Eric M Pauli, MD, David M Krpata, MD, Melissa S Phillips, MD, Jeffrey M Marks, MD, Raymond P Onders, MD. University Hospitals Case Medical Center, Cleveland, OH and The University of Tennessee Health Science Center, Knoxville, TN
Introduction: Four port laparoscopic cholecystectomy (4PLC), first introduced in 1985, is now considered standard of care. Recent advancements in minimally invasive techniques (single port laparoscopy and natural orifice surgery) offer theoretical advantages of reduced pain and improved cosmesis. We hypothesized that reducing the number of laparoscopic ports for cholecystectomy to three (3PLC) would result in reduced pain and improved cosmesis while at the same time avoiding the technical challenges posed by more novel minimally invasive methods.
Methods: Data were culled from the standard cholecystectomy arm of a multicenter, prospective single blinded, randomized trial of single incision versus standard laparoscopic cholecystectomy sponsored by Covidien. 3PLC or 4PLC was determined by surgeon practice patterns. Data measures included patient demographics, operative time, estimated blood loss and procedure conversion (3PLC to 4PLC or 3PCL/4PLC to open). Pain (worst and average) was assessed at intervals over the first post-operative month and cosmetic scoring was performed by the patient at intervals over 12 months.
Results: Eighty patients (63 4PLC and 17 3PLC) were included in the study. Patient characteristics, including age, sex, body mass index (BMI) and pre-operative pain scores were similar between the two groups. No patients required conversion of technique and blood loss was similar between the two groups (p=0.32). There were no common bile duct injuries. 3PLC had a statistically shorter operative time than 4PLC (34.3 vs. 48.1 min, p=0.003). The 3PLC group had significantly lower average pain scores on post-operative day one (3.47 vs. 4.66, p=0.014), but on all other days (pre-discharge and Day 3, 5, 14, 30) worst and average pain scores were similar. The self-reported cosmetic scale demonstrated no significant differences between the 4PLC and 3PLC groups at 3 months and 12 months (p=0.21 and p=0.69 respectively).
Conclusions: In this non-randomized, blinded, prospective, multicenter trial of 3PLC vs. 4PLC, 3PLC appears to be safe with a similar blood loss and procedural conversion rate. Reduced operative times in the 3PLC group can be explained by surgeon proficiency and reduced numbers of ports to place and to close. 3PLC had significantly reduced average pain on the first post-operative day. Pain scores were identical at all other times assessed during the first month. Cosmesis scoring did not favor 3PLC over 4PLC. 3PLC offers a safe alternative to 4PLC and may reduce early post-operative pain. 3PLC can be safely utilized as a training bridge for the techniques involved in single incision or reduced-port cholecystectomy.
Session Number: Poster – Poster Presentations
Program Number: P615