Is fourth port really required in laparoscopic cholecystectomy?

When Should I Use an Additional Port at the Time of Three-Port Laparoscopic Cholecystectomy?

Objective: Today, it is recommended that the laparoscopic cholecystectomy (LC) is made with standard three ports. In this study, we aimed to determine the preoperative and intraoperative factors that require the use of an additional fourth port during three-port LC. Materials and Methods: All patients who started LC with three ports between January 1, 2018 and December 31, 2019 were included in the study. The patients were divided into two groups as those who underwent three-port LC and those who required additional ports. Independent parameters affecting the transition from three ports to four ports were analyzed using logistic regression analysis. The patients who underwent LC with three ports were included in Group 1 and the patients requiring an additional port were included in Group 2. Results: A total of 234 patients (139 women and 95 men) were included in the study. The average age of patients was 52.95 ± 16.26 (20-89) and body mass index is 28.64 ± 5.4 (15.73-48.89), respectively. Three ports were used in 148 patients (Group 1), and an additional fourth port was used in 42 patients (Group 2). Female gender, history of upper laparotomy, presence of acute infection findings, urgent surgery, and advanced age were observed to increase the use of additional ports. In multivariate analysis, it was shown that the presence of hepatic barrier (P < .001) and the presence of complete adhesion in the gallbladder (P < .001) significantly increased the use of additional trocars during LC. In addition, female gender was found to cause an increase of 6.62 times (P < .001). Conclusion: Many factors may require the use of additional ports during three-port LC. The use of an additional fourth port should not be avoided, especially in cases where hilum dissection is prevented due to liver origin, in female patients and in cases with complete adhesion to the gallbladder.

Is the fourth port routinely required for laparoscopic cholecystectomy? Our three-port laparoscopic cholecystectomy experience

BACKGROUND

There have been many changes in number and place of trocars that have been described, since the first laparoscopic cholecystectomy (LC), but, in fact, all authors agree that laparoscopic procedure is accepted as gold standard. However, four trocars use in standard laparoscopic cholecystectomy, it has been argued that the fourth port is not necessary for grasping fundus of gallbladder so as to expose Calot's triangle. The aim of this study is to establish the safety of three-trocar LC in symptomatic gallbladder disease and also to determine the ratio of technical requirements of the fourth trocar.

METHODS

Between August 2010 and January 2016, 291 cases were operated in Kocaeli Derince Education and Research Hospital, department of general surgery for symptomatic gallbladder disease with three-port LC, and their records were examined retrospectively.

RESULTS

Two hundred and twenty patients were female (75.6 %) and seventy one (24.4 %) were male. Two hundred and eighteen of two hundred and ninety-one cases (74.92 %) were operated with three- port LC in a secure way. In seventy-three cases (25.08 %), one more port was needed to use. Mean operative time was 33.76 ± 11:18 min. (15-90 min). In these cases, major complications, such as main bile duct injury or bile leakage, that may increase the mortality and morbidity, did not occur. Only in one case (0.34 %) postoperative bleeding was seen from the liver bed, which was required exploration.

CONCLUSION

We concluded that in experienced hand, LC with three ports is safe and feasible technique if it is not endanger the course of the surgery.