Port Laparoscopic Cholecystectomy Research Articles

細径鉗子を用いたReduced port laparoscopic cholecystectomyの安全性に関する検討

序論：当科では腹腔鏡下胆囊摘出術において，症例を選択して細径鉗子，EZアクセスを用いたReduced Port Surgery（以下本術式）を行っている．本術式の安全性を検証するため，その成績を報告する．対象と方法：2012年９月から2014年12月までに腹腔鏡下胆囊摘出術を行った220例中173例を本術式で完遂した．本術式で完遂した173例を対象とし手術時間，出血量，術後合併症発症率，術後在院日数について検討を行った．結果：手術時間は42～248分，平均98.9分，出血量は少量～250ml，平均19.7mlであった．術後合併症発症率は7.5％（13/173）であり，合併症の内容は創感染が11例，腸間膜脂肪織炎が１例，術後出血が１例であった．術後在院日数は２～30日，平均4.75日であった．結語：本術式は従来法と比較し整容性にも優れ，安全性の担保された手術として本領域における標準術式の一つと成り得ると考えられた．

Modified Single Port Laparoscopic Cholecystectomy

Purpose: Currently, single port laparoscopic cholecystectomy (SLC) is gradually being expanded. However, its operative time and complications are reportedly variable according to the surgeon’s expertise and experience. In order to overcome these problems, we introduced surgical methods using a 2 ㎜ sized auxiliary device (NELIS, Korea) in cholecystectomy. Methods: Between March 2010 and October 2010, laparoscopic cholecystectomy was performed in 53 patients for non-inflammatory gallbladder stones or gallbladder polyps based on the computed tomography findings. Fourteen of 53 consecutive patients underwent SLC and others underwent CLC. The patient`s clinical characteristics and operative results were evaluated retrospectively. Results: Comparison of clinical characteristics between SLC and CLC groups indicated that the SLC group included younger patients (p=0.008), however other characteristics (sex, mean body index, and previous abdominal operation history) were not significantly different. Operative outcomesparameters including the intensity of postoperative pain, rate of wound complication, and postoperative hospital stay did not differ significantly between the 2 groups. Operative time of the SLC group was longer than that of the CLC group (p=0.002). However, the operative time was decreased according to the increasing SLC cases. By 3 months, patients in the SLC group reported significantly better cosmesis (p=0.036). Conclusion: SLC with an auxiliary device (2 mm, Hold port, NELIS) is technically feasible and might be an alternative method for obtaining a critical view of safety and cosmetic results.

Cosmesis and Body Image in Patients Undergoing Single-port Versus Conventional Laparoscopic Cholecystectomy: A Multicenter Double-blinded Randomized Controlled Trial (SPOCC-trial).

To evaluate cosmesis, body image, pain, and quality of life (QoL) after single-port laparoscopic cholecystectomy (SPLC) versus conventional 4-port laparoscopic cholecystectomy (4PLC). The impact of SPLC on improving cosmesis, body image, pain, and QoL has not been evaluated in double-blinded randomized controlled trials (RCT). This approach therefore remains controversial. Between October 2011 and February 2014, 110 patients from 2 centers were randomly assigned to SPLC (n = 55) or 4PLC (n = 55). Primary endpoints were a validated cosmesis (3-24 points) and body image (5-20 points) score after 3 and 12 months. Secondary endpoints included operative duration, postoperative pain, complications, QoL, and length of hospital stay. Patients, physicians, and nurses were blinded until the seventh postoperative day. Demographics were equally distributed between both groups (mean age: 46 years, SD: 14, 62 females, 34 males). The SPLC-group showed superior mean cosmesis and body image compared with the 4PLC-group at 12-weeks (21 vs 16, P < 0.001 and 5 vs 6, P = 0.013, respectively) and at 1-year (24 vs 16, P < 0.001 and 5 vs 6, P < 0.017, respectively). Operation duration was longer in the SPLC-group (mean 101 vs 90 minutes, p = 0.031). Although postoperative pain was less in the SPLC-group (mean VAS 1 vs 2, p = 0.005), there were no differences in complications, and length of hospital-stay. This is the first multicenter double-blinded RCT reporting superior short- and long-term cosmetic and body image, postoperative pain, and QoL in SPLC compared with 4PLC. Although cost-effectiveness is still a subject of ongoing debate, SPLC should be offered to patients undergoing surgery for benign gallbladder disease.

Single Incision Laparoscopic Cholecystectomy Performed via the “Marionette” Technique Shows Equivalence in Outcome and Cost to Standard Four Port Laparoscopic Cholecystectomy in a Selected Patient Population

The aim of our study is to compare single incision laparoscopic cholecystectomy (SILC) performed using the "marionette" technique (m-SILC), to the standard four-port technique [four-port laparoscopic cholecystectomy (4PLC)]. Patient information was extracted from a prospectively maintained database (n = 188). Our primary endpoint was operative costs (determined by operating time and instruments used). Secondary endpoints were length of stay, operative time, blood loss, and postoperative complication rates. Univariate and adjusted multivariate analysis was used to compare the outcomes. There were a total of 188 patients for this study. Gender, body mass index, American Society of Anesthesiologists class, and resident participation were similar. Patients undergoing m-SILC were younger (43.8 vs 49.8 years old), less likely to have cholangiogram (32% vs 54%), and were more likely to undergo cholecystectomy for chronic cholecystitis (73.3% vs 52%). In univariate analysis, cholecystectomy performed by the "marionette method" as compared with the 4PLC was associated with shorter operative time (67 vs 59 minutes respectively) and shorter hospital stay (1.2 vs 2.08 days respectively). In multivariate analysis, SILC was associated with shorter hospital stay and comparable operative time, blood loss, and postoperative complications. Instrumentation cost was less in SILC (by $94). SILC done by an experienced surgeon with the "marionette" technique on a carefully selected population shows a statistically significant cost benefit while maintaining clinically comparable outcomes to the standard 4PLC.

Surgeons take as long as 15 years to reach peak performance, study shows

Surgeons hit a plateau in their performance of 1-15 years depending on the procedure they are performing, a study in the Annals of Surgery has shown.1 A systematic review of 57 studies looking at the influence that experience and the number of procedures carried out have on individual surgeons’ performance found that, after an initial learning phase, surgeons hit a plateau in performance. This level is reached at any time from one to 15 years, or 25 to 750 cases, depending on the complexity of the procedure, the authors found. For example, single port laparoscopic cholecystectomy can be learned in eight cases, whereas it takes at least five years to learn septomeatoplasty, the authors found. They wrote that the presence …

The Feasibility of Fundal Retraction of the Gallbladder in the Single Port Laparoscopic Cholecystectomy: Comparison between a 4-instrument Fundal Retraction Group and a 3-instrument Group

Purpose: Owing to the accumulation of surgical experience, the indications of single port laparoscopic cholecystectomy (SLC) have increased. To overcome the difficulties and limitations of SLC, we included an additional instrument for use in retracting the gallbladder fundus. The aim of this study was to investigate the feasibility of 4-instrument fundal retraction SLC. Methods: We retrospectively analyzed 134 patients who had undergone SLC for benign gallbladder disease. We compared the clinical outcome between patients who had undergone SLC without fundal retraction (3-instrument SLC, n=102) and those who had undergone SLC with fundal retraction (4-instrument fundal retraction SLC, n=32). Results: Of 134 patients, 47 were male and 87 were female. A significantly higher proportion of patients in the 4-instrument fundal retraction group had gallbladder distention and wall thickening than patients in the 3-instrument SLC group. No statistically significant difference in the incidence of pericholecystic inflammation, adhesion, and gallbladder perforation; duration of operation, the incidence of complications, and duration of postoperative hospital stay was observed between the two groups. In univariate analysis to perform 4-instrument fundal retraction SLC, higher BMI, the presence of gallbladder distension, and wall thickening were significant factors. In multivariate analysis, gallbladder distention and the presence of concurrent operation during SLC were independently significant factors for performing 4-instrument fundal retraction SLC. Conclusion: Four-instrument fundal retraction SLC is a feasible and safe surgical procedure, particularly in patients with a high BMI, gallbladder distention, wall thickening, inflammation, or adhesions. If difficulties are encountered during 3-instrument SLC, simple fundal retraction using an additional instrument may be the preferred option prior to converting the operation to conventional laparoscopic cholecystectomy.

A Double-Blinded Randomized Trial to Compare the Effectiveness of Minimally Invasive Procedures Using Patient-Reported Outcomes

The Institute of Medicine has included the comparison of minimally invasive surgical techniques in its research agenda. This study seeks to evaluate a model for the comparison of minimally invasive procedures using patient-reported outcomes. A double-blinded randomized controlled trial (NCT01489436) was conducted. Baseline data were obtained, standardized anesthesia was induced, and patients were randomized to single-port (SP) or 4-port (FP) laparoscopic cholecystectomy. Perioperative care was standardized. The outcomes were pain (Visual Analog Scale) on postoperative day 1 (primary) and quality of life (Patient-Reported Outcomes Measures Information System and Linear Analog Self-Assessment), serum cytokines, and heart rate variability (secondary). Analysis was intention to treat. Using identical occlusive dressings, patients and the outcomes assessor remained blinded until postoperative day 2. Fifty-five patients were randomized to each arm. There was no difference in demographics. Visual Analog Scale pain score on postoperative day 1 was significantly different from baseline in each group (SP: 1.6 ± 1.9 to 4.2 ± 2.4 vs FP: 1.8 ± 2.3 to 4.2 ± 2.2), but not different from each other (p = 0.83). Patients in the FP arm reported significantly less fatigue on postoperative day 7 than patients in the SP group (3.1 ± 2.1 vs 4.2 ± 2.2; p = 0.009). Fewer patients in the FP group required postoperative oral narcotics before discharge (40% vs 60%; p = 0.056). Cytokines levels and heart rate variability were similar between arms. In patients followed for >1 year, no difference in umbilical hernia rates was noted. Early postoperative quality of life data captured differences in fatigue, indicating improved recovery after FP within a controlled trial. Physiologic measures were similar, suggesting that the differences between SP and FP are minimal.

English

This study includes the works of various surgeons who adopted newer methods of gall bladder removal vis a vis standard method of laparoscopic cholecystectomy through 4-ports. Newer methods include Single- incision laparoscopic cholecystectomy (SILC) and Natural Orifice Transluminal Endoscopic Surgery (NOTES). The work of various studies of Laparoscopic Cholecystectomy (LC), a gold standard so far analysed against the newer techniques with respect to complications directly related to the procedure such as biliary injury, bile leak, infection, trochar related injury and post-operative incisional hernia; Post-operative hospital stay and return to work and expenses incurred over the surgical procedure .Laparoscopic cholecystectomy 4-port standard procedure, still rules the roost. Newer methods like SILC and NOTES though around for more than 8 yrs but yet to click with surgeons and more importantly with patients. Patients still find the 4-port LC fine and satisfied with it. Laparoscopic cholecystectomy (4-port LC) continues to be the method of choice with surgeons throughout globe except in few pockets. It has been standardized for procedure details and rate of complications and conversions .Till now apart from some extra advantage of cosmetic superiority newer methods do not provide any extra advantage as far as complications, hospital stay, return to normal activity and treatment cost are concerned.

One, two, or three ports in laparoscopic cholecystectomy?

Single-port laparoscopic cholecystectomy (LC) has been compared with 3- or 4-port LC. To our knowledge, there are no studies comparing the 3-, 2-, and 1-port techniques. Patients were randomized into 3 groups: LC 1-port using SILS, LC 2-port using a laparoscope with a working channel, and LC 3-port using the standard ports. Pain was evaluated at recovery, 4 hours, 24 hours, day 5, and day 8, using an analog visual scale. Homogenous groups in their demographic characteristics; all confirmed gallbladder lithiasis. At recovery, there was less pain in group 1 (P = 0.002); at 4 hours pain was similar in all groups (P = 0.899); at 24 hours there was less pain in groups 2 and 3 (P = 0.031); and at days 5 and 8 there was marginal (P = 0.053) and significant (P = 0.003) relevance. In terms of pain perception, LC performed through 1 port does not offer advantages when compared with 2 or 3 ports. More clinical trials are needed to confirm these data.

A Preliminary Study of Surgeon Stress Measures During Randomized Controlled Trials of 4-port vs. Single Incision Cholecystectomies

With various minimally invasive approaches in the field of surgery and new techniques entering rapidly, it is important to evaluate the effectiveness of these different practices. Information about the impact on both patient and provider can be gained through research investigations. Since the workload placed on the surgeon may influence patient outcomes, this study measured levels of stress and fatigue for the surgeon participating in an NIH randomized control trial of single incision versus 4-port laparoscopic cholecystectomy. Through the administration of the SURG-TLX for 22 Single-Incision Laparoscopic Cholecystectomies and 24 4-port cholecystectomies, physical workload was the only measure statistically different between 4-port and SILC (P=0.028). There was a significant difference in the duration (P=0.029) based on the procedure that was completed. Mental stress was highly correlated to many of the variables in the Surg-TLX and duration, degree of difficulty, and complexity were all highly correlated. This research shows how the SILC procedure can cause more stress on the surgeon. When the situation is combined with longer surgeries, higher complexity, and a higher degree of difficulty, the patient outcomes may be at risk.

Two-port cholecystectomy maintains safety and feasibility in benign gallbladder diseases: A comparative study

Purpose: In an effort to overcome the limitations of single-port laparoscopic cholecystectomy (LC) while preserving the cosmetic benefits of reduced ports cholecystectomy, we have developed a 2-port LC that allows for the full, unrestricted use of 4 laparoscopic instruments.Methods: We retrospectively analyzed data of patients who had undergone either 4-port LC or 2-port LC for benign gallbladder diseases between March 2007 and March 2013. Two incisions of 2-port LC were composed of an umbilical incision as the manner of single-port laparoscopic surgery and a 5-mm epigastric incision. These two incisions were utilized for comfortable bimanual manipulation under the liver-elevated vision provided by a liver retractor.Results: During the study period, 766 patients underwent LC; 263 (34.3%) started with 4-port LC, and 503 (65.7%) started with 2-port LC. Of patients started with 2-port LC, 486 patients (96.6%) was ended up with 2-port without open conversion or addition of port(s). The two groups had similar operative time, open conversion rate, incidence of complications, analgesic requirement, and length of postoperative hospital stay. Multivariate analyses revealed that the independent factors related to prolonged operative time (≥90th percentile) in 2-port LC were the presence of cholecystitis (odds ratio [OR] 2.412, 95% CI 1.246–4.668, p = 0.009) and admission through the emergency department (OR 2.132, 95% CI 1.135–4.004, p = 0.019).Conclusion: This study suggests that 2-port LC for benign gallbladder diseases is as safe and feasible as 4-port LC when it is performed by surgeons trained in conventional laparoscopic techniques.

Can single incision laproscopic cholecystectomy replace the traditional four port laproscopic approach: a review.

The major aim of surgeons has always been a minimalist approach towards surgery, thereby reducing the complications associated with the surgery. The gold standard treatment for cholelithiasis with cholecystitis is currently the four port laparoscopic cholecystectomy (4 PLC). Recently, a newer technique has been introduced which uses a single port, rather than the four ports, for the removal of the gall bladder laparoscopically; it is known as Single Incision Laparoscopic Cholecystectomy (SILC). This is a comparatively minimal approach towards surgery. Therefore the purpose of this review is to compare the advantages and the disadvantages of SILC versus 4PLC, and hence, to give an idea of whether SILC is ready to replace the traditional approach as the new treatment of choice.

English

Single-incision laparoscopic surgery (SILS) is a recent advance that has taken the surgical community by storm. Single-incision laparoscopic cholecystectomy (SILC) is perhaps the most common SILS procedure used to treat patients with gallstone disease. There are three approaches to SILC: (a) one that uses special, purpose-made access devices or ports for introducing the laparoscope and instruments which are usually, but not always, roticulating ones; (b) passing three 5-mm trocars side-by-side through the fascia after exposing a wide area via a single umbilical incision; and (c) using two trocars at the umbilicus along with suspension sutures to retract the gallbladder. This article provides a detailed, step-by-step description of a technique of SILC using standard laparoscopic instruments. AIM: To evaluate the feasibility, advantages and shortcomings of Single Incision Laparoscopic Cholecystectomy using standard laproscopic instruments. METHOD: We attempted SILC in 50 patients between August 2011 and May 2012 and completed it successfully in 45 (unpublished data). The procedures were performed for elective indications (N=50). CONCLUSION: We have presented a technique of SILC using standard laparoscopic instruments that emulates all the steps of a safe multi-port cholecystectomy. We found that the technique has a relatively short learning curve and is reproducible. Preliminary studies show that SILC carries certain benefits over MLC. However, SILC should be considered a technique under evolution and further larger studies are required before it can be accepted as a replacement to Multi port Laparoscopic Cholecystectomy.

Results of the First 100 Single Port Laparoscopic Cholecystectomies in a Secondary Care Hospital

IntroductionDespite the excellent results obtained with standard laparoscopic cholecystectomy, the efforts for minimizing the ports needed to reduce postoperative pain, for a quicker recovery and to improve the patient's cosmetics continue. The aim of this study is to report the results of the first 100 cases of single port laparoscopic cholecystectomy performed in a secondary care hospital. Material and methodsProspective, observational and unicentric study including 100 patients between January 2010 and April 2012. Inclusion criteria: symptomatic cholelythiasis patients over 16 years of age on whom a single port laparoscopic cholecystectomy was performed. Exclusion criteria: history of acute cholecystitis, pancreatitis or suspected choledocholithiasis, Endoscopic retrograde cholangiopancreatography, BMI>35 and previous laparotomies. We studied epidemiological, surgical and safety variables. ResultsThe mean patient age was 39.89±11.5 years. The mean time of the surgical procedure was 67.94±25.5min. There were 2 cases of postoperative complications: a non-infected seroma and a biliar leak. In 2 cases the use of an accessory trocar was needed. The mean hospital stay was 1.13±0.8 days. A total of 35% patients were included in the major ambulatory surgery program. The overall patient satisfaction survey rating showed a high level of cosmetic satisfaction in 100% of patients. ConclusionsSingle port laparoscopic cholecystectomy is a good technique when performed in selected cases by expert surgeons. It is feasible to include the single port laparoscopic cholecystectomy in a major ambulatory surgery program. We have not had serious complications. There is a high cosmetic satisfaction index with this technique.

Tips for single-port laparoscopic cholecystectomy.

Single-port laparoscopic cholecystectomy (SPLC) is an emerging technique and gaining increased attention by its superiority in cosmesis. A 1.5-cm vertical transumbilical incision is used for the single port, followed by the glove method. Indications for SPLC are the same as those for standard 4-port laparoscopic cholecystectomy, including patients with morbid obesity, previous upper abdominal surgery, severe acute cholecystitis, or suspected presence of common bile duct stones. Some randomized controlled trials have shown negative results of SPLC regarding operative time, wound-related complications, and postoperative pain. However, our retrospective analysis shows equivalent clinical outcomes among the two approaches in terms of postoperative pain and complications. In this context, SPLC can be a good option for gallbladder pathologies.

Use of Percutaneous Needles in the Feasibility of Single-port Laparoscopic Cholecystectomy

IntroductionThe usefulness of percutaneous needles (PN) to replace traditional assistance ports in mini-invasive techniques with a single port is analyzed and their feasibility for conducting a single port laparoscopic cholecystectomy (SPLC) is demonstrated. Material and methodsA retrospective, linear and descriptive study covering 2431 patients with a diagnosis of acute and non-acute gallbladder disease has been conducted. The patients underwent a single port laparoscopic cholecystectomy using some type of PNs, replacing the assisting ports used in traditional laparoscopic cholecystectomy (TLC). Based on the progressive use of PNs–reins (R), hooked needles (HN) and passing suture needles (PSN)–to carry out the SPLC technique, 3 groups have been established: A, B and C. The results were compared using a Student t test, odds ratio and CI and were analyzed by means of the SPSS software v. 13.0. ResultsThe use of PNs showed an increased feasibility for the laparoscopic procedure, as they were included in the surgical technique. The R were useful when carrying out the SPLC in 78% of the cases and when the HK were added, the results increased to 88%. When using the 3 types (R, HN and PSN), the results increased by 96%. Statistical significance was obtained with these values: chi 2=67.13 and P<.001; odds ratio and 95% CI became significant when comparing the B/C, A/C, and A–B/C groups. ConclusionsThe PNs, replacing the assisting ports in laparoscopy, make it possible to attain a feasibility of the process in 96% of the cases. This percentage was similar to what is achieved with the TLC, which places the one port laparoscopy surgery technique as an advantageous and economic alternative. This application of the PNs could be made extensive to other single-port techniques, with a multi-valve platform and natural orifice 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.

Fewer-than-four ports versus four ports for laparoscopic cholecystectomy.

Traditionally, laparoscopic cholecystectomy is performed using two 10-mm ports and two 5-mm ports. Recently, a reduction in the number of ports has been suggested as a modification of the standard technique with a view to decreasing pain and improving cosmesis. The safety and effectiveness of using fewer-than-four ports has not yet been established. To assess the benefits (such as improvement in cosmesis and earlier return to activity) and harms (such as increased complications) of using fewer-than-four ports (fewer-than-four-ports laparoscopic cholecystectomy) versus four ports in people undergoing laparoscopic cholecystectomy for any reason (symptomatic gallstones, acalculous cholecystitis, gallbladder polyp, or any other condition). We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 8, 2013), MEDLINE, EMBASE, Science Citation Index Expanded, and the World Health Organization International Clinical Trials Registry Platform portal to September 2013. We included all randomised clinical trials comparing fewer-than-four ports versus four ports, that is, with standard laparoscopic cholecystectomy that is performed with two ports of at least 10-mm incision and two ports of at least 5-mm incision. Two review authors independently identified the trials and extracted the data. We analysed the data using both the fixed-effect and the random-effects models. For each outcome, we calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat analysis, whenever possible. We found nine trials with 855 participants that randomised participants to fewer-than-four-ports laparoscopic cholecystectomy (n = 427) versus four-port laparoscopic cholecystectomy (n = 428). Most trials included low anaesthetic risk participants undergoing elective laparoscopic cholecystectomy. Seven of the nine trials used a single port laparoscopic cholecystectomy and the remaining two trials used three-port laparoscopic cholecystectomy as the experimental intervention. Only one trial including 70 participants had low risk of bias. Fewer-than-four-ports laparoscopic cholecystectomy could be completed successfully in more than 90% of participants in most trials. The remaining participants were mostly converted to four-port laparoscopic cholecystectomy but some participants had to undergo open cholecystectomy.There was no mortality in either group in the seven trials that reported mortality (318 participants in fewer-than-four-ports laparoscopic cholecystectomy group and 316 participants in four-port laparoscopic cholecystectomy group). The proportion of participants with serious adverse events was low in both treatment groups and the estimated RR was compatible with a reduction and substantial increased risk with the fewer-than-four-ports group (6/318 (1.9%)) and four-port laparoscopic cholecystectomy group (0/316 (0%)) (RR 3.93; 95% CI 0.86 to 18.04; 7 trials; 634 participants; very low quality evidence). The estimated difference in the quality of life (measured between 10 and 30 days) was imprecise (standardised mean difference (SMD) 0.18; 95% CI -0.05 to 0.42; 4 trials; 510 participants; very low quality evidence), as was the proportion of participants in whom the laparoscopic cholecystectomy had to be converted to open cholecystectomy between the groups (fewer-than-four ports 3/289 (adjusted proportion 1.2%) versus four port: 5/292 (1.7%); RR 0.68; 95% CI 0.19 to 2.35; 5 trials; 581 participants; very low quality evidence). The fewer-than-four-ports laparoscopic cholecystectomy took 14 minutes longer to complete (MD 14.44 minutes; 95% CI 5.95 to 22.93; 9 trials; 855 participants; very low quality evidence). There was no clear difference in hospital stay between the groups (MD -0.01 days; 95% CI -0.28 to 0.26; 6 trials; 731 participants) or in the proportion of participants discharged as day surgery (RR 0.92; 95% CI 0.70 to 1.22; 1 trial; 50 participants; very low quality evidence) between the two groups. The times taken to return to normal activity and work were shorter by two days in the fewer-than-four-ports group compared with four-port laparoscopic cholecystectomy (return to normal activity: MD -1.20 days; 95% CI -1.58 to -0.81; 2 trials; 325 participants; very low quality evidence; return to work: MD -2.00 days; 95% CI -3.31 to -0.69; 1 trial; 150 participants; very low quality evidence). There was no significant difference in cosmesis scores at 6 to 12 months between the two groups (SMD 0.37; 95% CI -0.10 to 0.84; 2 trials; 317 participants; very low quality evidence). There is very low quality evidence that is insufficient to determine whether there is any significant clinical benefit in using fewer-than-four-ports laparoscopic cholecystectomy compared with four-port laparoscopic cholecystectomy. The safety profile of using fewer-than-four ports is yet to be established and fewer-than-four-ports laparoscopic cholecystectomy should be reserved for well-designed randomised clinical trials.

Clinical Evaluation of an Internal Adjustable Retractor in Laparoscopic Cholecystectomy

Reducing the number of abdominal incisions in laparoscopic cholecystectomy introduces ergonomic challenges while establishing the critical view during dissection of the triangle of Calot (TC). This study investigates the use of a novel internal retracting device in performing cholecystectomy with a reduced number of ports. A 3-port laparoscopic cholecystectomy was attempted by 4 surgeons unfamiliar with the novel device. Exposure of the TC was obtained using the internal retractor, which comprises 2 clips, linked by an adjustable thread. One clip is fixed on the gallbladder and the other is fixed to the peritoneum. The endpoint was to evaluate the efficacy and reliability of the device in establishing the critical view of safety. Thirteen patients with a mean body mass index of 25.29 kg/m(2) (standard deviation = 6.24; range = 17.6-36.7 kg/m(2)) were included in the study. The critical view was obtained in 10 of 13 patients. Application of the device was completed in a median time of 2.25 minutes without injury of the gallbladder or bile leak. Failure occurred in 3 patients, related to wrong manipulation of the device (2 patients), and correct placement of the device but inadequate exposure (1 patient). A conventional 4-port technique was used in these patients. Operators rated their experience with the device as an "easy-to-operate" device with a good safety profile and without any interference with the operative process. Throughout the minimization process specific to minimal access surgery, internal retractors will certainly allow for a reduction in the number of trocars used in laparoscopic procedures.

Clinical efficacy of transumbilical single-port laparoscopic cholecystectomy with ultrasonic knife for directly handling cystic artery

Objective To investigate the clinical feasibility and value of transumbilical single- port laparoscopic cholecystectomy with intraoperative ultrasonic knife for directly handling the cystic artery.Methods A retrospective analysis was performed on the clinical data of 231 patients who underwent laparoscopic cholecystectomy with intraoperative ultrasonic knife for directly handling the cystic artery in our department from March 2011 to December 2012.According to the required surgical approaches,the patients were divided into transumbilical single- port laparoscopic group(n = 125,group A) and three- port laparoscopic group(n = 106,group B).The two groups were compared in terms of operative time,intraoperative blood loss,postoperative analgesia,postoperative food intake,length of postoperative hospital stay,and postoperative complications,as well as the performance of the ultrasonic knife in directly handling the cystic artery.Comparison of continuous data between groups was made by t test,while comparison of categorical data was made by chi- square test.Results Group A had a significantly longer mean operative time than group B(20.21 ± 1.86 min vs 18.43 ± 1.37 min,P 0.05).There was no significant difference in mean intraoperative blood loss between groups A and B(23.23 ± 6.25 ml vs 22.34 ± 5.49 ml,P 0.05).Group A had significantly fewer patients who needed postoperative analgesia than group B(5 vs 21,P 0.05).The time to postoperative food intake showed no significant difference between groups A and B(6.56 ± 1.23 h vs 6.67 ± 1.45 h,P 0.05).The mean length of postoperative hospital stay was(2.98 ± 0.23) d in group A,versus(3.02 ± 0.18) d in group B(P 0.05).No indwelling drainage tube was used after operation in either group.There were no postoperative bleeding,bile duct injury,bile leakage,incisional wound infection,and other complications in the two groups.The ultrasonic knife had reliable hemostatic effect when directly sealing the cystic artery,without causing postoperative secondary bleeding.All patients were followed up for 2- 12 months(mean,6.5 months);they recovered well without incisional hernia,and the umbilical scar was not obvious,with relatively good cosmetic results.Conclusion Transumbilical single- port laparoscopic cholecystectomy has a comparable clinical effect to three- port laparoscopic cholecystectomy,causing little trauma,postoperative pain,and scar,and it is suitable for patients with a high demand for incision appearance.Directly sealing the cystic artery with the ultrasonic knife can reduce bleeding due to careful separation of the cystic artery and shorten the operative time.Therefore,it is a safe,feasible surgical approach and worthy of clinical application.