Randomized clinical trial of single- versus multi-incision laparoscopic cholecystectomy

Single-Incision Laparoscopic Cholecystectomy in Situs Inversus Totalis: A Case Report

BACKGROUND Situs inversus totalis (SIT) is a rare developmental anomaly. For many years, laparoscopic cholecystectomy has been a well-established and effective treatment for patients with cholecystolithiasis. However, when it comes to SIT patients with cholecystolithiasis, this surgery presents unique challenges. Due to its complete mirror inversion of viscera, it is uncomfortable to carry out standard laparoscopic cholecystectomy for some surgeons. Single-incision laparoscopic cholecystectomy (SILC) offers a minimally invasive alternative to traditional laparoscopic cholecystectomy, potentially enhancing aesthetic outcomes and minimizing postoperative discomfort. CASE REPORT A 67-year-old woman was admitted to the hospital due to abdominal pain. After admission, she completed a chest X-ray, electrocardiogram, B-ultrasound, and magnetic resonance cholangiopancreatography. Imaging examination revealed SIT and cholecystolithiasis. The laboratory examination results were normal. All contraindications to surgery were ruled out, and then SILC was performed under general anesthesia on January 22, 2024. The surgeon and assistant stood on the right side of the patient, and the abdominal SILC port with 3 operation channels was placed through a 2-cm traumatic incision. We used electric hooks and separating forceps to dissect the Calot triangle and gallbladder of the patient, and the gallbladder was successfully removed. The patient recovered well after the surgery. CONCLUSIONS For SIT patients with cholecystolithiasis, SILC is a safe and effective minimally invasive treatment option which has fewer surgical incisions and less postoperative pain. However, it demands experienced SILC surgeons, thorough preoperative examinations, and close attention to incision conditions after surgery.

Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials

Background

Conventional multi-port laparoscopic cholecystectomy (CMLC) has become the current 'gold standard' technique in gallbladder disease. Single-incision laparoscopic cholecystectomy (SILC) has gained attention due to its benefits in improving patient cosmetic results and pain reduction. We aim to assess the latest evidence on the feasibility, safety and surgical outcomes of SILC and CMLC.

Methods

We conducted searches for randomized controlled trials (RCTs) in PubMed, PubMed Central (PMC), and Europe PMC between December 2011 and 2021. The latest search was conducted in January 2022. We analyzed several outcomes, including perioperative complications, estimated blood loss, operation time, conversion to open surgery, hospital stay, pain score, cosmesis, and days of return to work. Cochrane Risk of Bias (RoB) 2.0 tool was used to evaluate quality of studies. Mantel-Haenszel's formula and Inverse Variance method were conducted to synthesize results. This study was accomplished in accordance with the PRISMA guidelines.

Results

A total of 37 studies were eligible, with a total of 2,129 and 2,392 patients who underwent SILC and CMLC. Our study demonstrated a superiority of SILC for the visual analog score (VAS) at six hours post-operation [mean difference (MD) -0.58 (95% CI -1.11, -0.05), p=0.03], cosmesis one-month post-operation [standard MD 2.12 (95% CI 1.10, 3.13), p<0.0001], and cosmesis six months post-operation [standard MD 0.53 (95% CI 0.06, 0.99), p<0.0001]. Meanwhile, SILC showed a longer operation time [MD 10.45 (95% CI 6.74, 14.17), p<0.00001]. In terms of VAS at four time points (4, 8, 12, and 24 hours), perioperative complications, estimated blood loss, conversion to open surgery, hospital stay and days to return to work, SILC did not differ from CMLC.

Conclusions

SILC is a safe, feasible and favorable procedure in terms of pain reduction and cosmetic results. The option between both procedures is based on surgeon preferences. Registration: PROSPERO ( CRD42022306532; 23 February 2022).

Incidence of incisional hernias and cosmetic outcome after laparoscopic single-incision cholecystectomy: a long-term follow-up cohort study of 125 patients

Background

Studies have evaluated long-term occurrence of incisional hernia, cosmesis, and postoperative pain after single-incision laparoscopic cholecystectomy (SILC). However, the follow-up periods were rarely defined longer than 12 months. The authors performed a cohort study to evaluate hernia rate and cosmesis in a prolonged follow-up period.

Methods

All patients that underwent SILC at the University Hospital Brandenburg an der Havel Hospital between December 2008 and November 2014 were evaluated in terms of postoperative complications, and a follow-up telephone interview including the existence of hernias and chronic pain was performed. Cosmesis and the overall satisfaction of the scar was measured by POSAS (Patient and Observer Scar Assessment Scale).

Results

In total 125 patients underwent SILC. The single-incision approach was completed in 94.4%, an additional trocar was necessary in 3.2% (n=4) and a conversion to 4 trocar cholecystectomy was required in 2.4% (n=3). Intraoperative complications occurred in 0.8% and postoperative complication in 12.8% of all patients. Follow-up telephone interview was performed in 49.6% of 125 patients. The mean follow-up period was 138.9 months (11.6 years). Overall, in 3.6%, an incisional hernia was diagnosed. A total of 3.6% reported pain in the region of the umbilicus with a mean VAS (visual analog scale) of 2/10. The mean POSAS score was 7.8. Overall, 82.3% of this cohort rate their satisfaction of the scar with a 1/7, resembling the best possible result of the scar.

Conclusion

The present study demonstrates that SILC is a safe alternative in terms of incisional hernia rate and complications with a high satisfaction of the scar even after one decade after surgery. In comparison to shorter follow-up period and multiport laparoscopic cholecystectomy, our result is comparable.

A Systematic Review and Meta-Analysis of Single-Incision Laparoscopic Cholecystectomy Versus Conventional Four-Port Laparoscopic Cholecystectomy

The present systematic review compares single-incision laparoscopic cholecystectomy (SILC) with conventional laparoscopic cholecystectomy (CLC) with the aim of assessing early postoperative pain and morbidity. The secondary outcomes assessed were the duration of surgery, length of hospital stay, and conversion to open surgery. A systematic search for medical records was conducted on PubMed, Embase, Medline, and the Cochrane Library. Meta-analysis was conducted using Review Manager 5.4. A total of 14 randomized control trials met the eligibility criteria, involving a total of 1762 patients. Early postoperative pain (four to six hours) (mean difference (MD): -0.86; 95%; confidence interval (CI): -1.16 to -0.55) showed significantly better results in the SILC group but showed no difference on the first or second postoperative day. There were significantly fewer complications (relative risk (RR): 1.7; 95%; CI: 1.16-2.50) recorded in the CLC group as compared to the SILC group. Operative time (MD: 19.66; 95% CI: 13.21-26.11) was significantly longer in the SILC group, while the duration of hospital stay (MD: -0.01; 95% CI: -0.28-0.26) and conversion to open surgery (RR: 0.99; 95% CI: 0.20-4.82) showed no significant difference. SILC had a significantly longer operative time and more complications as compared to CLC. However, it was associated with significantly lower early post-operative pain.

Comparative outcomes of needlescopic, single-incision laparoscopic, standard laparoscopic, mini-laparotomy, and open cholecystectomy: A systematic review and network meta-analysis of 96 randomized controlled trials with 11,083 patients

BACKGROUND

Most randomized trials on minimally invasive cholecystectomy have been conducted with standard (3/4-port) laparoscopic or open cholecystectomy serving as the control group. However, there exists a dearth of head-to-head trials that directly compare different minimally invasive techniques for cholecystectomy (eg, single-incision laparoscopic cholecystectomy versus needlescopic cholecystectomy). Hence, it remains largely unknown how the different minimally invasive cholecystectomy techniques fare up against one another.

METHODS

To minimize selection and confounding biases, only randomized controlled trials were considered for inclusion. Perioperative outcomes were compared using frequentist network meta-analyses. The interpretation of the results was driven by treatment effects and surface under the cumulative ranking curve values. A sensitivity analysis was also undertaken focusing on a subgroup of randomized controlled trials, which recruited patients with only uncomplicated cholecystitis.

RESULTS

Ninety-six eligible randomized controlled trials comprising 11,083 patients were identified. Risk of intra-abdominal infection or abscess, bile duct injury, bile leak, and open conversion did not differ significantly between minimally invasive techniques. Needlescopic cholecystectomy was associated with the lowest rates of wound infection (surface under the cumulative ranking curve value = 0.977) with an odds ratio of 0.095 (95% confidence interval: 0.023-0.39), 0.32 (95% confidence interval: 0.11-0.98), 0.33 (95% confidence interval: 0.11-0.99), 0.36 (95% confidence interval: 0.14-0.98) compared to open cholecystectomy, single-incision laparoscopic cholecystectomy, mini-laparotomy, and standard laparoscopic cholecystectomy, respectively. Mini-laparotomy was associated with the shortest operative time (surface under the cumulative ranking curve value = 0.981) by a mean difference of 22.20 (95% confidence interval: 13.79-30.62), 12.17 (95% confidence interval: 1.80-22.54), 9.07 (95% confidence interval: 1.59-16.54), and 8.36 (95% confidence interval: -1.79 to 18.52) minutes when compared to single-incision laparoscopic cholecystectomy, needlescopic cholecystectomy, standard laparoscopic cholecystectomy, and open cholecystectomy, respectively. Needlescopic cholecystectomy appeared to be associated with the shortest hospitalization (surface under the cumulative ranking curve value = 0.717) and lowest postoperative pain (surface under the cumulative ranking curve value = 0.928).

CONCLUSION

Perioperative outcomes differed across minimally invasive techniques and, in some instances, afforded superior outcomes compared to standard laparoscopic cholecystectomy. These findings suggest that there may be equipoise for exploring further the utility of novel minimally invasive techniques and potentially incorporating them into the general surgery training curriculum.

Identification and categorisation of relevant outcomes for symptomatic uncomplicated gallstone disease: in-depth analysis to inform the development of a core outcome set

BACKGROUND

Many completed trials of interventions for uncomplicated gallstone disease are not as helpful as they could be due to lack of standardisation across studies, outcome definition, collection and reporting. This heterogeneity of outcomes across studies hampers useful synthesis of primary studies and ultimately negatively impacts on decision making by all stakeholders. Core outcome sets offer a potential solution to this problem of heterogeneity and concerns over whether the 'right' outcomes are being measured. One of the first steps in core outcome set generation is to identify the range of outcomes reported (in the literature or by patients directly) that are considered important.

OBJECTIVES

To develop a systematic map that examines the variation in outcome reporting of interventions for uncomplicated symptomatic gallstone disease, and to identify other outcomes of importance to patients with gallstones not previously measured or reported in interventional studies.

RESULTS

The literature search identified 794 potentially relevant titles and abstracts of which 137 were deemed eligible for inclusion. A total of 129 randomised controlled trials, 4 gallstone disease specific patient-reported outcome measures (PROMs) and 8 qualitative studies were included. This was supplemented with data from 6 individual interviews, 1 focus group (n=5 participants) and analysis of 20 consultations. A total of 386 individual recorded outcomes were identified across the combined evidence: 330 outcomes (which were reported 1147 times) from trials evaluating interventions, 22 outcomes from PROMs, 17 outcomes from existing qualitative studies and 17 outcomes from primary qualitative research. Areas of overlap between the evidence sources existed but also the primary research contributed new, unreported in this context, outcomes.

CONCLUSIONS

This study took a rigorous approach to catalogue and map the outcomes of importance in gallstone disease to enhance the development of the COS 'long' list. A COS for uncomplicated gallstone disease that considers the views of all relevant stakeholders is needed.

Low long-term incidence of incisional hernia after cholecystectomy: A systematic review with meta-analysis

BACKGROUND

Various surgical approaches are available for cholecystectomy, but their long-term outcomes, such as incidence of incisional hernia, are largely unknown. Our aim was to investigate the long-term incidence of incisional hernia after cholecystectomy for different surgical approaches.

METHODS

This systematic review and meta-analysis was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A protocol was registered on PROSPERO (CRD42020178906). Three databases were searched for original studies on long-term complications of cholecystectomy with n > 40 and follow-up ≥6 months for incisional hernia. Risk of bias within the studies was assessed using the Newcastle-Ottawa Scale and the Cochrane "risk of bias" tool. Meta-analysis of the incidence of incisional hernia after 6 and 12 months was conducted when possible.

RESULTS

We included 89 studies. Of these, 77 reported on multiport or single-incision laparoscopic cholecystectomy. Twelve studies reported on open cholecystectomy and 4 studies on robotic cholecystectomy. Weighted mean incidence proportion of incisional hernia after multi-port laparoscopic cholecystectomy was 0.3% (95% confidence interval 0-0.6) after 6 months and 0.2% after 12 months (95% confidence interval 0.1-0.3). Weighted mean incidence of incisional hernia 12 months postoperatively was 1.5% (95% confidence interval 0.4-2.6) after open cholecystectomy and 4.5% (95% confidence interval 0.4-8.6) after single-incision laparoscopic cholecystectomy. No meta-analysis could be conducted for robotic cholecystectomy, but incidences ranged from 0% to 16.7%.

CONCLUSION

We found low 1-year incidences of incisional hernia after multiport laparoscopic and open cholecystectomy, whereas risks of incisional hernia were considerably higher after single-incision laparoscopic and robotic cholecystectomy.

Single-incision versus conventional multiport laparoscopic cholecystectomy: a current meta-analysis of randomized controlled trials

BACKGROUND

We performed this study to compare the safety and feasibility of single-incision laparoscopic cholecystectomy (SILC) with conventional multiple-port laparoscopic cholecystectomy (MPLC).

METHODS

We searched PubMed, Embase, Web of Science, the Cochrane Controlled Register of Trials (CENTRAL), and ClinicalTrials.gov for randomized controlled trials comparing SILC versus MPLC. We evaluated the pooled outcomes for complications, pain scores, and surgery-related events. This study was performed in accordance with PRISMA guidelines.

RESULTS

A total of 48 randomized controlled trials involving 2838 patients in the SILC group and 2956 patients in the MPLC group were included in this study. Our results showed that SILC was associated with a higher incidence of incisional hernia (relative risk = 2.51; 95% confidence interval = 1.23-5.12; p = 0.01) and longer operation time (mean difference = 15.27 min; 95% confidence interval = 9.67-20.87; p < 0.00001). There were no significant differences between SILC and MPLC regarding bile duct injury, bile leakage, wound infection, conversion to open surgery, retained common bile duct stones, total complication rate, and estimated blood loss. No difference was observed in postoperative pain assessed by a visual analogue scale between the two groups at four time points (6 h, 8 h, 12 h, and 24 h postprocedure).

CONCLUSIONS

Based on the current evidence, SILC did not result in better outcomes compared with MPLC and both were equivalent regarding complications. Considering the additional surgical technology and longer operation time, SILC should be chosen with careful consideration.

Trans-stomal single-port laparoscopic Hartmann's reversal is an efficacious and efficient procedure: a case-controlled study

BACKGROUND

Hartman's reversal remains challenging and is associated with a widely variable success rate. In a previous study, we reported that laparoscopy may lower the mortality and morbidity rates of the procedure. The aim of the current study was to assess the operative results of single-port laparoscopic Hartmann's reversal (SP-HR) as compared to the more standard, multi-port laparoscopic variant (MP-HR).

METHODS

We performed a retrospective, non-randomized, case-controlled study of 44 consecutive patients who had SP-HR (Group A) compared to 44 patients who had MP-HR (Group B). The study was conducted in a high-volume colorectal unit in a 1200-bed university affiliated hospital, The Poissy-Saint Germain Medical Complex, France.

RESULTS

Preoperative patients' characteristics (sex, body mass index, American Society of Anesthesiologists status, prior surgery, comorbidities, colonic disease) were comparable in both groups. The conversion rate was 13.6% and 4.5% in Group A and in Group B, respectively (p = 0.084) and consisted of placement of any additional ports. Conversion to open surgery did not occur in any patient in either group (p = 1). Mean operative time was shorter in Group A than in in Group B, (105 vs. 155 min; p = 0.0133). The mortality rate was 2.2% in Group A and 0% in Group B (p = 0.3145). The overall morbidity rate was 11.4% in Group A and 18.2% in Group B (p = 0.5344). The median length of hospital stay was significantly shorter in Group than in Group B (4.8 vs. 6.8 days; p = 0.0102).

CONCLUSIONS

The SP-HR technique was found to be safe and efficient. It compares favorably with MP-HR. Moreover, indirect cost savings could be induced by the reduction in the length of hospital stay.

Single-port versus multiport laparoscopic surgery comparing long-term patient satisfaction and cosmetic outcome

Introduction

Several studies and meta-analysis showed Single-port or Single-incision laparoscopic surgery (SPL) to be superior over Multiport laparoscopic surgery (MPL) mainly in terms of postoperative pain and cosmetic result. But very little is known whether these results are only a short-term effect or are persistent on the long run after SPL. We therefore evaluated and compared long-term outcomes regarding cosmesis and chronic pain after SPL and MPL.

Methods

We conducted a comparative study with propensity score matching of all patients undergoing SPL or MPL between October 2008 and December 2013 in terms of postoperative cosmetic results and chronic pain. Follow-up data were obtained from mailed patient questionnaires and telephone interviews. Postoperative cosmesis was assessed using the patients overall scar opinion on a 10-point scale and the Patients scale of the standardized Patient and Observer Scar assessment scale (POSAS). Chronic pain was assessed by 10-point scales for abdominal and umbilical scar pain.

Results

A total of 280 patients were included in the study with 188 patients (67.1%) after SPL and 92 patients (32.9%) following MPL. 141 patients (50.4%) underwent a cholecystectomy and 139 patients (49.6%) underwent an appendectomy. The mean follow-up time was 61.1 ± 19.1 months. The mean wound satisfaction assed by the overall scar and the PSOAS Patients scale score of the patients showed no significant difference between MPL and SPL. Patients after SPL reported more overall complains than after MPL (8.7% vs. 2.5%, respectively), but without statistical significance (p = 0.321). Umbilical pain scores were comparable between the two groups (1.4 ± 1.0 vs. 1.4 ± 1.0, p = 0.831).

Conclusion

We found no difference in long-term cosmetic outcomes after SPL and MPL. Chronic pain at the umbilical incision site was comparable on the long run.

Incidence and Risk Factors of Incisional Hernia After Single-Incision Endoscopic Surgery

Introduction: Abdominal wall complications are one of the most controversial issues regarding single-incision endoscopic surgery. The aim of this study was to analyze the incidence and risk factors of incisional hernia after single-incision endoscopic cholecystectomy. Materials and Methods: An observational retrospective study was performed, on a cohort of patients cholecystectomized laparoscopically through a transumbilical single incision due to gallbladder lithiasis or polyps. Postoperative complications were analyzed, with special interest in the incisional hernia rate, whose results were assessed in the long-term follow-up. Univariate and multivariate analyses were also performed to evaluate possible variables associated with the appearance of incisional hernia. Cumulative sum charts (CUSUM) were used to identify trends in the incisional hernia risk. Results: Some 109 patients were included in the study. With a mean follow-up of nearly 38 months, an incisional hernia incidence of 5.5% was found, with 67% being diagnosed during the first year of follow-up. In the Cox regression analysis, two variables showed an independent association with the emergence of incisional hernia, body mass index (hazard ratio [HR] 1.30; 95% confidence interval [CI 1.053-1.606]; P .015), and wound infection (HR 26.32; [3.186-217.40]; P .002]. CUSUM charts showed a decrease in the risk of incisional hernia after the first 10 cases. Conclusions: Single-incision endoscopic cholecystectomy is associated with a substantially high risk of postoperative incisional hernia (5.5%).

Minimally Invasive Single-Site Cholecystectomy in Obese Patients: Laparoscopic vs. Robotic

Robotic single-site cholecystectomy (RSSC) has emerged as an alternative procedure to overcome the shortcomings of single-fulcrum laparoscopic cholecystectomy in terms of the ergonomics and reducing the physical and mental stress of the surgeon. It is also necessary to assess the safety of RSSC for obese patients in a world with an increasing population of obese people. RSSC took a longer operation time, but the actual dissection time was similar to that of single-fulcrum laparoscopic cholecystectomy. There was no difference in postoperative pain, except for during the immediate postoperative period, and in the length of the hospital stay. RSSC had the advantage of reducing the incidence of intraoperative iatrogenic gallbladder perforation. It is critical to prevent any intraoperative bile leakage, which is associated as a worse prognostic factor in those patients with gallbladder cancer. Additional studies with a prospective design and larger number of study subjects will be required to confirm the safety and feasibility of RSSC. Moreover, the cost benefit and safety for treating malignant lesions are also issues to be addressed. RSSC is expected to be further expanded as an operative mode in the future.

Single-Port Versus Conventional Laparoscopic Cholecystectomy: Better Cosmesis at the Price of an Increased Incisional Hernia Rate?

Background: The incidence of trocar site hernia (TSH) in single-port laparoscopic cholecystectomy (SPC) is still a debated issue. Aim of this retrospective study was to compare the incidence of postoperative hernia and cosmetic results among patients undergoing SPC and multiport laparoscopic cholecystectomy (MPC) performed at a single institution. Methods: A series of 60 SPC and 60 MPC patients operated on between July 2016 and May 2018 were compared. Primary endpoint was to assess the incidence of TSH at long term. All the patients were admitted as outpatients for physical examination and scar measurement. Secondary endpoints were the cosmetic results assessed by a cosmesis score (CS) and the body image questionnaire (BIQ). Results: After a median 18-month follow-up (range: 6-29 months), a hernia in umbilical trocar site was detected in 4 (7.1%) SPC patients and 1 (2%) MPC patient, the difference not being statistically significant (P = .216). BIQ was almost equivalent in SPC and MPC groups (5.15 versus 5.27; P = .518), respectively. Statistically significant differences in favor of SPC were found in CS (22.3 versus 19.72; P = .001) and in total length of scars (1.2 cm versus 4 cm; P < .001). Conclusions: SPC technique has proved to be safe and effective in experienced hands. Superior cosmesis of SPC over MPC is confirmed, but close attention to fascial closure is a vital component of SPC, and surgeons performing single-site surgery need to be aware of this increased potential for hernia formation.

Etiologies of Long-Term Postcholecystectomy Symptoms: A Systematic Review

BACKGROUND

Cholecystectomy does not relieve abdominal symptoms in up to 40% of patients. With 700,000 cholecystectomies performed in the US, annually, about 280,000 patients are left with symptoms, making this a serious problem. We performed a systematic review to determine the different etiologies of long-term postcholecystectomy symptoms with the aim to provide guidance for clinicians treating these patients.

METHODS

A systematic search of the literature was performed using MEDLINE, EMBASE, and Web of Science. Articles describing at least one possible etiology of long-term symptoms after a laparoscopic cholecystectomy were included in this review. Long-term symptoms were defined as abdominal symptoms that were present at least four weeks after cholecystectomy, either persistent or incident. The etiologies of persistent and incident symptoms after LC and the mechanism or hypothesis behind the etiologies are provided. If available, the prevalence of the discussed etiology is provided.

RESULTS

The search strategy identified 3320 articles of which 130 articles were included. Etiologies for persistent symptoms were residual and newly formed gallstones (41 studies, prevalence ranged from 0.2 to 23%), coexistent diseases (64 studies, prevalence 1-65%), and psychological distress (13 studies, no prevalence provided). Etiologies for incident symptoms were surgical complications (21 studies, prevalence 1-3%) and physiological changes (39 studies, prevalence 16-58%). Sphincter of Oddi dysfunction (SOD) was reported as an etiology for both persistent and incident symptoms (21 studies, prevalence 3-40%).

CONCLUSION

Long-term postcholecystectomy symptoms vary amongst patients, arise from different etiologies, and require specific diagnostic and treatment strategies. Most symptoms after cholecystectomy seem to be caused by coexistent diseases and physiological changes due to cholecystectomy. The outcome of this research is summarized in a decision tree to give clinical guidance on the treatment of patients with symptoms after cholecystectomy.

European association for endoscopic surgery (EAES) consensus statement on single-incision endoscopic surgery

BACKGROUND

Laparoscopic surgery changed the management of numerous surgical conditions. It was associated with many advantages over open surgery, such as decreased postoperative pain, faster recovery, shorter hospital stay and excellent cosmesis. Since two decades single-incision endoscopic surgery (SIES) was introduced to the surgical community. SIES could possibly result in even better postoperative outcomes than multi-port laparoscopic surgery, especially concerning cosmetic outcomes and pain. However, the single-incision surgical procedure is associated with quite some challenges.

METHODS

An expert panel of surgeons has been selected and invited to participate in the preparation of the material for a consensus meeting on the topic SIES, which was held during the EAES congress in Frankfurt, June 16, 2017. The material presented during the consensus meeting was based on evidence identified through a systematic search of literature according to a pre-specified protocol. Three main topics with respect to SIES have been identified by the panel: (1) General, (2) Organ specific, (3) New development. Within each of these topics, subcategories have been defined. Evidence was graded according to the Oxford 2011 Levels of Evidence. Recommendations were made according to the GRADE criteria.

RESULTS

In general, there is a lack of high level evidence and a lack of long-term follow-up in the field of single-incision endoscopic surgery. In selected patients, the single-incision approach seems to be safe and effective in terms of perioperative morbidity. Satisfaction with cosmesis has been established to be the main advantage of the single-incision approach. Less pain after single-incision approach compared to conventional laparoscopy seems to be considered an advantage, although it has not been consistently demonstrated across studies.

CONCLUSIONS

Considering the increased direct costs (devices, instruments and operating time) of the SIES procedure and the prolonged learning curve, wider acceptance of the procedure should be supported only after demonstration of clear benefits.

Quality of life after single-incision laparoscopic cholecystectomy: A randomized, clinical trial

BACKGROUND

Controversy continues as to whether single-incision laparoscopic cholecystectomy, with the somewhat larger incision at the umbilicus, may lead to a worse postoperative quality of life and more pain compared with the more classic 4-port laparoscopic cholecystectomy. The aim of this study was to compare single-incision and 4-port laparoscopic cholecystectomy from the perspective of quality of life.

METHODS

This study was a multicenter, parallel-group, open-label, randomized clinical trial. A total of 120 patients who were scheduled to undergo elective cholecystectomy were randomly assigned 1:1 into the single-incision laparoscopic cholecystectomy or the 4-port laparoscopic cholecystectomy group and then assessed continuously for 2 weeks during the postoperative period. The primary outcome was quality of life, defined as the time to resume normal daily activities. Postoperative pain was also assessed. To explore the heterogeneity of treatment effects, we assessed the interactions of sex, age, and working status on recovery time.

RESULTS

A total of 58 patients in the single-incision group and 53 in the 4-port group (n = 111, 47 male, mean age 57 years) were analyzed. The mean time to resume daily activities was 10.2 days and 8.8 days, respectively, for single-incision and 4-port laparoscopic cholecystectomy (95% confidence interval -0.4 to 3.2, P = .12). Similarly, the time to relief from postoperative pain did not differ significantly between the groups. Statistically insignificant but qualitative interactions were noted; in the subgroups of women, full-time workers, and patients younger than 60 years, recovery tended to be slower after single-incision laparoscopic cholecystectomy.

CONCLUSION

Postoperative quality of life did not differ substantially between single-incision laparoscopic cholecystectomy and 4-port laparoscopic cholecystectomy. Patients younger than 60 years, women, and full-time workers tended to have a somewhat slower recovery after single-incision laparoscopic cholecystectomy.

Total 5-mm port approach: a feasible technique for both elective and emergency laparoscopic cholecystectomy

BACKGROUND

The laparoscopic approach is considered the standard of care for cholecystectomy. Attempts to minimize incisions with single site and natural orifice approaches have shown promise but also have limitations. Technological advances have facilitated decreased port size, which may have a variety of benefits. The aim of this study was to determine the feasibility of an all 5-mm port approach for patients undergoing both elective and emergency laparoscopic cholecystectomy.

METHODS

A consecutive series of laparoscopic cholecystectomies at three different hospitals using all 5-mm ports was prospectively evaluated. Recorded outcomes included operative findings, procedural difficulties, the need to extend the umbilical incision during extraction, operative time, length of stay and post-operative complications.

RESULTS

A total of 101 patients were included and all had a successful cholecystectomy without the need for additional ports. The umbilical incision was extended for gallbladder extraction in 29 (29%) patients. Eight (8%) patients experienced minor post-operative complications and there were no major complications. Cholangiography was performed in 98% of cases and three patients underwent successful common bile duct exploration without requiring additional ports. In a small number of cases, there was difficulty with the quality of the view through the 5-mm laparoscope but this was rectified by removing old or damaged laparoscopes from the circulating stock.

CONCLUSION

This study demonstrates that laparoscopic cholecystectomy using all 5-mm ports is both feasible and safe, and is comparable to published outcomes after conventional laparoscopic cholecystectomy. Further work is needed to determine whether this approach can also improve short- and long-term outcomes.

Single-incision laparoscopic cholecystectomy is responsible for increased adverse events: results of a meta-analysis of randomized controlled trials

BACKGROUND

Over the last decade, single-incision laparoscopic cholecystectomy (SLC) has gained popularity, although it is not evident if benefits of this procedure overcome the potential increased risk. Aim of the study is to compare the outcome of SLC with conventional multi-incision laparoscopic cholecystectomy (MLC) in a meta-analysis of randomized controlled trials only.

METHODS

A systematic Medline, Embase, and Cochrane Central Register of Controlled Trials literature search of articles on SLC and MLC for any indication was performed in June 2017. The main outcomes measured were overall adverse events, pain score (VAS), cosmetic results, quality of life, and incisional hernias. Linear regression was used to model the effect of each procedure on the different outcomes.

RESULTS

Forty-six trials were included and data from 5141 participants were analysed; 2444 underwent SLC and 2697 MLC, respectively. Mortality reported was nil in both treatment groups. Overall adverse events were higher in the SLC group (RR 1.41; p < 0.001) compared to MLC group, as well severe adverse events (RR 2.06; p < 0.001) and even mild adverse events (RR 1.23; p = 0.041). This was confirmed also when only trials including 4-port techniques (RR 1.37, p = 0.004) or 3-port techniques were considered (RR 1.89, p = 0.020). The pain score showed a standardized mean difference (SMD) of - 0.36 (p < 0.001) in favour of SLC. Cosmetic outcome by time point scored a SMD of 1.49 (p < 0.001) in favour of SLC. Incisional hernias occurred more frequently (RR 2.97, p = 0.005) in the SLC group.

CONCLUSIONS

Despite SLC offers a better cosmetic outcome and reduction of pain, the consistent higher rate of adverse events, both severe and mild, together with the higher rate of incisional hernias, should suggest to reconsider the application of single incision techniques when performing cholecystectomy with the existing technology.

Meta-analysis of single-port versus conventional laparoscopic cholecystectomy comparing body image and cosmesis

BACKGROUND

The purpose of this study was to evaluate improvements in cosmetic results and postoperative morbidity for single-incision laparoscopic cholecystectomy (SILC) in comparison with multiport laparoscopic cholecystectomy (MLC).

METHODS

A literature search was undertaken for RCTs comparing SILC with MLC in adult patients with benign gallbladder disease. Primary outcomes were body image and cosmesis scores at different time points. Secondary outcomes included intraoperative and postoperative complications, postoperative pain and frequency of port-site hernia.

RESULTS

Thirty-seven RCTs were included, with a total of 3051 patients. The body image score favoured SILC at all time points (short term: mean difference (MD) -2·09, P < 0·001; mid term: MD -1·33, P < 0·001), as did the cosmesis score (short term: MD 3·20, P < 0·001; mid term: MD 4·03, P < 0·001; long-term: MD 4·87, P = 0·05) and the wound satisfaction score (short term: MD 1·19, P = 0·03; mid term: MD 1·38, P < 0·001; long-term: MD 1·19, P = 0·02). Duration of operation was longer for SILC (MD 13·56 min; P < 0·001) and SILC required more additional ports (odds ratio (OR) 6·78; P < 0·001). Postoperative pain assessed by a visual analogue scale (VAS) was lower for SILC at 12 h after operation (MD in VAS score -0·80; P = 0·007). The incisional hernia rate was higher after SILC (OR 2·50, P = 0·03). All other outcomes were similar for both groups.

CONCLUSION

SILC is associated with better outcomes in terms of cosmesis, body image and postoperative pain. The risk of incisional hernia is four times higher after SILC than after MLC.

Incisional hernia after robotic single-site cholecystectomy: a pilot study

PURPOSE

Robotic LaparoEndoscopic Single-Site Surgery Cholecystectomy has been performed for 5 years using a dedicated platform (da Vinci^® Single-Site^®) with the da Vinci^® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). While short-term feasibility has been described, long-term assessment of this method is currently outstanding. The aim of this study was to assess long-term parietal complications of this technique.

METHODS

In this retrospective study, patients operated between 2011 and 2013 were evaluated. Parietal incision was assessed with ultrasonography and patients screened for residual pain from scar tissue. Demographic and perioperative data were also collected.

RESULTS

We evaluated 48 patients [38 female, 79.2%; median age 49 years (range: 24-81 years)]; mean BMI 25.9 kg/m² [±SD 4.1 kg/m²]. After a median follow-up of 39 months (range: 25-46 months), six incisional hernias (two patients had a positive echography but a negative clinical examination) were found (12.5%, 95% CI 7.5-30.2), and two patients had a surgical repair. The overall rate of incisional hernia was 16.7% (95% CI 7.5-30.2). Residual pain was observed in 5 of 48 patients.

CONCLUSION

This preliminary study suggests that a clinically significant rate of incisional hernias can occur after R-LESS-C. Larger studies comparing R-LESS-C to alternative methods with long-term follow-up are necessary.

The use of expanding ports in laparo-endoscopic single-site surgery may cause more pain: a meta-analysis of randomized clinical trials

BACKGROUND

Previous meta-analyses on the clinical outcome after laparo-endoscopic single-site surgery (LESS) versus conventional laparoscopic surgery (CLS) have not revealed any major differences in postoperative pain between the two procedures. This meta-analysis aims to evaluate the difference in postoperative pain between the two procedures, focusing on whether LESS was conducted with a non-expanding port (LESSnonex) or a port expanding (LESSex) within the incision.

METHOD

EMBASE, Medline, PubMed, Science Citation Index Expanded, and Cochrane Central Register of Controlled Trials were searched for randomized clinical trials (RCTs) on LESS versus CLS for general abdominal procedures. Weighted mean difference (WMD) and Odds ratios (OR) were calculated with 95% confidence intervals (CI).

RESULTS

A total of 29 RCTs with 2999 procedures were included. Pain (VAS 0-10) 6 h after surgery was significantly lower in the group where LESS was conducted with LESSnonex compared to CLS, WMD=-0.72 (- 1.10 to - 0.33). Pain 18-24 h was significantly higher in the group where LESS was conducted with LESSex compared to CLS, WMD = 0.38 (0.01-0.75). Wound-related complications were significantly more frequent in LESSex procedures compared to CLS, OR = 1.94 (1.03-3.63).

CONCLUSION

The present meta-analysis indirectly indicates that the type of access device that is used for an abdominal LESS procedure may contribute to the development of early postoperative pain as the use of a non-expanding model was associated with a more advantageous outcome. Direct randomized comparison of LESSnonex and LESSex is warranted to confirm if the use of expanding access devices generates more pain and wound complications.

COMPARATIVE ANALYSIS OF IMMUNOLOGICAL PROFILES IN WOMEN UNDERGOING CONVENTIONAL AND SINGLE-PORT LAPAROSCOPIC CHOLECYSTECTOMY

Background

Surgical trauma triggers an important postoperative stress response characterized by significantly elevated levels of cytokines, an event that can favor the emergence of immune disorders which lead to disturbances in the patient's body defense. The magnitude of postoperative stress is related to the degree of surgical trauma.

Aim

To evaluate the expression of pro-inflammatory (TNF-α, IFN-γ, IL-1β, and IL-17) and anti-inflammatory (IL-4) cytokines in patients submitted to conventional and single-port laparoscopic cholecystectomy before and 24 h after surgery.

Methods

Forty women with symptomatic cholelithiasis, ranging in age from 18 to 70 years, participated in the study. The patients were divided into two groups: 21 submitted to conventional laparoscopic cholecystectomy and 19 to single-port laparoscopic cholecystectomy.

Results

Evaluation of the immune response showed no significant difference in IFN-γ and IL-1β levels between the groups or time points analyzed. With respect to TNF-α and IL-4, serum levels below the detection limit (10 pg/ml) were observed in the two groups and at the time points analyzed. Significantly higher postoperative expression of IL-17A was detected in patients submitted to single-port laparoscopic cholecystectomy when compared to preoperative levels (p=0.0094).

Conclusions

Significant postoperative expression of IL-17 was observed in the group submitted to single-port laparoscopic cholecystectomy when compared to preoperative levels, indicating that surgical stress in this group was higher compared to the conventional laparoscopic cholecystectomy.

Single-incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy: a systematic review and meta-analysis

Background

Single-incision laparoscopic cholecystectomy (SILC) might maximize the advantages of laparoscopic cholecystectomy (LC) by reducing postoperative pain and improving cosmesis. However, the safety and feasibility of SILC has not yet been established. This study assesses safety, patient reported outcome measures and feasibility of SILC versus conventional LC.

Methods

Literature search for RCT’s comparing SILC with conventional LC in gallstone-related disease was performed in PubMed and Embase. The conventional LC was defined as two 10-mm and two 5-mm ports. Study selection was done according to predefined criteria. Two reviewers assessed the risk of bias. Pooled outcomes were calculated for adverse events, pain, cosmesis, quality of life and feasibility using fixed-effect and random-effects models.

Results

Nine RCT’s were included with total of 860 patients. No mortality was observed. More mild adverse events (RR 1.55; 95% CI 0.99–2.42) and significantly more serious adverse events (RR 3.00; 95% CI 1.05–8.58) occurred in the SILC group. Postoperative pain (MD -0.46; 95% CI -0.74 to -0.18) and cosmesis (SMD 2.38; 95% CI 1.50–3.26) showed significantly better results for the SILC group, but no differences were observed in quality of life. Operating time (MD 23.12; 95% CI 11.59–34.65) and the need for additional ports (RR 11.43; 95% CI 3.48–37.50) were significantly higher in the SILC group. No difference was observed in conversion to open cholecystectomy or hospital stay longer than 24 h.

Conclusions

SILC does not provide any clear advantages over conventional LC except for less postoperative pain and improved cosmesis. It is questionable whether these advantages outweigh the higher occurrence of adverse events and shortcomings in feasibility. Considering considerable heterogeneity and low methodological quality of the studies it is advisable to perform well-designed RCT’s in the future to address the safety and clinical benefits of SILC.

Prevention and acute management of biliary injuries during laparoscopic cholecystectomy: Expert consensus statement

Gallstone disease is very common and laparoscopic cholecystectomy is one of the most common surgical procedures all over the world. Parallel to the increase in the number of laparoscopic cholecystectomies, bile duct injuries also increased. The reported incidence of bile duct injuries ranges from 0.3% to 1.4%. Many of the bile duct injuries during laparoscopic cholecystectomy are not due to inexperience, but are the result of basic technical failures and misinterpretations. A working group of expert hepatopancreatobiliary surgeons, an endoscopist, and a specialist of forensic medicine study searched and analyzed the publications on safe cholecystectomy and biliary injuries complicating laparoscopic cholecystectomy under the organization of Turkish Hepatopancreatobiliary Surgery Association. After a series of e-mail communications and two conferences, the expert panel developed consensus statements for safe cholecystectomy, management of biliary injuries and medicolegal issues. The panel concluded that iatrogenic biliary injury is an overwhelming complication of laparoscopic cholecystectomy and an important issue in malpractice claims. Misidentification of the biliary system is the major cause of biliary injuries. To avoid this, the "critical view of safety" technique should be employed in all the cases. If biliary injury is identified intraoperatively, reconstruction should only be performed by experienced hepatobiliary surgeons. In the postoperative period, any deviation from the expected clinical course of recovery should alert the surgeon about the possibility of biliary injury.

Single-incision versus standard multi-incision laparoscopic colectomy in patients with malignant or benign colonic disease: a systematic review, meta-analysis and assessment of the evidence

BACKGROUND

Single-incision laparoscopic colectomy (SILC) requires only one umbilical port site and (depending on technique) a specimen extraction site. The aim of this study was the assessment of the available evidence for the comparison of SILC to conventional multi-port laparoscopic colectomy (MLC) in adult patients, in whom elective colectomy is indicated because of malignant or benign disease. First, previous meta-analyses on this topic were assessed. Secondly, a systematic review and meta-analysis of randomised controlled trials, was performed.

METHODS

Electronic literature searches (CENTRAL, MEDLINE and EMBASE; up to March 2016) were performed. Additionally, we searched clinical trials registries and abstracts from surgical society meetings. For meta-analysis, risk ratios (RR) or mean differences (MD) with 95 % confidence intervals were calculated and pooled. The quality of previous meta-analyses was evaluated against established criteria (AMSTAR) and their reported results were investigated for consistency.

RESULTS

We identified 6 previous meta-analyses of mostly low methodological quality (AMSTAR total score: 2 - 5 out of 11 items). To fill the evidence gaps, all these meta-analyses had included non-randomised studies, but usually without assessing their risk of bias. In our systematic review and meta-analysis of randomised controlled trials exclusively, we included two randomised controlled trials with a total of 82 colorectal cancer patients. There was insufficient evidence to clarify whether SILC leads to less local complications (RR = 0.52, 95 % CI 0.14 - 1.94) or lower mortality (1 death per treatment group). Length of hospital stay was significantly shorter in the SILC group (MD = -1.20 days, 95 % CI -1.95 to -0.44). One of the two studies found postoperative pain intensity to be lower at the first day. We also identified 7 ongoing trials with a total sample size of over 1000 patients.

CONCLUSION

The currently available study results are too sparse to detect (or rule out) relevant differences between SILC and MLC. The quality of the current evidence is low, and the additional analysis of non-randomised data attempts, but does not solve this problem. SILC should still be considered as an experimental procedure, since the evidence of well-designed randomised controlled trials is too sparse to allow any recommendation.

Minilaparoscopy-assisted transumbilical laparoscopic cholecystectomy

The role of laparoscopy in the modern surgery era is well established. With the prospect of being able to improve the already privileged current situation, new alternatives have been proposed, such as natural orifice endoscopic surgery (NOTES), the method for single transumbilical access (LESS - Laparo-endoscopic single-site surgery) and minilaparoscopy (MINI). The technique proposed by the authors uses a laparoscope with an operative channel like the flexible endoscope used in NOTES. All operative times are carried out through the umbilical trocar as in LESS, and assisted by a minilaparoscopy grasper. This new technic combines, and results from, the rationalization of technical particularities and synergy of these three approaches, seeking to join their advantages and minimize their disadvantages. RESUMO O papel da videolaparoscopia na era moderna da cirurgia encontra-se bem estabelecido. Com a perspectiva de ser possível melhorar a já privilegiada situação atual, novas alternativas têm sido propostas, como a cirurgia por orifícios naturais (NOTES), o método por acesso único transumbilical (LESS - Laparo-endoscopic single-site surgery) e a minilaparoscopia (MINI). A técnica proposta pelos autores utiliza-se de óptica com canal de trabalho como o endoscópio flexível do NOTES, executa-se todos os tempos operatórios pelo trocarte umbilical, como no LESS, e é assistido por pinça de minilaparoscopia. Esta nova técnica combina e resulta da racionalização de particularidades técnicas e do sinergismo destas três abordagens, buscando agregar suas vantagens e minimizar as suas desvantagens.

Outcomes in laparoscopic cholecystectomy by single incision with SPIDER surgical system are comparable to conventional multiport technique: one surgeon's experience

BACKGROUND

Single-incision laparoscopic cholecystectomy has emerged as an alternative to conventional multiport laparoscopic cholecystectomy (LC). Technical difficulty, prolonged surgical times and increased complication rates have been reported in single-incision laparoscopic surgery. One of the concerns is lack of triangulation of instruments. The SPIDER^® surgical system is a single-incision laparoscopic device that utilizes flexible instruments with the purpose of achieving adequate triangulation. The purpose of this study is to compare the outcomes of SPIDER versus LC.

METHODS

A retrospective chart review of patients who underwent LC and SPIDER cholecystectomy by a single surgeon during a concurrent 44-month period at Baptist Health South Florida hospitals was performed focusing on demographics, indication for surgery, complications and incisional hernia rates. Exclusion criteria were concomitant surgery and hernia repair at the time of surgery.

RESULTS

A total of 612 patients underwent minimally invasive cholecystectomy: 279 cases for SPIDER cholecystectomy and 333 for multiport LC. Baseline differences in patient characteristics between the SPIDER and LC groups were statistically significant. The SPIDER group had younger and healthier patients (lower ASA classification scores) with predominant diagnosis of cholelithiasis (69 %) compared to the LC group which had more complex cases. Total complications rate for both SPIDER and LC were 0.4 % (n = 1) and 3 % (n = 10), respectively. Conversion to open cholecystectomy occurred in one patient from the LC group (0.3 %). Conversion rate from SPIDER to additional ports or LC was performed in 5 cases (1.8 %) with no conversions to open surgery. Hemoperitoneum was reported in 2 cases, one for each approach, requiring reoperation.

CONCLUSION

Single-incision laparoscopic cholecystectomy with SPIDER is a safe and feasible technique with similar outcomes to multiport LC. However, statistical significant difference was reported in baseline characteristics of both groups. No incisional hernias were reported in this case series for either technique.

Task performance in standard laparoscopy in comparison with single-incision laparoscopy in a modified skills trainer

BACKGROUND

Single-incision laparoscopy (SIL) is similar to conventional laparoscopic surgery (LAP), but carries specific technical challenges due to lack of triangulation, reduced dexterity, conflicts due to inline instrumentation, and impaired visualization. This study was designed to evaluate technical skill performance of SIL versus LAP surgery in a simulated environment.

METHODS

We developed a modified laparoscopic skills trainer for SIL based upon the fundamentals of laparoscopic surgery (FLS) model. This includes a standard laparoscopic tower for visualization, allowing replication of the conflicts between scope and instruments. It also has a modified trainer box allowing use of different access devices and instruments for SIL. Sixteen subjects at different levels of training (novice through expert) completed four FLS tasks with standard LAP techniques. They then practiced the same tasks using SIL technique until they reached a steady state of performance. The first and last SIL trials were recorded.

RESULTS

Baseline SIL peg transfer was worse than FLS (254 ± 157 s vs 99 ± 27, p < 0.0002). Final SIL time was still significantly worse than FLS (173 ± 130, p < 0.02). FLS, baseline SIL, and final SIL circle cutting were not significantly different (p = 0.058). Final SIL loop ligation was significantly faster than FLS (48 ± 19 vs 70 ± 42, p < 0.05). FLS suturing was faster than SIL suturing (281 ± 188 vs. 526 ± 105, p < 0.01). There was substantial dropout due to frustration with SIL, and only two surgeons were able to successfully complete SIL suturing.

CONCLUSIONS

There are technical challenges with SIL that vary depending on task. Peg transfer and suturing were significantly impaired in SIL, while circle cutting was not significantly affected, and ligating loop was faster with SIL than LAP. These challenges may impact clinical outcomes of SIL and should influence training in SIL as well as future product development.

Single-incision laparoscopic surgery for biliary tract disease

Single-incision laparoscopic surgery (SILS), or laparoendoscopic single-site surgery, has been employed in various fields to minimize traumatic effects over the last two decades. Single-incision laparoscopic cholecystectomy (SILC) has been the most frequently studied SILS to date. Hundreds of studies on SILC have failed to present conclusive results. Most randomized controlled trials (RCTs) have been small in scale and have been conducted under ideal operative conditions. The role of SILC in complicated scenarios remains uncertain. As common bile duct exploration (CBDE) methods have been used for more than one hundred years, laparoscopic CBDE (LCBDE) has emerged as an effective, demanding, and infrequent technique employed during the laparoscopic era. Likewise, laparoscopic biliary-enteric anastomosis is difficult to carry out, with only a few studies have been published on the approach. The application of SILS to CBDE and biliary-enteric anastomosis is extremely rare, and such innovative procedures are only carried out by a number of specialized groups across the globe. Herein we present a thorough and detailed analysis of SILC in terms of operative techniques, training and learning curves, safety and efficacy levels, recovery trends, and costs by reviewing RCTs conducted over the past three years and two recently updated meta-analyses. All existing literature on single-incision LCBDE and single-incision laparoscopic hepaticojejunostomy has been reviewed to describe these two demanding techniques.

Do height and weight affect the feasibility of single-incision laparoscopic cholecystectomy?

BACKGROUND

Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common laparoscopic procedure worldwide. Single-incision laparoscopic surgery has recently emerged as a less invasive potential alternative to conventional three- or four-port laparoscopy. However, the feasibility of single-incision laparoscopic cholecystectomy (SILC) remains unclear, and there are no rigorous criteria in the literature. Identifying patients at risk of failure of this new technique is essential. The aim of our study was to determine risk factors that may predict failure of the procedure.

METHODS

From May 2010 to March 2012, 110 consecutive patients underwent SILC and were reviewed retrospectively. The main feasibility criterion was the procedure failure rate, defined as addition of supplementary port(s) and prolonged (>60 min) operative time. The factors evaluated were age, gender, height, weight, body mass index, previous abdominal surgery, indication for surgery and gallbladder suspension.

RESULTS

There was conversion in 16 patients (14.5%), and the operative time exceeded 60 min for 20 patients (30.9%). Univariate analysis showed a significant independent association between additional port requirement and each of weight as a continuous value, weight ≥80 kg, BMI >26.5 kg/m(2) and height >172 cm. Univariate analysis also showed a significant independent association between prolonged operative duration (>60 min) and each of height and weight as continuous values, height >172 cm and previous abdominal surgery. In the multivariate analysis, only weight remained independently associated with additional port requirement, and height remained independently associated with prolonged operative duration.

CONCLUSION

Preoperative identification of the factors increasing the risk of conversion may assist surgeons in making decisions concerning the management of patients, including appropriate use of SILC.

A multicenter study of initial experience with single-incision robotic cholecystectomies (SIRC) demonstrating a high success rate in 465 cases

BACKGROUND

Recently, the robotic single-site platform has been used to ameliorate the difficulties seen in single-incision laparoscopic surgery (SILC) while preserving the benefits of standard laparoscopic cholecystectomy. The purpose of this study is to describe the clinical outcomes of a large series of single-incision robotic cholecystectomy (SIRC).

METHODS

Medical records of consecutive patients who underwent SIRC were retrospectively reviewed. All procedures were performed by six surgeons at five different North American centers involved in the study. All patients included in the study underwent a cholecystectomy attempted through single site at the umbilicus, using the da Vinci(®) Surgical System (Intuitive Surgical Inc. Sunnyvale, CA).

RESULTS

A total of 465 patients met study criteria. Median age was 48 years (range 18-89); 351 (75.5 %) were female and 304 (66.4 %) were overweight or obese. Except for gender, case characteristics differed significantly by surgeon/site. Previous abdominal surgery was reported for 226 (48.6 %) cases. SIRC was successfully completed in 455 (97.8 %) cases, and there were no conversions to open surgery. Median surgical time was 52 min with a decreasing trend after 55-85 cases. Male gender, obesity and diagnoses other than biliary dyskinesia were independent predictors of longer surgical times. The complication rate was 2.6 %.

CONCLUSIONS

Our large, multicenter study demonstrates that robotic single-site cholecystectomy is safe and feasible in a wide range of patients.

A Double-Blinded Randomized Trial to Compare the Effectiveness of Minimally Invasive Procedures Using Patient-Reported Outcomes

BACKGROUND

The Institute of Medicine has included the comparison of minimally invasive surgical techniques in its research agenda. This study seeks to evaluate a model for the comparison of minimally invasive procedures using patient-reported outcomes.

STUDY DESIGN

A double-blinded randomized controlled trial (NCT01489436) was conducted. Baseline data were obtained, standardized anesthesia was induced, and patients were randomized to single-port (SP) or 4-port (FP) laparoscopic cholecystectomy. Perioperative care was standardized. The outcomes were pain (Visual Analog Scale) on postoperative day 1 (primary) and quality of life (Patient-Reported Outcomes Measures Information System and Linear Analog Self-Assessment), serum cytokines, and heart rate variability (secondary). Analysis was intention to treat. Using identical occlusive dressings, patients and the outcomes assessor remained blinded until postoperative day 2.

RESULTS

Fifty-five patients were randomized to each arm. There was no difference in demographics. Visual Analog Scale pain score on postoperative day 1 was significantly different from baseline in each group (SP: 1.6 ± 1.9 to 4.2 ± 2.4 vs FP: 1.8 ± 2.3 to 4.2 ± 2.2), but not different from each other (p = 0.83). Patients in the FP arm reported significantly less fatigue on postoperative day 7 than patients in the SP group (3.1 ± 2.1 vs 4.2 ± 2.2; p = 0.009). Fewer patients in the FP group required postoperative oral narcotics before discharge (40% vs 60%; p = 0.056). Cytokines levels and heart rate variability were similar between arms. In patients followed for >1 year, no difference in umbilical hernia rates was noted.

CONCLUSIONS

Early postoperative quality of life data captured differences in fatigue, indicating improved recovery after FP within a controlled trial. Physiologic measures were similar, suggesting that the differences between SP and FP are minimal.

No difference in incidence of port-site hernia and chronic pain after single-incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy: a nationwide prospective, matched cohort study

BACKGROUND

Conventional laparoscopic cholecystectomy (CLC) is regarded as the gold standard for cholecystectomy. However, single-incision laparoscopic cholecystectomy (SLC) has been suggested to replace CLC. This study aimed at comparing long-term incidences of port-site hernia and chronic pain after SLC versus CLC.

METHODS

We conducted a matched cohort study based on prospective data (Jan 1, 2009-June 1, 2011) from the Danish Cholecystectomy Database with perioperative information and clinical follow-up. Consecutive patients undergoing elective SLC during the study period were included and matched 1:2 with patients subjected to CLC using pre-defined criteria. Follow-up data were obtained from the Danish National Patient Registry, mailed patient questionnaires, and clinical examination. A port-site hernia was defined as a repair for a port-site hernia or clinical hernia located at one or more port sites.

RESULTS

In total, 699 patients were eligible and 147 patients were excluded from the analysis due to pre-defined criteria. The rate of returned questionnaires was 83%. Thus, 552 (SLC, n = 185; CLC, n = 367) patients were analyzed. The median observation time was 48 months (range 1-65) after SLC and 48 months (1-64) after CLC (P = 0.940). The total cumulated port-site hernia rate was 4 % and 6 % for SLC and CLC, respectively (P = 0.560). Incidences of moderate/severe chronic pain were 4 % and 5 % after SLC and CLC, respectively (P = 0.661).

CONCLUSIONS

We found no difference in long-term incidence of port-site hernia or chronic pain after SLC versus CLC.

Laparoscopic cholecystectomy using a novel single-incision surgical platform through a standard 15 mm trocar: initial experience and technical details

OBJECTIVE

Single-incision minimally invasive surgery has previously been associated with incisions 2.0-3.0 cm in length. We present a novel single-incision surgical platform compatible for insertion through a standard 15-mm trocar. The objective of this study is to evaluate the safety and feasibility of the platform.

METHODS

The technology is currently a Phase I investigational device. It features articulating surgical instruments and is inserted through a multiple-use introducer. The platform's introducer requires a standard 15-mm laparoscopic trocar. Cholecystectomy is performed through a 15-mm umbilical incision utilizing an additional epigastric 2-mm needle-port grasper for gallbladder retraction. A prospective feasibility study was performed at a single-center. Inclusion criteria were age 18-75 years and biliary colic. Patients were excluded if they had acute cholecystitis, dilation of the biliary tree, severe coagulopathy, BMI > 40 kg/m(2), or choledocholithiasis. Endpoints included the success rate of the platform, hospital length of stay, post-operative pain medication usage, cosmetic results, and presence of hernia.

RESULTS

Six patients (5 female) with an average age of 41 years and BMI 28 kg/m(2) underwent cholecystectomy with the platform. Average OR time was 91 min and umbilical incision length did not exceed 15 mm. One case was converted to standard laparoscopy due to mechanical failure of the clip applier instrument. There were no intraoperative complications. Post-operatively, two patients developed self-resolving umbilical ecchymoses. Average length of stay was 13 h. Pain control was achieved with diclofenac for less than 7 days. At 1 month follow-up there were no complications and no umbilical hernias.

CONCLUSIONS

This phase I study demonstrates that single-incision cholecystectomy through a 15-mm trocar with the Fortimedix Surgical B.V. single-incision surgical platform is feasible, safe, and reproducible. Additional benefits include excellent triangulation and range of motion as well as exceptional cosmetic results. Further studies will be needed to evaluate long-term hernia rates.