Cosmetic outcome is an important parameter when comparing single-incision laparoscopic surgery (SILS) and conventional multiport laparoscopic cholecystectomy (CLC)

Abstract

It was interesting to read the meta-analysis by Markar et al. [1] that compared single-incision laparoscopic surgery (SILS) and conventional multiport laparoscopic cholecystectomy (CLC). They studied postoperative pain during first day after surgery and postoperative complications as the primary parameters and length of hospital stay and operative time as the secondary parameters. However, we fail to understand why the cosmetic result was not taken as one of the primary outcome parameters. SILS is an endeavor to reduce multiple incisions by using a least visible intraumbilical incision, thus making SILS look like a scarless operation to the patient. SILS is also seen as a step forward toward natural orifice transluminal endoscopic surgery (NOTES). However, to the patient, the cosmetic benefit is the main attraction of SILS and NOTES. Additional instrumentation, increased operating time, the need to learn new skills, and added costs can be justified only if they add value to the patient’s outcome, which is primarily the cosmetic result in these cases. Postoperative pain is also an important outcome measure. In an interesting study, Blinman et al. [2] demonstrated that the total tension across a wound rises nonlinearly with increasing wound length. They further established that the total tension across multiple incisions is always less than the total tension for an incision of the same total length. Based on this concept, Garg et al. [3] calculated total tension across two 10 mm and two 5 mm port wounds of CLC and a single SILS wound of 24.9 mm and found the tension to be quite similar. Therefore, it is probable that postoperative pain may not differ much in SILS and CLC groups as has also been concluded in the meta-analysis [1]. Second, the authors included the study by Asakuma et al. [4] in the meta-analysis. Asakuma et al. mentioned in their methods that no attempt was made to randomize patients and the patient’s request for a particular procedure (SILS or CLC) was honored. In such a scenario, is it justified to include this study in the meta-analysis? Third, the authors indicated that in the study by Lee et al. [5] none of the patients had a bile leak, whereas the study’s authors reported that a bile leak occurred in six SILS patients and four CLC patients.