Innovative Approaches to Laparoscopic Cholecystectomy: A Comparison of Outcomes for Single Incision Laparoscopic Cholecystectomy, Multi-port Robotic Cholecystectomy, and Single Site Robotic Cholecystectomy.

Robert J Aragon, MD, Cheryl Lin, MD, Tamas J Vidovszky, MD, FACS, Aaron D Carr, MD, Mohamed R Ali, MD, FACS. Department of Surgery, University of California, Davis..

The past decade has witnessed the application of innovative approaches to laparoscopic cholecystectomy (LC). At our institution, we have performed single incision laparoscopic cholecystectomy (SILC), multi-port robotic cholecystectomy (MPRC), and single site robotic cholecystectomy (SSRC). We report our experience with the safety, feasibility, and outcomes of these three approaches.

All patients who underwent SILC, MPRC, or SSRC were included in this analysis. There were no patient-specific or diagnosis-related exclusion criteria. SILC and SSRC were performed through a single umbilical incision, while MPRC was performed through a standard four-port LC configuration. Demographic, diagnosis, operative, and outcome data were prospectively collected on all patients. For MPRC and SSRC, case start time (CST) was defined as the time from incision until being ready to dock the robot. Setup time (ST) spanned docking the robot and instrument placement. Robotic time (RT) was spent at the console performing the cholecystectomy. For all cases, total operative time (TOT) was defined from initial incision until skin closure. Statistical analysis was performed using ANOVA for continuous variables and Fisher’s exact test for discrete variables. Statistical significance was set at α=0.05.

In this study, 330 patients with mean age of 45±14 years and mean weight of 88.3±24.1 kg underwent SILC (n=36), MPRC (n=162), or SSRC (n=132). Most of the patients were women (73%). There were no statistically significant differences in age or gender distribution among the three groups of patients. MPRC patients weighed more than SILC patients (93.1±24.7 kg vs 74.4±15.8 kg, p=0.001) and SSRC patients (93.1±24.7 kg vs 86.2±23.6 kg, p=0.03). Patients underwent cholecystectomy for symptomatic cholelithiasis (79.1%), cholecystitis (13.64%), biliary dyskinesia (5.5%), and gallbladder polyposis (1.8%). There were no differences in the distribution of diagnoses among the groups (p=0.5194). Decreased TOT was observed for SILC (62.3±21.6 minutes) versus MPRC (80.9±24.8 minutes) and SSRC (81.3±23.3 minutes) (p=0.0002). Differences were observed between MPRC and SSRC in CST (17.2±8.7 minutes vs 10.1±8.7 minutes, p<0.0001) and ST (6.3±3.7 minutes vs 4.4±2.7 minutes, p<0.0001) but not in RT (38.2±15.5 minutes vs 39.7±15.0 minutes, p=0.4). Four SILC cases (11.1%), 7 MPRC cases (4.3%), and 13 SSRC cases (9.8%) were not completed via the intended approach (p=0.12). One additional port was inserted in two SILC cases (5.5%) and one SSRC case (0.7%). Conversion rates were not significantly different among SILC (5.6%), MPRC (4.3%), and SSRC (8.3%). Most conversions were to LC, with only one MPRC (0.6%) and one SSRC patient (0.7%) requiring open conversion. Requirement for hospital stay was higher in the SSRC group (8.3%) versus SILC (0%) and MPRC (0.6%) (p=0.001). Hospital readmission was highest in the SILC group (11.1%), lower in SSRC (6.8%), and lowest in MPRC (0.6%) (p=0.003). Reoperation was required in one SILC and one SSRC patient. Complication rate or need for postoperative cholangiography was not statistically different among the three groups.

SILC, MPRC, and SSRC can be performed effectively with low conversion, complication, and reoperation rates. Thus, individual applicability of these approaches will be a function of surgeon preference and nature of the practice environment.

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