Single-incision versus standard 4-port laparoscopic cholecystectomy: A single institute retrospective study

Noriaki Kameyama, PhD, Ryohei Miyata, PhD, Masato Tomita, MD, Hiroaki Mitsuhashi, MD, Shigeaki Baba, PhD. International Goodwill Hospital.

Background: We introduced the single-incision laparoscopic cholecystectomy (SILC) in May 2009 for selective cases with less inflamed gallbladders. Our indication of SILC was expanded for all the cholecystectomies in 2010. We tested various approaches including SILS portTM, EZ-accessTM, and Gel-pointTM and established pure SILC with the glove method in May 2011. This single institute retrospective study was aimed to evaluate the surgical outcomes of pure SILC compared to standard 4-port laparoscopic cholecystectomy (LC) after May 2011.

Methods: Between May 2011 and August 2013, we performed 246 cholecystectomies (SILC, n = 141; LC, n = 105) at our institute. Five patients with gallbladder cancer or pairing cholecystectomy with other intra-abdominal surgery were excluded, and 241 cases (SILC, n = 138; LC, n = 103) were analyzed. A 1.5 cm vertical transumbilical incision was used for SILC, followed by the glove method using the Alexis wound retractorTM (XS size) with two low-profile laparoscopic ports (all 5-mm trocars) and the Roticulator Endo Dissect™ inserted directly through the holes of the cut fingertip. An additional port was inserted when required. A 1.5 cm vertical transumbilical incision was used for LC with additional three 5-mm trocars. The surgical approach was selected by patients’ preferences. More patients selected SILC (141 vs. 105) with the higher levels of preference evident among female patients (selected SILC: male, 48%; female, 66%). SILC were performed by five surgeons, including two residents who performed four cases (2.9%). LC was performed by twelve surgeons, including four residents who performed 24 cases (23.3%).

Results: There were no differences in patient characteristics. Operative time was significantly shorter with SILC (65 min, range 29-160 min vs. 118 min, range 51-207 min). Significant differences were observed for lengths of hospital stay (4.0 vs. 5.5, SILC vs. LC) and total doses of analgesics (1.5 vs. 2.6, SILC vs. LC). Postoperative complications were significantly less in SILC. There were eight complications (8/138, 5.8%) in the SILC group, including fat lysis (6 cases), wound infection (1 case), and biloma (1 case). There were eleven complications (11/103, 10.7%) in the LC group, including common bile duct injury (1 case), large bowel injury (1 case), fat lysis (4 cases), wound infection (3 cases), biloma (1 case), and small-bowel obstruction (1 case). No hernias were observed during the follow-up period (1 to 12 months). A supplemental miniport was required for only four cases (4/138, 2.9%; 5-mm port for 3 cases and 3-mm port for 1 case), and LC was converted to open surgery in 5 cases (5/103, 4.9%).

Conclusions: Pure SILC is a feasible and safe procedure in the hands of expert laparoscopic surgeons. Pure SILC is the first choice for the treatment of most patients with gallbladder disease, and we have to make a decision for additional ports, if necessary.

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