Impact of obesity on surgical outcome after single-incision laparoscopic cholecystectomy

Critical values for body mass index related to morbidity in high-volume low-complexity general surgery: a systematic review and meta-analysis

INTRODUCTION

The aim of this study was to investigate the effect of body mass index (BMI, kg/m2) on outcomes of high-volume low-complexity (HVLC) general surgery procedures and to determine critical values for BMI when selecting patients into HVLC programmes.

METHODS

A systematic review was conducted of studies looking at patients in different BMI categories undergoing HVLC general surgery procedures (laparoscopic cholecystectomy, inguinal hernia repair and umbilical or paraumbilical hernia repair), in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. A comparison meta-analysis model was constructed to compare the outcomes using random-effects modelling. The QUIPS (Quality In Prognosis Studies) tool and GRADE (Grading of Recommendations Assessment, Development and Evaluation) system were used to assess bias.

RESULTS

A total of 26 studies including 486,392 patients were examined. In laparoscopic cholecystectomy, BMI ≥40 was associated with higher conversion to open surgery (odds ratio [OR]: 1.33, p=0.040) but did not affect complications (OR: 0.69, p=0.400) or length of hospital stay (mean difference [MD]: -0.01 days, p=0.900). In inguinal hernia repair, BMI ≥35 was associated with longer operative time (MD: 18.00 minutes, p<0.00001), and higher risk of wound complications (OR: 3.01, p<0.00001) and hospital readmission (OR: 1.46, p=0.0008). In umbilical or paraumbilical hernia repair, BMI ≥30 was associated with higher risk of wound complications (OR: 6.45, p<0.0001) and hospital readmission (OR: 5.56, p<0.00001), and longer operative time (MD: 4.01 minutes, p=0.030).

CONCLUSIONS

Obesity was associated with longer operative time (up to 23 minutes) and higher risk of postoperative morbidity (up to 4-fold) in HVLC procedures. BMI <40 (moderate GRADE certainty - laparoscopic cholecystectomy) and BMI <35 (moderate GRADE certainty - inguinal hernia) appear to represent optimal critical values for perioperative safety metrics.

Laparoscopic surgery and robotic surgery for single-incision cholecystectomy: an updated systematic review

The role of single-incision laparoscopic cholecystectomy (SILC) and single-incision robotic cholecystectomy (SIRC) is still unclear. We update the summarization of the feasibility and safety of SILC and SIRC. A comprehensive search of SILC and SIRC of English literature published on PubMed database between January 2015 and November 2020 was performed. A total of 70 articles were included: 41 covering SILC alone, 21 showing SIRC alone, 7 reporting both, and 1 study not specified. In total, 7828 cases were recorded (SILC/SIRC/not specified, 6234/1544/50); and the gender of 7423 cases was definitively reported: the female rate was 64.0% (SILC/SIRC/not specified, 62.1%/71.5%/74.0%). The weighted mean for body mass index (BMI), operative time, blood loss and post-operative hospital stay was 25.5 kg/m2 (SILC/SIRC, 25.0/27.0 kg/m2), 73.8 min (SILC/SIRC, 68.2/88.8 min), 12.6 mL (SILC/SIRC, 12.1/14.8 mL) and 2.5 days (SILC/SIRC, 2.8/1.9 days), respectively. The pooled prevalence of an additional port, conversion to open surgery, post-operative complications, intraoperative biliary injury, and incisional hernia was 4.1% (SILC/SIRC, 4.7%/1.9%), 0.9% (SILC/SIRC, 0.7%/1.5%), 5.9% (SILC/SIRC, 6.2%/4.1%), 0.1% (SILC/SIRC, 0.2%/0.09%), and 2.1% (SILC/SIRC, 1.4%/4.8%), respectively. Compared with conventional laparoscopic cholecystectomy, SIRC has experienced more postoperative incisional hernias (risk difference = 0.05, 95% confidence interval 0.02-0.07; P < 0.0001). By far, SILC and SIRC have not been considered a standard procedure. With the innovation of medical devices and gradual accumulation of surgical experience, feasibility and safety of performing SILC and SIRC will improve.

Single-Port Laparoscopic and Robotic Cholecystectomy in Obesity (>25 kg/m2)

BACKGROUND AND OBJECTIVES

Single-port cholecystectomy has emerged as an alternative technique to reduce the number of ports and improve cosmesis. Few previous studies have assessed obesity-related surgical outcomes following single-port cholecystectomy. In this study, technical feasibility and surgical outcomes of single-port laparoscopic cholecystectomy (SPLC) and robotic single-site cholecystectomy (RSSC) in obese patients were investigated.

METHODS

We conducted a two-center collaborative study and retrospectively reviewed initial experiences of RSSC and SPLC in patients whose body mass index was over 25 kg/m2. Medical records of patients were reviewed. Clinical characteristics and short-term oncologic outcomes were considered and compared between SPLC and RSSC groups.

RESULTS

RSSC and SPLC were performed in 39 and 78 patients, respectively. In comparative analysis, the total operative time was longer in the RSSC group (109.92 minutes vs. 60.99 minutes; P < .001).However, requiring additional port for completion of surgical procedure was less frequent in the RSSC group (0% vs. 12.8%; P = .029). Immediate postoperative pain score was not significantly different between the two groups (4.95 vs. 5.00; P = .882). However, pain score was significantly lower in the RSSC group at the time of discharge (1.79 vs. 2.38; P = .010). Conversion to conventional multiport cholecystectomy, intraoperative bile spillage, or complication rate was not significantly different between the two groups (P > .05).

CONCLUSIONS

SPLC and RSSC could be safely performed in selected patients with high body mass index, showing no significant clinical differences.

A large-cohort comparison between single incision laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy from a single center; 2080 cases

Backgrounds/Aims

This study was conducted to verify and compare the safety and feasibility of single incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy (CLC).

Methods

A total of 2,080 patients underwent laparoscopic cholecystectomy in a single center, Konyang University Hospital, between 2010 and 2016. We retrospectively compared the demographics, perioperative outcome, and postoperative complication results between the CLC and SILC groups.

Results

Among the 2,080 patients who underwent laparoscopic cholecystectomy, 1,080 had CLC and 1,000 had SILC. When retrospectively reviewed, the SILC group had significantly higher percentages of patients who were aged under 80 years, who were women, and had the American Society of Anesthesiologist score of lower than 3 points compared to those of the CLC group. Furthermore, the CLC group had a higher percentage of patients with acute cholecystitis or empyema, whereas the SILC group had a higher percentage of patients with chronic cholecystitis. Preoperative percutaneous transhepatic gallbladder drainage insertion or H-vac insertion was more frequently conducted, bleeding loss was more common, and hospital stay was longer in the CLC group. Postoperative complications such as wound infection, biloma, bile duct injury, and duodenal perforation were not significantly different between the two groups.

Conclusions

In conclusion, if performed after preoperative patient selection such as in younger and female patients with no abdominal operation history at the time of benign gallbladder surgery, SILC can be considered feasible and safe without additional complications when compared with CLC.