhance patient selection criteria, and
further elucidate the long-term benefits and risks associated with combined bariatric and gallbladder surgeries.

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