Prospective randomized blinded trial of pulmonary function, pain, and cosmetic results after laparoscopic vs. microlaparoscopic cholecystectomy

Needle device-assisted single-incision laparoscopic gastrectomy for early gastric cancer: A propensity score-matched analysis

INTRODUCTION

Single-incision laparoscopic gastrectomy can be difficult because of complex instrumentation and a limited working angle. We standardized a needle device-assisted single-incision laparoscopic gastrectomy (NA-SILG) procedure for early gastric cancer in 2013. Herein, we present our technique and evaluate it in comparison to the conventional laparoscopic gastrectomy CLG) technique.

METHODS

We retrospectively reviewed medical records of 149 patients who underwent a NA-SILG or distal (CLG) for early gastric cancer between January 2013 and August 2016. We performed 1:1 propensity score matching between the two groups.

RESULTS

Eighteen patients who underwent a NA-SILG and 131 who underwent a CLG were included. Almost all patients were in clinical stage IA. Operative times were 216 ± 29.7 minutes and 220 ± 51.7 minutes for the NA-SILG and CLG groups, respectively; the median intraoperative bleeding amounts were 5 mL and 10 mL for the NA-SILG and CLG groups, respectively. The median number of retrieved lymph nodes was 41.5 and 57 for the NA-SILG and CLG groups, respectively. The number of patients needing analgesics was significantly lower in the NA-SILG group (P = .003) than in the CLG group. Neither group had postoperative complications more severe than Clavien-Dindo classification III.

CONCLUSION

Needle device-assisted SILG is safe and feasible for early gastric cancer treatment in slim figure patients. It has short and long-term outcomes comparable to the CLG but is less invasive and results in less postoperative 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.

Minilaparoscopic Cholecystectomy Versus Conventional Laparoscopic Cholecystectomy: An Endless Debate

Background: Our systematic review and meta-analysis examine the impact of minilaparoscopic cholecystectomy (MLC) versus conventional laparoscopic cholecystectomy (CLC). Some authors previously compared these surgical approaches without reaching any clear conclusion, since then, further trials have been performed, but an update was needed. Materials and Methods: PubMed, EMBASE, and the CENTRAL were systematically searched for randomized controlled trials comparing MLC versus CLC up to August 2019. The outcome measures used for comparison were operative time (OT), overall morbidity, intra- and postoperative complications, conversion and reintervention rate, length of hospital stay (LOS), postoperative pain (POP), and cosmetic results. A meta-analysis of relevant studies was performed using RevMan 5.3. Results: Fifteen studies, including 863 patients, were considered eligible to collect data and entered the meta-analysis. A total of 415 patients in the MLC group versus 448 in the CLC group were compared. No statistical difference as for overall morbidity, intra- and postoperative complications, conversion and reintervention rate, LOS, and cosmetic results were retrieved among the groups. CLC results faster and MLC shows to be the least painful. Conclusions: According to the available high-level evidence, both surgical approaches resulted substantially equivalent to perform LC, with some advantages of CLC as for OT and of MLC concerning POP. As a consequence, we can conclude that either procedure is superior or inferior to the other one; actually, we are not able to suggest the adoption of any of the two on a routine basis.

Mini-Laparoscopic Gynecological Surgery Using Smaller Ports Minimizes Incisional Pain and Postoperative Scar Size: A Paired Sample Analysis

Objective. The aim of this study was to assess postoperative incisional pain and cosmetic scores in mini-laparoscopic gynecological surgeries undertaken with different port sizes. Material and Method. In this prospective study, all women who underwent mini-laparoscopic gynecological surgery with 2.4-, 3-, and 5-mm lateral ports for benign gynecological conditions between March 2017 and April 2019 were included. The primary outcome was postoperative incisional pain at rest, walking, and after a provoked Valsalva maneuver assessed by numeric rating scale scores at 6 hours, 12 hours, 24 hours, and 3 days and 7 days after surgery. Secondary outcome measures included cosmetic scores of each port site (evaluated by using patient-observer scar assessment scale [POSAS]), operation time, and intra- and postoperative complications. Results. A total of 330 lateral port sites in 110 patients who underwent benign gynecological surgery via mini-laparoscopy were assessed for pain and cosmetic appearance. Pain scores at each time point were significantly lower for 2.4- and 3-mm ports than those for 5-mm ports; however, no significant difference was detected between 2.4-mm and 3-mm port sites (P = .6). The difference was more evident at 24 hours when routine analgesic drugs were stopped (P = .004). For POSAS scores, both 2.4-mm and 3-mm ports were superior to 5-mm port sites (P = .002); however, there was no significant difference between 2.4-mm and 3-mm port sites (P = .2). There were 2 port-related complications: one subcutaneous emphysema and one bleeding from a 5-mm trocar site 1 hour after surgery. Conclusion. Mini-laparoscopic gynecologic surgery using smaller ports resulted in decreased postoperative incisional pain and superior cosmetic appearance.

Mini-Laparoscopic Versus Conventional Laparoscopic Surgery for Benign Adnexal Masses

Background

Minimally invasive endoscopic surgery has become an acceptable method for gynecologic indications for more than 20 years. We aimed to compare clinical and surgical outcomes between mini-laparoscopic surgery (MLS) and conventional laparoscopic surgery (CLS) for benign adnexal masses. As far as we know, no comparative study exists between these two minimal invasive procedures.

Methods

During the period between January 2014 and December 2016, a total number of 132 laparoscopic surgeries were performed for bening adnexal masses in our clinic. Seventy women underwent CLS and 62 women underwent MLS. Pathological results and operating time of procedures, estimated blood loss, preoperative and postoperative complications, patient scale and observer scale (POSAS) and length of hospital stay were recorded.

Results

There was no difference between the two groups regarding preoperative diagnosis, intraoperative surgical procedure performed, and length of hospital stay. The groups were compared in terms of postoperative pathological diagnosis using the Chi-square test, and there was a statistically significant difference between the two groups. Comparing the operation time and hematocrit change, there were statistically significant differences between the two groups. Both patient and observer PSOAS scar scores were better in MLS group (P < 0.05).

Conclusions

Mini-laparoscopy can be safely and effectively used to perform benign adnexal mass surgery.

Hybrid Transvaginal NOTES and Mini-Laparoscopic Colectomy: Benefit Through Synergy

Background and Objectives:

Hybrid-natural orifice surgery combines the advantages of traditional transabdominal laparoscopic surgery, while limiting surgical trauma to the abdominal wall. Among various routes of intra-abdominal access, the transvaginal method is most appealing because of its utility and proven safety. We describe a series of 4 colonic resections performed with this approach, combined with minilaparoscopy and needlescopic approaches, and discuss the technical aspects, efficacy, and applicability of this technique.

Methods:

Three patients were selected to undergo hybrid transvaginal natural-orifice right hemicolectomy. A fourth patient, who underwent a segmental resection of a splenic flexure carcinoma, was included. Transvaginal port access was obtained via posterior colpotomy, and was used for dissection, vascular ligation, bowel division, and anastomosis. We used a combination of standard laparoscopic, minilaparoscopic, and needlescopic instruments transabdominally, focusing on reduced size and number of access points.

Results:

Duration of laparoscopy, oncologic outcomes and rate of operative morbidity were comparable to the published literature. Early return of gastrointestinal function and low analgesic requirements was observed in all patients. No morbidity related to transvaginal access was observed and the procedure was performed without difficulty in all cases.

Conclusion:

Colonic resection performed by hybrid natural-orifice technique offers several advantages over purely transabdominal laparoscopic procedures. Transvaginal access is easy to perform and offers excellent safety, efficacy, and versatility, especially for right hemicolectomy. Techniques to reduce abdominal wall surgical trauma, such as minilaparoscopy and needlescopic graspers, can be combined effectively in colonic resections, and may act synergistically to reduce postoperative pain and improve outcomes.

The effectiveness of laparoendoscopic single-site surgery (LESS) compared with conventional laparoscopic surgery for ectopic pregnancy with hemoperitoneum

OBJECTIVE

The purpose of this study was to compare clinical outcomes of conventional laparoscopic surgery and laparoendoscopic single-site surgery (LESS) in the surgical treatment of tubal ectopic pregnancy.

MATERIAL AND METHODS

A total of 156 patients were diagnosed with ectopic pregnancies by ultrasonography and serum β-human chorionic gonadotrophin (β-hCG) levels at Pusan National University Yangsan Hospital from January 2009 through December 2013. We excluded 28 patients who only received medical treatment, 15 patients who underwent surgery by laparotomy for severe hypovolemic shock, and 30 patients who presented with less than 1 L of hemoperitoneum. Of the 83 patients with massive hemoperitoneum, 38 patients had LESS performed while the remaining 45 patients underwent conventional laparoscopic surgery.

RESULTS

In this study, there were no statistically significant differences in clinical outcomes in either surgical method except for operative time. Operative time of LESS was significantly shorter than conventional surgery for patients with more than 500 mL of hemoperitoneum.

CONCLUSION

LESS is a safe and feasible surgical approach in the treatment of tubal ectopic pregnancy. At the same time, LESS has been shown to be more effective than conventional laparoscopic surgery in handling massive hemoperitoneum of more than 1 L, which is a common complication of ectopic pregnancy.

Two-port mini laparoscopic cholecystectomy compared to standard four-port laparoscopic cholecystectomy

INTRODUCTION:

Two-port mini laparoscopic cholecystectomy (LC) has been proposed as a safe and feasible technique. However, there are limited studies to evaluate the effectiveness of the procedure. This study is a prospective randomised trial to compare the standard four-port LC with two-port mini LC.

MATERIALS AND METHODS:

A total of 116 consecutive patients undergoing LC were randomised to four-port/two-port mini LC. In two-port mini LC, a 10-mm umbilical and a 5-mm epigastric port were used. Outcomes measured were duration and difficulty of operation, post-operative pain, analgesia requirements, post-operative stay, complications and cosmetic score at 30 days.

RESULTS:

Out of 116 patients, the ratio of M:F was 11:92, with mean age 40.79 ± 12.6 years. Twelve patients (nine in four-port group and three in two-port group) were lost to follow-up. The mean operative time were similar (P = 0.727). Post-operative pain was significantly low in the two-port group at up to 24 hrs (P = 0.023). The overall analgesia requirements (P = 0.003) and return to daily activity (P = 0.00) were significantly lower in two-port group. The cosmesis score of the two-port group was better than four-port group (P = 0.00). However, the length of hospital stay (P = 0.760) and complications (P = 0.247) were similar between the two groups.

CONCLUSION:

Two-port mini LC resulted in reduced pain, need for analgesia, and improved cosmesis without increasing the operative time and complication rates compared to that in four-port LC. Thus, it can be recommended in selected patients.

Is minisite cholecystectomy less traumatic? Prospective randomized study comparing minisite and conventional laparoscopic cholecystectomies

The main objectives of minisite cholecystectomy (MC) are to have smaller incisions, better cosmetic results, less trauma, and a lower morbidity rate. This prospective randomized study compares MC with conventional laparoscopic cholecystectomy (CLC) in terms of surgical trauma and cosmetic results in 44 patients. Conversion from MC to CLC was required in five patients. No conversion to open surgery was needed in the CLC group. The average operating time was slightly longer in the MC group, but the difference was not statistically significant (81 minutes versus 72 minutes, p = 0.22). The population characteristics, postoperative respiratory function measurements, pain scores, and analgesic requirements were similar in the two groups. The average score for scar tissue was significantly lower in the MC group (0.73 versus 1.93, p = 0.0045). Only the cosmetic results of MC were superior to CLC. This technique could be a feasible alternative procedure in patients seeking better cosmetic results. However, further studies with larger sample sizes are needed to evaluate the postoperative morbidity of MC.

The efficacy and safety of different kinds of laparoscopic cholecystectomy: a network meta analysis of 43 randomized controlled trials

Background and Objective

We conducted a network meta analysis (NMA) to compare different kinds of laparoscopic cholecystectomy [LC] (single port [SPLC], two ports [2PLC], three ports [3PLC], and four ports laparoscopic cholecystectomy [4PLC], and four ports mini-laparoscopic cholecystectomy [mini-4PLC]).

Methods

PubMed, the Cochrane library, EMBASE, and ISI Web of Knowledge were searched to find randomized controlled trials [RCTs]. Direct pair-wise meta analysis (DMA), indirect treatment comparison meta analysis (ITC) and NMA were conducted to compare different kinds of LC.

Results

We included 43 RCTs. The risk of bias of included studies was high. DMA showed that SPLC was associated with more postoperative complications, longer operative time, and higher cosmetic score than 4PLC, longer operative time and higher cosmetic score than 3PLC, more postoperative complications than mini-4PLC. Mini-4PLC was associated with longer operative time than 4PLC. ITC showed that 3PLC was associated with shorter operative time than mini-4PLC, and lower postoperative pain level than 2PLC. 2PLC was associated with fewer postoperative complications and longer hospital stay than SPLC. NMA showed that SPLC was associated with more postoperative complications than mini-4PLC, and longer operative time than 4PLC.

Conclusion

The rank probability plot suggested 4PLC might be the worst due to the highest level of postoperative pain, longest hospital stay, and lowest level of cosmetic score. The best one might be mini-4PLC because of highest level of cosmetic score, and fewest postoperative complications, or SPLC because of lowest level of postoperative pain and shortest hospital stay. But more studies are needed to determine which will be better between mini-4PLC and SPLC.

Changing our view of minimally invasive gynecologic surgery: a review of laparoendoscopic single-site surgery and a report on new approaches

The recent emergence of laparoendoscopic single-site surgery (LESS) has had a great impact on gynecology. As LESS grows in popularity, attention has been paid to the procedure's cosmetic benefits. Although in theory LESS is an ideal approach that leaves no visible scars and improves patients' quality of life, the outcomes are not always ideal according to recently published data. Therefore, alternative approaches, such as mini-laparoscopy, are also becoming more popular. Herein, we review randomized trials studying the benefits of LESS in gynecology and discuss alternative approaches. Finally, we propose the mimic approach as the next generation for non-visible scar surgery.

Miniports versus standard ports for laparoscopic cholecystectomy

BACKGROUND

In conventional (standard) port laparoscopic cholecystectomy, four abdominal ports (two of 10 mm diameter and two of 5 mm diameter) are used. Recently, use of smaller ports, miniports, have been reported.

OBJECTIVES

To assess the benefits and harms of miniport (defined as ports smaller than the standard ports) laparoscopic cholecystectomy versus standard port laparoscopic cholecystectomy.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until February 2013 to identify randomised clinical trials of relevance to this review.

SELECTION CRITERIA

Only randomised clinical trials (irrespective of language, blinding, or publication status) comparing miniport versus standard port laparoscopic cholecystectomy were considered for the review.

DATA COLLECTION AND ANALYSIS

Two review authors collected the data independently. We analysed the data with both fixed-effect and random-effects models using RevMan analysis. For each outcome we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI).

MAIN RESULTS

We included 12 trials with 734 patients randomised to miniport laparoscopic cholecystectomy (380 patients) versus standard laparoscopic cholecystectomy (351 patients). Only one trial which included 70 patients was of low risk of bias. Miniport laparoscopic cholecystectomy could be completed successfully in more than 80% of patients in most trials. The remaining patients were mostly converted to standard port laparoscopic cholecystectomy but some were also converted to open cholecystectomy. These patients were included for the outcome conversion to open cholecystectomy but excluded from other outcomes. Accordingly, the results of the other outcomes are on 343 patients in the miniport laparoscopic cholecystectomy group and 351 patients in the standard port laparoscopic cholecystectomy group, and therefore the results have to be interpreted with extreme caution.There was no mortality in the seven trials that reported mortality (0/194 patients in miniport laparoscopic cholecystectomy versus 0/203 patients in standard port laparoscopic cholecystectomy). There were no significant differences between miniport laparoscopic cholecystectomy and standard laparoscopic cholecystectomy in the proportion of patients who developed serious adverse events (eight trials; 460 patients; RR 0.33; 95% CI 0.04 to 3.08) (miniport laparoscopic cholecystectomy: 1/226 (adjusted proportion 0.4%) versus standard laparoscopic cholecystectomy: 3/234 (1.3%); quality of life at 10 days after surgery (one trial; 70 patients; SMD -0.20; 95% CI -0.68 to 0.27); or in whom the laparoscopic operation had to be converted to open cholecystectomy (11 trials; 670 patients; RR 1.23; 95% CI 0.44 to 3.45) (miniport laparoscopic cholecystectomy: 8/351 (adjusted proportion 2.3%) versus standard laparoscopic cholecystectomy 6/319 (1.9%)). Miniport laparoscopic cholecystectomy took five minutes longer to complete than standard laparoscopic cholecystectomy (12 trials; 695 patients; MD 4.91 minutes; 95% CI 2.38 to 7.44). There were no significant differences between miniport laparoscopic cholecystectomy and standard laparoscopic cholecystectomy in the length of hospital stay (six trials; 351 patients; MD -0.00 days; 95% CI -0.12 to 0.11); the time taken to return to activity (one trial; 52 patients; MD 0.00 days; 95% CI -0.31 to 0.31); or in the time taken for the patient to return to work (two trials; 187 patients; MD 0.28 days; 95% CI -0.44 to 0.99) between the groups. There was no significant difference in the cosmesis scores at six months to 12 months after surgery between the two groups (two trials; 152 patients; SMD 0.13; 95% CI -0.19 to 0.46).

AUTHORS' CONCLUSIONS

Miniport laparoscopic cholecystectomy can be completed successfully in more than 80% of patients. There appears to be no advantage of miniport laparoscopic cholecystectomy in terms of decreasing mortality, morbidity, hospital stay, return to activity, return to work, or improving cosmesis. On the other hand, there is a modest increase in operating time after miniport laparoscopic cholecystectomy compared with standard port laparoscopic cholecystectomy and the safety of miniport laparoscopic cholecystectomy is yet to be established. Miniport laparoscopic cholecystectomy cannot be recommended routinely outside well-designed randomised clinical trials. Further trials of low risks of bias and low risks of random errors are necessary.

Costs and clinical outcomes of conventional single port and micro-laparoscopic cholecystectomy

Cost for single-port cholecystectomy in the outpatient setting was found to be greater than the cost for micro-laparoscopic or conventional laparoscopic cholecystectomy.

Background and Objective:

This study compares hospital costs and clinical outcomes for conventional laparoscopic, single-port, and mini-laparoscopic cholecystectomy from US hospitals.

Methods:

Eligible patients were aged ≥18 years and undergoing laparoscopic cholecystectomy with records in the Premier Hospital Database from 2009 through the second quarter of 2010. Patients were categorized into 3 groups—conventional laparoscopic, single port, or mini-laparoscopic—based on the International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes and hospital charge descriptions for surgical tools used. A procedure was considered mini-laparoscopic if no single-port surgery products were identified in the charge master descriptions and the patient record showed that at least 1 product measuring <5 mm was used, not more than 1 product measuring >5 mm was used, and the measurements of the other products identified equaled 5 mm. Summary statistics were generated for all 3 groups. Multivariable analyses were performed on hospital costs and clinical outcomes. Models were adjusted for demographics, patient severity, comorbid conditions, and hospital characteristics.

Results:

In the outpatient setting, for single-port surgery, hospital costs were approximately $834 more than those for mini-laparoscopic surgery and $964 more than those for conventional laparoscopic surgery (P < .0001). Adverse events were significantly higher (P < .0001) for single-port surgery compared with mini-laparoscopic surgery (95% confidence interval for odds ratio, 1.38–2.68) and single-port surgery versus conventional surgery (95% confidence interval for odds ratio, 1.37–2.35). Mini-laparoscopic surgery hospital costs were significantly (P < .0001) lower than the costs for conventional surgery by $211, and there were no significant differences in adverse events.

Conclusions:

These findings should inform practice patterns, treatment guidelines, and payor policy in managing cholecystectomy patients.

Minilaparoscopic fundoplication: technical adaptations and initial experience

CONTEXT

Gastroesophageal reflux disease (GERD) is a highly prevalent disease. Treatment is divided into lifestyle modifications, medical and surgical treatment. Surgical laparoscopy is the gold standard treatment. In the last decade, there were an extensive research on procedures, less aggressive than laparoscopy and with better esthetic results. Minilaparoscopy is "reemerging" as a safe, effective and with excellent cosmetic results in selected patients treated for gastroesophageal reflux disease. We present a serie of 27 patients treated for GERD by minilaparoscopic laparoscopy.

MATERIAL

Between October 2009 July 2011 a total of 27 patients underwent fundoplication by minilaparoscopy. It is used one 10mm trocar, a telescope of 30 degrees and four 3 mm trocars at regular positions. Regular surgical steps are done with no modifications. Cardiac tape, suture needles, and eventually extracting bag, gauze, are placed and taken out through the umbilical port. With these technical adjustments, we can perform the procedure safely and effectively, similarly to standard laparoscopic technique.

RESULTS

Of the 27 patients, 22 were female and 5 male. The average body mass index was 25.5 kg/m². Hiatal hernias were small (<3 cm) in 24 patients. Mean operative time was 60 minutes. In all cases the hiatoplasty was performed with simple or 'x' stitches of 2.0 Ethibond. There was no need for conversion to standard laparoscopy or open surgery. The length of hospital stay was less than or equal to 24 hours in all patients. In this series of patients there were no postoperative complications. We did not observe any complication of the surgical wound. There were no evidence of recurrence of symptoms or endoscopic changes.

CONCLUSION

Hiatoplasty associated with fundoplication using minilaparoscopic instruments is safe, feasible and effective. If compared to other "new access", has a spectacular esthetic results. Can be done with only minor technical adjustments, for any experienced laparoscopic surgeon, and is perfectly adaptable to our financial reality.

Is Single-Port Access Laparoscopy Less Painful Than Conventional Laparoscopy for Adnexal Surgery? A Comparison of Postoperative Pain and Surgical Outcomes

Objective. This study aimed to compare postoperative pain and surgical outcomes after transumbilical single-port access (SPA) and conventional multiport laparoscopic surgery for adnexal lesions. Methods. A retrospective case–control study was conducted matched by age, body mass index, and frequency of previous abdominal surgery. A total of 110 SPA laparoscopy patients (cases) were matched with a cohort of 107 patients who underwent conventional laparoscopy (controls) for benign adnexal lesions. SPA system consisted of a wound retractor, surgical glove, two 5-mm trocars, and one 11-mm trocar. Postoperative pain scores were measured immediately after surgery and at 6, 24, and 48 hours postsurgery using the numerical rating scale. Results. Postoperative pain scores did not differ between the 2 groups ( P = .552). However, higher number of painkiller administrations was observed in the SPA laparoscopy group (median 3 vs 1, P < .001). The type of surgery and intraoperative blood loss were the significant factors influencing the number of painkiller administrations after controlling for other parameters by linear regression ( P < .0001). The SPA laparoscopy group had less intraoperative blood loss (45.3 vs 87.5 mL, P < .001) and shorter hospital stay (2.1 ± 0.8 vs 2.7 ± 1.0 days, P < .001) compared with the conventional laparoscopy group. Operative time and perioperative complications did not differ between groups. Conclusions. There was no difference in pain intensity between the SPA and conventional laparoscopic group in this study. Future trials are warranted to better define the benefits of SPA surgery in terms of postoperative pain.

Minilaparoscopy and laparoendoscopic single-site surgery: mini- and single-scar in urology

PURPOSE

To review the development of laparoscopic single-site surgery (LESS) and minilaparoscopy (ML), with particular attention to the urological field, focusing on nomenclature, history and outcomes.

METHODS

A literature search was conducted on laparoendoscopic single-site surgery, minilaparoscopy, needlescopy and microlaparoscopy. The most relevant papers were selected over the last 30 years.

RESULTS

830 manuscripts were found about LESS, 251 in urology, two CRTs and nine match-case controls. 258 papers were about ML and 55 in urology. ML is the main topic (169 papers), followed by needlescopy (58) and microlaparoscopy (32). The most significant articles are four non-randomized match-case control studies.

CONCLUSIONS

Over the last few years, many urological laparoscopic operations have been successfully performed by LESS. However, the actual role of LESS remains to be determined with controversial data about postoperative pain control and almost no results on cosmesis. We are facing second-generation ML with superior performance granted by new endoscopes and most effective instruments. ML has demonstrated in almost all urologic indications to be feasible, safe and able to improve cosmetic and postoperative pain control. Anyway, CRTs are still lacking and only studies from other discipline can corroborate this trend.

Needlescopic surgery for liver, gallbladder and spleen diseases

BACKGROUND

We propose that needlescopic surgery (NS) should be considered as a way of improving the esthetic result and post-operative quality of life of patients and of reducing costs and stress on surgeons, and we have evaluated the results of NS.

METHODS

We used NS in 157 patients between May 1998 and December 2010: cholecystectomy in 150 patients, marsupialization of splenic and hepatic cysts in 4 and splenectomy in 3, respectively. Under general anesthesia, one 12-mm and two or three 2- or 3-mm ports were introduced into the operative field. The specimen was retrieved from the 12-mm wound using a plastic bag.

RESULTS

The procedures were successfully completed in all patients without conversion to an open procedure. In eight (5.3%) of 150 cholecystectomies a change to 5-mm instruments was required. The mean operation times and postoperative hospital stays for cholecystectomy, splenectomy, and marsupialization of splenic and hepatic cysts were 80.2 min and 3.2 days, 167 min and 5.6 days, 170 min and 7 days, and 120 min and 7 days, respectively. There were a few perioperative complications. The most important factor for reducing operation time and achieving a low conversion rate is the use of at least one 3- or 5-mm port for the grasping instruments in cholecystectomy. We recognized a residual cyst requiring splenectomy 62 months after marsupialization in one case. Technical points for performing safe procedures on solid organs were: no direct organ mobilization to avoid organ injuries, the rotation of the operating table and the utilization of organ gravity to create a better operative field, the minimum use of the needlescope to perform a safe maneuver and the improvement of bi-manual technique.

CONCLUSIONS

NS is a safe and feasible procedure for achieving minimal invasive surgery. We should consider NS as a first choice to treat operable diseases in this laparoscopic era.

Is there still any role for minilaparoscopic-cholecystectomy? A general surgeons' last five years experience over 932 cases

Laparoscopy has rapidly emerged as the preferred surgical approach in a number of different diseases because it ensures correct diagnoses and appropriate treatment. The use of mini-instruments (5 mm or less in diameter) and, when possible, the reduction of the number of trocars used might be its natural evolution. Laparoscopic cholecystectomy is a gold standard technique. The aim of the present work is to illustrate the results of the prospective experience of minilaparoscopic cholecystectomy (5 mm MLC) performed at our institution. Between August 2005 and July 2010 a total of 932 patients (mean age 45 years) underwent a laparoscopic cholecystectomy. Amongst them, 887 (95.1%) were operated on with a 5 mm-three trocar approach and in the remaining 45 cases (4.8%) a 3 mm trocar was used. The primary endpoint was the feasibility rate of the techniques. Secondary endpoints were safety and the impact of the techniques on duration of laparoscopy. In two cases conversion to laparotomy was necessary. We needed to add a fourth-5 mm trocar in the 10.7% of the cases (95 patients) in the 5 mm MLC. There were two cases of redo-laparoscopy in this group due to bile leakage from the cystic duct in one case, and to bleeding from the gallbladder bed in the other. Minor occurrence ranged as high as 2.1% in the 5 mm-MLC group, while it was nil in the 3 mm-MLC patients. The present experience shows that the 5 mm-three trocars MLC is a safe, easy, effective and reproducible approach to gallbladder diseases. Such features make the technique a challenging alternative to conventional laparoscopy both in the acute and the scheduled setting. We consider the 3 mm-MLC approach suitable only in selected cases, young and thin patients, due to the fragility of the smaller instruments.

Reevaluation of needlescopic surgery

BACKGROUND

Although the use of single-incision laparoscopic surgery (SILS) has spread rapidly, most procedures employ additional needlescopic instruments to ensure safety and shorten the operation time. Therefore, on the basis of results obtained in our department, the present study was conducted to reevaluate the current state of needlescopic surgery (NS) to improve the cosmetic results and postoperative quality of life of patients and to reduce cost and degree of stress on surgeons.

METHODS

Between May 1998 and February 2011, we performed NS in 202 patients. The diagnoses included gallbladder diseases in 151 patients, spontaneous pneumothorax in 11, thyroid tumor and axillary lymph node metastases in 10 patients each, splenic cyst and appendicitis in 4 patients each, idiopathic thrombocytopenic purpura and postoperative abdominal wall hernia in 3 patients each, primary aldosteronism and hepatic cyst in 2 patients each, and adhesional bowel obstruction and gastric stromal tumor in 1 patient each. Under general anesthesia, one 12-mm and tow or three 2- or 3-mm ports were introduced into the operative field. The specimen was retrieved via the 12-mm wound using a plastic bag.

RESULTS

The operations were completed in all patients without the need to convert to an open procedure. In 8 (5.3%) of the 151 cholecystectomies, a change to 5-mm instruments was required. There were no perioperative complications. Pertinent technical points included avoidance of direct organ mobilization to minimize injury, rotation of the operating table and utilization of organ gravity to create a better operative field, minimum use of needlescope to ensure safe maneuvering, and improvement of the bi-hand technique.

CONCLUSIONS

NS is a safe and feasible procedure that allows experienced surgeons to achieve minimally invasive surgery with low morbidity, without the need to convert to a conventional or open procedure.

Minilaparoscopic versus conventional laparoscopic hysterectomy: results of a randomized trial

STUDY OBJECTIVE

To compare operative outcomes and postoperative pain of laparoscopic hysterectomy (LH) versus minilaparoscopic hysterectomy (MLH).

DESIGN

Randomized controlled trial (Canadian Task Force Classification I).

SETTING

Tertiary care center.

PATIENTS

Seventy-six women scheduled to undergo a hysterectomy for a supposed benign gynecologic condition.

INTERVENTIONS

Participants were randomly assigned to LH (n = 38) or MLH (n = 38). MLH was performed with use of 3-mm ports. Both patients and assessors of the postoperative outcomes were blinded to the size of port used, and patients' wounds were concealed by standard-size nontransparent dressings.

MEASUREMENTS

Primary outcome was postoperative pain (both rest and incident on coughing and abdominal pain, as well as shoulder pain) by use of a 100-mm visual analogue scale.

MAIN RESULTS

The two groups were similar in terms of operative outcomes. No intraoperative conversion from MLH to both LH and open surgery occurred. No significant difference in pain scores at 1, 3, 8, and 24 hours after surgery between groups was found. Rescue analgesic requirement was similar in the MLH and LH groups (21.1% vs 13.2%, p =.54).

CONCLUSIONS

Ports can safely be reduced in size without a negative impact on the surgeon's ability to perform LH. MLH appears to have no advantage over LH in terms of postoperative pain.

Minilaparoscopic versus conventional laparoscopic cholecystectomy a systematic review and meta-analysis

OBJECTIVE

This review broadly examines the impact of minilaparoscopic versus conventional laparoscopic cholecystectomy. The primary outcome was failure of surgical technique. The secondary outcomes were to examine adverse events, cosmesis, length of time to return to activity, quality of life, and length of operation.

METHODS

Five databases, 2 conference proceedings, reference lists of retrieved articles, and a Web-based trial registry were searched to identify eligible studies. Experts in the field of laparoscopic surgery were also contacted to provide information for the review.This systematic review and meta-analysis were conducted in accordance with the QUORUM guidelines.

RESULTS

Eighteen studies met eligibility criteria. Methodologic quality was unclear in most trials. Patients having a minilaparoscopic technique had higher conversion rates than patients having a conventional laparoscopic technique [OR 2.25 (1.18-4.30)]. Although minilaparoscopic surgeries were converted, more often there was not a trend toward increased conversion to an open technique. There was a trend toward fewer adverse events using a minilaparoscopic technique [0.57 (0.31-1.04)], however it was not significant. Cosmesis was improved in minilaparoscopic patients at 1 month [mean difference −0.74(−1.09 to −0.38)]. Patients receiving minilaparoscopic procedures returned to activity quicker [mean difference −0.74 (−1.23–0.25)].

CONCLUSIONS

Further randomized trials are needed to determine whether minilaparoscopic techniques truly offer any advantages. Important patient outcomes such as failure of technique, adverse events, cosmesis, and quality of life should be emphasized to determine whether there is any benefit over conventional laparoscopic cholecystectomy.

Micro-laparoscopic cholecystectomy: an alternative to single-port surgery

INTRODUCTION

Recent advances in minimally invasive surgery aimed at diminishing incision size have led to the development of single-port surgery (SPS). SPS has an increased level of complexity and requires a higher level of surgical skill compared to traditional laparoscopy. We explored micro-laparoscopy as an alternative to routine laparoscopic cholecystectomy.

METHODS

The study is a retrospective review of consecutive elective laparoscopic cholecystectomies performed by a single surgeon at a community teaching hospital over 24 months. All surgeries were performed using a 5-mm trocar for the umbilical port and 3-mm trocars for other ports in standard configuration.

RESULTS

Seventy-nine cholecystectomies were performed by micro-laparoscopy during the 24-month period. Three cases required upgrade in trocar size for technical reasons, resulting in a completion rate of 96%. Intraoperative cholangiography was performed in 70 cases (89%). There were no conversions to open surgery. There were no intra- or postoperative complications, and all patients were discharged on the day of surgery.

CONCLUSION

Micro-laparoscopic cholecystectomy is safe, feasible, and represents an alternative to other minimally invasive techniques. Future developments in surgical technology will allow the use of even smaller instruments, diminishing the surgical "footprint" even further and contributing to better cosmesis and decreased postoperative pain in cholecystectomy patients.

Needlescopic clipless cholecystectomy as an efficient, safe, and cost-effective alternative with diminutive scars: the first 1000 cases

BACKGROUND

The advent of natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS), surgery without skin scarring, is now challenging every surgeon to improve the esthetic results for patients. Minilaparoscopic cholecystectomy (MLC) represents a refinement in laparoscopic surgery, potentially as cosmetically effective as NOTES. Nevertheless, because of the increased cost and difficulty in managing the equipment, it has not been widely accepted among surgeons.

OBJECTIVE

To report modifications of the minilaparoscopic technique that make it possible to conduct needlescopic procedures safely and effectively, thereby, considerably reducing costs and promoting the dissemination of this operation.

METHOD

One thousand consecutive patients who underwent MLC were analyzed, from January 2000 to May 2009 (78.7% women; average age 45.9 y).

SURGICAL TECHNIQUE

after performing the pneumoperitoneum at the umbilical site, 4 trocars were inserted; 2 of 2 mm, 1 of 3 mm, and 1 of 10 mm in diameter, through which a laparoscope was inserted. Neither the 3-mm laparoscope, nor clips, nor manufactured endobags were used. The cystic artery was safely sealed by electrocautery near the gallbladder neck and the cystic duct was sealed with surgical knots. Removal of the gallbladder was carried out, in an adapted bag made with a glove wrist, through the 10-mm umbilical site.

RESULTS

The operative time was 43 minutes. The average hospital stay was 16 hours. There was no conversion to open surgery; 2.8% of patients underwent conversion to standard (5 mm) laparoscopic cholecystectomy because of difficulties with the procedure; there were 1.9% minor umbilical site infections and 1.0% umbilical herniations. There was no mortality; no bowel injury, no bile duct injury, and no postoperative hemorrhage, only 1 patient with Luschka's duct bile leakage needed a reoperation.

CONCLUSIONS

The MLC technique shows no differences in risks as compared with other laparoscopic cholecystectomy procedures. It also entails a considerable reduction in cost, and, as it does not use the 3-mm laparoscope or disposable materials, it is possible to perform MLC on a larger number of patients. Owing to the near invisibility of scars, MLC may also be considered as cosmetically effective as NOTES and SILS.

Miniport versus standard ports for laparoscopic cholecystectomy

BACKGROUND

In conventional (standard) laparoscopic cholecystectomy, four abdominal ports (two of 10 mm diameter and two of 5 mm diameter) are used. Recently, use of smaller ports have been reported.

OBJECTIVES

To assess the benefits and harms of miniport (defined as ports smaller than conventional ports) laparoscopic cholecystectomy versus standard laparoscopic cholecystectomy.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until September 2009 for identifying the randomised trials.

SELECTION CRITERIA

Only randomised clinical trials (irrespective of language, blinding, or publication status) comparing miniport versus standard ports laparoscopic cholecystectomy were considered for the review.

DATA COLLECTION AND ANALYSIS

Two authors collected the data independently. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each outcome we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI).

MAIN RESULTS

We included thirteen trials with 803 patients randomised to miniport (n = 416) versus standard ports laparoscopic cholecystectomy (n = 387). In twelve trials, four ports were used. In one trial, three ports were used. The bias risk of all trials was high. Miniport laparoscopic cholecystectomy could be completed successfully in 87% of patients. The remaining patients were mostly converted to standard laparoscopic cholecystectomy but some were also converted to open cholecystectomy. Further information about these patients who underwent conversion to open cholecystectomy was not available in most trials. In the patients on whom information was available, there was no mortality reported; and there was no significant difference in the surgery-related morbidity or conversion to open cholecystectomy. Most trials excluded the patients who were converted to standard laparoscopic cholecystectomy. In patients who underwent successful miniport laparoscopic cholecystectomy, the pain was significantly lower in the miniport group than in the standard port at various time points.

AUTHORS' CONCLUSIONS

Miniport laparoscopic cholecystectomy can be completed successfully in more than 85% of patients. Patients, in whom elective miniport laparoscopic cholecystectomy was completed successfully, had lower pain than those who underwent standard laparoscopic cholecystectomy. However, because of the lack of information on its safety, miniport laparoscopic cholecystectomy cannot be recommended outside well-designed, randomised clinical trials.

Needlescopic versus laparoscopic cholecystectomy: a meta-analysis

BACKGROUND

To systematically analyse clinical trials on needlescopic (NC) versus laparoscopic cholecystectomy (LC) that evaluated the effectiveness of both procedures for the management of cholelithiasis.

METHODS

A systematic review of the literature was undertaken. Clinical trials on NC versus LC were selected according to specific criteria and analyzed to generate summative data expressed in standardized mean difference.

RESULTS

Sixteen trials on NC versus LC encompassing 1549 patients were retrieved from electronic databases. Only six randomized controlled trials on 317 patients qualified for the meta-analysis according to inclusion criteria. NC was associated with longer operative time and higher conversion rate as compared with LC. There was statistically significant heterogeneity among trials. Intraoperative complications, postoperative complications and total stay in hospital were not significantly different. NC was superior to LC in terms of less post-operative pain and better cosmetic outcomes.

CONCLUSION

NC is a safe and effective procedure for the management of gallstone disease. NC is as effective as LC for perioperative complications and total stay in hospital. NC is superior to LC for less post-operative pain and better cosmetic results. NC is associated with longer operative time and higher conversion rate.

Is smaller necessarily better? A systematic review comparing the effects of minilaparoscopic and conventional laparoscopic cholecystectomy on patient outcomes

BACKGROUND

In recent years, minilaparoscopic cholecystectomy (MLC; total size of trocar incision < 25 mm) has been increasingly advocated for the removal of the gallbladder, due to potentially better surgical outcomes (e.g., better cosmetic result, reduced pain, shorter hospital stay, quicker return to activity), but an evidence-based approach has been lacking. The current systematic review was undertaken to evaluate the importance of total size of trocar incision in improving surgical outcomes in adult laparoscopic cholecystectomy (LC).

METHODS

The literature was systematically reviewed using MEDLINE and EmBASE. Only randomized controlled trials in English, investigating minilaparoscopic versus conventional LC (total size of trocar incision > or = 25 mm) and reporting pain scores were included. Quantitative analyses (meta-analyses) were performed on postoperative pain scores and other patient outcomes from more than one study where feasible and appropriate. Qualitative analyses consisted of assessing the number of studies showing a significant difference between the techniques.

RESULTS

Thirteen trials met the inclusion criteria. There was a trend towards reduced pain with MLC compared with conventional LC, without reduction in opioid use. Patients in the MLC group had slightly reduced length of hospital stay, but there were no significant differences for return to activity. The two interventions were also similar in terms of operating times and adverse events, but MLC was associated with better cosmetic result (largely patient rated). There was a significantly greater likelihood of conversion to conventional LC or to open cholecystectomy in the MLC group than there was of conversion to open cholecystectomy in the conventional LC group [OR 4.71 (95% confidence interval 2.67-8.31), p < 0.00001].

CONCLUSIONS

The data included in this review suggest that reducing the size of trocar incision results in some limited improvements in surgical outcomes after LC. However, it carries a higher risk of conversion to conventional LC or open cholecystectomy.

Minilaparoscopic colorectal resection: a preliminary experience and an outcomes comparison with classical laparoscopic colon procedures

BACKGROUND

Laparoscopy has rapidly emerged as the preferred surgical approach for a number of different diseases because it allows for a correct diagnosis and proper treatment. However, it is not being applied in a widespread manner for the management of benign or malignant colorectal disease. Its natural evolution seems to be the development of mini-instruments and optics (diameter, </=5 mm). This study aimed to illustrate retrospectively the results of an initial minilaparoscopic colorectal surgery experience at two different institutions.

METHODS

Between January 2001 and December 2006, a total of 517 patients underwent a laparoscopic colon procedure. Among them, 161 (31.1%) underwent surgery with mini-instruments. The primary end point was the feasibility rate for minilaparoscopic colon resection. The secondary end points were safety and the impact of the technique on the duration of laparoscopy.

RESULTS

No conversion to classical laparoscopy and eight cases converted to the open approach were registered. The rate for major complications was 3.1%, whereas the rate for minor complications ranged as high as 11.8%.

CONCLUSIONS

Even if limited by its retrospective design, the reported experience shows that minilaparoscopic surgery may be a safe and effective approach to colon pathology. The described features make minilaparoscopy a challenging alternative to laparoscopy for colon disease. If proven to be cost effective without undue risk, as long as adequate training is obtained and proper preparation is observed, minilaparoscopy may become a standard surgical approach for selected patients.

Minilaparoscopic versus conventional laparoscopic cholecystectomy: a meta-analysis of randomized controlled trials

PURPOSE

We evaluated reports of minilaparoscopic cholecystectomy as compared to conventional laparoscopic cholecystectomy.

MATERIALS AND METHODS

We searched the Medline, Embase, and Cochrane library databases for randomized controlled trials reported between January 1996 to December 2005. The outcome measures used were operative time, length of hospital stay, postoperative pain, postoperative analgesic requirement, and cosmetic results. Meta-analysis methods were used to measure the pooled estimate of the effect size.

RESULTS

Data from 712 patients (352 minilaparoscopic cholecystectomy and 360 conventional laparoscopic cholecystectomy) in 12 randomized controlled trials were analyzed. The statistically significant advantages of minilaparoscopic cholecystectomy were less postoperative pain and better cosmesis. Conventional laparoscopic cholecystectomy showed a trend to shorter operative time that did not reach statistical significance.

CONCLUSION

Minilaparoscopic cholecystectomy could be a feasible alternative to conventional laparoscopic cholecystectomy in select patients, resulting in less pain and better cosmetic results. Additional well-designed randomized controlled and, if possible, blinded trials, with large sample sizes, are required to confirm this conclusion.

Minimizing ancillary ports size in gynecologic laparoscopy: A randomized trial

STUDY OBJECTIVE

To evaluate the feasibility, safety, and effect on postoperative pain of laparoscopy for the management of adnexal masses by downsizing ancillary trocars from 5- to 3-mm.

DESIGN

Randomized, controlled trial (Canadian Task Force classification I).

SETTING

Gynecologic department of a university hospital

PATIENTS

A total of 102 women with an adnexal mass scheduled for gynecologic laparoscopic procedures were randomized to undergo laparoscopy using either conventional 5-mm ancillary trocars (n=52) or 3-mm instruments (n=50). Preoperative suspicion of malignancy, deep infiltrating endometriosis, and indications for hysterectomy or myomectomy were considered as exclusion criteria.

INTERVENTIONS

Laparoscopic procedures for the treatment of benign adnexal masses.

MEASUREMENTS AND MAIN RESULTS

Both groups were similar in patient age, body mass index, history of abdominal surgery, and type of procedures. Intraoperative complications occurred in no patient (0%) in the 3-mm group and in two patients (3.8%) in the 5-mm group (p=.49). Conversion from 3- to 5-mm instrumentation was necessary in one procedure. No difference was found in the operative time between the 3-mm and the 5-mm groups (54 min [range 15-175 min] vs 50 min [range 20-150 min], p=.89). The severity of incisional pain was evaluated with a 100-mm visual analog scale at 1, 3, and 24 hours after surgery. Postoperative pain was significantly lower in the 3-mm than in the 5-mm group 1 hour after laparoscopy (20 [range 0-60] vs 32.5 [range 0-80], p=.04). The proportion of women requiring analgesia before discharge, the timing of analgesic requirement, and the total amount of medication in the first 24 hours after surgery were similar in the two groups.

CONCLUSION

Three-millimeter ancillary trocars can safely replace traditional-size equipment for the management of adnexal masses without a negative impact on the surgeon's ability to perform gynecologic laparoscopy and are associated with less immediate postoperative pain.

One-trocar salpingectomy for the treatment of tubal pregnancy: a ‘marionette-like’ technique

Laparoscopic salpingectomy for the treatment of tubal pregnancy has traditionally been performed with two ancillary trocars. We report a novel single-port technique requiring only an umbilical operative laparoscope and a percutaneous midline suture, inserted with a straight needle, to retract the affected fallopian tube. A total of 10 ectopic pregnancies have been successfully treated with this approach. The procedure was not technically demanding and the operative time was comparable to that of standard laparoscopic methods. No intraoperative and postoperative complication occurred. Ancillary trocars were not necessary in any of these cases. Our results showed that one-trocar salpingectomy is a feasible and safe technique.

A procedure-specific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy has advantages over the open procedure for postoperative pain. However, a systematic review of postoperative pain management in this procedure has not been conducted.

METHODS

A systematic review was conducted according to the guidelines of the Cochrane Collaboration. Randomized studies examining the effect of medical or surgical interventions on linear pain scores in patients undergoing laparoscopic cholecystectomy were included. Qualitative and quantitative analyses were performed. Recommendations for patient care were derived from review of these data, evidence from other relevant procedures, and clinical practice observations collated by the Delphi method among the authors.

RESULTS

Sixty-nine randomized trials were included and 77 reports were excluded. Recommendations are provided for preoperative analgesia, anesthetic and operative techniques, and intraoperative and postoperative analgesia.

CONCLUSIONS

A step-up approach to the management of postoperative pain following laparoscopic cholecystectomy is recommended. This approach has been designed to provide adequate analgesia while minimizing exposure to adverse events.

An "all 5-mm ports" selective approach to laparoscopic cholecystectomy, appendectomy, and anti-reflux surgery

Laparoscopic appendectomy, cholecystectomy, or anti-reflux procedures are conventionally performed with the use of one and often two 10/12-mm ports. While needlescopic or micropuncture laparoscopic procedures reduce postoperative pain, they invariably involve the use of one 10/12-mm port and the instruments applied have their ergo-dynamic shortcomings. Between September 2002 and March 2003, we have attempted an "all 5-mm ports" approach in 49 laparoscopic procedures, which included 18 of 59 laparoscopic cholecystectomies (31%), 26 diagnostic laparoscopies for suspected appendicitis (of which we proceeded to a laparoscopic appendectomy in 17 patients), and in the last 5 of 9 laparoscopic Nissen fundoplications. Conversion of one of the 5-mm ports to a 10-mm port was required in 5 of the 18 (28%) laparoscopic cholecystectomies and in 6 of the 17 (35%) laparoscopic appendectomies to facilitate organ retrieval in patients with large gallstones (>5 mm in diameter) and in obese patients with fatty mesoappendix. There were no conversions to open surgery. No significant differences in the operating time between the laparoscopic procedures performed by the all 5-mm ports approach or the conventional approach were observed. No intraoperative or postoperative complications occurred in this series. The "all 5-mm ports" approach to laparoscopic cholecystectomy and appendectomy in selected patients and to laparoscopic fundoplication appears feasible and safe. A randomised comparison between this approach and the conventional laparoscopic approach to elective cholecystectomy and fundoplication in which two of the ports employed are of the 10-mm diameter is warranted.

"Needlescopic" heller myotomy

MIS continues to evolve with the introduction of new techniques and technology. This report discusses the use of "needlescopic" technology in the surgical management of achalasia. Heller myotomy procedures performed between January 1, 1997, and July 1, 2000, were analyzed and the results of 14 needlescopic procedures were compared with 15 laparoscopic procedures. Demographic and short-term outcome data were compared for each group using chi2, Fisher exact, and Student t tests where appropriate. Both groups were similar in age and gender. However, the needlescopic group weighed less (72.2 vs. 83.5 kg; P = 0.05). Intraoperatively, the needlescopic procedures were shorter (98.2 vs. 131.9 minutes; P = 0.03). There were no conversions to open surgery or differences in the number of intraoperative complications for either group. Postoperatively, the groups had similar complications, time to normal diet, and analgesia requirements. Nonetheless, the needlescopic group had a shorter length of stay in hospital (1.1 vs. 2.0 days; P = 0.04). Needlescopic Heller myotomy appears to be a safe treatment option, resulting in a decreased length of stay and improved wound cosmesis.

Needlescopic fundoplication

BACKGROUND

Minimally invasive surgery continues to evolve, with an emphasis on developing new techniques and applying new technology to surgical procedures. The purpose of this study was to compare the short-term outcomes of needlescopic fundoplication with those of conventional laparoscopic fundoplication.

METHODS

Between January 1999 and June 2000, 38 needlescopic fundoplications were performed, and the short-term outcomes for these patients were compared with those for a contemporary matched cohort of patients who had undergone a conventional laparoscopic fundoplication.

RESULTS

There was a nonsignificant trend toward decreased operative time (143.4 to 127 min; p = 0.13), blood loss (54.3 to 48 ml; p = 0.30), narcotic requirements (29.5 to 19.5 morphine equivalents; p = 0.32), and length of hospital stay (1.78 to 1.49 days; p = 0.10) in the needlescopic group. There were no significant differences in intraoperative complications (2.6% vs 2.6%; p = 1.0). Two needlescopic cases were converted to laparoscopic cases because of obesity. Postoperatively, there were no significant differences in rates of early dysphagia (7.9% vs 7.9%), bloating (13.2% vs 5.3%; p = 0.43), or other complications (5.3% vs 5.3%) between the groups. There was a significant reduction in mean operative time for needlescopic fundoplication after the first four cases (166 +/- 44 vs 120 +/- 32 min; p = 0.03).

CONCLUSIONS

Needlescopic fundoplication poses no disadvantage, and it offers the added cosmetic benefit of smaller incisions.

[Recovery of lung function after laparoscopic cholecystectomy: the role of postoperative pain]

OBJECTIVES

Lung function has been shown to deteriorate after laparoscopic cholecystectomy (LC). The present study evaluated 1) the rate of recovery after LC, and 2) the pathogenic role of postoperative pain in functional deterioration.

DESIGN

Lung function was measured 24 hours before LC, upon hospital discharge (48-72 h after LC), and 10 days later. All patients received metamizol after LC until discharge (2 g every 6 h i.v.). Half the patients (analgesia group) received tramadol (150 mg i.m.) 30 minutes before lung function testing on the day of hospital discharge. The remaining patients constituted the control group.

PATIENTS

Twenty healthy subjects (53 4 years old) undergoing LC for gall bladder removal. All signed informed consent forms. Measures and outcomes: Patient characteristics and preoperative lung function results were similar in both groups. LC duration and postoperative course were also similar in both groups. All were discharged without complications within 72 hours after LC. Lung function upon discharge (FVC, FEV1, TLC, PaO2 and AaPO2) had deteriorated in both groups (p<0.001). Deterioration was less marked in the analgesia group (p < 0.05). Ten days later, lung function had normalized for all subjects.

CONCLUSIONS

These results indicate that after LC, 1) lung function is still abnormal when the patient is discharged from hospital, 2) lung function has fully recovered within 10 days, and 3) postoperative pain contributes significantly to temporary deterioration in lung function.