Authors’ reply to: single-incision laparoscopic surgery (SILS) vs. conventional multiport cholecystectomy: systematic review and meta-analysis

Abstract

We thank Garg et al. [1] for their interest in our publication [2]. The meta-analysis was aimed at comparing clinical outcome following single-incision (SILS) vs. multiport laparoscopic cholecystectomy. We demonstrated that SILS cholecystectomy was a safe procedure with a similar clinical outcome to standard multiport laparoscopic cholecystectomy. In their letter Garg et al. [1] raise four points of interest that we wish to deal with in turn. First, we agree that improved cosmesis is one of the major benefits of single-incision surgery. However, with the advent of any new surgical technique, patient safety must be the primary concern before the focus can turn to more subjective outcomes such as cosmesis or pain. This meta-analysis clearly demonstrated that SILS cholecystectomy is a safe procedure for uncomplicated gallstone disease in the hands of experienced laparoscopic surgeons. There was insufficient comparable data to allow the analysis of cosmesis as a primary outcome measure. As part of the discussion in our article we described three studies that reported improved patient wound satisfaction scores (different scoring systems were used making meta-analysis impossible). We also alluded to the need for future highpowered randomized studies to examine patient wound satisfaction associated with these different techniques. Second, the authors suggested that postoperative pain may reflect a function of wound tension. This may be a contributing factor, yet not one of the papers that they cited made any correlation of wound tension with the subjective nature of pain. This makes their conclusions difficult to follow. More importantly, the extent of dissection, the site of the incision, wound infection rates, and the method of closure will also affect the pain response. Therefore, to imply that wound tension is solely responsible is a gross oversimplification. One of the major benefits of laparoscopic cholecystectomy has been the significant reduction in postoperative pain when compared to standard open cholecystectomy. In several institutions across the world, laparoscopic cholecystectomy is performed as a day-case procedure, which directly reflects the benefits in postoperative pain seen with this technique. Thus, as the authors suggest, it may be challenging to demonstrate a significant improvement in pain associated with SILS cholecystectomy as multiport laparoscopic cholecystectomy has already dramatically improved pain associated with open surgery. However, this meta-analysis does demonstrate equivalent short-term pain scores for both techniques. Third, Garg et al. [1] raised concerns regarding the methodology employed in trial selection. In particular, they highlighted the inclusion of the Asakuma et al. [3] study. A method of quasirandomization was used by Asakuma et al. [3], with ‘‘allocation to SILS or conventional multiport cholecystectomy based solely on the day of the week.’’ As Garg et al. [1] mentioned in their correspondence, ‘‘there was no attempt to randomize patients blindly, and patient requests for a particular procedure were honored.’’ While we agree with their statement that this method of treatment allocation is not randomization in its purest sense, Asakuma et al. [3] attempted to randomize patients to each treatment. However, we are happy to acknowledge that differences in opinion may exist regarding the inclusion and exclusion of trials based on the methodology of randomization employed. Fourth, Garg et al. [1] suggested that an error occurred in the Table 5 in reporting the incidence of bile leak in the Lee et al. [4] paper. In their paper Lee et al. [4] described S. Markar (&) J. Kinross Academic Surgical Unit, St. Mary’s Hospital, 10th Floor, Praed Street, London W2 1NY, UK e-mail: sheraz_markar@hotmail.com