Laparoendoscopic Single-site Cholecystectomy Research Articles

Smoking History and the Development of Incisional Umbilical Hernia After Laparoscopic and Laparoendoscopic Single-Site Cholecystectomy.

The aim of this study was to analyze umbilical hernia occurrences in patients who underwent laparoscopic or laparoendoscopic single-sight (LESS) cholecystectomy. Patients who underwent cholecystectomy by a single surgeon between 2015 and 2020 were surveyed. Data are presented as median (mean +/- standard deviation). Two hundred and fifty-three patients were sent the survey and 130 (51%) patients responded. The overall age was 57 (31 +/- 18) and the overall BMI was 30 (31 +/- 7). Twelve (9%) patients developed an umbilical hernia. Seventeen patients were active smokers and four (24%) developed an umbilical hernia. One hundred and thirteen patients were inactive smokers and eight (7%) developed an umbilical hernia. There was a statistical significance between umbilical hernia occurrence and smoking history (P < .05). Active smokers have a higher risk of developing an umbilical hernia following a minimally invasive cholecystectomy, regardless of operative approach. Elective cholecystectomy should be reconsidered for current smokers.

Comparison of a new gasless method and the conventional CO2 pneumoperitoneum method in laparoendoscopic single-site cholecystectomy: a prospective randomized clinical trial

To avoid CO2 pneumoperitoneum-associated cardiopulmonary side-effects during conventional laparoscopic surgeries, we have developed a gasless laparoscopic operation field formation (LOFF) device for laparoendoscopic single-site surgery. The aim of this study is to analyze the safety and efficacy of the LOFF device for laparoendoscopic single-site cholecystectomy and to verify its advantage of avoiding CO2 pneumoperitoneum-associated complications. In this prospective, randomized, observer-blinded clinical trial, eligible participants were randomized in a 1:1 ratio to undergo either conventional CO2 pneumoperitoneum assisted laparoendoscopic single-site cholecystectomy (LESS) or the new gasless LOFF device assisted laparoendoscopic single-site cholecystectomy (LOFF-LESS). Outcomes including intra-operative respiratory and hemodynamic parameters, operation time, conversion rate, complication rate, et al were compared between the two groups. A total of 100 patients were randomized to the LESS group [n = 50; mean (SD) age, 49.5 (13.9) years; 24 (48.0%) women] and the LOFF-LESS group [n = 50, mean (SD) age, 47.4 (13.3) years; 27 (54.0%) women]. Compared with the LOFF-LESS group, the LESS group witnessed significant fluctuations in intra-operative respiratory and hemodynamic parameters. The tracheal extubation time of the LESS group was significantly longer (P = 0.001). The gasless LOFF device is safe and feasible for simple laparoscopic cholecystectomy and has a predominance of avoiding CO2 pneumoperitoneum-associated cardiopulmonary side-effects. Trial registration number: ChiCTR2000033702Graphic abstract

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.

10-mm Laparo-Endoscopic Single-Site Cholecystectomy Using Multiple Magnetically Anchored and Controlled Instruments

BackgroundTo study the feasibility of laparo-endoscopic single-site (LESS) cholecystectomy through a 10-mm incision using a miniature magnetically anchored and controlled laparoscopy system and a grasper system. MethodsThe miniature magnetically anchored and controlled laparoscopy system consisted of a miniature magnetically anchored camera (MMAC), an external magnetic anchoring unit, and a vision output device. The camera weighed 9.8 g and measured Φ10 mm × 50 mm. The magnetically anchored and controlled grasper system consisted of a magnetically anchored grasper (MAG), an external magnetic anchoring unit, and a push–pull device. The MAG had a titanium alloy clip head and a magnetic tail. The laparoscopy system and grasper system were used simultaneously to perform LESS cholecystectomy through a single 10-mm incision in model canines. ResultsLESS cholecystectomy through a 10-mm incision using the MMAC and MAG was attempted in six dogs. The mean operative time was 85.75 ± 7.14 min. The operation was completed successfully in four cases, with failure occurring in one case due to gallbladder rupture and in another due to bile duct injury. The MMAC provided clear imaging, and the MAG provided sufficient exposure to perform the cholecystectomy. The use of multiple magnetically anchored and controlled instruments did not result in notable collisions. ConclusionsThe designed MMAC and MAG system could be easily maneuvered. LESS cholecystectomy may be feasible through a single 10-mm incision with the simultaneous use of multiple magnetically anchored and controlled instruments.

Laparoendoscopic Single-Site Cholecystectomy: First Experiences with a New Standardized Technique Replicating the Four-Port Technique.

After reports on laparoendoscopic single-site (LESS) cholecystectomy, concerns have been raised over the level of difficulty and a potential increase in complications when moving away from conventional gold standard multiport laparoscopy due to incomplete exposure and larger umbilical incisions. With continued development of technique and technology, it has now become possible to fully replicate this gold standard procedure through an LESS approach. First experiences with the newly developed technique and instrument are reported. Fifteen patients presenting with cholelithiasis without signs of inflammation were operated using all surgical steps considered appropriate for the conventional four-port laparoscopic approach, but applied through a single access device. Operation-centered outcomes are presented. There were no peri- or postoperative complications. Mean operating time was 32.3 minutes. No conversion to regular laparoscopy was required. The critical view of safety was achieved in all cases. Mean skin incision length was 2.2 cm. The application of a standardized technique combined with the use of a four-port LESS device allows us to perform LESS cholecystectomy, giving us a correct exposure of the structures and without increasing the mean operating time combining previously reported advantages of LESS. A universal trait of any new technique should be safety and reproducibility. This will enhance its applicability by large number of surgeons and to large number of patients requiring cholecystectomy.

Laparoendoscopic single-site cholecystectomy and common bile duct exploration using conventional instruments

BackgroundOptimization of quality of life is an important goal in the advanced surgery. Herein we share our fifteen cases to demonstrate the feasibility of scarless laparoendoscopic single-site common bile duct (CBD) exploration using conventional instruments in the management of CBD stones. MethodsFifteen patients (4 male) underwent transumbilical laparoendoscopic single-site cholecystectomy and CBD exploration: the patients were diagnosed with CBD stones. The endoscopic nasobiliary drainage (ENBD), endoscopic retrograde biliary drainage (ERBD) or J-type tube was introduced into the CBD preoperatively or intraoperatively. A 2-cm periumbilical incision was made for the placement of three trocars. Conventional rigid laparoscopic instruments were solely used throughout the procedure, and operative techniques were carried out in the same fashion as for conventional T-tube-free laparoscopic cholecystectomy and CBD exploration. ResultsThe procedures were completed uneventfully in the mean duration of 125.7 min. Three patients occurred pigtail J-tube displacement and all three were later excreted safely in stool. ConclusionsLaparoendoscopic single-site cholecystectomy and CBD exploration appears to be a technically feasible alternative to standard laparoscopic procedure, and can be performed using conventional laparoscopic instruments. Laparoscopic primary closure with preoperative ENBD and ERBD tubes and with intraoperative J-tubes is safe and feasible.

Retrospective single-surgeon study of outcomes after laparoendoscopic single-site cholecystectomy and sigmoidectomy.

PurposeLaparoendoscopic single-site (LESS) surgery is performed through a single port but requires a larger incision than conventional laparoscopy, which theoretically increases the risk of laparoscopic port hernia. Our primary objective is to determine the trocar site hernia rate among our patients.MethodsThis retrospective study is based on the analysis of demographic, intraoperative, and postoperative data of 219 patients who underwent cholecystectomy or sigmoidectomy by LESS surgery between December 1st, 2009 and November 30th, 2012.ResultsCholecystectomy and sigmoidectomy LESS surgery were performed on 190 and 29 patients, respectively. Three patients developed a trocar site hernia within a median follow-up time of 34.7 months. Eleven patients were obese, 20 had a history of abdominal surgery, and 20 had a preoperative umbilical hernia but none of them developed a trocar site hernia, neither did the 11 subsequently pregnant women. Significant association was found between preoperative umbilical hernia and early complications including incisional cellulitis and hematoma.ConclusionsA rate of 1.4 % of trocar site hernia was observed in our study population. This rate is similar to the one reported after conventional laparoscopy. Peri-umbilical incision, longer than that with conventional laparoscopy, allowed better preexisting hernia handling, made anatomical closing easier among obese patients, and facilitated specimen extraction thus limiting traumatic operations.

Oxidative stress in multi-port and single-port cholecystectomy

BackgroundThis study was designed to analyze and compare plasma levels of 8-isoprostane (8-epiPGF2α), a biomarker of lipid peroxidation, and uric acid (UA), a marker of the antioxidant status, in standard laparoscopic (LC) and laparoendoscopic single-site cholecystectomy (LSSC). Materials and methodsForty patients with noncomplicated cholelithiasis were randomized to undergo either LSSC (n = 20) or LC (n = 20). The patients had body mass index <30, American Society of Anesthesiologists score I or II, and no previous upper gastrointestinal surgery. Blood samples were taken preoperatively and 6 h and 24 h postoperatively. Levels of 8-epiPGF2α were determined using enzyme-linked immunosorbent assay, whereas levels of UA were calculated using automated analyzer. ResultsNo significant differences were observed in operative data among the groups. Levels of 8-epiPGF2α were significantly higher in LSSC compared with LC at 6 h (P = 0.003) and 24 h (P < 0.001). 8-epiPGF2α levels showed significant changes over time in LC (LSSC: P = 0.720, LC: P < 0.001). UA levels were significantly higher in LC compared with LSSC, 24 h postoperatively (P = 0.021). No significant changes over time in the UA levels in both groups (LSSC: P = 0.056, LC: P = 0.205). ConclusionsLSSC is associated with increased oxidative stress compared with LC. Further studies are needed to confirm these results.

Robotic single port cholecystectomy (R-LESS-C): Experience in 36 patients

Laparoendoscopic single-site surgery (LESS) has emerged as a result of a search for "pain-less" and "scar-less" surgery. Laparoendoscopic single-site cholecystectomy (LESS-C) is probably the most common application in general surgery, although it harbors certain limitations. It was proposed that the da Vinci Single-Site (Si) robotic system may overcome some of the difficulties experienced during LESS, providing three dimensional views and the ability to work in a right-handed fashion. Thirty-six robotic single port cholecystectomies (R-LESS-C) performed with the da Vinci Si robotic system are evaluated in this paper R-LESS-C performed in 36 patients were reviewed. The data related to the perioperative period (i.e., anesthesia time, operation time, docking time, and console time) was recorded prospectively, whereas the hospitalization period, postoperative visual analogue scale (VAS) pain scores were collected retrospectively. A total number of 36 patients, with a mean age of 40.1 years (21-64 years), underwent R-LESS-C. There were five men and 31 women. The mean anesthesia and operation times were 79.3 minutes (45-130 minutes) and 61.8 minutes (34-110 minutes), respectively. The mean docking time was 9.8 minutes (4-30 minutes) and the mean console time was 24.9 minutes (7-60 minutes). The mean hospital stay was 1.05 days (1-2 days) and the mean pain score (VAS) was 3.6 (2-8) in the first 24 hours. Incisional hernia was recorded in one patient. R-LESS-C can be performed reliably with acceptable operative times and safety. The da Vinci Si robotic system may ease LESS-C. Two issues should be considered for routine use: expensive resources are needed and the incidence of incisional hernia may increase.

Laparoendoscopic single-site cholecystectomyvsthree-port laparoscopic cholecystectomy: A large-scale retrospective study

To perform a large-scale retrospective comparison of laparoendoscopic single-site cholecystectomy (LESSC) and three-port laparoscopic cholecystectomy (TPLC) in a single institution. Data were collected from 366 patients undergoing LESSC between January 2005 and July 2008 and were compared with the data from 355 patients undergoing TPLC between August 2008 and November 2011 in our department. Patients with body mass index greater than 35 kg/m(2), a history of major upper abdominal surgery, signs of acute cholecystitis, such as fever, right upper quadrant tenderness with or without Murphy's sign, elevated white blood cell count, imaging findings suggestive of pericholecystic fluid, gallbladder wall thickening > 4 mm, and gallstones > 3 cm, were excluded to avoid bias. Altogether, 298 LESSC and 315 TPLC patients met the inclusion criteria. The groups were well matched with regard to demographic data. There were no significant differences in terms of postoperative complications (contusion: 19 vs 25 and hematoma at incision: 11 vs 19), hospital stay (mean ± SD, 1.4 ± 0.2 d vs 1.4 ± 0.7 d) and visual analogue pain score (mean ± SD, 8 h after surgery: 2.3 ± 1.4 vs 2.3 ± 1.3 and at day 1: 1.2 ± 0.4 vs 1.3 ± 1.2) between the LESSC and TPLC patients. Four patients required the addition of extra ports and 2 patients were converted to open surgery in the LESSC group, which was not significantly different when compared with TPLC patients converted to laparotomy (2 vs 2). LESSC resulted in a longer operating time (mean ± SD, 54.8 ± 11.0 min vs 33.5 ± 9.0 min), a higher incidence of intraoperative gallbladder perforation (56 vs 6) and higher operating cost (mean ± SD, 1933.7 ± 64.4 USD vs 1874.7 ± 46.2 USD) than TPLC. No significant differences in operating time (mean ± SD, 34.3 ± 6.0 min vs 32.7 ± 8.7 min) and total cost (mean ± SD, 1881.3 ± 32.8 USD vs 1876.2 ± 33.4 USD) were found when the last 100 cases in the two groups were compared. A correlation was observed between reduced operating time of LESSC and increased experience (Spearman rank correlation coefficient, -0.28). More patients in the LESSC group expressed satisfaction with the cosmetic result (98% vs 85%). LESSC is a safe and feasible procedure in selected patients with benign gallbladder diseases, with the significant advantage of cosmesis.

Laparoendoscopic single-site cholecystectomy in a pregnant patient

Feasibility and safety of laparoscopic cholecystectomy during pregnancy for patients with symptomatic or complicated gallstone disease is well established. Laparoendoscopic single-site cholecystectomy (LESS-chole) is a new modality in which the entire surgery is undertaken via a transumbilical incision. We describe a 33-year-old patient who underwent a LESS-chole in the 20th week of pregnancy for gallstone disease complicated by episodes of obstructive jaundice and acute pancreatitis. This is the first reported case of LESS-chole performed using conventional laparoscopic instruments. The technical aspects as well as the various perioperative measures utilized to undertake this procedure safely are outlined.

Single-incision Laparoscopic Cholecystectomy: A New Retraction Technique

Background : Laparo-endoscopic single site cholecystectomy receives great interest from the surgical community. It has potential for reducing postoperative pain, length of hospital stay and improving cosmesis. Minimally invasive surgeons have been forced to develop techniques for providing adequate retraction of the gallbladder. Herein, we describe a new retraction technique to improve the dissection of Calot’s triangle.Surgical technique : Twelve patients underwent laparo-endoscopic single site laparoscopic cholecystectomy using this retraction technique. An intra-umbilical skin incision was made by pulling out the umbilicus. A SILS® port was placed through an open approach. We inserted a 10-mm 30o camera through the SILS® port without using any trocar. One suture was knotted in the middle of the gallbladder. Gallbladder retraction was achieved by the use of an EndoClose® needle that was inserted into abdominal cavity at the subcostal border. The floppy knot was held by the notched end of the EndoClose® needle. This device provided retraction of the gallbladder in every direction.Conclusions : Adequate retraction greatly simplifies laparo-endoscopic single site cholecystectomy. New retraction techniques will enable wider use of this novel minimally invasive approach. Further work is needed to investigate the advantages of this new technique.

Laparo-endoscopic single-site (LESS) cholecystectomy with epidural vs. general anesthesia

Laparo-endoscopic single-site (LESS) surgery involves a single umbilical incision, lending itself to epidural anesthesia. This prospective, randomized study was undertaken to evaluate epidural anesthesia for patients undergoing LESS cholecystectomy, to assess the feasibility, and to analyze all intraoperative and postoperative complications. The secondary objectives were to determine differences in postoperative pain and time until PACU discharge-to-home readiness between patients. With institutional review board approval, 20 patients with chronic cholecystitis, cholelithiasis, and/or biliary dyskinesia were randomized to receive spinal epidural anesthesia (n = 10) or general anesthesia (n = 10). Postoperative pain at rest was recorded in the PACU every 10 min, and at rest and walking at discharge using the visual analog scale (VAS). Operative time and time until PACU discharge-to-home readiness were recorded. Results are expressed as mean ± SD. Patient age, American Society of Anesthesiologists class, and body mass index were similar. There were no additional ports/incisions, conversions to "open" operations, or conversions to general anesthesia. There were no differences in operative duration. Time until postanesthesia care unit discharge-to-home ready was not significantly different. The most common postoperative adverse event was urinary retention (1 epidural and 3 general anesthesia patients). Resting postoperative VAS pain score at discharge was 4.7 ± 2.5 vs. 2.2 ± 1.6 (p = 0.02, general versus epidural anesthesia respectively); the stressed VAS pain score at discharge was 6.1 ± 2.3 vs. 3.1 ± 2.8 (p = 0.02, general versus epidural anesthesia respectively). LESS cholecystectomy with epidural anesthesia was completed with no operative or anesthetic conversions, and less postoperative pain at discharge. Epidural anesthesia appears to be a preferable alternative to general anesthesia for patients undergoing LESS cholecystectomy.

Re: Laparoendoscopic single-site cholecystectomy versus conventional laparoscopic cholecystectomy: a systematic review of randomized controlled trials

Re: Laparoendoscopic single-site cholecystectomy versus conventional laparoscopic cholecystectomy: a systematic review of randomized controlled trials

Consensus statement of the consortium for LESS cholecystectomy

Many surgeons attempting Laparo-Endoscopic Single Site (LESS) cholecystectomy have found the operation difficult, which is inconsistent with our experience. This article is an attempt to promote a standardized approach that we feel surgeons with laparoscopic skills can perform safely and efficiently. This is a four-trocar approach consistent with the four incisions utilized in conventional laparoscopic cholecystectomy. After administration of general anesthesia, marcaine is injected at the umbilicus and a 12-mm vertical incision is made through the already existing anatomical scar of the umbilicus. A single four-trocar port is inserted. A 5-mm deflectable-tip laparoscope is placed through the trocar at the 8 o'clock position, a bariatric length rigid grasper is inserted through the trocar at the 4 o'clock position (to grasp the fundus), and a rigid bent grasper is placed through the 10-mm port (to grasp the infundibulum). This arrangement of the instruments promotes minimal internal and external instrument clashing with simultaneous optimization of the operative view. This orientation allows retraction of the gallbladder in a cephalad and lateral direction, development of a window between the gallbladder and the liver which promotes the "critical view" of the cystic duct and artery, and provides triangulation with excellent visualization of the operative field. The operation is concluded with diaphragmatic irrigation of marcaine solution to minimize postoperative pain. Standardization of LESS cholecystectomy will speed adoption, reduce intraoperative complications, and improve the efficiency and safety of the approach.

Commentary on “Cystic Duct Leaks After Laparoendoscopic Single-Site Cholecystectomy”: A Word of Caution

Commentary on “Cystic Duct Leaks After Laparoendoscopic Single-Site Cholecystectomy”: A Word of Caution

Cystic Duct Leaks After Laparoendoscopic Single-Site Cholecystectomy

Leakage from the clipped cystic duct stump (cystic duct stump leak [CDSL]) as a cause of biliary peritonitis has not been emphasized enough. It deserves special mention because it is not an uncommon cause and it is easier to treat. With the advent of laparoendoscopic single-site (LESS) cholecystectomy, its occurrence in relation to other causes of biliary peritonitis needs reexamination. Details of 756 patients undergoing LESS cholecystectomy were analyzed, and patients presenting with biliary peritonitis were identified. The investigative profile included an ultrasound, contrast-enhanced computed tomography scan, and endoscopic retrograde cholangiopancreatography (ERCP) to identify the site of leak. The management in addition to stenting included abdominal tube drainage. There were 5 (0.66%) patients, all female, with biliary peritonitis, and 4 of them (0.53%) had cystic stump leakage as identified by ERCP. The usual time of presentation was in the first week after surgery, with acute abdominal pain and vomiting. Common bile duct stenting was carried out, after choledocholithotomy where required, at the same ERCP session. Tube abdominal drain was required in 2 patients, and 1 patient had to undergo exploratory laparotomy for an associated acute intestinal obstruction. All the patients recovered completely. The stent was removed between 4 and 6 weeks after ERCP. Effective CDSL management requires early recognition and management. ERCP is the cornerstone for correct identification, and common bile duct stenting was curative in all patients.

Laparoendoscopic Single-Site Versus Traditional Laparoscopic Surgery in Patients with Cholecystectomy: A Meta-analysis

To evaluate the primary outcomes of traditional laparoscopic cholecystectomy (TLC) compared with laparoendoscopic single-site cholecystectomy (LESSC). Randomized controlled trials (RCTs) comparing TLC with LESSC were included by a systematic literature research. The inclusion and extraction of the data were completed by two authors independently. Meta-analysis was performed using Review Manager version 5.1.4 software. The clinical outcomes were evaluated by odds ratio (OR) and standard mean difference (SMD) according to the different types of data. Sensitivity and heterogeneity analyses were used to account for rationality of pooling data and sources of heterogeneity. Seven RCTs involving 611 patients met the predefined inclusion criteria. The cosmetic score of the LESSC group was significantly higher at 1 week (SMD = 0.48; 95% confidence intervals [CI] 0.24, 0.73; P = .0001), 2 weeks (SMD = 0.87; 95% CI 0.61, 1.13; P < .00001), and 1 month (SMD = 0.88; 95% CI 0.62, 1.44; P<.00001) postoperatively. However, LESSC showed a lesser physical quality of life (PQOL) score at 3 days (SMD = -0.28; 95% CI -0.52, -0.44; P = .02), 1 week (SMD = -0.31; 95% CI -0.55, 0.06; P = .01), and 2 weeks (SMD = -0.30; 95% CI -0.55, -0.05; P = .02) postoperatively. There was no significant difference between the two groups in operating time, perioperative complication, intraoperative blood loss, postoperative hospital stay, Visual Analog Scale pain score, and PQOL on 1 day, 5 days, and 1 month postoperatively. LESSC is associated with a higher cosmetic score and a lesser short-term PQOL score compared with TLC.

Laparoendoscopic single‐site cholecystectomy versus conventional laparoscopic cholecystectomy: a systematic review of randomized controlled trials

Laparoendoscopic single-site surgery is a revolution in minimally invasive surgery in recent years, and cholecystectomy is the most common intervention. However, laparoendoscopic single-site cholecystectomy (LESSC) is a controversial procedure. Its safety, cosmetic results, complications, post-operative pain and post-operative stay are not confirmed by multi-centre randomized controlled studies. This review examined the impact of LESSC versus conventional laparoscopic cholecystectomy (CLC). The primary outcomes were conversional rate and intraoperative and post-operative complications, and other outcomes were cosmetic results, operative time, post-operative pain and post-operative stay. Pubmed, EMbase, Web of Science, Ovid, clinical trials of the US National Institutes of Health and Cochrane Database of Systematic Reviews and Controlled Trials Register were searched to identify all possible randomized controlled trials (RCTs). Two reviewers completed article search, and eligible data were entered into a computerized spreadsheet for analysis. Nine studies were obtained using the search strategy. Patients accepting LESSC had a higher conversion rate than those having CLC (7.17 (3.00, 17.11) (P < 0.01)). There was no significant difference for total complications between the two groups (1.17 (0.76, 1.80) (P = 0.46)), but incidence of incisional hernia and haemorrhage (seroma) in the LESSC group was obviously higher than that in the CLC group. Operative time was much longer in the LESSC group (mean difference: 10.69 (3.14, 18.24) (P = 0.006)). Cosmetic results favoured LESSC; however, post-operative abdominal pain and post-operative stay were not significantly different between the two groups in most of the nine studies. LESSC can be safely performed with better cosmetic results; however, it carries a higher conversion rate and a longer operative time, and offers no benefit in terms of post-operative abdominal pain and post-operative stay. Further RCTs, according to the CONSORT statement, are advocated to validate its objective benefits.

Combined Laparoendoscopic Single-Site Surgery: Initial Experience of a Single Center

This study reports the initial experience with combined laparoendoscopic single-site surgery (LESS) referring to cholecystectomy, appendectomy, oophorocystectomy and liver cyst and renal cyst fenestration and explore the feasibility and safety of combined LESS. From October 2008 to May 2011 selective 24 patients underwent combined LESS in our center. The single incision in umbilicus was about 2cm. All the operations were performed by the same surgical team and used conventional rigid instruments. In 24 patients, combined laparoendoscopic single-site cholecystectomy and appendectomy were performed in 17 cases, combined cholecystectomy and liver cyst fenestration in 5 cases and combined cholecystectomy and oophorocystectomy in 2 cases. Twenty one patients were successfully operated and the other 3 were converted to conventional laparoscopic surgery because of separating Calot's triangle difficulty. The mean operating time was 87.3 minutes. One urinary retention (4.2%) and one fat liquefaction in abdominal incision (4.2%) occurred and were cured conservatively. There was no mortality in the study. Combined laparoendoscopic single-site surgery is safe, feasible, minimally invasive and cosmetic technique but is more difficult than conventional laparoscopic surgery. It is a reasonable alternative to be performed in selective patients by experienced laparoscopic surgeons.