Conventional Four-port Laparoscopic Cholecystectomy Research Articles

Three-Port Laparoscopic Cholecystectomy as a Safe and Feasible Alternative to the Conventional Four-Port Laparoscopic Cholecystectomy.

Aims A prospective observational study was performed to assess the feasibility and safety of three-port laparoscopic cholecystectomy. Parameters comprising age, sex, number of cases in which intra-operative difficulty were encountered, and outcomes such as number of cases that required conversion to four-port laparoscopic cholecystectomy, postoperative pain on the visual analog scale (VAS), and postoperative hospital stay were assessed. We also documented difficult cases that were operated successfully with three ports, and the number of cases that needed conversion to four ports along with the reason for the conversion. Material and methods The patients were operated upon in the supine position in all cases. A pre-emptive analgesia with 1% lignocaine was administered in all cases prior to making the incision. The first port was 10-mm supraumbilical and inserted by the open technique. After insertion of the umbilical port, pneumoperitoneum was created by maintaining a maximum pressure of 12 mmHg and a flow rate of 8 L/minute. A camera head with a 30° telescope was introduced in the peritoneal cavity, and diagnostic laparoscopy was performed. A 10-mm subxiphoid port and a 5-mm subcostal port were placed under vision, with the latter placed more lateral and inferior to the conventional port position for better triangulation and ergonomics. The outcomes measured were operative time, the number of cases requiring a fourth port, postoperative pain (VAS), and postoperative hospital stay (number of days patients stayed in the hospital post-surgery until discharge). Data were collected using MS Excel, and an analysis was performed using SPSS Version 21.0. Results Data of 102 patients were analyzed prospectively. The mean age of the patients was 50.98 years, with an SD of 16.88, and the gender ratio was 73:29 (female: male). The mean operative time was 52.68 ± 20.84 minutes, with an SD of 20.84. Difficulty was encountered in 18.6% of cases in the form of pericholecystic adhesions, aberrant Calot's anatomy, empyema or mucocele of the gallbladder, or bleeding from the liver bed or cystic artery stump. Postoperative pain was less in our study due to the reduced number of ports and the use of a pre-emptive analgesia, with a mean VAS score of 1.22 and an SD of 0.56. The mean postoperative hospital stay was 1.08 days, with an SD of 0.31. We needed to convert to a four-port procedure for safety in 2.9% cases. The operative time and postoperative hospital stay in our study were similar to those of other studies, but our average pain score was less due to the use of the pre-emptive analgesia. Only three cases required conversion to four ports, and 99 cases were successfully managed with three ports without compromising safety. No bile duct injury occurred in any of our 102 cases. Conclusion From this study, we conclude that three-port cholecystectomy is feasible, and it can be performed even in difficult cases without compromising safety. The surgical time is similar to that of four-port cholecystectomy, and the postoperative stay is shorter. The decreased number of ports and the pre-emptive analgesia reduced postoperative pain, cosmesis was better, and the incidence of bile duct injury did not increase. The procedure can also be converted to four-port cholecystectomy at any time if safety is compromised. Therefore, three-port cholecystectomy is a viable and safe option in the treatment of gallstone disease.

Cost-effective scarless cholecystectomy using a modified endoscopic minimally invasive reduced appliance technique (Emirate).

The current gold-standard surgical treatment for symptomatic gallstone disease is the conventional four-port laparoscopic cholecystectomy (CLC). In recent years, however, celebrities and social media have altered people's attitudes regarding surgery. Consequently, CLC has undergone several changes to reduce scarring and improve patient satisfaction. In this case-matched control study, the cost-effectiveness of a modified endoscopic minimally invasive reduced appliance technique (Emirate) that uses less equipment and three 5 mm reusable ports only at precisely specified anatomical sites was compared to CLC. Single-center retrospective matched cohort analysis including 140 consecutive patients treated with Emirate laparoscopic cholecystectomy ("ELC-group"), matched 1:1 by sex, indications for surgery, surgeon expertise, and preop bile duct imaging, with 140 patients receiving CLC in the same period of time ("CLC group"). We performed a retrospective case-matched review of 140 patients who had Emirate laparoscopic cholecystectomy for gallstones between January 2019 and December 2022. The groups included 108 females and 32 males with an equal ratio of surgical expertise-115 procedures were performed by consultants and 25 by trainees. In each group, 18 patients had preoperative MRCP or ERCP and 20 had acute cholecystitis as indications for surgery. Preoperative characteristics such as age (39 years in the Emirates group and 38.6 years in the CLC group), BMI (29.3 years in the Emirates group and 30 years in the CLC group), stone size, or liver enzymes showed no statistical difference between the two groups. In both groups, the average hospital stay was 1.5 days, and there was no conversion to open surgery, nor was there any bleeding requiring blood transfusion, bile leakage, stone slippage, bile duct injury, or invasive intervention postoperatively. When compared to the CLC group, the ELC group had significantly faster surgery times (t-test, p = 0.001), lower levels of the bile duct enzyme ALP (p = 0.003), and much lower costs (t-test, p = 0.0001). The Emirate laparoscopic cholecystectomy method is a safe alternative to the traditional four-port laparoscopic cholecystectomy that is also much faster and less expensive.

Three-port Versus Four-port Laparoscopic Cholecystectomy- An Interventional Prospective Study in Public Sector Hospitals

Introduction: Cholelithiasis is a common ailment and affects about 10% of general population. Currently, the vast majority of operations for cholelithiasis are performed using laparoscopic techniques. Aim: To compare the three-port laparoscopic cholecystectomy with conventional four-port laparoscopic cholecystectomy. Materials and Methods: A prospective interventional study was conducted on 180 cases admitted to the hospitals attached to BMCRI, Bengaluru, from November 2018 to November 2020. The clinical profile of each patient was noted. The cases were confirmed by ultrasonography and they were randomised into two groups. One group underwent three-port laparoscopic cholecystectomy and the other group underwent four-port laparoscopic cholecystectomy. Intraoperative complications, conversion rates, postoperative pain, postoperative complications and duration of stay in the hospital were compared. Statistical data was analysed using Statistical Package for Social Sciences (SPSS) version 20.0 and data was compared using Chi-square test. Results: Most of the participants were from 31-40 years (45.6%, 44.4%) in both the groups, more common in females. The mean duration of surgery in three-port and four-port group was 30.43±15.964 and 36.81±15.592 minutes, respectively. Out of 90 (100%), 56 (62.2%) in three-port group had Visual Analogue Scale (VAS) score 2 and 66 (73.3%) in four-port group had VAS score 3 (χ2=71.34; p=0.001). Conversion rates to open cholecystectomy were almost similar in both the groups. Hospital stay was also similar in both groups. Conclusion: A three-port laparoscopic cholecystectomy had lesser operating time and lesser analgesics requirement with similar intra and postoperative complication when compared to four-port laparoscopic cholecystectomy.

Three-port versus conventional four-port laparoscopic cholecystectomy: a comparative study

Objectives This prospective comparative study aims at evaluating the feasibility of three-port technique without affecting safety and at comparing the outcome of three-port and four-port techniques. Patients and methods This study included 94 patients with symptomatic gallstone disease and gallbladder polyp in Surgical Department, Minia University Hospital, from beginning of 2018 to beginning of 2019. Patients who were unwilling to be a part of the study, jaundiced patients with radiologically evidence of common bile duct stones, patients unfit for general anesthesia, patients with liver cirrhosis, patients with portal hypertension, patients with coagulopathy, patients with acute pancreatitis, patients with generalized peritonitis, or patients with malignancy were excluded. All patients were operated by the same operating team. Patients were randomized for three-port laparoscopic cholecystectomy (LC) group (45 patients) or four-port LC group (49 patients). Numeric Pain Rating Scale, operative time, operative difficulty, intraoperative and postoperative complications, duration required to stop oral analgesics, and duration required to return to normal activity were recorded. Results Numeric Pain Rating Scale, required number of diclofenac ampoules, duration required for oral analgesia, and duration required to return to normal activity were significantly less in three-port group. Other parameters were comparable between the two groups. Conclusion It seems that three-port LC is a safe and feasible technique with superior clinical outcomes to four-port LC.

Evolution of Laparoscopic Cholecystectomy: From Multiport to Single Port

Context: Laparoscopic approach with its several techniques has become the standard method for cholecystectomy over the past decades. As technical instruments have improved and varied, the interest in endoscopic surgery has turned towards minimal invasive single site access surgery with fewer instruments, thus resulting in minimal pain, minimal scarring and better cosmesis. Evidence Acquisition: A systematic literature searching of databases MEDLINE, EMBASE, and Google Scholar was done from 1982 and updated in December 2015. Search terms were “cholecystectomy”, “laparoscopic cholecystectomy”, “four port laparoscopic cholecystectomy”, “single-incision laparoscopic surgery”. Results: Four-port laparoscopic cholecystectomy was accepted as the “gold standard” in the treatment of patients with cholelithiasis before millennium. Thereafter, two-port laparoscopic cholecystectomy was reported as a novel, safe and rapid method of gallbladder removal in consecutive reports. Single-site laparoscopic cholecystectomy with non-conventional multi-channel port method was first introduced as an alternative to the standard multi-port laparoscopic cholecystectomy in adult patients in the last decade. Success rates of performing conventional four-port laparoscopic cholecystectomy were ranging from 93% to 100% and single site laparoscopic cholecystectomy was ranging from 84% to 100%. Conclusions: Currently, it has been widely accepted that laparoscopic cholecystectomy is the gold standard for cholecystectomy. Although single site laparoscopic cholecystectomy is becoming more popular with the recent advancements, conventional multiport laparoscopic cholecystectomy is being widely used as the primary treatment modality for the gallbladder removal.

Prospective randomized comparison of single-incision laparoscopic cholecystectomy with new facilitating maneuver vs. conventional four-port laparoscopic cholecystectomy.

We aimed to investigate the technical feasibility of single-incision laparoscopic cholecystectomy (SILC) with our new facilitative maneuver and to compare it with the gold standard four-port laparoscopic cholecystectomy (LC). Operation time, cosmetic score and incisional hernia rates between LC (n=20) and SILC-1 (first 20 consecutive operations with the new technique) and 2 (subsequent 20 operations with the new technique) were compared. The median operation time for LC, SILC-1 and SILC-2 were; 35 min (12-75), 47.5 min (30-70), and 30 min (12-80), respectively (p=0.005). The operation duration was similar in LC and SILC-2 (p=0.277) groups. Wound seroma rate was higher in SILC-1 (45%) and SILC-2 (30%) groups than LC (5%) group (p=0.010). Cosmetic score was similar between all the groups. Hernia rates were 15.8% and 5.3% in the SILC-1 and SILC-2 groups, respectively, while there was no hernia in the LC group. SILC with new facilitating maneuver is comparable with classical four-port laparoscopic cholecystectomy in terms of ease, operation time, reproducibility and safety. Besides these advantages, the single-incision access technique must be optimized to provide comparable wound complication and postoperative hernia rates before being recommended to patients.

Single-incision laparoscopic cholecystectomy using reusable conventional instruments

Introduction Laparoscopic cholecystectomy is considered the gold standard for the treatment of symptomatic cholelithiasis. Single-incision laparoscopic surgery refers to the operative technique in which a surgical procedure is carried out through one incision. Patients and methods Prospectively randomly selected 30 patients with chronic calcular cholecystitis or gall bladder polyps for whom single-incision laparoscopic cholecystectomy (SILC) was performed between January 2011 and July 2013 were recruited to evaluate the feasibility of the procedure using conventional reusable cannulas and straight instruments with no more cost than that used in conventional four-port laparoscopic cholecystectomy. The Marionette technique at the three-point suspension of the gall bladder was used. Results The operative time ranged from 35 to 110 min, with a mean of 53.3 min. No patient required conversion to open surgery. One patient only required the addition of one more port. Two patients required the placement of a drain. In terms of postoperative complications, no patient developed bile leakage, postoperative bleeding, postoperative jaundice, or incisional hernias. Conclusion SILC was a technically more challenging but safe procedure compared with conventional laparoscopic cholecystectomy because of the close proximity of the working instruments with limited triangulation; limited range of motion of the laparoscope and instruments, and decreased number of ports all contributed toward increased difficulty. The Marionette technique in three points was a very important step in the procedure. The operating time is long initially, but it reduces as surgeons become more experienced.

Development of a novel controllable, multidirectional, reusable metallic port with a wide working space

Background: Endoscopic surgery is currently a standard procedure in many countries. Furthermore, conventional four-port laparoscopic cholecystectomy is developing into a single-port procedure. However, in many developing countries, disposable medical products are expensive and adequate medical waste disposable facilities are absent. Advanced medical treatments such as laparoscopic or single-port surgeries are not readily available in many areas of developing countries, and there are often no other sterilization methods besides autoclaving. Moreover, existing reusable metallic ports are impractical and are thus not widely used. Material and methods: We developed a novel controllable, multidirectional single-port device that can be autoclaved, and with a wide working space, which was employed in five patients. Results: In all patients, laparoscopic cholecystectomy was accomplished without complications. Conclusion: Our device facilitates single-port surgery in areas of the world with limited sterilization methods and offers a novel alternative to conventional tools for creating a smaller incision, decrease postoperative pain, and improve cosmesis. This novel device can also lower the cost of medical treatment and offers a promising tool for major surgeries requiring a wide working space.

Interim report: A randomized controlled trial comparing postoperative pain in single‐incision laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy

Single-incision laparoscopic cholecystectomy (SILC) is increasingly practiced, but there have been no well-powered randomized trials investigating the technique. This non-inferiority trial aims to compare SILC with conventional four-port laparoscopic cholecystectomy (LC) with postoperative pain as the primary endpoint. We aim to randomize 100 patients into equal arms of SILC or LC. Exclusion criteria were: (i) acute cholecystitis; (ii) an ASA score of 3 or above; (iii) bleeding disorders; or (iv) previous upper abdominal surgery. Patients and postoperative assessors were blinded to the procedure received. The site and severity of pain was compared based on the visual analogue scale at 4 hours, 24 hours and 14 days postoperatively; non-inferiority was assumed when the lower boundary of the 95% confidence interval of the difference was above -1, and superiority when P ≤ 0.05. We recruited 24 SILC and 26 LC patients. There were no conversions to open cholecystectomy or from SILC to LC. SILC was non-inferior for pain at umbilical sites at rest and at extra-umbilical sites at all times. At 24 hours postoperatively, SILC was associated with significantly less pain at extra-umbilical sites (rest: P = 0.002; movement: P = 0.004). There were no incidents of biliary injury or retained gallstones. Of the 24 SILC patients, 12.5% had postoperative complications (vomiting, mild fluid overload, wound infection) compared with 0% of LC patients (P = 0.110); all complications resolved with conservative management. Operating time, analgesic use, return to function, and overall satisfaction did not differ significantly between the two groups. SILC is associated with reduced pain and is feasible in routine surgical practice.

Single-incision laparoscopic cholecystectomy with routine intraoperative cholangiography and common bile duct exploration via the umbilical port

Laparoscopic cholecystectomy currently is the gold standard technique for gallbladder removal. The use of routine intraoperative cholangiography (IOC) is widely practiced during conventional four-port laparoscopic cholecystectomy (4PLC) to confirm biliary anatomy and allow for immediate management of unexpected choledocholithiasis. Single-incision laparoscopic surgery (SILS) offers a more aesthetic technique for gallbladder removal and has been reported by several groups. However, no series to date have included routine IOC without a separate incision. This study aimed to demonstrate the feasibility of the SILS technique for cholecystectomy with routine IOC (LCIOC) and common bile duct (CBD) exploration as needed via the umbilical port. A database was prospectively completed for a series of 60 consecutive patients undergoing single-incision LCIOC via the umbilical port. Details of the patients, operations, indications, outcomes, and follow-up evaluation were included. Of the 60 patients included in the database, 55 (91.7%) successfully underwent single-incision laparoscopic cholecystectomy (SILC), whereas the remaining five patients required conversion to 4PLC. No patient required conversion to open cholecystectomy (OC). Of the 55 successful SILC patients, 53 (88.3%) successfully received IOCs, 48 of which were normal. The remaining five IOCs demonstrated choledocholithiasis, four of which could be managed laparoscopically without the need for conversion to either 4PLC or OC. One patient required postoperative endoscopic retrograde cholangiopancreatography (ERCP). Complications included four wound infections (7.8%), one incisional hernia (2.0%), and one bile leak (3.2%). The operating time ranged from 35 to 180 min and decreased with experience. This study represents the largest series to date of single-incision laparoscopic cholecystectomies with routine IOC via the umbilical port and is the first study to demonstrate that the laparoscopic management of choledocholithiasis during SILC is feasible.

Prospective randomized comparative study of single incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy

Background This study aimed to compare the outcomes of single-incision laparoscopic cholecystectomy (SILC) versus conventional 4-port laparoscopic cholecystectomy (LC). Methods From November 2009 to August 2010, 51 patients with symptomatic gallstone or gallbladder polyps were randomized to SILC (n = 24) or 4-port LC (n = 27). Results Mean surgical time (43.5 vs 46.5 min), median blood loss (1 vs 1 mL) and mean hospital stay (1.5 vs 1.8 d) were similar for both the SILC and 4-port LC group. There were no open conversions and no major complications. The mean total wound length of the SILC group was significantly shorter (1.76 vs 2.25 cm). The median visual analogue pain score at 6 hours after surgery was similar (4.5 vs 4.0) but the SILC group had a significantly worse pain score on day 7 (1 vs 0). There was no difference in time to resume usual activity (mean, 5.6 vs 5.0 d). The median cosmetic score of SILC was significantly higher than at 3 months after surgery (7 vs 6). Conclusions SILC was feasible and safe for properly selected patients in experienced hands.

Is Fourth Port Really Required in Laparoscopic Cholecystectomy?

Since the advent of four-port laparoscopic cholecystectomy, many modifications regarding port number and size have been tried. The feasibility of three-port technique has been found comparable to the conventional four-port laparoscopic cholecystectomy. To assess the feasibility and safety of three-port laparoscopic cholecystectomy in a prospective study. Between March 2007 and March 2009, fifty patients with cholelithiasis aged between 15 and 56years underwent three-port cholecystectomy in a prospective study in Government medical college, Srinagar. A single surgeon did all the cases and there was no criterion for the patient selection. These were consecutive fifty surgeries done by the surgeon. The outcome was assessed in terms of intra-operative and post-operative parameters. The mean (range) age was 45 (15-56) years and there were thirty-nine females and eleven males in the study. All the procedures were completed successfully without any conversions to open or any major complications; though three patients needed the addition of a fourth port as in conventional laparoscopic cholecystectomy. The mean (range) operative time was 55 (30-90) min and the average blood loss was 30ml. The mean (range) hospital stay was 1 (1-3) days. All patients returned to routine work within 1week of surgery. The mean follow-up was 5 (2-7) months. We conclude, from the results above, that three-port laparoscopic cholecystectomy is safe and feasible. There are only two visible surgical scars, better cosmetic appearance with no increased risk of bile duct injury. It reduces the manpower in the form of a second assistant. Thus, it can be recommended as a safe alternative procedure to conventional four-port laparoscopic cholecystectomy.

Single-port endoscopic cholecystectomy: a bridge between laparoscopic and translumenal endoscopic surgery

The intentional puncture of the normal viscera is likely the most important issue limiting the widespread use of natural orifice translumenal endoscopic surgery (NOTES). We developed a new procedure for cholecystectomy using a flexible endoscope via a single port placed in the abdominal wall without visceral puncture (single-port endoscopic cholecystectomy; SPEC) as a bridge between laparoscopic surgery and NOTES. This study aimed to evaluate the technical feasibility of SPEC. Five pigs were subjected to SPEC. An endoscope was inserted through a 12-mm port placed in the right upper abdomen. After grasping and retracting the gallbladder using a 2-mm retractor that was directly introduced into the peritoneal cavity, gallbladder excision with ligation of the cystic artery and duct using endoclips was carried out. A complete gallbladder excision was carried out easily and safely in all cases. No major adverse events occurred. The mean operating time was 67 min (range 52-84 min). SPEC is a technically feasible procedure. It is simpler, easier, and safer than NOTES cholecystectomy. SPEC could be a less invasive alternative to the conventional four-port laparoscopic cholecystectomy.