Comparison of Single Incision Laparoscopic Cholecystectomy and Conventional Laparoscopic Cholecystectomy: A Meta-Analysis of Randomized Controlled Trials

Pankaj Garg, MBBS MS, Vikas Gupta, MBBS MS MCH, Jai D Thakur, MBBS, Geetha R Menon, PhD. 1. Fortis Super Speciality Hospital, Mohali, India & MMIMS, Mullana, India, 2. PGIMER, Chandigarh, India, 3. Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA , 4. ICMR, New Delhi, India

Background
Single incision laparoscopic cholecystectomy(SILC) has been developed as a step forward in minimal access surgery. The principal benefit of SILC is supposed to be better cosmesis and reduced pain. The purpose of this study was to compare different morbidity parameters between SILC and conventional laparoscopic cholecystectomy (CLC).
Methods
The databases- Pubmed, Ovid, Embase SCI database, Cochrane & Google Scholar were searched for single incision laparoscopic cholecystectomy and all related terms. The studies between 1995 to September, 2011 were extracted by two independent reviewers. Out of 2057 yielded studies, 14 studies comparing SILC & CLC were extracted and out of these, 5 randomized controlled trials (RCT) were selected for meta-analysis. The assessment of risk of bias in the trials was based on adequate sequence generation, allocation concealment, blinding, whether incomplete outcome data was addressed and selective outcome reporting. For continuous variables, statistical analysis was carried out using the weighted mean difference(WMD) as the summary statistic and for categorical variables, odds ratio was used as the summary statistic. The primary endpoint analyzed was pain at 24 hours after the operation and the secondary end points were cosmetic satisfaction, operating time, hospital stay and incidence of post operative complications namely bile leak, hernia formation and wound infection.
Results
A total of 287 patients (SILC-150, CLC-137) were analyzed from 5 randomized controlled trials (RCT). The operating time was significantly longer in SILC (mean difference=15.54, 95% CI: 11.01 to 20.08, p< 0.00001). The objective post operative pain scores at 24 hours, though less in SILC group, was not statistically different between the two groups (mean difference =0.27, 95% CI: -0.55 to 0.01, p=0.06, not significant). SILC group had significantly favorable cosmetic scoring compared to CLC (mean difference-1.16, 95% CI: 0.75 to 1.56, p< 0.00001). The hospital stay was similar in both the group (mean difference= -0.15, 95% CI: -0.35 to 0.05, p=0.15). All the post operative complications, though higher in SILC group, were statistically comparable in both the groups- bile leak (RR=1.17, 95% CI: 0.37 to 3.75, p= 0.79, not significant), wound infection (RR=1.49, 95% CI: 0.29 to 7.63, p= 0.63, not significant) & hernia formation (RR=2.58, 95% CI: 0.26 to 25.60, p= 0.42, not significant).
Conclusions
Single incision laparoscopic cholecystectomy(SILC) has cosmetic benefit over conventional laparoscopic cholecystectomy (CLC). SILC had significantly longer operating time which is perhaps due to the learning curve. However, there is no difference between other morbidity parameters such as post operative pain at 24 hours, and the hospital stay. Post operative complications such as bile leak, wound infection and hernia formation, though higher in SILC, were statistically similar in both the groups. Though SILS has cosmetic benefit over CLC, studies have demonstrated that cosmesis after CLC is also remarkable and acceptable. Against this background, the future of SILC depends on the long term safety of SILC especially the hernia formation and biliary injuries.
 

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