Minilaparoscopic Cholecystectomy Research Articles

COMPARISON OF SAFETY OF MINILAPAROSCOPIC AND CONVENTIONAL LAPAROSCOPIC CHOLECYSTECTOMY

Abstract. Aim: to assess the safety of mini-laparoscopic cholecystectomy (MLC) compared to traditional laparoscopic cholecystectomy (LC) based on a critical view of safety (CVS).
 Materials and methods: an analysis of 46 video recordings of MLC surgeries and 156 LC surgeries performed for chronic calculous cholecystitis and gallbladder polyps between 2015 and 2022 was conducted, using the concept of CVS and the quality of its achievement. An analysis of anatomical variations was also performed.
 Results and discussion: the average age was 38.5 years in the MLC group and 53.8 years in the LC group, with an average operation time of (59.4±2.13) minutes and (63.01±2.01) minutes, respectively. CVS was achieved in 97.8 % of cases in MLC and 93.0 % in LC. Anatomical variations were present in 31.1 % of cases in MLC and 30.1% in LC. There were no complications of MLC, conversions from MLC to LC, or open surgery.
 Conclusions: The frequency of achieving CVS in MLC was higher than in LHE (97.8 % vs. 93.0 %). Anatomical variations of the biliary system should always be considered for the safe cholecystectomy. MLC is a safe technique that is not inferior to standard LCE in elective surgery in patients with a normal BMI, and at the same time has better cosmetic results.

Minimally Invasive Approaches for Cholecystectomy

Abstract Surgical removal of the gallbladder is cholecystectomy. In Western countries, laparoscopic cholecystectomy (LC) is widely used procedure. Single-incision LC (SILC), mini LC (MLC) these surgeries developed by doctors, also natural orifice transluminal endoscopic surgery to lessen the invasiveness of the treatment. The goal of this study was to see how effective these novel less invasive techniques for LC are in treating gallstone disease. The current literature is inadequate for a proper management of new LC procedures. None of these methods have shown to be superior to traditional LC. SILC is now not recommended since it is linked to the predominance of bile duct damage also incisional hernia. Even though hybrid transvaginal cholecystectomy is becoming more popular in objective practice, cholecystectomies are still experimental. As a result of the fact that it is standardized, because MLC is standardized and nearly identical to traditional laparoscopic surgery, it may provide limited benefits without increasing postoperative problems, making it suitable for routine elective cholecystectomy. The technological issues could be addressed by modifying new surgical equipment that needs to grow with the nuances of SILC and cholecystectomy. Regardless of where these treatments may be used in the upcoming days, robotization may be required to make them the standard of care.

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.

Efficacy of mini-laparoscopic cholecystectomy and laparoscopic cholecystectomy in acute cholecystitis.

Laparoscopic cholecystectomy (LC) reduces hospital length of stay, generating lower costs, less postoperative pain and an esthetic incision, with the disadvantage of converting to an open cholecystectomy. According to Collet, it has a conversion rate to open cholecystectomy of 4.8%. And with only 3 holes would be enough without having another hole exposed, having only a 3.85 % conversion rate. According to the Bangladesh study, minilaparoscopic cholecystectomy (MCL) has a conversion rate of 0.39% being lower than LC, although of the 7200 people in their study, only 22 people had complications such as incisional umbilical hernia and wound infection. Both techniques properly managed are extremely useful, with some differences in scar size and conversion rate, but they´re similar in postoperative pain, length of stay, recovery, etc. The CML is preferably used in young people who prefer esthetics and good results.

Mini-laparoscopic cholecystectomy: evolution of a new technique

BackgroundSince the first laparoscopic cholecystectomy (LC) in 1985, there has been much advancement in laparoscopic surgery in terms of reduction in number and size of ports. We report a new technique of performing mini laparoscopic cholecystectomy using only three ports, 5 mm each. The indications of this procedure include GB polyps, GB dyskinesia, microlithiasis, and idiopathic pancreatitis.Case presentationIn this case report, we present a new technique that has been performed safely in a 49-year-old male patient with pancreatitis caused by microlithiasis. This was performed using a novel three port procedure consisting of only 5 mm ports, and he was discharged as a day case without complications. Informed patient consent was obtained.ConclusionsThe fundamentals of this mini-LC technique remain the same as that of a standard laparoscopic cholecystectomy throughout the procedure. It is a feasible option in selected cases, and it has the potential to further augment the inherent benefits of minimal access surgery namely less analgesia, improved cosmesis and faster recovery. Further trials will help ascertain its potential advantages.

Feasibility of Minilaparoscopic Cholecystectomy. A pilot Study

Feasibility of Minilaparoscopic Cholecystectomy. A pilot Study

Minilaparoscopic cholecystectomy and Nissen fundoplication in combination with a fast track protocols in the Covid-19 pandemia environment

Objective. Studying of the results of application of minilaparoscopic cholecystectomy and minilaparoscopic Nissen fundoplication in combination with protocols fast track in the Covid-19 pandemia environment.
 Materials and metods. Minilaparoscopic cholecystectomy was conducted in 17 patients, minilaparoscopic Nissen fundoplication - in 8 patients.Results. For minilaparoscopic cholecystectomy were used one 10-mm, one 5-mm trocar and two 3-mm trocars for minigraspers. For minilaparoscopic fundoplication there were applied two 5-mm trocars and two 3-mm trocars for minigraspers, also 5-mm Nathanson’s retractor was installed without trocar. After mimilaparoscopic cholecystectomy the pain syndrome on the second day was estimated at average (1.3 ± 1.4) points (0 - 5 points), average duration of postoperative period have constituted (2.2 ± 0.4) bed-days (2 - 3 bed-days). After minilaparoscopic fundoplication the pain syndrome on the second day was estimated at average in (1.4 ± 1.4) points (0 - 3 points), average duration of postoperative period have constituted (2.7 ± 0.9) bed-days (2 - 4 bed-days).
 Conclusion. Minilaparoscopic operations may be applied successfully in chronic calculous cholecystitis, small axial hiatal hernias and gastro-esophageal reflux disease. After minilaparoscopic operations in combination with elaborated protocol of fast track minimizes the pain syndrome and terms of the patients’ stationary stay, what is actual in the Covid-19 pandemia environment, and cosmetic result is improving as well. Further elaboration of the material for determination of role of these minilaparoscopic operations is needed.

Twenty years of mini-laparoscopy in Brazil: What we have learned so far.

The mini-laparoscopic cholecystectomy (MLC) was first performed in 1996, as the logical advancement of the conventional laparoscopic cholecystectomy. In Brazil, mini-laparoscopy was first performed in 1998, by Professors Peter Goh and Go Wakabaiashi, who performed a cholecystectomy using 3-mm instruments. The first study, with a considerable number of patients, was performed in Recife by Dr. Carvalho, and he reported that 719 patients were submitted to a MLC with a small rate of conversion for conventional laparoscopy. We discuss the development of mini-laparoscopy in Brazil for the past 20 years.

THE FIRST RESULTS OF A MINI-LAPAROSCOPIC CHOLECYSTECTOMY USING THE FAST-TRACK PROTOCOL

Summary. The aim of the study is to analyze the first results of mini-laparoscopic cholecystectomy in acute and chronic calculouscholecystitis using the fast-track protocol. The study included women aged 20 to 50 years with a body mass index of 18 to 35 kg/m2, whom the cosmetic effect of the operation was important, and quick rehabilitation times. The average age of the patients was 38 years (from 33 to 48 years). The average body mass index was 24.2 kg/m2 (from 19.0 to 30.1 kg/m2). The patient was divided into 2 groups. The main group consisted of 9 women who underwent mini-laparoscopic cholecystectomy, including 2 cases of acute calculouscholecystitis, with using the fast-track protocol. The control group consisted of 7 women who underwent the traditional laparoscopic cholecystectomy using a standard protocol for post-operative management.

A Prospective Randomised Comparative Study between Clip Less Versus Conventional Laparoscopic Cholecystectomy

Introduction: For the surgical treatment of gall bladder diseases, laparoscopic Chole cystectomy has been accepted as
 the gold standard. The minimally invasive procedure is undeniably superior in various respects when compared with
 open surgery and this is also true on the aesthetic criteria when the conventional laparoscopic cholecystectomy (CLC) is
 compared with the mini-laparoscopic cholecystectomy (MLC).
 Objective: Evaluate the hospital charges associated with these procedures and specify the differences concerning these
 techniques.
 Method: Comparative and retrospective study of hospital charges, with 40 consecutive patients, who underwent
 laparoscopic cholecystectomy.
 There were two groups with 20 patients each. One group underwent conventional laparoscopic cholecystectomy and in
 the other the minimally invasive approach was performed. The arithmetic mean was used to compare the total charges
 for the entire procedures.
 Results: The MLC procedures showed no significant difference in total hospital charges compared to the CLC approach.
 Conclusion: The equivalence of hospital charges for the two procedures suggests that the mini-laparoscopic
 cholecystectomy (MLC) should be widely recognized among surgeons as offering better aesthetic results the
 conventional laparoscopic procedure. Studies comparing patient satisfaction with the surgical result, difference in postoperative
 morbidity, pain, and recuperation for the two procedures are needed. 
 
 charges, surgery, laparoscopy, needlescopic instruments

Gallbladder to the left side of the falciform ligament in absence of Situs Inversus “Sinistroposition” – Case series of 2 patients with this anomaly who underwent mini-laparoscopic cholecystectomy

IntroductionGallbladders located to the left of falciform ligament, without situs inversus, are denominated sinistroposition or true left-sided gallbladders; it is considered a rare anatomic anomaly with a prevalence in between 0.1% and 0.7%. Left-sided gallbladder usually occur as a component of situs inversus. Presentation of casesWe report a case series of two patients of true left-sided gallbladder that were found at our institution from 2015 to 2017; the anatomic anomalies were discovered during the performance of mini-laparoscopic cholecystectomy due to acute cholecystitis with cholelithiasis in both cases. Both patients underwent a successful surgery and there were no postsurgical complications. DiscussionThe reported prevalence of left-sided gallbladder is between 0.1% and 0.7%, thus considered a rare anatomic finding. Currently, with advances in diagnostic imaging modalities, the report of left-sided gallbladder has increased nowadays. It may be a more common anomaly than previously thought. ConclusionTrue left-sided gallbladder can be an incidental finding; it is in part due to the fact that radiographic images do not typically detect this anomaly, therefore surgeons must be aware of this condition because it is associated with anomalies in the intrahepatic portal vein and biliary tree.

Minilaparoscopic versus single incision cholecystectomy for the treatment of cholecystolithiasis: a meta-analysis and systematic review

BackgroundOver the past decade, mini-laparoscopic cholecystectomy (MLC) and single-port laparoscopic cholecystectomy (SILC) have been the two main successful mini-invasive surgical interventions for the treatment of cholecystolithiasis since the advent of laparoscopic cholecystectomy (LC). In this study, we conducted a meta-analysis to compare the two treatment alternatives.MethodsWe searched PubMed, CNKI and the Cochrane library for trials that compared MLC and SILC. Risk difference (RD) and mean difference (MD) were calculated with a 95% confidence interval (CI).ResultsFour randomized controlled trials (RCTs) and 2 non-randomized comparative studies (nRCSs) involving 2764 patients were identified. A longer operating time (MD -10.49; 95% CI -18.10, −2.88; P = 0.007) and a shorter wound length (MD 3.65; 95% CI 0.51, 6.78; P = 0.02) were found to be associated with SILC compared with MLC. No significant differences were revealed in conversion, hospital stay, pain relief and cosmetic results. Although a lower incidence of complications was observed with MLC (8.2%) compared with SILC (15.9%), but the difference was not statistically significant (RD -0.06; 95% CI -0.12, 0.00; P = 0.07).ConclusionsMLC has an advantage over SILC in terms of operating time rather than hospital stay, pain relief, cosmetic results. Though conversion and complication rates were higher with SILC, there existed no statistically differences in the two measures between the two procedures. Whether MLC confers any benefits in terms of conversion or complications still warrants further studies.

Is mini-laparoscopic cholecystectomy any better than the gold standard?: A comparative study.

BACKGROUND:Mini-laparoscopic cholecystectomy (MLC) has widened the horizons of modern laparoscopic surgery. Standard four port laparoscopic cholecystectomy (SLC), which has long been established as the “Gold Standard” for gall bladder diseases, is under reconsideration following the advent of further minimally-invasive procedures including MLC. Our study aims to provide a comparison between MLC and SLC and assesses whether MLC has any added benefits.MATERIALS AND METHODS:Patients with symptomatic gall bladder disease undergoing MLC or SLC during the 2.5-month period were included in the study. Thirty-two patients underwent MLC while SLC was performed on 40 patients by the same surgeon. Data was collected prospectively and analysed retrospectively using a predesigned questionnaire.RESULTS:In our study, both the groups had similar age, body mass index (BMI) and gender distribution. No cases of MLC required insertion of additional ports. The mean operative time for MLC was 38.2 min (33-61 min), which is longer than SLC; but it was not statistically significant. There was no significant difference in mean operative blood loss, postoperative pain, analgesia requirement and mobilization. Patients who underwent MLC were able to return to normal activity earlier than patients undergoing SLC (P < 0.01).CONCLUSION:Our experience suggests that MLC can safely be used as an alternative to SLC. Compared to SLC, it has the added benefit of an early return to work along with excellent cosmetic results. Further large scale trials are required to prove any additional benefit of MLC.

Impact of miniport laparoscopic cholecystectomy versus standard port laparoscopic cholecystectomy on recovery of physical activity: a randomized trial.

We conducted a randomized trial comparing minilaparoscopic cholecystectomy (MLC) to conventional laparoscopic cholecystectomy (CLC) to determine whether MLC accelerated recovery of physical activity after elective surgery (NCT01397565). A total of 115 patients scheduled for elective cholecystectomy were randomized to either CLC or MLC. Both procedures used a 10-mm umbilical port, but the three upper abdominal ports were 5mm in CLC and 3mm in MLC. Primary outcome was self-reported physical activity 1month after surgery as estimated by Community Health Activities Model Program for Seniors questionnaire (kcal/kg/week). Secondary outcomes were umbilical pain, abdominal pain, nausea and fatigue (VAS, 1-10), and cosmetic result at one and 3months. Patients received identical surgical dressings for 1week, and assessors were blinded to group allocation. Forty-two patients randomized to CLC group and 33 patients randomized to MLC remained in the trial and were analyzed. Both groups were similar at baseline characteristics. In the MLC group, at least one 5-mm port was used in 17 (51.5%) mainly due to unavailability of ML equipment. Median (IQR) physical activity for the CLC and MLC groups was similar at baseline (23.4 [13.1, 44.6] vs 23.6 [14.2, 66.9] kcal/kg/week, p=0.35) and at 1month (20 [7.9, 52.5] vs 16.8 [11.8, 28.6] kcal/kg/week, p=0.90). One month post-op, umbilical pain and abdominal pain were similar, but the CLC group reported higher fatigue (4 [1-5] vs 1 [0-4], p=0.05) and worse scar appearance scores (4 [3, 4] vs 4.5 [4, 5], p=0.009). At 3months, the CLC group had worse scar appearance (4 [3-5] vs 5 [4-5], p=0.02) and lower scar satisfaction scores (4 [3, 4] vs 4 [3.5-4], p=0.04). Recovery of physical activity was similar after MLC and CLC. MLC resulted in less fatigue and better scar appearance and satisfaction. These benefits were seen despite the need to upsize one or more ports in more than half of patients related to availability of the miniature instruments.

Routine mini-laparoscopic cholecystectomy: Outcome in 200 patients

In order to improve the outcome of classical laparoscopic cholecystectomy (CLC), surgeons have attempted to minimize tissue trauma. The aim of this study is to describe the technique of mini-laparoscopic cholecystectomy (MLC) and to report the outcome of this approach when used as a routine procedure. Since January 2012, all consecutive patients undergoing MLC were included in this study. Operative and perioperative data were prospectively collected. Additionally, cost analysis was performed. From 2012 to 2015, 200 MLC were performed (F/M: 132/68, mean age 45±16years). Mean operative duration was 97±32min for the first 50patients and 75±25min for the subsequent 150patients (P<0.0001). Modifications in the number or size of trocars were necessary in nine of the first 50procedures and in seven of the subsequent 150procedures (P=0.003). Perioperative morbidity included gallbladder perforation (n=28) or moderate (<50mL) bleeding (n=6). Postoperative morbidity was 4%. The mean global cost for a MLC procedure was 1757±1855euros. This cost decreased from 2946±3115euros in the first 50patients to 1390±1278euros in the subsequent 150patients (P=0.001). Mini-laparoscopy can be used for routine elective cholecystectomy. This approach is associated with low morbidity and good cosmetic results.

Transjejunal Extraction of Gallbladder After Mini-Laparoscopic Cholecystectomy in Patients with Previous Roux-en-Y Gastric Bypass: A Small Case Series.

The length of incisions on the abdominal wall directly correlates with wound-related morbidities and patient comfort. Both mini-laparoscopy (only ≤5-mm trocars) and natural orifice specimen extraction avoid larger abdominal incisions. This study described a new natural orifice translumenal endoscopic surgery (NOTES(®); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) cholecystectomy technique by combination of these two advanced laparoscopic techniques for cholelithiasis in patients who had prior laparoscopic Roux-en-Y gastric bypass (LRYGB) for obesity. Three patients (two males, one female; 39, 62, and 34 years old, respectively) were admitted with symptomatic cholelithiasis (multiple millimeter-sized gallstones), and all had previously had LRYGB. They were treated by mini-laparoscopic cholecystectomy using three 5-mm trocars. The gallbladder was removed through the dilated efferent limb of the jejunum, 5 cm distal from the gastrojejunostomy. Transjejunal extraction was performed under endoscopic guidance. The gallbladder in the jejenum was passed through the anastomosis and extracted with an endoscopic snare by the transoral way. The enterotomy was closed intracorporeally. There was no conversion or additional trocar requirement. All the procedures were completed successfully without problems. Respective operating times were 95, 75, and 120 minutes. Only 1 patient required postoperative analgesic; the others did not. The patients started to get a liquid diet on the night of surgery and were discharged on Days 1, 1, and 2, respectively, with normal diet recommendations. There were no morbidities. Mini-laparoscopic cholecystectomy is technically feasible in patients with previous LRYGB. Prior LRYGB was not an obstacle for transoral specimen extraction. The dilated efferent jejunal limb is a good alternative route for natural orifice specimen extraction. This report described the first natural orifice surgery through the small bowel.

Minilaparoscopic cholecystectomy - the new non-visible scars technique. Preliminary report of first series.

IntroductionSurgery without scars is the dream of many patients and surgeons as well. It includes many new laparoscopic techniques (LESS, SILS, hybrid NOTES), but data concerning common bile duct (CBD) lesions are unavailable.AimTo establish the new technique of minilaparoscopic cholecystectomy (MCh): non-visible scar intervention without increasing the risk of CBD lesions.Material and methodsForty consecutive patients with symptomatic gallbladder lithiasis were qualified for elective laparoscopic cholecystectomy (LCh) using one 10/11 mm umbilical port, one 5 mm right suprapubic port and two minilaparoscopic, disposable, no-port graspers. There were 26 women and 14 men, with the mean age 56 (17–72) years and with the average body mass index 28 (18–33) kg/m2. CO2 Veress 15 mm Hg pneumoperitoneum was performed after transumbilical incision, and the first 10/11 mm port was inserted at the beginning for the 5 mm laparoscope and finally for typical instruments. Next under camera control, a 5 mm trocar was inserted in the right ‘bikini line’. To this port the laparoscope was relocated from the umbilicus, and under its control two minilaparoscopic, disposable, non-port graspers were introduced after small, 2 mm skin incisions in the right anterior axillary line and in the right mesogastrium to catch the gallbladder. Next through the umbilical port, using typical instruments, the cystic duct and artery were dissected, clipped and cut. The gallbladder was removed through the umbilical port whole.ResultsThere was no conversion to open cholecystectomy. In 5 cases drainage of the gallbladder lodge was necessary through a 5 mm port in the right bikini line. The time of the intervention ranged from 90 min during the introduction of the new method to 50 min for the last procedures. No postoperative complications were observed, and all patients were discharged at the same time as after conventional LCh.ConclusionsTwo-port laparoscopic cholecystectomy performed with two minilaparoscopic no-port graspers does not increase the risk of CBD lesions. It provides an excellent cosmetic effect and is very convenient for the surgeon like typical LCh.

New minimally invasive approaches for cholecystectomy: Review of literature.

Laparoscopic cholecystectomy is the most commonly performed abdominal intervention in Western countries. In an attempt to reduce the invasiveness of the procedure, surgeons have developed single-incision laparoscopic cholecystectomy (SILC), minilaparoscopic cholecystectomy (MLC) and natural orifice transluminal endoscopic surgery (NOTES). The aim of this review was to determine the role of these new minimally invasive approaches for elective laparoscopic cholecystectomy in the treatment of gallstone related disease. Current literature remains insufficient for the correct assessment of emerging techniques for laparoscopic cholecystectomy. None of these procedures has demonstrated clear benefits over conventional laparoscopic cholecystectomy. SILC cannot be currently recommended as it can be associated with an increased risk of bile duct injury and incisional hernia incidence. NOTES cholecystectomy is still experimental, although hybrid transvaginal cholecystectomy is gaining popularity in clinical practice. As it is standardized and almost identical to the standard laparoscopic technique, MLC could lead to limited benefits without exposing patients to increased postoperative complications, being therefore adoptable for routine elective cholecystectomy. Technical challenges of SILC and NOTES cholecystectomy could be addressed with the evolution of new surgical tools that need to catch up with the innovative minds of surgeons. Regardless the place of these approaches in the future, robotization may be necessary to impose them as standard treatment.

Grand challenge: on the way to scarless visceral surgery.

Grand challenge: on the way to scarless visceral surgery.

The Efficacy and Safety of Different Kinds of Laparoscopic Cholecystectomy: A Network Meta Analysis of 43 Randomized Controlled Trials

Background and ObjectiveWe conducted a network meta analysis (NMA) to compare different kinds of laparoscopic cholecystectomy [LC] (single port [SPLC], two ports [2PLC], three ports [3PLC], and four ports laparoscopic cholecystectomy [4PLC], and four ports mini-laparoscopic cholecystectomy [mini-4PLC]).MethodsPubMed, the Cochrane library, EMBASE, and ISI Web of Knowledge were searched to find randomized controlled trials [RCTs]. Direct pair-wise meta analysis (DMA), indirect treatment comparison meta analysis (ITC) and NMA were conducted to compare different kinds of LC.ResultsWe included 43 RCTs. The risk of bias of included studies was high. DMA showed that SPLC was associated with more postoperative complications, longer operative time, and higher cosmetic score than 4PLC, longer operative time and higher cosmetic score than 3PLC, more postoperative complications than mini-4PLC. Mini-4PLC was associated with longer operative time than 4PLC. ITC showed that 3PLC was associated with shorter operative time than mini-4PLC, and lower postoperative pain level than 2PLC. 2PLC was associated with fewer postoperative complications and longer hospital stay than SPLC. NMA showed that SPLC was associated with more postoperative complications than mini-4PLC, and longer operative time than 4PLC.ConclusionThe rank probability plot suggested 4PLC might be the worst due to the highest level of postoperative pain, longest hospital stay, and lowest level of cosmetic score. The best one might be mini-4PLC because of highest level of cosmetic score, and fewest postoperative complications, or SPLC because of lowest level of postoperative pain and shortest hospital stay. But more studies are needed to determine which will be better between mini-4PLC and SPLC.