Safety and feasibility of using a 5 mm high-definition angled scope in laparoscopic cholecystectomy

Safety and feasibility of using a 5 mm high-definition angled scope in laparoscopic cholecystectomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Safety and feasibility of using a 5 mm high-definition angled scope in laparoscopic cholecystectomy Mohie El-Din Mostafa Madany, Mansor M Kabbash, Hussien A Mostafa, and 20 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4379323/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The trocar site hernia following laparoscopic cholecystectomy is an important complication after this type of operation. Thus, the scientific community is always welcoming any new approach aiming to reduce its rate. Methods The objective of this retrospective study is to assess the rate of trocar site hernia as well as other complications after a new approach 5-10-5-5 with a 5 mm High-Definition 30-degree Angled Scope. Records and videos of the operations of eligible patients who underwent laparoscopic cholecystectomy at the Aswan University Hospital's general surgery department were included. Results 1027 patients were included in the analysis of this study. Most of the participants were females, representing 93.18% of patients. The mean age of participants was 44.48 ± 11.94 years, the mean ± SD operative time was 88.90 ± 28.30 minutes, and the median (IQR) was 83.5 (32.5) minutes. After the follow-up period of 9–49 months, the average follow-up period was 28.63 ± 11.95 months, and no patient developed a trocar site hernia. Conclusion The new approach 5-10-5-5 with 5 mm High-Definition 30-degree Angled Scope technique provides a safe, and effective technique for laparoscopic cholecystectomy. 5 mm High-Definition Angled Scope 5-10-5-5 approach trocar site hernia laparoscopy cholecystectomy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Figure 15 Figure 16 Figure 17 Figure 18 Figure 19 Introduction Laparoscopic surgery has emerged as the preferred standard of care for a variety of surgical procedures, offering reduced perioperative complications, accelerated recovery, and superior cosmetic results [ 1 ]. It has now become the preferred method for nearly all abdominal surgeries. The concept of laparoscopic surgery was initially introduced by American surgeon Ruddock in the early 1930s, emphasizing its diagnostic superiority over open surgery [ 2 , 3 ]. The inaugural laparoscopic procedure was performed by Professor Mϋhe of Bħblingen in 1985 [ 4 ]. Since its introduction, laparoscopic surgery's minimal morbidity and mortality rates have led to widespread adoption. However, the increased use of laparoscopy in surgical interventions has raised concerns, including the occurrence of trocar site hernias. Despite its rare incidence (1–3%), trocar site hernias (TSH) represent a source of morbidity [ 5 ]. This is noteworthy as laparoscopic surgery, while requiring small incisions for trocar insertion, continues to be associated with favorable outcomes. The most common approach uses a 10-mm laparoscope through a 10–12-mm umbilical port, combined with 2 × 5-mm lateral ports and a 5–10-mm epigastric port [ 6 ]. Technical developments in minimally invasive abdominal surgery have introduced novel approaches such as mini-laparoscopic [ 7 ], 3-incision [ 8 ], single incision [ 9 ], and natural orifice [ 10 ] cholecystectomy. These have evolved to reduce post-operative pain and complications, improve patient satisfaction, and allow an earlier return to work compared with the traditional four-port operation. Twelve-millimeter laparoscopic ports are associated with higher rates of trocar site hernias compared with 10-mm ports [ 11 ]. However, there is insufficient data to show that 5-mm ports result in lower rates of trocar site hernias than larger-sized ports [ 5 ]. Therefore, this current study aimed to assess the safety, feasibility, and possible advantages or disadvantages of using a HD 5-mm 30-degree angled scope in laparoscopic cholecystectomy. Methods Study Design The study complied with the most recent version of the Declaration of Helsinki and adopted the well-recognized GCP criteria. Furthermore, it was authorized by the Local Ethics Committee and complied with all applicable national rules and regulations. Under the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) Statement checklist, this study was planned as a single-group quasi-experimental investigation [17]. Considering the retrospective nature of the study, informed consent as waived by the IRB. The study, approved by the institutional review board, Faculty of Medicine, Aswan University, was conducted on patients who attended the general surgery outpatient clinic at Aswan University Hospital from December 2019 until March 2023. Retrospectively, we will review the medical records of patients who underwent laparoscopic cholecystectomy, who were operated upon at our institute in the mentioned period, using a HD 5-mm 30-degree non-articulated angled scope. The study covered all cases—male or female, 18 years of age or older—that came to the center and underwent Laparoscopic Cholecystectomy. For inclusion in the analysis of the study, patients must have undergone laparoscopic cholecystectomy using a HD 5-mm 30-degree angled scope, have a complete recorded video of the operation available, and complete follow-up data are available. Records of patients who were operated upon using any scope other than a 5 mm HD 30-degree non-articulated angled scope or patients who had an umbilical or paraumbilical hernia done with laparoscopic cholecystectomy were excluded from the analysis. Technique description The operative technique for cholecystectomy was the standard four-port approach 10-10-5-5, but we used a 5 mm HD 30-degree angled scope through a 5.5 mm umbilical port (5-10-5-5). We used the Veress needle to create pneumoperitoneum. The first port was inserted in the umbilicus, except for patients with previous operations in the umbilicus, in whom we inserted it in the right hypochondrium. Operative findings were documented and the degree of difficulty dissecting the GB and the cystic duct and artery [ 13 ]. The umbilical fascial incision was not closed, and also the umbilical skin incision. Retrieval of the GB was in a homemade retrieval bag prepared from a surgical glove. Moreover, should there are big stones, some dilatation of the port was made. We protected the port site with our retrieval bag and applied gentle traction on the GB with some manipulations, otherwise, we opened the GB and grasped the stones by Allis forceps one after one. The epigastric port was always closed even if not dilated. The 5 mm port was inserted in the skin crease of the umbilicus. The edges of this small incision which was made transversely in line with the umbilical crease were so coapted that it needed no stitches for closure. Data regarding the quality of view, the operative findings and duration, procedural difficulties, complications, and conversion were checked for in the records. Operative time and length of hospital stay were also recorded as surrogate markers for operative difficulty and early complications, respectively. Operative complications were recorded in the immediate post-operative period and routine follow-up was done. The demographic data included the incidence, presence of comorbidities, BMI, history of previous abdominal operations, and indications for surgery. Objectives: This study's main goal is to assess the new method in terms of the rate of trocar site hernia (TSH). The surgical success, length of the procedure, and complications (such as infection, seroma, hematoma) were the secondary outcome variables. Statistical analysis Considering the preliminary descriptive nature of this study, a sample size calculation was not performed. Continuous data were presented in mean ± SD (Standard deviation) or median + IQR (Interquartile range) according to the normality test of the variable distribution. For qualitative data, we used numbers and percentages. SPSS software (Statistical Package for the Social Sciences, version 25.0, SSPS Inc, Chicago, IL, USA) was used for the statistical analyses. Results In this study, the data of 1027 patients who underwent laparoscopic cholecystectomy from December 2019 to March 2023 were included in the analysis of this study. Baseline characteristics As seen in Table 1 , the average age of patients was 44.48 ± 11.94 years. The majority of cases were female 957 (93.18%). Only 30 cases (2.92%) had normal weight, 318 (30.96%) were “overweight,” and 679 (66.11%) were “Obese”. The average BMI was 32.75 ± 4.79 Kg/m2. Only 100 (9.74%) had hypertension, 104 (10.13%) DM, and 37 (3.60%) IHD. About half of the cases, 521 (50.73%), were ASA II, 482 (46.93%) were ASA I and only 24 (2.34%) were ASA III. Table 1 Baseline characteristics Indication Frequency % Chronic calculator cholecystitis 905 88.12% Acute calculator cholecystitis 63 6.13% Symptomatic gallbladder polyps 16 1.56% Pyocele of the GB 15 1.46% Mucocele of the GB 9 0.88% Adenomyomatosis of the GB 7 0.68% Perforated GB 5 0.49% Gangrenous GB 4 0.39% Gallstone pancreatitis 3 0.29% Continuous variables Age BMI Valid number 1023 1027 Mean 44.48 32.75 Standard deviation 11.94 4.79 Minimum 25.00 24.50 Lower quartile 35.00 28.90 Median 44.00 32.60 Upper quartile 54.00 36.90 Maximum 67.00 41.50 Interquartile Range 19.00 8.00 As for the indication for operation, 905 (88.12%) of patients had chronic calcular cholecystitis and 3 (0.29%) Gallstone pancreatitis. Other indications are shown in Table 1 . Operative details: All cases underwent laparoscopic cholecystectomy the new (5-10-5-5 technique). All the ports had a width of 5 mm except the epigastric one (10 mm). As depicted in Table 2 , the mean ± SD operative time was 88.90 ± 28.30 minutes, and the median (IQR) was 83.5 (32.5) minutes. Port site bleeding occurred in one case (Fig. 1 ). Table 2 Operative and postoperative details Operative-time mins Hospital-stay, days FU-Time, months Valid number 1027 1027 1027 Mean 104.28 1.11 28.63 Standard deviation 32.33 0.55 11.95 Minimum 48.00 1.00 9.00 Lower quartile 77.00 1.00 18.00 Median 101.00 1.00 29.00 Upper quartile 131.00 1.00 39.00 Maximum 165.00 5.00 49.00 Interquartile Range 54.00 0.00 21.00 Omental entrapment in a Veress needle occurred in another case (Fig. 2 ). The first port insertion was made within peritoneal adhesions in one case (Fig. 3 ). An extra port was needed in ectopic GB in one case and another for assessment of a left groin hernia in another case. The success rate of the surgery was 100%, with no case needing to be redone or converted to open surgery. The average ± SD duration of hospital stay was 1.11 ± 0.55 days, and the median (IQR) was 1 (0). Postoperative follow-up: Only 9 cases (0.88%) experienced seroma, 4 (0.39%) hematoma, and another 18 (1.75%) port-site infection during one month of the post-operative period. All were in the epigastric port except for 2 cases of infection in the umbilical port and one in the lateral lumbar port. The average follow-up period was 28.63 ± 11.95 months. In 108 cases (10.52%) the follow-up duration was 9–12 months, 320 (31.16%) 13–24 months, and 599 (58.33) 25–49 months. None experienced trocar site hernia during the study's follow-up period. Discussion In this retrospective study, the new approach of laparoscopic cholecystectomy (5-10-5-5) with a 5 mm High-Definition 30-degree Angled Scope, was evaluated with a focus on its effectiveness and safety. All cases underwent laparoscopic cholecystectomy with the new (5-10-5-5) technique. According to the results of the current study, the success rate of the surgery was 100%, with no case needing to be redone or converted to open surgery. Port site bleeding occurred in one case. Omental entrapment in the Veress needle occurred in another case. The first port insertion was made within peritoneal adhesions in one case. An extra port was needed in ectopic GB in one case and another for assessment of a left groin hernia in another case. The average ± SD duration of hospital stay was 1.11 ± 0.55 days, and the median (IQR) was 1 (0). Only 9 cases (0.88%) experienced seroma, 4 (0.39) hematoma and another 18 (1.75) port-site infection during one month of the post-operative period. The average follow-up period was 28.63 ± 11.95 months. In 108 cases (10.52%) the follow-up duration was 9–12 months, 320 (31.16%) 13–24 months, and 599 (58.33) 25–49 months. None of the cases experienced TSH during the study's follow-up period. Despite the advantages of laparoscopic surgery, awareness of potential complications such as trocar site hernia is crucial. These complications underscore the importance of careful postoperative monitoring and prompt intervention to ensure optimal patient outcomes. The evolving understanding of these complications contributes to refining surgical techniques and improving patient safety in the field of laparoscopic procedures. Laparoscopic surgery, like any surgical procedure, carries various potential consequences, as documented in the existing literature. Among these, trocar site hernia stands out as the most reported complication [ 14 , 9 ]. Trocar site hernia can manifest in three distinct types: early-onset, late-onset, and specific varieties. The early-onset variant, occurring immediately post-surgery, often results in a Richter hernia or other minor bowel obstruction. In contrast, the late-onset type presents a few months after the procedure, characterized by localized abdominal bulging without small intestine obstruction. The specific form involves the protrusion of the intestine and/or omentum, indicating dehiscence of the entire abdominal wall [ 16 ]. The utilization of the HD 5mm 30-degree angled scope in Laparoscopic Cholecystectomy presents numerous advantages, as evidenced by our current work and experience. One notable benefit is the ability to diagnose and manage bleeding at the Veress needle insertion site through the 5mm lateral port. This is achieved while the 5mm camera is inserted through the 5mm right hypochondrial port. Similarly, if bleeding occurs at the umbilical port (see Fig. 1 before), various techniques such as bipolar diathermy, fascial closure devices, the Madany closure technique, or external sutures can be employed, all under direct vision using our specialized scope (Fig. 4 ). The 5mm scope allows for the insertion of the first port both in the umbilicus and the right hypochondrium. This is particularly beneficial in cases where previous operations in the umbilical region or there is a concomitant umbilical, paraumbilical (Fig. 5 ), or incisional hernia (Fig. 6 ) that necessitates precise, vision-assisted placement of the umbilical port (Fig. 7 ). Additionally, in situations where doubts arise about the veress needle insertion (Fig. 8 ), especially concerning potential entanglement with the omentum or risk of injury to a viscus, preferential insertion of the scope through this port is recommended (see Fig. 3 before). Moreover, the 5mm scope proves invaluable when dealing with adhesions that may be encountered by the veress or the first port. A second port can be easily inserted, enabling the assessment and management of adhesions with optimal ergonomics for the entire surgical team (Fig. 9 ). The 5mm scope's versatility shines in the 5-10-5-5 approach, facilitating the thorough assessment of the camera port and efficient handling of any bleeding complications (see Fig. 1 before). It allows meticulous exploration of the abdomen through various ports and offers the option to insert an extra 5mm port when necessary. For instance, encountering a left groin hernia intraoperatively prompts the insertion of an additional 5mm port close to the hernial defect, allowing for detailed examination and determination of its nature (e.g., patent processus vaginalis (Figs. 10 & 11 ) or true hernia. While for assessment of the right groin hernia, if encountered, all these data can be obtained through the 5 mm midclavicular or the lateral port (Figs. 12 & 13 ), while the medial umbilical ligament may obscure the field if the scope is inserted through the umbilical port (Fig. 14 ). This approach is similarly beneficial in the proper assessment of ventral hernias (Fig. 15 ) and midline adhesions (Fig. 16 ). Contrastingly, the use of the scope through the epigastric port (10 mm) poses limitations in exposing the midline of the anterior abdominal wall and the umbilical region. Its restricted angulation with the sternum (Figs. 17 & 18 ), particularly in cases involving a redundant fatty bulky falciform ligament, which hinders optimal exposure. In contrast, the 5mm scope can be easily maneuvered inside the gallbladder, either intentionally or accidentally opened, providing a clear view of stones, masses, or any lesions. This proves efficient in cases of complex operations requiring subtotal cholecystectomy, allowing for the detection, and stenting of the cystic duct orifice (Fig. 19 ). Additional benefits include its utility in cases of ectopic gallbladders, where an extra 5mm port may be employed. In summary, the 5mm scope stands out as a versatile and indispensable tool in Laparoscopic Cholecystectomy, offering enhanced visibility, optimal ergonomics, and adaptability to various intraoperative scenarios. The retrospective nature of this current study is one limitation. The second, it did not compare the novel procedure to a traditional technique. However, the sample size of 1027 is quite enough to highlight the effectiveness and safety of our unique method. Another advantage of this study is the long duration of follow-up. To further bolster the evidence supporting its efficacy and safety, this novel method will be tested in a randomized controlled trial against alternative approaches. Conclusion The new approach 5-10-5-5 with a 5 mm High-Definition 30-degree Angled Scope is a revolutionary technique that we mentioned in our paper. The procedure has been shown to be safe and effective. Declarations Author Contribution All authors are members of our Department of General Surgery, at Aswan University. All share in performing this great work, reviewing the recorded videos, and selecting the patients with inclusion criteria. Reviewing the postoperative follow-up. Recording the possible values from using this new technique. All share in the writing of this manuscript. The corresponding author collected these written parts to design the entire manuscript. Even the figures are prepared by all according to the video records they had reviewed. Statistics were superviszed by Professor Mansor M Kabbash. The final approval of the manuscript was done by Professor Hussien A Mostafa. Figures were selected by Dr. Ahmed M Maghraby. The corresponding author was the owner of the idea of this work. All authors review the manuscript. All were the laparoscopic surgeons who perform these operations. Data Availability All video recording of our work are available. All data are available at our institute. Ethical considerations: The study as approved by the Local Ethics Committee. Consent to Participate declarations: not applicable. Funding Declaration No fund was granted. Clinical Trial Number: not applicable. The study is retrospective. Competing Interest declaration: All authors have nothing to declare. References Aitchison LP, Chen AZL, Toms C, Sandroussi C, Yeo DA, Steffens D. To stitch or not to stitch: the skin closure of laparoscopic port sites, a meta-analysis. Surg Endosc. 2022;36(10):7140–59. 10.1007/s00464-022-09269-9 . Vitale GC. Endoscopy and surgeons. Surg Innov. 2004;11(4):253. 10.1177/155335060401100408 . Kelley WE Jr. The evolution of laparoscopy and the revolution in surgery in the decade of the 1990s. JSLS. 2008;12(4):351–7. Reynolds W Jr. The first laparoscopic cholecystectomy. JSLS. 2001 Jan-Mar;5(1):89–94. PMID: 11304004; PMCID: PMC3015420. Swank HA, Mulder IM, la Chapelle CF, Reitsma JB, Lange JF, Bemelman WA. 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Improving the reporting quality of nonrandomized evaluations of behavioral and public health interventions: the TREND statement. Am J Public Health. 2004;94(3):361–6. Shah PR. Port site closure after laparoscopic surgery. J Minim Access Surg. 2010;6:22–3. Botea F, Torzilli G, Sarbu V. A simple, effective technique for port-site closure after laparoscopy. JSLS. 2011;15(1):77–80. 10.4293/108680811X13022985131778 . Hussain A, Mahmood H, Singhal T, Balakrishnan S, Nicholls J, El-Hasani S. Long-term study of port site incisional hernia after laparoscopic procedures. JSLS. 2009;13:346–9. Tonouchi H, Ohmori Y, Kobayashi M, Kusunoki M. Trocar Site Hernia. Arch Surg. 2004;139(11):1248–56. 10.1001/archsurg.139.11.1248 . Additional Declarations No competing interests reported. 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University","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"A","lastName":"Marghany","suffix":""},{"id":314423362,"identity":"03771a22-6f81-4818-ad9b-fef05e703f34","order_by":21,"name":"Hany Shokry","email":"","orcid":"","institution":"Aswan University","correspondingAuthor":false,"prefix":"","firstName":"Hany","middleName":"","lastName":"Shokry","suffix":""},{"id":314423363,"identity":"57b1e3d8-2d01-44c7-b98d-f4a688b7bf44","order_by":22,"name":"Mohamed Rabie Saad","email":"","orcid":"","institution":"Aswan University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Rabie","lastName":"Saad","suffix":""}],"badges":[],"createdAt":"2024-05-07 00:11:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4379323/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4379323/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59968616,"identity":"6f0bf5b7-794b-4fd4-8479-8776dfcc1284","added_by":"auto","created_at":"2024-07-10 02:36:09","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":47575,"visible":true,"origin":"","legend":"\u003cp\u003eUmbilical port bleeding\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/01c9c7d4f00e86d1f7044ef5.jpg"},{"id":59969691,"identity":"56c0293e-be67-449e-af47-633150f2c367","added_by":"auto","created_at":"2024-07-10 02:52:09","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":59504,"visible":true,"origin":"","legend":"\u003cp\u003eVeress needle entangles the greater omentum.\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/c754ac5763065162eaf26679.jpg"},{"id":59969310,"identity":"d5c29505-b931-4f51-aaa3-cbd330133058","added_by":"auto","created_at":"2024-07-10 02:44:09","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":237379,"visible":true,"origin":"","legend":"\u003cp\u003eThe umbilical port insertion within adhesions.\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/7e03c1caef97cec8282027cb.jpg"},{"id":59968618,"identity":"de811e27-2961-4ce0-b9cd-40583d3989e0","added_by":"auto","created_at":"2024-07-10 02:36:09","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":24798,"visible":true,"origin":"","legend":"\u003cp\u003eFascial closure device to control port site bleeding.\u003c/p\u003e","description":"","filename":"Picture4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/2706eb46e488a2cbad51d72f.jpg"},{"id":59969311,"identity":"b45d4230-70bf-400a-83a2-674eee9589d5","added_by":"auto","created_at":"2024-07-10 02:44:09","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":87947,"visible":true,"origin":"","legend":"\u003cp\u003eParaumbilical hernia.\u003c/p\u003e","description":"","filename":"Picture5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/2c648977d992ac1ac7b2f3db.jpg"},{"id":59968620,"identity":"c33e4db9-7f03-4438-8538-88e19542a794","added_by":"auto","created_at":"2024-07-10 02:36:09","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":153905,"visible":true,"origin":"","legend":"\u003cp\u003eIncisional hernia.\u003c/p\u003e","description":"","filename":"Picture6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/219768a301e88e25854e04db.jpg"},{"id":59968628,"identity":"39740981-dddb-4b31-a3f5-6f92fc2fc885","added_by":"auto","created_at":"2024-07-10 02:36:10","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":159922,"visible":true,"origin":"","legend":"\u003cp\u003evision-assisted placement of the umbilical port.\u003c/p\u003e","description":"","filename":"Picture7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/dac41b61b7e03389f7bce622.jpg"},{"id":59968623,"identity":"c9f4bc8d-e3e7-4855-bb60-0de543446fc6","added_by":"auto","created_at":"2024-07-10 02:36:09","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":132677,"visible":true,"origin":"","legend":"\u003cp\u003eAssessment of veress needle insertion if we are in doubt.\u003c/p\u003e","description":"","filename":"Picture8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/4e2890415541c1e3dde74f2b.jpg"},{"id":59969313,"identity":"f14a89d6-d5fe-4fa9-b437-1b2c16262cb3","added_by":"auto","created_at":"2024-07-10 02:44:09","extension":"jpg","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":181471,"visible":true,"origin":"","legend":"\u003cp\u003eThe umbilical port is dissected away from the adhesions.\u003c/p\u003e","description":"","filename":"Picture9.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/08eb2e0c9e9a500a637ae2ac.jpg"},{"id":59968631,"identity":"36f60aea-c571-4ed4-a880-0fd17e40f0ce","added_by":"auto","created_at":"2024-07-10 02:36:10","extension":"jpg","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":137353,"visible":true,"origin":"","legend":"\u003cp\u003ePatent Processus vaginalis where our scope is in the umbilical port.\u003c/p\u003e","description":"","filename":"Picture10.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/f208e7eb71a8252f7772af52.jpg"},{"id":59969316,"identity":"76617c44-cd37-4a9c-99a7-60ea9e0c09fa","added_by":"auto","created_at":"2024-07-10 02:44:11","extension":"jpg","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":199923,"visible":true,"origin":"","legend":"\u003cp\u003ePatent Processus vaginalis where our scope is in a left latera port.\u003c/p\u003e","description":"","filename":"Picture11.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/aa9789ecbcf22694977008d6.jpg"},{"id":59968630,"identity":"6145fcbf-05a9-4e89-811d-ab6e20907f2d","added_by":"auto","created_at":"2024-07-10 02:36:10","extension":"jpg","order_by":12,"title":"Figure 12","display":"","copyAsset":false,"role":"figure","size":237545,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative diagnosis of right oblique inguinal hernia.\u003c/p\u003e","description":"","filename":"Picture12.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/0f7ca581dc831922296b4670.jpg"},{"id":59968626,"identity":"3907afce-a527-484a-ab35-fe3486e091cb","added_by":"auto","created_at":"2024-07-10 02:36:09","extension":"jpg","order_by":13,"title":"Figure 13","display":"","copyAsset":false,"role":"figure","size":85930,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative diagnosis of right oblique inguinal hernia.\u003c/p\u003e","description":"","filename":"Picture13.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/ac393bae2dfe60a82a5fb588.jpg"},{"id":59968625,"identity":"2d2bfb0b-ecf0-4bfc-8c45-36c2bbe483e4","added_by":"auto","created_at":"2024-07-10 02:36:09","extension":"jpg","order_by":14,"title":"Figure 14","display":"","copyAsset":false,"role":"figure","size":150927,"visible":true,"origin":"","legend":"\u003cp\u003eThe right medial umbilical ligament obscuring the right internal inguinal ring when the scope is in the umbilical port.\u003c/p\u003e","description":"","filename":"Picture14.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/047aeeb7c75ed138dd8ce46d.jpg"},{"id":59968622,"identity":"1267c5db-db9e-48a2-86c9-0707e568d14f","added_by":"auto","created_at":"2024-07-10 02:36:09","extension":"jpg","order_by":15,"title":"Figure 15","display":"","copyAsset":false,"role":"figure","size":202480,"visible":true,"origin":"","legend":"\u003cp\u003eVentral incisional hernia with multiple defects.\u003c/p\u003e","description":"","filename":"Picture15.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/0a9c1cd7c45b6c2c22da9284.jpg"},{"id":59968635,"identity":"19f4a119-2eb8-4465-b079-d89aefb380aa","added_by":"auto","created_at":"2024-07-10 02:36:11","extension":"jpg","order_by":16,"title":"Figure 16","display":"","copyAsset":false,"role":"figure","size":135527,"visible":true,"origin":"","legend":"\u003cp\u003eMidline infra umbilical adhesiolysis with bipolar diathermy used with ease through the lateral port.\u003c/p\u003e","description":"","filename":"Picture16.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/27a20f3fa6b4e625d8fda24a.jpg"},{"id":59969315,"identity":"29d3773d-af9b-4618-bc76-830dd2dcb89f","added_by":"auto","created_at":"2024-07-10 02:44:10","extension":"jpg","order_by":17,"title":"Figure 17","display":"","copyAsset":false,"role":"figure","size":149222,"visible":true,"origin":"","legend":"\u003cp\u003eThe restricted angulation of the epigastric port limits the exposure of the midline infraumbilical adhesions.\u003c/p\u003e","description":"","filename":"Picture17.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/c4edd8548ddee91ab9f1d79d.jpg"},{"id":59968627,"identity":"07aa2281-63bf-415e-9eae-96f6890b6a72","added_by":"auto","created_at":"2024-07-10 02:36:10","extension":"jpg","order_by":18,"title":"Figure 18","display":"","copyAsset":false,"role":"figure","size":139207,"visible":true,"origin":"","legend":"\u003cp\u003eThe use of bipolar diathermy through the umbilical port is not easy.\u003c/p\u003e","description":"","filename":"Picture18.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/9195e26ce4a68d09d487a665.jpg"},{"id":59968632,"identity":"6855ee7a-af6a-4a6d-9465-003cb13a256a","added_by":"auto","created_at":"2024-07-10 02:36:10","extension":"jpg","order_by":19,"title":"Figure 19","display":"","copyAsset":false,"role":"figure","size":217060,"visible":true,"origin":"","legend":"\u003cp\u003eCanulation of the cystic duct.\u003c/p\u003e","description":"","filename":"Picture19.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/f22865130be724e499e61627.jpg"},{"id":59970155,"identity":"02081bc1-68b3-414b-a339-e95bcddf1de4","added_by":"auto","created_at":"2024-07-10 03:08:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3301536,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4379323/v1/7ace1e41-41f0-497d-b01f-c5d7763ad0ea.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Safety and feasibility of using a 5 mm high-definition angled scope in laparoscopic cholecystectomy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLaparoscopic surgery has emerged as the preferred standard of care for a variety of surgical procedures, offering reduced perioperative complications, accelerated recovery, and superior cosmetic results [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It has now become the preferred method for nearly all abdominal surgeries. The concept of laparoscopic surgery was initially introduced by American surgeon Ruddock in the early 1930s, emphasizing its diagnostic superiority over open surgery [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The inaugural laparoscopic procedure was performed by Professor Mϋhe of Bħblingen in 1985 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSince its introduction, laparoscopic surgery's minimal morbidity and mortality rates have led to widespread adoption. However, the increased use of laparoscopy in surgical interventions has raised concerns, including the occurrence of trocar site hernias. Despite its rare incidence (1\u0026ndash;3%), trocar site hernias (TSH) represent a source of morbidity [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This is noteworthy as laparoscopic surgery, while requiring small incisions for trocar insertion, continues to be associated with favorable outcomes.\u003c/p\u003e \u003cp\u003eThe most common approach uses a 10-mm laparoscope through a 10\u0026ndash;12-mm umbilical port, combined with 2 \u0026times; 5-mm lateral ports and a 5\u0026ndash;10-mm epigastric port [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTechnical developments in minimally invasive abdominal surgery have introduced novel approaches such as mini-laparoscopic [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], 3-incision [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], single incision [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], and natural orifice [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] cholecystectomy. These have evolved to reduce post-operative pain and complications, improve patient satisfaction, and allow an earlier return to work compared with the traditional four-port operation. Twelve-millimeter laparoscopic ports are associated with higher rates of trocar site hernias compared with 10-mm ports [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, there is insufficient data to show that 5-mm ports result in lower rates of trocar site hernias than larger-sized ports [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Therefore, this current study aimed to assess the safety, feasibility, and possible advantages or disadvantages of using a HD 5-mm 30-degree angled scope in laparoscopic cholecystectomy.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003e The study complied with the most recent version of the Declaration of Helsinki and adopted the well-recognized GCP criteria. Furthermore, it was authorized by the Local Ethics Committee and complied with all applicable national rules and regulations. Under the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) Statement checklist, this study was planned as a single-group quasi-experimental investigation [17]. Considering the retrospective nature of the study, informed consent as waived by the IRB.\u003c/p\u003e \u003cp\u003e The study, approved by the institutional review board, Faculty of Medicine, Aswan University, was conducted on patients who attended the general surgery outpatient clinic at Aswan University Hospital from December 2019 until March 2023. Retrospectively, we will review the medical records of patients who underwent laparoscopic cholecystectomy, who were operated upon at our institute in the mentioned period, using a HD 5-mm 30-degree non-articulated angled scope. The study covered all cases\u0026mdash;male or female, 18 years of age or older\u0026mdash;that came to the center and underwent Laparoscopic Cholecystectomy.\u003c/p\u003e \u003cp\u003eFor inclusion in the analysis of the study, patients must have undergone laparoscopic cholecystectomy using a HD 5-mm 30-degree angled scope, have a complete recorded video of the operation available, and complete follow-up data are available.\u003c/p\u003e \u003cp\u003eRecords of patients who were operated upon using any scope other than a 5 mm HD 30-degree non-articulated angled scope or patients who had an umbilical or paraumbilical hernia done with laparoscopic cholecystectomy were excluded from the analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eTechnique description\u003c/h2\u003e \u003cp\u003eThe operative technique for cholecystectomy was the standard four-port approach 10-10-5-5, but we used a 5 mm HD 30-degree angled scope through a 5.5 mm umbilical port (5-10-5-5). We used the Veress needle to create pneumoperitoneum. The first port was inserted in the umbilicus, except for patients with previous operations in the umbilicus, in whom we inserted it in the right hypochondrium. Operative findings were documented and the degree of difficulty dissecting the GB and the cystic duct and artery [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The umbilical fascial incision was not closed, and also the umbilical skin incision. Retrieval of the GB was in a homemade retrieval bag prepared from a surgical glove. Moreover, should there are big stones, some dilatation of the port was made. We protected the port site with our retrieval bag and applied gentle traction on the GB with some manipulations, otherwise, we opened the GB and grasped the stones by Allis forceps one after one. The epigastric port was always closed even if not dilated. The 5 mm port was inserted in the skin crease of the umbilicus. The edges of this small incision which was made transversely in line with the umbilical crease were so coapted that it needed no stitches for closure.\u003c/p\u003e \u003cp\u003eData regarding the quality of view, the operative findings and duration, procedural difficulties, complications, and conversion were checked for in the records. Operative time and length of hospital stay were also recorded as surrogate markers for operative difficulty and early complications, respectively. Operative complications were recorded in the immediate post-operative period and routine follow-up was done. The demographic data included the incidence, presence of comorbidities, BMI, history of previous abdominal operations, and indications for surgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eObjectives:\u003c/h2\u003e \u003cp\u003eThis study's main goal is to assess the new method in terms of the rate of trocar site hernia (TSH). The surgical success, length of the procedure, and complications (such as infection, seroma, hematoma) were the secondary outcome variables.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eConsidering the preliminary descriptive nature of this study, a sample size calculation was not performed. Continuous data were presented in mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (Standard deviation) or median\u0026thinsp;+\u0026thinsp;IQR (Interquartile range) according to the normality test of the variable distribution. For qualitative data, we used numbers and percentages. SPSS software (Statistical Package for the Social Sciences, version 25.0, SSPS Inc, Chicago, IL, USA) was used for the statistical analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn this study, the data of 1027 patients who underwent laparoscopic cholecystectomy from December 2019 to March 2023 were included in the analysis of this study.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics\u003c/h2\u003e \u003cp\u003eAs seen in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the average age of patients was 44.48\u0026thinsp;\u0026plusmn;\u0026thinsp;11.94 years. The majority of cases were female 957 (93.18%). Only 30 cases (2.92%) had normal weight, 318 (30.96%) were \u0026ldquo;overweight,\u0026rdquo; and 679 (66.11%) were \u0026ldquo;Obese\u0026rdquo;. The average BMI was 32.75\u0026thinsp;\u0026plusmn;\u0026thinsp;4.79 Kg/m2. Only 100 (9.74%) had hypertension, 104 (10.13%) DM, and 37 (3.60%) IHD. About half of the cases, 521 (50.73%), were ASA II, 482 (46.93%) were ASA I and only 24 (2.34%) were ASA III.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eBaseline characteristics\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic calculator cholecystitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e905\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.12%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute calculator cholecystitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.13%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptomatic gallbladder polyps\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.56%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePyocele of the GB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.46%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMucocele of the GB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.88%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenomyomatosis of the GB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.68%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerforated\u0026nbsp;GB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.49%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGangrenous GB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.39%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGallstone pancreatitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.29%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eContinuous variables\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eValid number\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1027\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStandard deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower quartile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpper quartile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterquartile Range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs for the indication for operation, 905 (88.12%) of patients had chronic calcular cholecystitis and 3 (0.29%) Gallstone pancreatitis. Other indications are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eOperative details:\u003c/h2\u003e \u003cp\u003eAll cases underwent laparoscopic cholecystectomy the new (5-10-5-5 technique). All the ports had a width of 5 mm except the epigastric one (10 mm).\u003c/p\u003e \u003cp\u003eAs depicted in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD operative time was 88.90\u0026thinsp;\u0026plusmn;\u0026thinsp;28.30 minutes, and the median (IQR) was 83.5 (32.5) minutes. Port site bleeding occurred in one case (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOperative and postoperative details\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOperative-time mins\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHospital-stay, days\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFU-Time, months\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eValid number\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1027\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStandard deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower quartile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpper quartile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e131.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e165.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterquartile Range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOmental entrapment in a Veress needle occurred in another case (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe first port insertion was made within peritoneal adhesions in one case (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAn extra port was needed in ectopic GB in one case and another for assessment of a left groin hernia in another case. The success rate of the surgery was 100%, with no case needing to be redone or converted to open surgery. The average\u0026thinsp;\u0026plusmn;\u0026thinsp;SD duration of hospital stay was 1.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55 days, and the median (IQR) was 1 (0).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative follow-up:\u003c/h2\u003e \u003cp\u003eOnly 9 cases (0.88%) experienced seroma, 4 (0.39%) hematoma, and another 18 (1.75%) port-site infection during one month of the post-operative period. All were in the epigastric port except for 2 cases of infection in the umbilical port and one in the lateral lumbar port.\u003c/p\u003e \u003cp\u003eThe average follow-up period was 28.63\u0026thinsp;\u0026plusmn;\u0026thinsp;11.95 months. In 108 cases (10.52%) the follow-up duration was 9\u0026ndash;12 months, 320 (31.16%) 13\u0026ndash;24 months, and 599 (58.33) 25\u0026ndash;49 months. None experienced trocar site hernia during the study's follow-up period.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this retrospective study, the new approach of laparoscopic cholecystectomy (5-10-5-5) with a 5 mm High-Definition 30-degree Angled Scope, was evaluated with a focus on its effectiveness and safety. All cases underwent laparoscopic cholecystectomy with the new (5-10-5-5) technique.\u003c/p\u003e \u003cp\u003eAccording to the results of the current study, the success rate of the surgery was 100%, with no case needing to be redone or converted to open surgery. Port site bleeding occurred in one case. Omental entrapment in the Veress needle occurred in another case. The first port insertion was made within peritoneal adhesions in one case. An extra port was needed in ectopic GB in one case and another for assessment of a left groin hernia in another case.\u003c/p\u003e \u003cp\u003eThe average\u0026thinsp;\u0026plusmn;\u0026thinsp;SD duration of hospital stay was 1.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55 days, and the median (IQR) was 1 (0). Only 9 cases (0.88%) experienced seroma, 4 (0.39) hematoma and another 18 (1.75) port-site infection during one month of the post-operative period. The average follow-up period was 28.63\u0026thinsp;\u0026plusmn;\u0026thinsp;11.95 months. In 108 cases (10.52%) the follow-up duration was 9\u0026ndash;12 months, 320 (31.16%) 13\u0026ndash;24 months, and 599 (58.33) 25\u0026ndash;49 months. None of the cases experienced TSH during the study's follow-up period.\u003c/p\u003e \u003cp\u003eDespite the advantages of laparoscopic surgery, awareness of potential complications such as trocar site hernia is crucial. These complications underscore the importance of careful postoperative monitoring and prompt intervention to ensure optimal patient outcomes. The evolving understanding of these complications contributes to refining surgical techniques and improving patient safety in the field of laparoscopic procedures. Laparoscopic surgery, like any surgical procedure, carries various potential consequences, as documented in the existing literature. Among these, trocar site hernia stands out as the most reported complication [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Trocar site hernia can manifest in three distinct types: early-onset, late-onset, and specific varieties. The early-onset variant, occurring immediately post-surgery, often results in a Richter hernia or other minor bowel obstruction. In contrast, the late-onset type presents a few months after the procedure, characterized by localized abdominal bulging without small intestine obstruction. The specific form involves the protrusion of the intestine and/or omentum, indicating dehiscence of the entire abdominal wall [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe utilization of the HD 5mm 30-degree angled scope in Laparoscopic Cholecystectomy presents numerous advantages, as evidenced by our current work and experience. One notable benefit is the ability to diagnose and manage bleeding at the Veress needle insertion site through the 5mm lateral port. This is achieved while the 5mm camera is inserted through the 5mm right hypochondrial port. Similarly, if bleeding occurs at the umbilical port (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e before), various techniques such as bipolar diathermy, fascial closure devices, the Madany closure technique, or external sutures can be employed, all under direct vision using our specialized scope (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe 5mm scope allows for the insertion of the first port both in the umbilicus and the right hypochondrium. This is particularly beneficial in cases where previous operations in the umbilical region or there is a concomitant umbilical, paraumbilical (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e),\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eor incisional hernia (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ethat necessitates precise, vision-assisted placement of the umbilical port (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAdditionally, in situations where doubts arise about the veress needle insertion (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e),\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eespecially concerning potential entanglement with the omentum or risk of injury to a viscus, preferential insertion of the scope through this port is recommended (see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e before).\u003c/p\u003e \u003cp\u003eMoreover, the 5mm scope proves invaluable when dealing with adhesions that may be encountered by the veress or the first port. A second port can be easily inserted, enabling the assessment and management of adhesions with optimal ergonomics for the entire surgical team (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe 5mm scope's versatility shines in the 5-10-5-5 approach, facilitating the thorough assessment of the camera port and efficient handling of any bleeding complications (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e before). It allows meticulous exploration of the abdomen through various ports and offers the option to insert an extra 5mm port when necessary. For instance, encountering a left groin hernia intraoperatively prompts the insertion of an additional 5mm port close to the hernial defect, allowing for detailed examination and determination of its nature (e.g., patent processus vaginalis (Figs.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e10\u003c/span\u003e \u0026amp; \u003cspan refid=\"Fig11\" class=\"InternalRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eor true hernia. While for assessment of the right groin hernia, if encountered, all these data can be obtained through the 5 mm midclavicular or the lateral port (Figs.\u0026nbsp;\u003cspan refid=\"Fig12\" class=\"InternalRef\"\u003e12\u003c/span\u003e \u0026amp; \u003cspan refid=\"Fig13\" class=\"InternalRef\"\u003e13\u003c/span\u003e),\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ewhile the medial umbilical ligament may obscure the field if the scope is inserted through the umbilical port (Fig.\u0026nbsp;\u003cspan refid=\"Fig14\" class=\"InternalRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThis approach is similarly beneficial in the proper assessment of ventral hernias (Fig.\u0026nbsp;\u003cspan refid=\"Fig15\" class=\"InternalRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eand midline adhesions (Fig.\u0026nbsp;\u003cspan refid=\"Fig16\" class=\"InternalRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eContrastingly, the use of the scope through the epigastric port (10 mm) poses limitations in exposing the midline of the anterior abdominal wall and the umbilical region. Its restricted angulation with the sternum (Figs.\u0026nbsp;\u003cspan refid=\"Fig17\" class=\"InternalRef\"\u003e17\u003c/span\u003e \u0026amp; \u003cspan refid=\"Fig18\" class=\"InternalRef\"\u003e18\u003c/span\u003e),\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eparticularly in cases involving a redundant fatty bulky falciform ligament, which hinders optimal exposure.\u003c/p\u003e \u003cp\u003eIn contrast, the 5mm scope can be easily maneuvered inside the gallbladder, either intentionally or accidentally opened, providing a clear view of stones, masses, or any lesions. This proves efficient in cases of complex operations requiring subtotal cholecystectomy, allowing for the detection, and stenting of the cystic duct orifice (Fig.\u0026nbsp;\u003cspan refid=\"Fig19\" class=\"InternalRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAdditional benefits include its utility in cases of ectopic gallbladders, where an extra 5mm port may be employed.\u003c/p\u003e \u003cp\u003eIn summary, the 5mm scope stands out as a versatile and indispensable tool in Laparoscopic Cholecystectomy, offering enhanced visibility, optimal ergonomics, and adaptability to various intraoperative scenarios.\u003c/p\u003e \u003cp\u003eThe retrospective nature of this current study is one limitation. The second, it did not compare the novel procedure to a traditional technique. However, the sample size of 1027 is quite enough to highlight the effectiveness and safety of our unique method. Another advantage of this study is the long duration of follow-up. To further bolster the evidence supporting its efficacy and safety, this novel method will be tested in a randomized controlled trial against alternative approaches.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe new approach 5-10-5-5 with a 5 mm High-Definition 30-degree Angled Scope is a revolutionary technique that we mentioned in our paper. The procedure has been shown to be safe and effective.\u003c/p\u003e "},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors are members of our Department of General Surgery, at Aswan University. All share in performing this great work, reviewing the recorded videos, and selecting the patients with inclusion criteria. Reviewing the postoperative follow-up. Recording the possible values from using this new technique. All share in the writing of this manuscript. The corresponding author collected these written parts to design the entire manuscript. Even the figures are prepared by all according to the video records they had reviewed. Statistics were superviszed by Professor Mansor M Kabbash. The final approval of the manuscript was done by Professor Hussien A Mostafa. Figures were selected by Dr. Ahmed M Maghraby. The corresponding author was the owner of the idea of this work. All authors review the manuscript. All were the laparoscopic surgeons who perform these operations.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll video recording of our work are available. All data are available at our institute.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study as approved by the Local Ethics Committee.\u003c/p\u003e\n\u003cp\u003eConsent to Participate declarations: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo fund was granted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003enot applicable. The study is retrospective.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest declaration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have nothing to declare.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAitchison LP, Chen AZL, Toms C, Sandroussi C, Yeo DA, Steffens D. To stitch or not to stitch: the skin closure of laparoscopic port sites, a meta-analysis. Surg Endosc. 2022;36(10):7140\u0026ndash;59. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00464-022-09269-9\u003c/span\u003e\u003cspan address=\"10.1007/s00464-022-09269-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVitale GC. Endoscopy and surgeons. Surg Innov. 2004;11(4):253. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/155335060401100408\u003c/span\u003e\u003cspan address=\"10.1177/155335060401100408\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelley WE Jr. The evolution of laparoscopy and the revolution in surgery in the decade of the 1990s. JSLS. 2008;12(4):351\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReynolds W Jr. The first laparoscopic cholecystectomy. JSLS. 2001 Jan-Mar;5(1):89\u0026ndash;94. PMID: 11304004; PMCID: PMC3015420.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSwank HA, Mulder IM, la Chapelle CF, Reitsma JB, Lange JF, Bemelman WA. Systematic review of trocar-site hernia. Br J Surg. 2012;99(3):315\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDonohue JH, Grant CS, Farnell MB, van Heerden JA. Laparoscopic cholecystectomy: operative technique. Mayo Clin. Proc. 1992; 67: 441\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaribhakti SP, Mistry JH. Techniques of laparoscopic cholecystectomy: nomenclature and selection. J Min Access Surg. 2015;11:113\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeggett PL, Churchman-Winn R, Miller G. Minimizing ports toimprove laparoscopic cholecystectomy. Surg Endosc. 2000;14:32\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNavarra G, Pozza E, Occhionorelli S, Carcoforo P, Donini I. Onewound laparoscopic cholecystectomy. Br J Surg. 1997;84:695.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZorro\u0026rsquo;n R, Filgueiras M, Maggioni LC, Pombo L, Lopes Carvalho G, Lacerda Oliveira A. Transvaginal cholecystectomy: report of the first case. Surg Innov. 2007;14:279\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKadar N, Reich H, Liu CY, Manko GF, Gimpelson R. Incisional hernias after major laparoscopic gynecologic procedures. Am J Obstet Gynecol. 1993;168:1493\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDes Jarlais DC, Lyles C, Crepaz N, TREND Group. Improving the reporting quality of nonrandomized evaluations of behavioral and public health interventions: the TREND statement. Am J Public Health. 2004;94(3):361\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShah PR. Port site closure after laparoscopic surgery. J Minim Access Surg. 2010;6:22\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBotea F, Torzilli G, Sarbu V. A simple, effective technique for port-site closure after laparoscopy. JSLS. 2011;15(1):77\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4293/108680811X13022985131778\u003c/span\u003e\u003cspan address=\"10.4293/108680811X13022985131778\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHussain A, Mahmood H, Singhal T, Balakrishnan S, Nicholls J, El-Hasani S. Long-term study of port site incisional hernia after laparoscopic procedures. JSLS. 2009;13:346\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTonouchi H, Ohmori Y, Kobayashi M, Kusunoki M. Trocar Site Hernia. Arch Surg. 2004;139(11):1248\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/archsurg.139.11.1248\u003c/span\u003e\u003cspan address=\"10.1001/archsurg.139.11.1248\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"5 mm High-Definition Angled Scope, 5-10-5-5 approach, trocar site hernia, laparoscopy, cholecystectomy","lastPublishedDoi":"10.21203/rs.3.rs-4379323/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4379323/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe trocar site hernia following laparoscopic cholecystectomy is an important complication after this type of operation. Thus, the scientific community is always welcoming any new approach aiming to reduce its rate.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe objective of this retrospective study is to assess the rate of trocar site hernia as well as other complications after a new approach 5-10-5-5 with a 5 mm High-Definition 30-degree Angled Scope. Records and videos of the operations of eligible patients who underwent laparoscopic cholecystectomy at the Aswan University Hospital's general surgery department were included.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003e1027 patients were included in the analysis of this study. Most of the participants were females, representing 93.18% of patients. The mean age of participants was 44.48\u0026thinsp;\u0026plusmn;\u0026thinsp;11.94 years, the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD operative time was 88.90\u0026thinsp;\u0026plusmn;\u0026thinsp;28.30 minutes, and the median (IQR) was 83.5 (32.5) minutes. After the follow-up period of 9\u0026ndash;49 months, the average follow-up period was 28.63\u0026thinsp;\u0026plusmn;\u0026thinsp;11.95 months, and no patient developed a trocar site hernia.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe new approach 5-10-5-5 with 5 mm High-Definition 30-degree Angled Scope technique provides a safe, and effective technique for laparoscopic cholecystectomy.\u003c/p\u003e","manuscriptTitle":"Safety and feasibility of using a 5 mm high-definition angled scope in laparoscopic cholecystectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-10 02:36:03","doi":"10.21203/rs.3.rs-4379323/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5131a9d3-bcfa-41fa-9f0e-395990fa5b4e","owner":[],"postedDate":"July 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-10T02:36:06+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-10 02:36:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4379323","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4379323","identity":"rs-4379323","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}