Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy. Ann Surg. 2011;254:22-27. [PMID: 21494123 DOI: 10.1097/sla.0b013e3182192f89]

Meta-analysis of prospective randomized studies comparing single-incision laparoscopic cholecystectomy (SILC) and conventional multiport laparoscopic cholecystectomy (CMLC)

BACKGROUND

Single-incision laparoscopic cholecystectomy (SILC) has gained acceptance among surgeons as there is a trend to minimize the invasiveness of laparoscopy. The aim of this meta-analysis has been to assess the feasibility and safety of SILC when compared to conventional multiport laparoscopic cholecystectomy (CMLC).

METHODS

A literature search for trials comparing SILC and CMLC was performed. Studies were reviewed for the outcomes of interest: patient characteristics; operative time and conversion rate; postoperative pain; length of hospital stay; postoperative complications; and patient satisfactory score (0-10). Standardized mean difference (SMD) was calculated for continuous variables and odds ratio for qualitative variables.

RESULTS

Twelve prospective randomized trials comparing SILC and CMLC were analyzed. Overall, 892 patients were randomized to either SILC (465) or CMLC (427). Operative time was significantly longer in SILC (63.0 vs. 45.8 min, SMD = 1.004, 95% CI = 0.434-1.573). Patient satisfactory score significantly favored SILC (8.2 vs. 7.2, SMD = -0.759, 95% CI = -1.064 to -0.455). No other difference was found.

CONCLUSIONS

SILC is a safe and effective procedure for the treatment of uncomplicated benign gallbladder disease with a significant patient satisfaction. New multicenter randomized trials are expected to evaluate SILC in more complex circumstances such as acute cholecystitis, previous abdominal surgery, and severe obesity.

Current status and future directions of robotic single-site surgery: a systematic review

CONTEXT

Despite the increasing interest in laparoendoscopic single-site surgery (LESS) worldwide, the actual role of this novel approach in the field of minimally invasive urologic surgery remains to be determined. It has been postulated that robotic technology could be applied to LESS to overcome the current constraints.

OBJECTIVE

To summarize and critically analyze the available evidence on the current status and future of robotic applications in single-site surgery.

EVIDENCE ACQUISITION

A systematic literature review was performed in April 2011 using PubMed and the Thomson-Reuters Web of Science. In the free-text protocol, the following terms were applied: robotic single site surgery, robotic single port surgery, robotic single incision surgery, and robotic laparoendoscopic single site surgery. Review articles, editorials, commentaries, and letters to the editor were included only if deemed to contain relevant information. In addition, cited references from the selected articles and from review articles retrieved in the search were assessed for significant manuscripts not previously included. The authors selected 55 articles according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria.

EVIDENCE SYNTHESIS

The volume of available clinical outcomes of robotic LESS (R-LESS) has considerably grown since the pioneering description of the first successful clinical series of single-port robotic procedures. So far, a cumulative number of roughly 150 robotic urologic LESS cases have been reported by different institutions across the globe with a variety of techniques and port configurations. The feasibility of robot-assisted single-incision colorectal procedures, as well as of many gynecologic procedures, has also been demonstrated. A novel set of single-site instruments specifically dedicated to LESS is now commercially available for use with the da Vinci Si surgical system, and both experimental and clinical use have been reported. However, the current robotic systems were specifically designed for LESS. The ideal robotic platform should have a low external profile, the possibility of being deployed through a single access site, and the possibility of restoring intra-abdominal triangulation while maintaining the maximum degree of freedom for precise maneuvers and strength for reliable traction. Several purpose-built robotic prototypes for single-port surgery are being tested.

CONCLUSIONS

Significant advances have been achieved in the field of R-LESS since the first reported clinical series in 2009. Given the several advantages offered by current the da Vinci system, it is likely that its adoption in this field will increase. The recent introduction of purpose-built instrumentation is likely to further foster the application of robotics to LESS. However, we are still far from the ideal robotic platform. Significant improvements are needed before this technique might reach widespread adoption beyond selected centers. Further advances in the field of robotic technology are expected to provide the optimal interface to facilitate LESS.

Surgery for Crohn's disease: new developments

BACKGROUND/AIMS

Crohn's disease is a chronic relapsing inflammatory bowel disease requiring surgery in a large number of patients. This review describes new developments in surgical techniques for treating Crohn's disease.

RESULTS

Single-incision laparoscopic surgery decreases abdominal wall trauma by reducing the number of abdominal incisions, possibly improving postoperative results in terms of pain and cosmetics. The resected specimen can be extracted through the single-incision site or the future stoma site. Another option is to use natural orifices for extraction (i.e. transcolonic/transanal), but actual benefits of these procedures have not yet been determined. In patients with extensive perianal disease or rectal involvement, transperineal completion proctectomy is often feasible, thereby avoiding relaparotomy. By using a close rectal intersphincteric resection, damage to the pelvic autonomic nerves is avoided. In addition, the risk of presacral abscess formation is reduced by leaving the mesorectal tissue behind.

CONCLUSION

Minimally invasive surgery and associated techniques have become standard clinical practice in surgical treatment of patients with Crohn's disease. New developments aim at further reducing the hospital stay and morbidity, and improving the cosmetic outcomes.

Relevance of reduced-port laparoscopic distal gastrectomy for gastric cancer: a pilot study

BACKGROUND/AIMS

Single-port and reduced-port laparoscopic surgeries are performed as a less invasive form of surgery than conventional laparoscopy. In this study, short-term patient outcomes were compared between reduced-port laparoscopic distal gastrectomy (RPLDG) and conventional laparoscopy-assisted distal gastrectomy (LADG) to evaluate the feasibility of RPLDG for gastric cancer.

METHODS

Between August 2010 and July 2011, 38 patients underwent LADGs that were performed by a single surgeon. Of these, 20 patients underwent RPLDG, and 18 patients underwent conventional LADG. Short-term outcomes were compared between the two groups.

RESULTS

Surgical procedures, total operation time (278.8 versus 228.7 min, p = 0.0002) and time for lymph node dissection (181.3 versus 136.3 min, p = 0.0001) were significantly longer in the RPLDG group compared with the LADG group, while the volume of blood loss during reconstruction was reduced (17.5 versus 49.6 ml, p = 0.0019). Cosmetic satisfaction in the RPLDG group showed significant superiority over that in the conventional LADG group (p = 0.0252).

CONCLUSION

RPLDG was shown to be an acceptable and satisfactory procedure for the treatment of gastric cancer. To confirm the feasibility of this surgical procedure, it is necessary to conduct a well-designed randomized controlled study comparing RPLDG and conventional LADG in many patients.

Single-port laparoscopic cholecystectomy in patients of advanced age: why not?

OBJECTIVE

To compare the perioperative outcome of elderly patients undergoing either single-port cholecystectomy (SPC) or standard multiport laparoscopic cholecystectomy (SMLC).

PATIENTS AND METHODS

Patients older than 50 years who underwent SPC using the reusable X-Cone were compared with age-matched, sex-matched, and body mass index-matched patients after SMLC, and postoperative outcome was analyzed.

RESULTS

Of 97 patients who underwent SPC during July 2009 and August 2011, 33 patients (34%) were older than 50 years. Baseline characteristics were comparable for either group, as was the operative time (min) (SPC: 82.7 ± 25.1 vs. SMLC: 83.9 ± 22.1; P=0.85), postoperative hospital stay (d) (SPC: 3.7 ± 1.6 vs. SMLC: 3.9 ± 1.5; P=0.61), and postoperative complication rate [SPC: 4 of 33 patients (12.1%) vs. SMLC: 3 of 33 patients (9.1%); P=1.0].

CONCLUSIONS

Our study suggests that older age might not be predictive of an inferior outcome after SPC, compared with patients who were treated with the "golden standard."

Single-incision laparoscopic cholecystectomy vs. conventional laparoscopic cholecystectomy: a meta-analysis of randomized controlled trials

INTRODUCTION

We analyzed different morbidity parameters between single-incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy (CLC).

METHODS

Pubmed, Ovid, Embase, SCI database, Cochrane, and Google Scholar were searched. The primary endpoints analyzed were cosmetic result and the postoperative pain (at 6 and 24 h) and the secondary endpoints were operating time, hospital stay, incidence of overall postoperative complications, wound-related complications, and port-site hernia.

RESULTS

Six hundred fifty-nine patients (SILC-349, CLC-310) were analyzed from nine randomized controlled trials. The objective postoperative pain scores at 6 and 24 h and the hospital stay were similar in both groups. The total postoperative complications, wound-related problems, and port-site hernia formation, though higher in SILC, were also comparable in both groups. SILC had significantly favorable cosmetic scoring compared to CLC [weighted mean difference = 1.0, p = 0.0001]. The operating time was significantly longer in SILC [weighted mean difference = 15.63, p = 0.0001].

CONCLUSIONS

Single-incision laparoscopic cholecystectomy does not confer any benefit in postoperative pain (6 and 24 h) and hospital stay as compared to conventional laparoscopic cholecystectomy while having significantly better cosmetic results at the same time. Postoperative complications, though higher in SILC, were statistically similar in both the groups.

Single-incision laparoscopic surgery: outcomes from 224 colonic resections performed at a single center using SILS

BACKGROUND

Compared with single-incision laparoscopy, multiport laparoscopy is associated with greater risk of postoperative wound pain, infection, incisional hernias, and suboptimal cosmetic outcomes. The feasibility of minimally invasive single-incision laparoscopic surgery (SILS) for colorectal procedures is well-established, but outcome data remain limited.

METHODS

Patients with benign diverticular disease, Crohn's disease, or ulcerative colitis admitted to Klinikum Leverkusen, Germany, for colonic resection between July 2009 and March 2011 (n = 224) underwent single-incision laparoscopic surgery using the SILS port system. Surgeons had ≥7 years' experience in laparoscopic colon surgery but no SILS experience. Patient demographic and clinical data were collected prospectively. Pain was evaluated by using a visual analog scale (0-10). Data were analyzed by using the SPSS PASW Statistics 18 database.

RESULTS

The majority of patients underwent sigmoid colectomy with high anterior resection (AR) or left hemicolectomy (n = 150) for diverticulitis. Our conversion rate to open surgery was 6.3 %, half in patients undergoing sigmoid colectomy with high AR or left hemicolectomy, 95 % of whom had diverticulitis. Mean operating time was 166 ± 74 (range, 40-441) min in the overall population, with shorter times for single-port transanal tumor resection (SPTTR; 89 ± 51 min; range, 40-153 min) and longer times for proctocolectomy (325 min; range, 110-441 min). Mean hospital stay was approximately 10 days, longer after abdominoperineal rectal resection or proctocolectomy (12-16 days). Most complications occurred following sigmoid colectomy with high AR or left hemicolectomy [19/25 (76 %) of early and 4/5 (80 %) of late complications, respectively]. Pain was <4 on a scale of 0-10 in all cases on postoperative day 1, and typically decreased during the next 2 days.

CONCLUSIONS

Our findings support the feasibility and tolerability of colorectal surgery, conducted by experienced laparoscopic surgeons without specific training in use of the SILS port.

Single-port laparoscopic adrenalectomy for a right-sided aldosterone-producing adenoma: a case report

Introduction

Single-port laparoscopic adrenalectomy is one of the most interesting surgical advances. Here, we evaluate the safety and feasibility of single-port laparoscopic adrenalectomy as treatment for a right-sided aldosterone-producing adenoma.

Case presentation

A 39-year-old Japanese woman presented with hypertension and hypokalemia. Abdominal computed tomography and an endocrinological workup revealed a 19mm right adrenal tumor with primary aldosteronism. Our patient was informed of the details of the surgical procedure and our efforts to reduce the number of incisions needed - ideally, to a single incision - when removing her adrenal gland. A single-port laparoscopic adrenalectomy was attempted. A multichannel port was inserted through a 2.5cm umbilical incision. A 5mm flexible laparoscope, articulating laparoscopic dissector and tissue sealing device were the primary tools used in the operation. The right liver lobe was evaluated using a percutaneous instrument, providing good visualization of the operative field surrounding her right adrenal gland. The single-port laparoscopic adrenalectomy was successfully completed without any intraoperative complications. The operating time was 76 minutes, and her blood loss was 5mL. Oral intake was resumed on the first postoperative day, and the length of her hospital stay was three days. Her postoperative course was uneventful with no morbidity within one month of follow-up, and our patient had excellent cosmetic results.

Conclusions

Single-port laparoscopic adrenalectomy is a safe and feasible procedure for patients with a right-sided adrenal tumor when performed by a surgeon experienced in laparoscopic and adrenal surgery. However, more surgical experience using this technique is required to confirm our initial impressions.

Innovations in Endosurgery-Journey into the Past of the Future: To Ride the SILS Bandwagon or Not?

Progress in surgical practice has paralleled the civilizational evolution. Surgery has progressed from being the last resort in saving life to being form and function preserver. Post-renaissance Industrial age gave an impetus to this march of surgery. The currently on going digital technological revolution has further catalysed this march. Having achieved the stabilized and acceptable clinical outcomes, the surgeon has embarked on a journey of improving patient reported outcomes (PRO). Improvement in PROs with the advent of laparoscopic surgery with the attendant emphasis on minimising invasion has led to debates about invasion being just parietal or holistic in physiological sense. There is a concern that parietal invasiveness shouldn't be a trade-off for compromised clinical outcomes. Single Incision Laparoscopic Surgery (SILS) in its current avatar with current instrumentation seems to be an enthusiastic bandwagon rolling on with the cosmetic benefits acting as veil to hide the potential clinical concerns. History of surgical innovations is riddled with tales of vindictiveness and vicissitude. Lest the same fate befalls SILS we would do better to examine the SILS bandwagon in its current form till the emerging technologies address the current concerns.

Single-incision laparoscopic cholecystectomy: is it a plausible alternative to the traditional four-port laparoscopic approach?

The current standard-of-care for treatment of cholecystectomy is the four port laparoscopic approach. The development of single incision/laparoendoscopic single site surgery (SILC/LESS) has now led to the development of new techniques for removal of the gallbladder. The use of SILC/LESS is now currently being evaluated as the next step in treatment of cholecystectomy. This review is an attempt to consolidate the current knowledge and analyze the feasibility of world-wide implementation of SILC/LESS.

Laparoendoscopic single-site cholecystectomy versus conventional laparoscopic cholecystectomy: a systematic review of randomized controlled trials

BACKGROUND

Laparoendoscopic single-site surgery is a revolution in minimally invasive surgery in recent years, and cholecystectomy is the most common intervention. However, laparoendoscopic single-site cholecystectomy (LESSC) is a controversial procedure. Its safety, cosmetic results, complications, post-operative pain and post-operative stay are not confirmed by multi-centre randomized controlled studies.

OBJECTIVES

This review examined the impact of LESSC versus conventional laparoscopic cholecystectomy (CLC). The primary outcomes were conversional rate and intraoperative and post-operative complications, and other outcomes were cosmetic results, operative time, post-operative pain and post-operative stay.

DATA SOURCES

Pubmed, EMbase, Web of Science, Ovid, clinical trials of the US National Institutes of Health and Cochrane Database of Systematic Reviews and Controlled Trials Register were searched to identify all possible randomized controlled trials (RCTs).

METHODS

Two reviewers completed article search, and eligible data were entered into a computerized spreadsheet for analysis.

RESULTS

Nine studies were obtained using the search strategy. Patients accepting LESSC had a higher conversion rate than those having CLC (7.17 (3.00, 17.11) (P < 0.01)). There was no significant difference for total complications between the two groups (1.17 (0.76, 1.80) (P = 0.46)), but incidence of incisional hernia and haemorrhage (seroma) in the LESSC group was obviously higher than that in the CLC group. Operative time was much longer in the LESSC group (mean difference: 10.69 (3.14, 18.24) (P = 0.006)). Cosmetic results favoured LESSC; however, post-operative abdominal pain and post-operative stay were not significantly different between the two groups in most of the nine studies.

CONCLUSIONS

LESSC can be safely performed with better cosmetic results; however, it carries a higher conversion rate and a longer operative time, and offers no benefit in terms of post-operative abdominal pain and post-operative stay. Further RCTs, according to the CONSORT statement, are advocated to validate its objective benefits.

Surgical Stress Response and Clinical Outcomes of Single Port Laparoscopic Cholecystectomy: Prospective Nonrandomized Study

The levels of interleukin-6 (IL-6) are proportionate to injury; it is the most commonly used quantitative marker in surgical studies. Cytokines and the acute-phase response play an important role in controlling the human immune system. The objective of this study was to compare the systemic acute cytokine response and clinical outcomes of conventional laparoscopic and single port laparoscopic cholecystectomy. We compared patients who underwent single port laparoscopic cholecystectomy (the single port group) with patients who underwent conventional laparoscopic cholecystectomy (the conventional group) according to the clinical variables, IL-6, leukocyte subpopulations, and visual analog scale (VAS) pain score. The mean age in the single port group was significantly younger ( P = 0.010) and the mean operation time in the conventional group was significantly shorter ( P = 0.002). Postoperative 4-hour VAS pain score was slightly worse in the single port laparoscopic cholecystectomy group, but was not significantly different. We found no difference in clinical outcomes, the level of serum IL-6, C-reactive protein, leukocyte subpopulations, and complications between the two groups. Stress response in single port laparoscopic cholecystectomy is equal to conventional surgery. Postoperative 4-hour VAS pain score was slightly worse and the operation time is significantly longer in the single port laparoscopic cholecystectomy group.

Comparison of cosmetic outcome between single-incision laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy: an objective study

BACKGROUND

Single-incision laparoscopic cholecystectomy (SILC) has been projected to have better cosmetic outcome compared with conventional laparoscopic cholecystectomy (CLC). However, there are scarce data that have objectively compared the patient's perception of cosmetic outcome after SILSC and CLC.

METHODS

The SILC and CLC patients, who were operated in the last 2 years, were personally interviewed and assessed using the Patient Scar Assessment Questionnaire. A lower score indicated a better patient outcome. The satisfaction with the appearance and the symptoms due to the scars was assessed in all the patients.

RESULTS

Fifty-two patients were included in the study (25 SILC, 27 CLC). The age and sex distributions and body mass indexes were similar in both groups. The scores of different parameters assessed as per Patient Scar Assessment Questionnaire-appearance (SILC, 1.08 ± 0.4; CLC, 1.14 ± 0.5: P=.57), symptoms (SILC, 1.16 ± 0.5; CLC, 1.18 ± 0.4; P=.83), scar consciousness (SILC, 1.04 ± 0.2; CLC, 1.07 ± 0.3; P=.6), satisfaction with symptoms (SILC, 1.12 ± 0.3; CLC, 1.18 ± 0.4; P=.52), and satisfaction with appearance (SILC, 1.04 ± 0.2; CLC, 1.11 ± 0.3; P=.34)-were similar in both groups. The overall satisfaction scores were also statistically similar in both groups (SILC, 5.44 ± 1.4; CLC, 5.70 ± 1.7; P=.54). Overall, a majority of patients (>80%) in both groups gave the lowest score (1), indicating maximum satisfaction, in all the categories.

CONCLUSIONS

Patient perception regarding cosmetic outcome after SILC and CLC was similar in both groups. SILC does not seem to offer any significant cosmetic advantage over CLC. This point needs to be assessed in detail by larger studies, as cosmetic benefit is projected as one of the major advantages of single-incision surgery.

Single-port laparoscopic spleen preserving distal pancreatectomy

Single-port laparoscopic surgery has become increasingly popular, with widened indication to more types of surgery. This report will present our initial experience with spleen-preserving distal pancreatectomy technique through a small transumbilical incision using the single-port approach for a cystic tumor of pancreatic body. The surgery was done using specialized single-port instruments and normal laparoscopic instruments. The total operative time for this surgery is 233 minutes, and it was completed without drains. Patient was discharged from the hospital on the third day postoperatively in good condition.

Single-incision laparoscopic surgery (SILS) vs. conventional multiport cholecystectomy: systematic review and meta-analysis

BACKGROUND

Single-incision laparoscopic surgery (SILS) has gained increasing attention due to the potential to maximize the benefits of laparoscopic surgery. The aim of this systematic review and pooled analysis was to compare clinical outcome following SILS and standard multiport laparoscopic cholecystectomy for the treatment of gallstone-related disease.

METHODS

An electronic search of Embase and Medline databases for articles from 1966 to 2011 was performed. Publications were included if they were randomised controlled studies in which patients underwent either single-incision or multiport cholecystectomy. The primary outcome measures for the meta-analysis were postoperative complications and postoperative pain score [visual analogue scale (VAS) on the day of surgery]. Secondary outcome measures were operating time and length of hospital stay. Weighted mean difference was calculated for the effect size of SILS on continuous variables, and pooled odds ratios were calculated for discrete variables.

RESULTS

In total, 375 cholecystectomy operations from 7 randomised controlled trials were included, 195 by single-incision (SILS) and 180 by conventional multiport. Operating time was significantly longer in the SILS group compared to the standard multiport laparoscopic cholecystectomy group (weighted mean difference = 2.13; P = 0.0001). There was no significant difference in the incidence of postoperative complications, postoperative pain score (VAS), or the length of hospital stay between the two groups.

CONCLUSION

The results of this meta-analysis demonstrate that single-incision laparoscopic cholecystectomy is a safe procedure for the treatment of uncomplicated gallstone disease, with postoperative outcome similar to that of standard multiport laparoscopic cholecystectomy. Future high-powered randomized studies should be focused on elucidating subtle differences in postoperative complications, reported postoperative pain, and cosmesis following SILS cholecystectomy in more severe biliary disease.

Are natural orifice transluminal endoscopic surgery and single-incision surgery viable techniques for cholecystectomy?

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) and single-incision surgery (SIS) are less invasive alternatives to traditional laparoscopic techniques. Concerns exist over the safety of these new approaches, and randomized controlled trials have yet to confirm a net benefit. If NOTES and SIS techniques are to become standard practice, then they should be shown to be safe and hold clear benefits to patients. We aim at comparing the available results by using these techniques in a standard laparoscopic operation (cholecystectomy).

METHODS

A systematic review using available databases (MEDLINE, EMBASE, and the Cochrane Controlled Trials Register) and the published English language medical literature was performed. All the archived articles were cross-referenced. Outcome data obtained from a Cochrane review of laparoscopic cholecystectomy were used as the control group. All the operations performed via a single incision were grouped under SIS, and operations in which a natural orifice (alone or as a hybrid technique) was analyzed, under NOTES group. Mortality and complications were the primary outcome measures.

RESULTS

One hundred thirty-five papers including 4703 patients (714 NOTES, 3989 SIS) were selected for analysis. Overall complication rate was 4.2% in the NOTES group versus 4.3% in the SIS group, with a distinct complication profile. No mortality was reported in either group. NOTES procedures had a longer mean operative time than SIS techniques (107 versus 79 minutes). The conversion rate between NOTES and SILS was similar (3.4% versus 3.3%, respectively).

DISCUSSION

No difference in the incidence of complications was observed with the newer techniques. Adequately powered randomized control trials are needed to clarify whether SIS/NOTES cholecystectomy has a similar length of hospital stay to traditional laparoscopic cholecystectomy. The increased occurrence of specific types of complications and their use in acute pathology needs further investigation to warrant further use in routine surgical practice.

Trocar-site hernia after single-port cholecystectomy: not an exceptional complication?

BACKGROUND

When compared with standard multiport laparoscopy, the larger fascial incision in single-port surgery (SPS) may imply a potentially increased risk of surgical-site complications, such as herniation. The long-term risk of access-site complications in SPS is still unpredictable.

METHODS

Between July 2009 and May 2011, n=78 patients (n=54 females), with a median age of 42 years (range: 18-85 years), underwent single-port cholecystectomy. The median body mass index was 25.4 kg/m(2) (range: 17-39 kg/m(2)). All surgeries were performed by a single surgeon (K.K.) using a completely reusable single-port access device (X-Cone™; KARL STORZ GmbH, Tuttlingen, Germany), and fascial closure technique was comparable in all patients. The first 50 patients (n=32 females) attended a structured follow-up examination including a meticulous clinical examination and ultrasonography of the access site at a median follow-up time of 17 months (range: 9-23 months).

RESULTS

We recorded postoperative complications in 5 of the 50 patients (10%) after single-port cholecystectomy. Four occurred in the early postoperative course and presented as mild wound complications. One of the 50 patients (2%) experienced a symptomatic trocar-site hernia (TSH) 4 months after surgery. No biliary complications (bile leakage, retained stones, etc.) were recorded.

CONCLUSIONS

Although potentially biased by a relatively small number of patients, our study provides evidence that TSH after single-port cholecystectomy is (i) not less frequent when compared with standard laparoscopy, (ii) not as infrequent as suggested by the current literature, and (iii) not only associated with technical failure or patients' comorbidity.

Cosmesis and body image after single-port laparoscopic or conventional laparoscopic cholecystectomy: a multicenter double blinded randomised controlled trial (SPOCC-trial)

BACKGROUND

Emerging attempts have been made to reduce operative trauma and improve cosmetic results of laparoscopic cholecystectomy. There is a trend towards minimizing the number of incisions such as natural transluminal endoscopic surgery (NOTES) and single-port laparoscopic cholecystectomy (SPLC). Many retrospective case series propose excellent cosmesis and reduced pain in SPLC. As the latter has been confirmed in a randomized controlled trial, patient's satisfaction on cosmesis is still controversially debated.

METHODS/DESIGN

The SPOCC trial is a prospective, multi-center, double blinded, randomized controlled study comparing SPLC with 4-port conventional laparoscopic cholecystectomy (4PLC) in elective surgery. The hypothesis and primary objective is that patients undergoing SPLC will have a better outcome in cosmesis and body image 12 weeks after surgery. This primary endpoint is assessed using a validated 8-item multiple choice type questionnaire on cosmesis and body image. The secondary endpoint has three entities: the quality of life 12 weeks after surgery assessed by the validated Short-Form-36 Health Survey questionnaire, postoperative pain assessed by a visual analogue scale and the use of analgesics. Operative time, surgeon's experience with SPLC and 4PLC, use of additional ports, conversion to 4PLC or open cholecystectomy, length of stay, costs, time of work as well as intra- and postoperative complications are further aspects of the secondary endpoint. Patients are randomly assigned either to SPLC or to 4PLC. Patients as well as treating physicians, nurses and assessors are blinded until the 7th postoperative day. Sample size calculation performed by estimating a difference of cosmesis of 20% (alpha = 0.05 and beta = 0.90, drop out rate of 10%) resulted in a number of 55 randomized patients per arm.

DISCUSSION

The SPOCC-trial is a prospective, multi-center, double-blind, randomized controlled study to assess cosmesis and body image after SPLC.

TRIAL REGISTRATION

(clinicaltrial.gov): NCT 01278472.

Single port laparoscopic appendectomy: are we pursuing real advantages?

Single port appendectomy, due to its cosmetic appeal and to a technique similar to classic laparoscopic appendectomy, is provoking an increasing number of publications and case series to explore its feasibility and effective improvements for patients with acute appendicitis. The margins for improvement are not so large, as laparoscopic appendectomy is, after 20 years from its beginning, still debated. A literature search has been accomplished to investigate the outcomes of the operation. 23 case series or retrospective comparisons with classic laparoscopy have been found. The numbers and low quality of the published data do not permit to draw evidence based conclusions. Still, trends seem to evidence an increase in complications especially in complicated appendicitis, which suggests caution in its dissemination outside clinical trials.