Classic Laparoscopic Cholecystectomy Research Articles

Lower abdominal approach in laparoscopic cholecystectomy: A propensity score-matching analysis and prospective cohort study

BackgroundClassic laparoscopic cholecystectomy) using multiple ports is a widely used method with excellent surgical outcomes. However, the resulting wounds do not meet the cosmetic needs of patients. Therefore, this study aimed to find a new minimally invasive surgical method for invisible wounds while maintaining surgical safety through a new port site. MethodsIn this prospective cohort study, we used propensity score matching analysis to evaluate the perioperative outcomes of multiport laparoscopic cholecystectomy using articulating devices with the lower abdominal approach. We performed a propensity score matching analysis of prospectively maintained data from 228 patients who underwent classic laparoscopic cholecystectomy using straight instruments and laparoscopic cholecystectomy with a lower abdominal approach using articulating devices between January and October 2022. A single surgeon performed all operations included in the study. We evaluated several perioperative outcomes. ResultsNo differences were found in potential confounding factors, such as sex, age, admission type, previous abdominal surgery, and medical comorbidities, between the 2 groups after propensity score matching. In the classic laparoscopic cholecystectomy group, the mean operation time was shorter (43.73 ± 23.71 vs 50.60 ± 9.75 min; P < .04). No significant difference was noted in the 2 groups’ numerical rating scale scores for pain, body mass index, and incidence of postoperative complications. The mean length of hospital stay was longer for patients who underwent classic laparoscopic cholecystectomy (4.27 vs 2.07 days; P = .064). The lower abdominal laparoscopic cholecystectomy group had delayed defecation after surgery. ConclusionRegarding surgical outcomes and minimal invasiveness, lower abdominal laparoscopic cholecystectomy is a feasible cholecystectomy method.

RANDOMIZED CONTROL TRIAL OF CONVENTIONAL LAPAROSCOPIC VERSUS SINGLE INCISION LAPAROSCOPIC CHOLECYSTECTOMY

Background:From big incision to minimally invasive multiport classic laparoscopic cholecystectomy (CLC) and now to single incision laparoscopic cholecystectomy (SILC) surgeryhas travelled a long way. There are proposedadvantages and potential disadvantages of SILC compared to the gold standard CLC. However, debate still exists whether SILC has anything more to offer. We compared various parameters of patient satisfaction, quality of life and short term surgical outcomes between CLC and SILC. Method: RCT was conducted forduration of one year. Patients were assigned into SILC and CLC groups. Operative time, length of hospital stay, quality of life (SF 36 questionnaire), patients overall and cosmetic satisfaction and postoperative pain using 10-point visual analogue scale (VAS) were assessed.The data analysis was done using software SPSS version20.0. Results: A total of 36 patients (28 women and 8 men) with mean age 39.88±11.99 yearswere allocated into SILC (n=18) and CLC (n=18) groups.The mean operative time for SILC was significantly longer than CLC (66.33 vs 46.50 minutes, P=0.001). VAS recorded higher pain in first 24 hours postoperatively in SILC than CLC group (4.467 vs 2.667, P=0.06). However, at the time of discharge patients in CLC had greater pain than SILC group (0.22 vs 0.133, P&gt;0.99).No significant variability was seen in length of hospital stay (SILC 3.60 vs CLC 3.38 days, P=0.47). The QOL on first follow up visit showed statistically significant difference in two of the domain of SF 36, namely vitality and bodily pain. Patients overall and cosmetic satisfaction showed no superiority of SILC over CLC. Conclusions:Although patient prefers SILC in wake of cosmetic reasons, still it is a long way off from replacing CLC. Larger operative time and lack of standardization makes SILC still an evolving procedure and judicious patient selection is must for better outcome.

Comparative Study of Standard Four-Port, Three Port and Single Incision Laparoscopic Cholecystectomy Performed by a Single Surgeon in Nobel Medical College Teaching Hospital, Nepal

Introduction: Laparoscopic Cholecystectomy is a standard operative procedure for patients with gallbladder diseases and is the most common laparoscopic procedure performed worldwide. The aim of this study is to analyze the different methods of laparoscopic cholecystectomies done by a single surgeon at Nobel Medical College Teaching Hospital.&#x0D; Objectives: The objective and aim of this study are comparing 4 port classic Laparoscopic Cholecystectomy (4PLC), 3 port (3PLC) and Laparo-Endoscopic Single-Site Cholecystectomy (LESC) performed by a single surgeon and correlate worldwide experience with outcomes in our institution.&#x0D; Methodology: The study includes retrospective analysis of 8192 patients who underwent elective laparoscopic Cholecystectomy (LC) from October 2010 to July 2020 performed by the single surgeon. All cases divided into 3 groups depending on the type of LC (4PLC, 3PLC, LESC). The data included the type of the surgery, gender, age, operative time, conversion and complication rate and duration of hospital stay.&#x0D; Results: The hospital stays, operation time and conversion rate decreased from group I to group III. Female patients out numbered the male ones (M:F=1:4). The hospital stays (3.4 days), operation time (35 min), conversion (0.4%) and complications (0.7%) rate decreased from Group of 4PLC to Group of LESC (1.5 days, 13 min, 0.1% conversion, 0.4% complication respectively) which is true for almost all other similar studies.&#x0D; Conclusion: The advantages of LESC include a better cosmetic effect and reduced chance of infections. It has been postulated to be superior in scarless surgery with added benefits of lower pain level and reduced need for analgesics, shorter hospital stays, quicker return to work and lower financial expenses.

Higher cost of single incision laparoscopic cholecystectomy due to longer operating time. A study of opportunity cost based on meta-analysis.

We aimed to calculate the opportunity cost of the operating time to demonstrate that single incision laparoscopic cholecystectomy (SILC) is more expensive than classic laparoscopic cholecystectomy (CLC). We identified studies comparing use of both techniques during the period 2008-2016, and to calculate the opportunity cost, we performed another search in the same period of time with an economic evaluation of classic laparoscopy. We performed a meta-analysis of the items selected in the first review considering the cost of surgery and surgical time, and we analyzed their differences. We subsequently calculated the opportunity cost of these time differences based on the design of a cost/time variable using the data from the second literature review. Twenty-seven articles were selected from the first review: 26 for operating time (3.138 patients) and 3 for the cost of surgery (831 patients), and 3 articles from the second review. Both echniques have similar operating costs. Single incision laparoscopy surgery takes longer (16.90min) to perform (p <0.00001) and this difference represents an opportunity cost of 755.97 € (cost/time unit factor of 44.73 €/min). SILC costs the same as CLC, but the surgery takes longer to perform, and this difference involves an opportunity cost that increases the total cost of SILC. The value of the opportunity cost of the operating time can vary the total cost of a surgical technique and it should be included in the economic evaluation to support the decision to adopt a new surgical technique.

Single-access Laparoscopic Cholecystectomy Versus Classic Laparoscopic Cholecystectomy

Single-incision laparoscopic surgery has been proposed as a minimally invasive technique with the advantages of fewer scars and reduced pain. The aim of this study was to perform a systematic review and meta-analysis of prospective randomized clinical trials of single-access laparoscopic cholecystectomy (SALC) versus classic laparoscopic cholecystectomy (CLC). All randomized controlled trials were identified through electronic searches (MEDLINE, PubMed, SAGES, and Cochrane Central Register of Controlled Trials) up to October 2011. Methodologically appropriate clinical trials identified in the search process were included in a meta-analysis to provide a pooled estimate of effect. Nine true randomized controlled trials were included in the analysis and reported a total of 695 patients, divided into the SALC group of 362 patients and the CLC group of 333 patients. Median operating time was longer with 57 minutes in SALC versus 45 minutes in CLC (P=0.00001). There was no significant difference in length of stay (SALC 1.36 d vs. CLC 1.15 d, P=0.18). Conversion to laparotomy in either group was similar; however, in 18 of 66 SALC patients an additional instrument was used, compared with 1 of 67 CLC patients (P=0.0003). Complications were not significant different [16% in SALC vs. 12% in the CLC group (P=0.74)]. Median postoperative pain with the visual analog scale score was 3.8 points in SALC versus 3.15 points in the CLC group (P=0.48). Cosmetic satisfaction was significantly more satisfying with 9 points favoring SALC versus 0 points favoring CLC (P=0.0005) in contrast to the quality-of-life questionnaire where there was no significant difference in patient overall satisfaction between SALC and CLC groups (P=0.0515). SALC required longer operative times than CLC without significant benefits in patient overall satisfaction, postoperative pain, and hospital stay. Only satisfaction with the cosmetic result showed a significantly higher preference towards SALC.

Single incision laparoscopic cholecystectomy: for what benefit?

BackgroundA single‐incision laparoscopic cholecystectomy (SILC) was developed to improve outcomes as compared with the four‐port classic laparoscopic cholecystectomy (CLC). Any potential benefits associated with a SILC have been suggested by previous studies reporting few patients with different surgical techniques. The aim of this study was to describe the experience with a standardized SILC as compared with CLC. MethodsFrom June 2010 to January 2012, 40 patients underwent a SILC [median age: 47.5 years (25–92)] and operative and peri‐operative data were prospectively collected. Over the same period, 37 patients underwent a CLC. A 10‐point visual analogue scale (VAS) was used for qualitative data. The costs of SILC and CLC were also compared. ResultsFor those patients undergoing a SILC the median operating time was 70 min (24–110). There were no conversions. An additional trocar was necessary in 16 patients. Four patients developed post‐operative complications. The median immediate post‐operative pain score was 5 (0–10). The median quality of life and cosmetic satisfaction at the initial post‐operative visit were 10 (6–10) and 10 (5–10), respectively (VAS). Although the surgical results of both groups were similar, post‐operative complications were exclusively reported in the SILC group (two incisional hernias). ConclusionStandardization of SILC is possible but associated with an important rate of additional trocar placement and a disturbing rate of incisional hernias.

The outcomes of SILS cholecystectomy in comparison with classic four-trocar laparoscopic cholecystectomy.

IntroductionGeneral approval of laparoscopy as well as persistent urge to minimize operative trauma with still existing difficulties in putting natural orifice transluminal endoscopic surgery (NOTES) into practice have contributed to the introduction of laparoscopic operations through one incision in the umbilicus named single incision laparoscopic surgery (SILS).AimThe main aim of this study was to assess the benefits to patients of applying SILS cholecystectomy as a method of gallbladder removal based on the comparison with classic four-port laparoscopic cholecystectomy.Material and methodsBetween 18.03.2009 and 09.12.2009, 100 patients were included in the study and they underwent elective gallbladder removal by applying the laparoscopic technique. All patients were divided into two equal groups: qualified for SILS cholecystectomy (group I) and qualified for classic four-trocar laparoscopic cholecystectomy (group II), whose ASA physical status was I and II. BMI was limited to 35 kg/m2. Outcome measures included operative time, intensity of postoperative pain and consumption of painkillers, hospital stay, need for conversion, complications, and cosmetic effects.ResultsMean operating time in group I was 66 min and in group II 47.2 min. Intensity of pain evaluated by using the visual analogue scale (VAS) 6 h after the operation in group I was 3.49 and in group II 4.53, whereas 24 h after the operation in group I it was 1.18 and in group II 1.55. The painkiller requirement in group I was smaller than in group II. Mean hospital stay after the operation in group I was 1.33 days and in group II 1.96 days. There were 4 conversions in group I and one conversion in group II. Among the complications in group I there were noted 2 cases of right pneumothorax, 1 case of choleperitonitis and 4 complications connected with wound healing. There was one injury of the duodenum and one wound infection in group II.ConclusionsSingle-incision laparoscopic surgery cholecystectomy can be an alternative to classic laparoscopic cholecystectomy, especially with reference to young people with body mass index less than 35 kg/m2, without serious systemic diseases, operated on electively due to benign gallbladder diseases.

Less pain after transvaginal/transumbilical cholecystectomy than after the classical laparoscopic technique: short-term results of a matched-cohort study

Natural orifice surgery (NOS) is gaining acceptance as an alternative to the traditional laparoscopic technique, especially for cholecystectomy through the transvaginal route. However, NOS remains controversial concerning expected advantages in terms of short- and long-term outcomes and potential side effects. This study was designed to compare short-term outcomes between transvaginal/transumbilical and classical laparoscopic cholecystectomy (LC). A prospective matched-cohort study compared the authors' first 50 transvaginal/transumbilical cholecystectomies (TVC) with a group of 50 classical LCs from the corresponding period matched in terms of age, body mass index, and American Society of Anesthesiology classification. In both groups, elective surgery was performed for symptomatic cholecystolithiasis. In the NOS group, a hybrid procedure was performed with one transumbilical rigid instrument and two transvaginal rigid instruments. A numeric rating scale was used for daily pain assessment, initiated postoperatively in the recovery room. Both groups were compared with regard to length of surgery, intra- and postoperative complications, length of hospital stay, postoperative pain, and consumption of analgesics. The length of surgery and the rate of complications were similar in the two groups. But significant advantages were found for the transvaginal access in terms of pain using Numeric Rating Scale (NRS) on the day of surgery (NRS, 1.5/10 vs 3.1/10; p = 0.003) as well as in the morning (NRS, 1.9/10 vs 2.8/10; p = 0.047) and in the evening (NRS, 1.1/10 vs 1.8/10; p = 0.025) of postoperative day 1, and with regard to the length of the postoperative hospital stay (2.7 vs 3.4 days; p = 0.035). The findings show that TVC is a safe procedure for female patients. It has a risk comparable with that of classic LC, causes significantly less pain in the early postoperative period, and leads to a significantly shorter hospital stay. Prospective randomized trials are necessary to confirm these results.

Laparoendoscopic Single Site (LESS) Versus Classic Video-Laparoscopic Cholecystectomy: A Randomized Prospective Study

Laparoscopic cholecystectomy (LC) is the gold-standard for the treatment of gallbladder stone disease. In recent years laparoendoscopic single site surgery (LESS) has gained greater interest and diffusion for the treatment of gallstones and also in bariatric and colonic surgery. However, no randomized controlled trials are present in the literature that confirm the clinical advantages of LESS compared with the classic laparoscopic procedures. For this reason, we present the preliminary results of this randomized prospective study regarding the feasibility and safety of LESS cholecystectomy versus classic laparoscopic technique. Between October 2009 and April 2010, 50 patients were randomly assigned to three-port classic laparoscopic cholecystectomy (n = 25) or LESS procedure (n = 25). Exclusion criteria were: (1) previous abdominal surgery, (2) signs of acute cholecystitis, choledocholithiasis, or acute pancreatitis, (3) ASA grade III or more, (4) lack of written informed consent, and (5) BMI ≥ 30 Kg/m(2).All the patients' details were recorded: age, weight, height, body mass index, operative time, length of hospital stay, patients' pain and wound satisfaction score. Abdominal pain was registered at 6, 12, and 24 h postoperatively. Wound satisfaction score (very unsatisfied = 1, unsatisfied = 2, acceptable = 3, satisfied = 4, very satisfied = 5) was registered for each patient at the seventh postoperative day. No differences were registered between the two groups about gender, age, weight, height, and BMI. Also postoperative hospital stay was similar (P = 0.71). In three patients (1 in group A and 2 in group B) a 5-mm trocar was added. Intraoperative cholangiography was performed in five patients (2 in group A and 3 in group B). Mean operative time was significantly longer in LESS procedures (41.3 ± 12.0 versus 35.6 ± 5.8; P = 0.04). Abdominal postoperative pain was similar in LC and LESS cholecystectomy. Wound satisfaction score showed statistically significant differences between the two groups: in LESS group, patients were more satisfied with the presence of a small umbilical medication (P < 0.05). In this randomized prospective study, we conclude that LESS cholecystectomy is an excellent alternative to traditional three-port cholecystectomy for patients with uncomplicated disease, and no previous abdominal surgery. Although no differences are present about hospital stay and postoperative pain compared with classic laparoscopic cholecystectomy, in our experience LESS has had a significant impact on patients' wound satisfaction.

Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial

The attempt to further reduce operative trauma in laparoscopic cholecystectomy has led to new techniques such as natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS). These new techniques are considered to be painless procedures, but no published studies investigate the possibility of different pain scores in these new techniques versus classic laparoscopic cholecystectomy. In this randomized control study, we investigated pain scores in SILS cholecystectomy versus classic laparoscopic cholecystectomy. Forty patients (34 women and 6 men) were randomly assigned to two groups. In group A (n = 20) four-port classic laparoscopic cholecystectomy was performed. Patients in group B (n = 20) underwent SILS cholecystectomy. In all patients, preincisional local infiltration of ropivacaine around the trocar wounds was performed. Infusion of ropivacaine solution in the right subdiaphragmatic area at the beginning of the procedure plus normal saline infusion in the same area at the end of the procedure was performed in all patients as well. Shoulder tip and abdominal pain were registered at 2, 6, 12, 24, 48, and 72 h postoperatively using visual analog scale (VAS). Significantly lower pain scores were observed in the SILS group versus the classic laparoscopic cholecystectomy group after the first 12 h for abdominal pain, and after the first 6 h for shoulder pain. Total pain after the first 24 h was nonexistent in the SILS group. Also, requests for analgesics were significantly less in the SILS group, while no difference was observed in incidence of nausea and vomiting between the two groups. SILS cholecystectomy, as well as the invisible scar, has significantly lower abdominal and shoulder pain scores, especially after the first 24 h postoperatively, when this pain is nonexistent. (Registration Clinical Trial number: NTC00872287, www.clinicaltrials.gov ).

Laparascopic Cholecystectomy and Open-Heart Surgery at the Same Time

Abdominal procedures in patients with coronary artery disease or severe valvular disease have high risk of mortality and morbidity. In order to prevent bile peritonitis after cardiac surgery, to reduce the hospitalization course, and to decrease the mortality and morbidity after the surgery, laparoscopic cholecystectomy and open-heart surgery were performed at the same time. Laparoscopic cholecystectomy and open-heart surgery were performed on two patients who had been referred to Cardiothoracic Ward of Modarres Hospital, Tehran, Iran. Simultaneous classic laparoscopic cholecystectomy was successfully performed on two different open-heart patients, one with coronary artery disease for coronary artery bypass surgery and the other with severe mitral valve disorder for mitral valve replacement. Abdominal procedures are suggested to be done with cardiac surgery at the same time with laparoscopic technique to reduce mortality and morbidity in these patients.