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.

Comparison of three-port versus four-port laparoscopic cholecystectomy

Background: In the era of laparoscopic surgery, early recovery and less post-operative pain are major goals to improve patient care and cut down cost. Several studies have demonstrated less post-operative pain and early recovery with the reduction in size and number of ports. Aims and Objectives: To compare three-port laparoscopic cholecystectomy (LC) with four-port LC in chronic calculous cholecystitis patients. We compared the feasibility of the procedure, total operative time, intraoperative difficulties, post-operative pain, incidence of complications, and cosmetic results. Materials and Methods: The study was done in Maharani Laxmi Bal Medical College, Jhansi, between April 2021 and November 2022, including 2 groups of patients (Group A-50 patients of three-port LC and Group B-50 patients of four-port LC). Results: Most of the participants were from 18 to 30 years (32%, 38%) and 31 to 40 years (30%, 12%) in both the groups. The mean duration of surgery in three-port and four-port group was 41.64±6.972 and 42.22±13.784 min, respectively (p=0.79). Hospital stay was three-port and four-port group was 3.33±0.789 and 3.86±0.707 days, respectively (p=0.0001). 100 patients were included, with 2085 patients. The mean age of the studied patients was 46.38 years with female preponderance. The mean operative time for three ports was 66.90 min and for four ports, it was 75.45 min. The mean duration of post-operative stay for three-port was 4.66, and for the conventional group, it was 5.30. Conclusion: Three-port lap cholecystectomy can be advocated to be better than the 4-port technique, but especially in experienced hands, and 4-port LC is better for beginners.

Is the application of subcostal transversus abdominis plane block effective for pain control in classical four-port laparoscopic cholecystectomy?

The utilization of transversus abdominis plane (TAP) block for postoperative pain management has proven to be efficacious. The purpose of this inquiry is to evaluate the effectiveness of right-sided TAP blockade guided by ultrasonography (USG) in managing pain subsequent to laparoscopic cholecystectomy. A total of 60 patients were equallydistributed into two groups. The control group was comprised of patients who did not receive a TAP block, whereas the TAP block group consisted of patients who underwent an ultrasound-guided, right-sided unilateral subcostal TAP block with 20 mL of 0.25% bupivacaine. A Verbal Numerical Rating Scale was administered to all participants for pain assessment at postoperative intervals of 0th, 6th, 12th and 24th hours. Additionally, the overall amount of supplementary analgesic used after surgery, age distribution among each gender classification and body mass index range categories as well as operation time duration; use or non-use of drain; and incidence rate for postoperative complications were recorded for each patient individually. The mean age of participants was 47.72 ± 13.80 years, with a female-to-male ratio of 41/19. The control group exhibited significantly higher pain scale measurements than the block group at the postoperative 0th and the postoperative 24th hour. Drain replacement yielded notably higher pain scores for both TAP and control groups at the postoperative 0th hour. Neither BMI nor operation duration had significant effects on postsurgical pain in either patient group—whether or not they received a TAP block treatment. Our research shows that the implementation of a TAP block and exclusion of surgical area drainage placement yield favorable results in mitigating postoperative pain. Notably, BMI and procedure duration do not exhibit any discernible impact on postoperative pain management.

Topical antibiotics in the prevention of port-site infection after elective day care laparoscopic cholecystectomy.

Wound-related infections and complications are rare after day care laparoscopic cholecystectomy (LC). They can have a significant adverse impact on the postoperative course after an uneventful elective LC. The use of topical antibiotics over the port site may prevent such complications. This trial was conducted from January 2018 to June 2019. Two hundred and fifty patients who met the inclusion and exclusion criteria were included in the study. They were randomized into the topical antibiotic group (Group A, n = 125) and control group (Group B, n = 125). All patients underwent four-port LC. Mupirocin 2% topical antibiotic ointment was applied to all four-port sites in Group A, whereas no topical antibiotic was used in Group B. One dose of prophylactic systemic antibiotics was given to all patients in both groups. The mean age was 43.22 ± 12.7 years in Group A and 43.44 ± 12.5 years in Group B. The comorbidities and the other variables were comparable between the two groups. The port-site infection (PSI) was observed in one patient in Group A and three patients in Group B, which was statistically nonsignificant (P = 0.622). The mean time of detection of infection was 4.75 ± 1.7 days. All the infections were superficial surgical site infections. Microbiological swabs culture of the infected wounds yielded no growth of bacteria. The PSI after LC is very less. The use of topical antibiotics to prevent PSIs after LC could not be established.

Modified optical port entry site for laparoscopic cholecystectomy: Our experience.

<b><br>Introduction:</b> The four-port laparoscopic cholecystectomy is a recognized entity in the surgical management of gallstone disease. We report our experience and feasibility of optical port entry site modification.</br> <b><br>Material and Methods:</b> To assess the feasibility and safety of laparoscopic cholecystectomy with a different port placement, we undertook a prospective study with 60 patients at Seth GSMC and KEM Hospital, India between Jan 2022 and July 2022. Our study offered the benefit of a flexible optical port entry site, using a 5 mm optical trocar instead of the conventional 10 mm trocar. A single surgeon did all the cases and definite criteria of simple cases of gallstone disease patterned on clinical and radiological grounds.</br> <b><br>Results:</b> 60 cases of gallstone disease were subjected to the new technique of laparoscopic cholecystectomy over seven months. 39 cases were females and 21 were males. The age range of our patients was between 20 and 55 years with a median age of 39 years. Mean Body mass index 30 (range 25 - 37). The mean operative time was 30 min (range 15 - 45 min) and a follow-up period ranged from 10 to 14 months. No cases were converted to open. We did not encounter any untoward mishaps during surgery.</br> <b><br>Discussion:</b> Our modification of the optical port placement and size received good results and patient satisfaction. Moreover, the placement of the port at a site further from the midline and umbilicus decreases the risk of development of trocar site incisional hernia.</br&gt.

Comparison between single incision laparoscopic cholecystectomy using conventional laparoscopic instruments vs. four port laparoscopic cholecystectomy in patients of symptomatic cholelithiasis: a prospective randomised study

Background: The desire to reduce invasiveness, pain, discomfort and improve cosmesis and early return of patient to normal activities is the basis for single incision laparoscopic surgery. The primary aim was to compare post-operative pain and the secondary aim to compare duration of surgery, intraoperative bile spill or stone spill, duration of hospital stay, any postoperative complications and cosmetic outcome between SILC and the gold standard for symptomatic gall stone disease, FPLC (Four port laparoscopic cholecystectomy). Methods: A total of 150 patients were randomized into two groups, A (SILC) and B (FPLC). Post-operative pain and other intra-operative and post -operative parameters were compared. Results: The age ranged between 20 years to 76 years most of them being females with body mass index ranging between 19 and 35 kg/m2. Comparison of pain score was done using MEWS scale; which was found to be statistically significantly SILC at 6 hours, mean difference (MD)-0.833 while at 24 hours the difference was not significant (MD- 0.234). Duration of surgery was significantly more (MD-12.17 minutes) in SILC. No addition of port or conversion to open cholecystectomy was required. There were no significant difference between post-operative complications between the two groups. Cosmesis was significantly better in terms of look of the scar (MD-0.867) and recommending it to their relatives (MD-0.700) in SILC group. Conclusions: SILC is a safe and easily learnable procedure which can be safely be done using conventional laparoscopic instruments in low risk patients. Duration of surgery even after expertise is gained remains to be more than FPLC.

Safe and Aesthetic; Laparoscopic Cholecystectomy on The Bikini Line

Objective: Laparoscopic cholecystectomy (LC) is the gold standard treatment for symptomatic cholelithiasis and is the most commonly performed surgical procedure worldwide. It is superior to open cholecystectomy in terms of aesthetics, but the visibility of the trocar ports is a cosmetic problem due to increasing aesthetic concerns. We report the results of patients who underwent conventional four port LK with all incisions below the bikini line.
 Material and Method: The study included patients who underwent LK through bikini incision in our clinic between 01.11.2020 and 31.11.2021. Age, gender, comorbidities, indications for cholecystectomy, previous abdominal surgeries, anesthesia scores, and body mass index (BMI) were recorded. The procedure was not performed in patients undergoing emergency surgery for acute cholecystitis and other causes.
 Results: The study included 9 patients, all of whom were female. The mean age was 30 ± 7.8 years and mean BMI was 23.1 ± 4.3. Mean operative time was 33.9 ± 8.5 minutes. Open operation was not performed in any patient. The hospitalization period was one day for all patients. There were no complications in any of the patients. Eight of the nine patients (89%) expressed cosmetic satisfaction in the first month after surgery.
 Conclusion: The prevalence of LC leads to an increase in the number of patients expecting less scarring. Here, we propose a modified four-port laparoscopic cholecystectomy that is easy to perform, safe, requires no additional cost, and has high patient satisfaction

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

Three-port versus Four-port Laparoscopic Cholecystectomy

Comparative outcomes of single-incision laparoscopic, mini-laparoscopic, four-port laparoscopic, three-port laparoscopic, and single-incision robotic cholecystectomy: a systematic review and network meta-analysis.

Benign gallbladder diseases are common in surgery department, and the laparoscopic cholecystectomy (LC) is the gold standard procedure for benign diseases of gallbladder. Laparoscopic cholecystectomy is conventionally performed using four laparoscopic ports. However, the clinical application of different LCs is equivocal and there is no comprehensive comparison to explore which surgical options could benefit patients with benign gallbladder diseases. A network meta-analysis (NMA) to evaluate the efficacy of the different LCs could benefit patients with benign gallbladder diseases by comprehensive comparison. A systematic literature search was performed using PubMed, Embase, and Cochran Library. Totally, 17 randomized controlled trials (RCTs) (n = 1627) met study selection criteria and were incorporated in this NMA study. The first ranking probabilities of the five surgical options to alleviate postoperative pain scores were: 54.4% for single-incision robotic cholecystectomy (SIRC), 25.2% for single-incision laparoscopic cholecystectomy (SALC), and 24.9% for mini-laparoscopic cholecystectomy (Mini). The first ranking probabilities for reducing postoperative complications in the surgical options were: 61.3% for three-port laparoscopic cholecystectomy and 21.8% for four-port laparoscopic cholecystectomy. The first ranking probabilities for reducing hospital stay(days) in the surgical options were: 32.3% for SIRC, 29.0% for three-port laparoscopic cholecystectomy and 19.8% for four-port laparoscopic cholecystectomy. The first ranking probabilities for reducing operation time showed that the three-port technique had the shortest operation time, followed by three-port laparoscopic cholecystectomy (51.3%), four-port laparoscopic cholecystectomy (26.8%), and mini-laparoscopic cholecystectomy (21.6%). Our study found that the optimal surgical plan for different outcomes varies, making it difficult to give a comprehensive recommendation. Three-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy may be the best options in terms of reducing surgical complications and operative time. Meanwhile, SIRC is the best options for relieving postoperative pain relief. SIRC and three-port laparoscopic cholecystectomy can reduce hospital stay (days) compared other LCs.

Bikini Line Approach for Cosmetic Laparoscopic Cholecystectomy

Four-port laparoscopic cholecystectomy (LC) is a standard procedure. Several alternative approaches have been described to make trocar scars invisible. This study describes and was successfully administered as a pilot for feasibility and safety of a bikini line port for better aesthetic results. In patients with symptomatic cholelithiasis undergoing LC between June 2021 and December 2021, bikini line ports were used in 67 patients. With the patient in the supine position, the first trocar (11 mm) was inserted into the abdomen through the umbilicus. The other three trocars were placed in the lower abdomen at the bikini line with the help of the camera. Standard instruments were used to perform the surgery. The mean operative time was 54.66 SD 14.1 min. No intraoperative or postoperative adverse events took place. The median follow-up for this cohort was 24 weeks. Cosmetic results were satisfactory for all patients. The use of one umbilical camera port and the other three ports in the bikini line in the lower abdomen completely hides the scars from the ports’ incision. The technique was quickly adopted by regular laparoscopic surgeons with usual instruments, much to the satisfaction of patients.

Three-port laparoscopic cholecystectomy is safe and efficient in the treatment of surgical biliary disease: a retrospective cohort study.

Multiple studies have suggested that three-port laparoscopic cholecystectomy is both feasible and safe. However, this approach has failed to gain acceptance outside of clinical trials, leaving adopters of this approach vulnerable to medico-legal scrutiny. We hypothesized that the three-port approach to laparoscopic cholecystectomy (LC) is safe and efficient in experienced hands. All LC (including robotic) cases were performed on patients 18years and older between November 2018 and March 2020. Operations utilizing three ports were compared to those performed using more than three ports. The primary outcomes measured were total operative time, conversion-to-open rate, and the complication rate. A two-sample test was performed to compare operative times, and a Fisher's exact test was used to compare conversion-to-open and complication rates. Linear regression models were used to account for the effect of confounders. 924 total LCs were performed by 30 surgeons in the study period (71 three-port, 853 four or more ports). The mean operative time was 10min shorter in the three-port group in comparison (64.1 ± 1.4min vs. 74.4 ± 1.8min, p < 0.01), despite a threefold higher rate of intraoperative cholangiogram in these cases (23.0% vs. 7.9%, p < 0.001). There was no significant difference in either the conversion-to-open rate (1.6% vs. 5.1%, p = 0.35), or the overall complication rate (7.1% vs. 8.7%, p = 0.82). Operative time for LC performed through three ports was significantly less than those performed through the traditional four port approach, despite utilizing intraoperative cholangiogram nearly three times as often. There was no difference in the conversion-to open rate or complication rate. These results provide considerable evidence that three-port laparoscopic cholecystectomy is comparable to four-port laparoscopic cholecystectomy in operative duration, conversion-to-open rate, and complication rate.

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.

Feasibility and Safety of Three-Port Laparoscopic Cholecystectomy Compared to Four-Port Laparoscopic Cholecystectomy.

BackgroundThe standard four-port laparoscopic cholecystectomy (LC) is the gold standard procedure. The various clinical trials and reports in the literature have suggested that the three-port technique LC can be done safely with acceptable results.Still, that the three-port LC offers any added benefits to the patient is a controversial issue especially in view of safety and feasibility. In this study, we report the experience of three-port LC compared to four-port LC technique, its safety, feasibility and outcomes.Materials and methodsA prospective randomized study was conducted between two groups which included 165 cases - 93 patients were included in three-port LC (Group A) and 72 patients in four-port LC (Group B). Operative time, intraoperative complications, postoperative pain, length of hospital stay, analgesics requirement, conversion to open and return to normal activities were parameters of evaluation.ResultsDemographic data was comparable in both the groups. Three-port LC Group A had lesser post-operative pain and analgesics requirements. The mean postoperative pain visual analogue scale (VAS) score on day 1 was (4.16 and 6.24), on day 7 was (1.26 and 1.81) in three-port group and in four-port LC group, respectively. The mean days of analgesics requirement were 2.56 days and 4.21 days among three-port group and four-port group, respectivelyLength of hospital stay was less and returning to work was early in three-port group. There was no statistical difference in operative time. The mean operative time among three-port LC group A and four-port LC group B was 36+/-8.6 minutes (30-68) and 39+/-7 minutes (30-90), respectively. The overall outcomes were comparable to four-port LC.ConclusionThree-port LC is a feasible and safe procedure for LC with satisfactory outcomes like lesser postoperative pain, postoperative stay and less scars, when performed by experienced hands, especially in acute cholecystitis. The use of fourth port should be done when required in a difficult situation.

TP6.1.8 Meta-analysis and trial sequential analysis of three-port versus four-port laparoscopic cholecystectomy (Level 1 Evidence)

Abstract Aims to compare the outcomes of three-port and four-port laparoscopic cholecystectomy. Methods In compliance with PRISMA statement standards, electronic databases were searched to identify all comparative studies investigating outcomes of three-port versus four-port laparoscopic cholecystectomy. Two techniques were compared using direct comparison meta-analysis model. The risks of type 1 or type 2 error in the meta-analysis model were assessed using trial sequential analysis model. The certainty of the available evidence was assessed using GRADE system. Random effects modelling was applied to calculate pooled outcome data. Results Analysis of 2524 patients from 17 studies showed that three-port and four-port laparoscopic cholecystectomy techniques were comparable in terms of operative time (MD:-0.13,P=0.88), conversion to open operation (OR:0.80,P=0.43), gallbladder perforation (OR:1.43,P=0.13), bleeding from gallbladder bed (OR: 0.81, P = 0.34), bile duct injury (RD: 0.00, P = 0.97), iatrogenic visceral injury (RD:-0.00,P=0.81), bile or stone spillage (OR:1.67,P=0.08), port site infection (OR:0.90,P=0.76) and need for reoperation (RD:-0.00,P=0.94). However, the three-port technique was associated with lower VAS pain score at 12 hours (MD:-0.66,P&amp;lt;0.00001) and 24 hours (MD:-0.54,P&amp;lt;0.00001) postoperatively, shorter length of hospital stay (MD: -0.09, P = 0.41), and shorter time to return to normal activities (MD:-0.79,P=0.02). Conclusions Robust evidence (Level 1 with high certainty) suggests that in an elective setting with uncomplicated cholelithiasis as indication for cholecystectomy, three-port laparoscopic cholecystectomy is comparable with the four-port technique in terms of procedural and morbidity outcomes and may be associated with less postoperative pain, shorter length of hospital stay and shorter time to return to normal activities.

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.

Staples Versus Sutures for Skin Closure in Standard Four Port Laparoscopic Cholecystectomy: A Prospective Cohort Study.

IntroductionMany studies have been done comparing sutures versus skin staples in various wounds. To the author's knowledge, there is no study comparing these two in an laparoscopic cholecystectomy (LC) wound. Our study aims at comparing the clinical outcome of skin closure by monofilament nylon suture and stainless-steel skin stapler in standard four-port LC. The results of this study can help in developing guidelines for skin closure in LC.ObjectiveTo compare the clinical outcome of skin closure by monofilament nylon suture and stainless-steel skin stapler in standard four-port LC.MethodsThe study was conducted as a time-bound prospective cohort study on diagnosed patients of cholelithiasis admitted in a single unit of the Department of Surgery at All India Institute of Medical Sciences, Rishikesh, India from February 2018 to February 2019. The standard four-port LC was done by the same surgeon. After the completion of the surgery, port closure was done using absorbable sutures, and skin was closed by either 2.0 monofilament nylon suture (Ethilon, Ethicon, Scotland) or stainless-steel staples (Proximate plus MD, 35W, Ethicon, Scotland). The time taken for skin closure in both the groups was noted using a stopwatch. Each wound was assessed on the post of day (POD) 1 during discharge, on POD 10 during suture/stapler removal, and POD 30 by the operating surgeon for pain, wound infection, scar status using validated scales.Statistical analysis usedThe outcome measures were calculated as mean and standard deviation. Continuous variables were analyzed using a two-tailed student t-test.ResultsOut of 48 suture vs 45 stapler cases the average time for closure is 277.14 seconds in suture vs 77.2 seconds (p = 0.0001) in the stapler group. All other parameters studied were not statistically significant among the two cohorts.ConclusionWe conclude that stapler requires minimum time for closure with no statistically significant difference in wound infection, post-op pain, pain during removal, and scar results are the same in both the groups.

Meta-analysis and trial sequential analysis of three-port vs four-port laparoscopic cholecystectomy (level 1 evidence).

To compare the outcomes of three-port and four-port laparoscopic cholecystectomy. In compliance with PRISMA statement standards, electronic databases were searched to identify all comparative studies investigating outcomes of three-port vs four-port laparoscopic cholecystectomy. Two techniques were compared using direct comparison meta-analysis model. The risks of type 1 or type 2 error in the meta-analysis model were assessed using trial sequential analysis model. The certaintyof evidence was assessed using GRADE system. Random effects modelling was applied to calculate pooled outcome data. Analysis of 2524 patients from 17 studies showed that both techniques were comparable in terms of operative time (MD:- 0.13, P = 0.88), conversion to open operation (OR:0.80, P = 0.43), gallbladder perforation (OR: 1.43, P = 0.13), bleeding from gallbladder bed (OR:0.81, P = 0.34), bile duct injury (RD: 0.00, P = 0.97), iatrogenic visceral injury (RD: - 0.00, P = 0.81), bile or stone spillage (OR:1.67, P = 0.08), port site infection (OR: 0.90, P = 0.76), port site hernia (RD: 0.00, P = 0.89), port site haematoma (RD: - 0.01, P = 0.23), port site seroma (RD: 0.00, P = 1.00), and need for reoperation (RD: - 0.00, P = 0.94). However, the three-port technique was associated with lower VAS pain score at 12h (MD: - 0.66, P < 0.00001) and 24h (MD: - 0.54, P < 0.00001) postoperatively, shorter length of hospital stay (MD:-0.09, P = 0.41), and shorter time to return to normal activities (MD: - 0.79, P = 0.02). Trial sequential analysis confirmed that the meta-analysis was conclusive with no significant risks of type 1 or type 2 error. Robust evidence (level 1 with high certainty) suggests that in an elective setting with uncomplicated cholelithiasis as indication for cholecystectomy, three-port laparoscopic cholecystectomy is comparable with the four-port technique in terms of procedural and morbidity outcomes and may be associated with less postoperative pain, shorter length of hospital stay and shorter time to return to normal activities.

Three port versus four port laparoscopic cholecystectomy: a prospective comparative clinical study

Background: Although, traditional laparoscopic cholecystectomy is performed using four-port technique, various modifications were made to further enhance the advantages of laparoscopic cholecystectomy. Aim of the study is to compare the results of three-port and four-port laparoscopic cholecystectomy at single centre in terms of technical feasibility, safety of the procedure, operative time, intra-operative complications, postoperative pain and post-operative analgesia requirement.Methods: It was a prospective comparative study conducted in the department of surgery Smimer medical college Surat, India from July 2018 to July 2019. The study was performed on all adult patients with ultrasound documented cholelithiasis. The total number of patients studied was 50 which were divided into two groups of 25 each.Results: Demographic data were comparable for both study groups. Patients in the 3-port group had shorter mean operative time (47.3±29.8 min versus 60.8±32.3 min) for the 4-port group (p=0.04). Post-operative requirement of analgesia was less in 3 port group as compared to 4 port group. Pain visual analog scale (VAS) score, intra operative complications, post- operative complications and return to normal activity were significant in our study. Hospital stay and patient satisfaction were non- significant.Conclusions: The three-port technique is as safe as the standard four-port technique and can be a viable alternative to four port cholecystectomy with an advantage of less analgesic requirement, early post-operative ambulance, early oral feed, and better cosmetic results.

Laparoscopic cholecystectomy in patients with portal cavernoma without portal vein decompression

Introduction:Laparoscopic cholecystectomy (LC) in patients with extrahepatic portal vein obstruction causing portal cavernoma (PC) is considered high risk because of portosystemic collateral veins in the hepatocystic triangle. The literature is limited to isolated case reports. We describe our experience of LC in patients with PC.Patients and Methods:Data of patients with PC who underwent LC for symptomatic gallstones or related complications was reviewed. Patients with simultaneous cholecystectomy with splenorenal shunt and open cholecystectomy were excluded. Pre-operative evaluation consisted of complete blood count, international normalisation ratio and liver function tests, ultrasound of the abdomen with Doppler, contrast-enhanced computerised tomography, magnetic resonance cholangiopancreatography and esophagogastroscopy as indicated. A standard four-port LC was performed. The technical principles followed were to avoid injury to the collateral veins, liberal use of energy sources and division of dominant collateral veins between clips.Results:Seven adult patients including three females underwent LC. Three patients had thrombosis of previous surgical shunt with persistent PC. The remaining four patients did not have any indication for shunt surgery. Successful LC was performed in six patients. The median duration of surgery was 170 (130–250 min). Blood transfusion was not required. All the patients had uneventful post-operative recovery. The histopathology of gall bladder consists of acute cholecystitis in three patients and chronic cholecystitis in four.Conclusion:LC is feasible in patients with PC at a centre with experience in both laparoscopic and portal hypertension surgeries. Excellent outcome with low rate of conversion to open surgery can be achieved.