Minilaparoscopic versus conventional laparoscopic cholecystectomy a systematic review and meta-analysis. Ann Surg. 2011;253:244-258. [PMID: 21183848 DOI: 10.1097/sla.0b013e318207bf52]

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

Abstract

The current gold-standard surgical treatment for symptomatic gallstone disease is the conventional four-port laparoscopic cholecystectomy (CLC). In recent years, however, celebrities and social media have altered people's attitudes regarding surgery. Consequently, CLC has undergone several changes to reduce scarring and improve patient satisfaction. In this case-matched control study, the cost-effectiveness of a modified endoscopic minimally invasive reduced appliance technique (Emirate) that uses less equipment and three 5 mm reusable ports only at precisely specified anatomical sites was compared to CLC.

Methods

Single-center retrospective matched cohort analysis including 140 consecutive patients treated with Emirate laparoscopic cholecystectomy ("ELC-group"), matched 1:1 by sex, indications for surgery, surgeon expertise, and preop bile duct imaging, with 140 patients receiving CLC in the same period of time ("CLC group").

Results

We performed a retrospective case-matched review of 140 patients who had Emirate laparoscopic cholecystectomy for gallstones between January 2019 and December 2022. The groups included 108 females and 32 males with an equal ratio of surgical expertise-115 procedures were performed by consultants and 25 by trainees. In each group, 18 patients had preoperative MRCP or ERCP and 20 had acute cholecystitis as indications for surgery. Preoperative characteristics such as age (39 years in the Emirates group and 38.6 years in the CLC group), BMI (29.3 years in the Emirates group and 30 years in the CLC group), stone size, or liver enzymes showed no statistical difference between the two groups. In both groups, the average hospital stay was 1.5 days, and there was no conversion to open surgery, nor was there any bleeding requiring blood transfusion, bile leakage, stone slippage, bile duct injury, or invasive intervention postoperatively. When compared to the CLC group, the ELC group had significantly faster surgery times (t-test, p = 0.001), lower levels of the bile duct enzyme ALP (p = 0.003), and much lower costs (t-test, p = 0.0001).

Conclusion

The Emirate laparoscopic cholecystectomy method is a safe alternative to the traditional four-port laparoscopic cholecystectomy that is also much faster and less expensive.

Suprapubic Cholecystectomy Improves Cosmetic Outcome Compared to Classic Cholecystectomy

Currently, cholecystectomy is performed laparoscopically. While the conventional approach (CA) with four access ports persists, other methods seek to reduce trauma or to optimize cosmetic results. In this study, the safety and cosmetic outcome of a suprapubic approach (SA) were evaluated. Between 2015 and 2016, patients undergoing elective cholecystectomy either by CA or by a suprapubic approach (SA) at our institution were included. The cosmetic outcome, postoperative morbidity, operative time and length of stay were evaluated. Pictures of the site of intervention were taken 6−12 months postoperatively and rated on a scale from 1 (unsatisfying aesthetic result) to 5 (excellent aesthetic result). Five “non-medical” and five “medical” raters as well as one board-certified plastic surgeon performed the ratings. A total of 70 patients were included (n = 28 SA, n = 42 CA). The two groups did not differ in baseline characteristics (age, gender, BMI). The SA group showed a significantly better aesthetic outcome compared to the CA group 4.8 (4.8−4.9) vs. 4.2 (3.8−4.4), (p > 0.001). Medical raters: 4.0 (3.8−4.2) vs. 4.8 (4.6−5.0), (p < 0.001); non-medical raters: 4.2 (3.8−4.6) vs. 5.0 (4.8−5.0), (p < 0.001); plastic surgeon: 4.0 (4.0−4.0) vs. 5.0 (5.0−5.0), (p < 0.001). Fair interrater consistency was demonstrated with an ICC of 0.47 (95% CI = 0.38−0.57). No significant difference in the complication rate (1 (3.5%) in SA vs. 6 (14%) in CA, (p = 0.3)), or the operating time 66 (50−86) vs. 70 (65−82) min, (p = 0.3), were observed. Patients stayed for a median of three (3−3) days in the SA group and 3 (3−4) days in the CA group (p = 0.08). This study demonstrated that the suprapubic approach is an appropriate alternative to conventional laparoscopic cholecystectomy, presenting a better cosmetic outcome with a similar complication rate.

Acupuncture for Pain and Function in Patients with Nonspecific Low Back Pain: Study Protocol for an Up-to-Date Systematic Review and Meta-Analysis

Aim

Design

Methods

Results

OUP accepted manuscript

Minilaparoscopic cholecystectomy was proposed with the aim to improve the cosmesis and reduce the impact on the abdominal wall. Our aim was to analyze the knowledge currently available on this topic with a review of literature and with our experience to suggest patient-centered approach over the use of minilaparoscopic cholecystectomies and appendectomies. From January 2021 to October 2021, we performed 21 minilaparoscopic cholecystectomies and 12 minilaparoscopic appendectomies. Within the established 1-month and 3-month follow-up intervals, clinical examination and scar evaluation were assessed and a satisfaction questionnaire was completed by all the patients. No intraoperative or postoperative complications were recorded. Patients’ pain decreases significantly during hospital stay and 30 patients (90,1%) were discharged with VAS 0. The same happened with aesthetic score, that was 2,23 the postoperative-day-1, decrease to 1,87 1 week later and was 1,12 at 1- and 3-month follow-up.

Comparative outcomes of needlescopic, single-incision laparoscopic, standard laparoscopic, mini-laparotomy, and open cholecystectomy: A systematic review and network meta-analysis of 96 randomized controlled trials with 11,083 patients

BACKGROUND

Most randomized trials on minimally invasive cholecystectomy have been conducted with standard (3/4-port) laparoscopic or open cholecystectomy serving as the control group. However, there exists a dearth of head-to-head trials that directly compare different minimally invasive techniques for cholecystectomy (eg, single-incision laparoscopic cholecystectomy versus needlescopic cholecystectomy). Hence, it remains largely unknown how the different minimally invasive cholecystectomy techniques fare up against one another.

METHODS

To minimize selection and confounding biases, only randomized controlled trials were considered for inclusion. Perioperative outcomes were compared using frequentist network meta-analyses. The interpretation of the results was driven by treatment effects and surface under the cumulative ranking curve values. A sensitivity analysis was also undertaken focusing on a subgroup of randomized controlled trials, which recruited patients with only uncomplicated cholecystitis.

RESULTS

Ninety-six eligible randomized controlled trials comprising 11,083 patients were identified. Risk of intra-abdominal infection or abscess, bile duct injury, bile leak, and open conversion did not differ significantly between minimally invasive techniques. Needlescopic cholecystectomy was associated with the lowest rates of wound infection (surface under the cumulative ranking curve value = 0.977) with an odds ratio of 0.095 (95% confidence interval: 0.023-0.39), 0.32 (95% confidence interval: 0.11-0.98), 0.33 (95% confidence interval: 0.11-0.99), 0.36 (95% confidence interval: 0.14-0.98) compared to open cholecystectomy, single-incision laparoscopic cholecystectomy, mini-laparotomy, and standard laparoscopic cholecystectomy, respectively. Mini-laparotomy was associated with the shortest operative time (surface under the cumulative ranking curve value = 0.981) by a mean difference of 22.20 (95% confidence interval: 13.79-30.62), 12.17 (95% confidence interval: 1.80-22.54), 9.07 (95% confidence interval: 1.59-16.54), and 8.36 (95% confidence interval: -1.79 to 18.52) minutes when compared to single-incision laparoscopic cholecystectomy, needlescopic cholecystectomy, standard laparoscopic cholecystectomy, and open cholecystectomy, respectively. Needlescopic cholecystectomy appeared to be associated with the shortest hospitalization (surface under the cumulative ranking curve value = 0.717) and lowest postoperative pain (surface under the cumulative ranking curve value = 0.928).

CONCLUSION

Perioperative outcomes differed across minimally invasive techniques and, in some instances, afforded superior outcomes compared to standard laparoscopic cholecystectomy. These findings suggest that there may be equipoise for exploring further the utility of novel minimally invasive techniques and potentially incorporating them into the general surgery training curriculum.

Minilaparoscopic Cholecystectomy Versus Conventional Laparoscopic Cholecystectomy: An Endless Debate

Background: Our systematic review and meta-analysis examine the impact of minilaparoscopic cholecystectomy (MLC) versus conventional laparoscopic cholecystectomy (CLC). Some authors previously compared these surgical approaches without reaching any clear conclusion, since then, further trials have been performed, but an update was needed. Materials and Methods: PubMed, EMBASE, and the CENTRAL were systematically searched for randomized controlled trials comparing MLC versus CLC up to August 2019. The outcome measures used for comparison were operative time (OT), overall morbidity, intra- and postoperative complications, conversion and reintervention rate, length of hospital stay (LOS), postoperative pain (POP), and cosmetic results. A meta-analysis of relevant studies was performed using RevMan 5.3. Results: Fifteen studies, including 863 patients, were considered eligible to collect data and entered the meta-analysis. A total of 415 patients in the MLC group versus 448 in the CLC group were compared. No statistical difference as for overall morbidity, intra- and postoperative complications, conversion and reintervention rate, LOS, and cosmetic results were retrieved among the groups. CLC results faster and MLC shows to be the least painful. Conclusions: According to the available high-level evidence, both surgical approaches resulted substantially equivalent to perform LC, with some advantages of CLC as for OT and of MLC concerning POP. As a consequence, we can conclude that either procedure is superior or inferior to the other one; actually, we are not able to suggest the adoption of any of the two on a routine basis.

Hybrid Transvaginal NOTES and Mini-Laparoscopic Colectomy: Benefit Through Synergy

Background and Objectives:

Hybrid-natural orifice surgery combines the advantages of traditional transabdominal laparoscopic surgery, while limiting surgical trauma to the abdominal wall. Among various routes of intra-abdominal access, the transvaginal method is most appealing because of its utility and proven safety. We describe a series of 4 colonic resections performed with this approach, combined with minilaparoscopy and needlescopic approaches, and discuss the technical aspects, efficacy, and applicability of this technique.

Methods:

Three patients were selected to undergo hybrid transvaginal natural-orifice right hemicolectomy. A fourth patient, who underwent a segmental resection of a splenic flexure carcinoma, was included. Transvaginal port access was obtained via posterior colpotomy, and was used for dissection, vascular ligation, bowel division, and anastomosis. We used a combination of standard laparoscopic, minilaparoscopic, and needlescopic instruments transabdominally, focusing on reduced size and number of access points.

Results:

Duration of laparoscopy, oncologic outcomes and rate of operative morbidity were comparable to the published literature. Early return of gastrointestinal function and low analgesic requirements was observed in all patients. No morbidity related to transvaginal access was observed and the procedure was performed without difficulty in all cases.

Conclusion:

Colonic resection performed by hybrid natural-orifice technique offers several advantages over purely transabdominal laparoscopic procedures. Transvaginal access is easy to perform and offers excellent safety, efficacy, and versatility, especially for right hemicolectomy. Techniques to reduce abdominal wall surgical trauma, such as minilaparoscopy and needlescopic graspers, can be combined effectively in colonic resections, and may act synergistically to reduce postoperative pain and improve outcomes.

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

INTRODUCTION

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).

METHODS

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 5 mm in CLC and 3 mm in MLC. Primary outcome was self-reported physical activity 1 month 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 3 months. Patients received identical surgical dressings for 1 week, and assessors were blinded to group allocation.

RESULTS

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 1 month (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 3 months, 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).

CONCLUSION

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

INTRODUCTION

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.

METHODS

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.

RESULTS

From 2012 to 2015, 200 MLC were performed (F/M: 132/68, mean age 45±16 years). Mean operative duration was 97±32min for the first 50 patients and 75±25min for the subsequent 150 patients (P<0.0001). Modifications in the number or size of trocars were necessary in nine of the first 50 procedures and in seven of the subsequent 150 procedures (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±1855 euros. This cost decreased from 2946±3115 euros in the first 50 patients to 1390±1278 euros in the subsequent 150 patients (P=0.001).

CONCLUSION

Mini-laparoscopy can be used for routine elective cholecystectomy. This approach is associated with low morbidity and good cosmetic results.

Minilaparoscopy-assisted transumbilical laparoscopic cholecystectomy

The role of laparoscopy in the modern surgery era is well established. With the prospect of being able to improve the already privileged current situation, new alternatives have been proposed, such as natural orifice endoscopic surgery (NOTES), the method for single transumbilical access (LESS - Laparo-endoscopic single-site surgery) and minilaparoscopy (MINI). The technique proposed by the authors uses a laparoscope with an operative channel like the flexible endoscope used in NOTES. All operative times are carried out through the umbilical trocar as in LESS, and assisted by a minilaparoscopy grasper. This new technic combines, and results from, the rationalization of technical particularities and synergy of these three approaches, seeking to join their advantages and minimize their disadvantages. RESUMO O papel da videolaparoscopia na era moderna da cirurgia encontra-se bem estabelecido. Com a perspectiva de ser possível melhorar a já privilegiada situação atual, novas alternativas têm sido propostas, como a cirurgia por orifícios naturais (NOTES), o método por acesso único transumbilical (LESS - Laparo-endoscopic single-site surgery) e a minilaparoscopia (MINI). A técnica proposta pelos autores utiliza-se de óptica com canal de trabalho como o endoscópio flexível do NOTES, executa-se todos os tempos operatórios pelo trocarte umbilical, como no LESS, e é assistido por pinça de minilaparoscopia. Esta nova técnica combina e resulta da racionalização de particularidades técnicas e do sinergismo destas três abordagens, buscando agregar suas vantagens e minimizar as suas desvantagens.

Diagnosis and treatment of cholelithiasis: A review based on meta-analyses

Cholelithiasis is common disease whose diagnosis and treatment are important for doctors. Nowadays, main diagnostic methods include X-ray, ultrasonography, CT and MRI. Major treatments are surgical and endoscopic approaches. With evidence based medicine developing, more and more meta-analyses, which provide much best evidence, are reported. By means of summarizing these meta-analyses, we provide the best evidence for clinicians to update their knowledge on the diagnosis and treatment of cholelithiasis.

Trocar types in laparoscopy

BACKGROUND

Laparoscopic surgery has led to great clinical improvements in many fields of surgery; however, it requires the use of trocars, which may lead to complications as well as postoperative pain. The complications include intra-abdominal vascular and visceral injury, trocar site bleeding, herniation and infection. Many of these are extremely rare, such as vascular and visceral injury, but may be life-threatening; therefore, it is important to determine how these types of complications may be prevented. It is hypothesised that trocar-related complications and pain may be attributable to certain types of trocars. This systematic review was designed to improve patient safety by determining which, if any, specific trocar types are less likely to result in complications and postoperative pain.

OBJECTIVES

To analyse the rates of trocar-related complications and postoperative pain for different trocar types used in people undergoing laparoscopy, regardless of the condition.

SEARCH METHODS

Two experienced librarians conducted a comprehensive search for randomised controlled trials (RCTs) in the Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, CDSR and DARE (up to 26 May 2015). We checked trial registers and reference lists from trial and review articles, and approached content experts.

SELECTION CRITERIA

RCTs that compared rates of trocar-related complications and postoperative pain for different trocar types used in people undergoing laparoscopy. The primary outcomes were major trocar-related complications, such as mortality, conversion due to any trocar-related adverse event, visceral injury, vascular injury and other injuries that required intensive care unit (ICU) management or a subsequent surgical, endoscopic or radiological intervention. Secondary outcomes were minor trocar-related complications and postoperative pain. We excluded trials that studied non-conventional laparoscopic incisions.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted the study selection, risk of bias assessment and data extraction. We used GRADE to assess the overall quality of the evidence. We performed sensitivity analyses and investigation of heterogeneity, where possible.

MAIN RESULTS

We included seven RCTs (654 participants). One RCT studied four different trocar types, while the remaining six RCTs studied two different types. The following trocar types were examined: radially expanding versus cutting (six studies; 604 participants), conical blunt-tipped versus cutting (two studies; 72 participants), radially expanding versus conical blunt-tipped (one study; 28 participants) and single-bladed versus pyramidal-bladed (one study; 28 participants). The evidence was very low quality: limitations were insufficient power, very serious imprecision and incomplete outcome data. Primary outcomesFour of the included studies reported on visceral and vascular injury (571 participants), which are two of our primary outcomes. These RCTs examined 473 participants where radially expanding versus cutting trocars were used. We found no evidence of a difference in the incidence of visceral (Peto odds ratio (OR) 0.95, 95% confidence interval (CI) 0.06 to 15.32) and vascular injury (Peto OR 0.14, 95% CI 0.0 to 7.16), both very low quality evidence. However, the incidence of these types of injuries were extremely low (i.e. two cases of visceral and one case of vascular injury for all of the included studies). There were no cases of either visceral or vascular injury for any of the other trocar type comparisons. No studies reported on any other primary outcomes, such as mortality, conversion to laparotomy, intensive care admission or any re-intervention. Secondary outcomesFor trocar site bleeding, the use of radially expanding trocars was associated with a lower risk of trocar site bleeding compared to cutting trocars (Peto OR 0.28, 95% CI 0.14 to 0.54, five studies, 553 participants, very low quality evidence). This suggests that if the risk of trocar site bleeding with the use of cutting trocars is assumed to be 11.5%, the risk with the use of radially expanding trocars would be 3.5%. There was insufficient evidence to reach a conclusion regarding other trocar types, their related complications and postoperative pain, as no studies reported data suitable for analysis.

AUTHORS' CONCLUSIONS

Data were lacking on the incidence of major trocar-related complications, such as visceral or vascular injury, when comparing different trocar types with one another. However, caution is urged when interpreting these results because the incidence of serious complications following the use of a trocar was extremely low. There was very low quality evidence for minor trocar-related complications suggesting that the use of radially expanding trocars compared to cutting trocars leads to reduced incidence of trocar site bleeding. These secondary outcomes are viewed to be of less clinical importance.Large, well-conducted observational studies are necessary to answer the questions addressed in this review because serious complications, such as visceral or vascular injury, are extremely rare. However, for other outcomes, such as trocar site herniation, bleeding or infection, large observational studies may be needed as well. In order to answer these questions, it is advisable to establish an international network for recording these types of complications following laparoscopic surgery.

Systematic review and meta-analysis of single-port versus conventional laparoscopic hysterectomy

BACKGROUND

The choice between single-port laparoscopic hysterectomy (SPLH) and conventional laparoscopic hysterectomy (CLH) remains unclear.

OBJECTIVES

To evaluate the feasibility, safety, and comparative effectiveness of SPLH and CLH.

SEARCH STRATEGY

PubMed, Web of Science, and the Cochrane Library were searched in February 2015 using combinations of the terms "single port," "single incision," "single site," "laparoscopic hysterectomy," and "laparoendoscopic hysterectomy."

SELECTION CRITERIA

Randomized controlled trials (RCTs) and retrospective studies comparing SPLH and CLH were included if they reported at least one quantitative outcome.

DATA COLLECTION AND ANALYSIS

Study characteristics, quality, and outcomes were assessed. The primary outcomes were procedure failure and perioperative complications. Odds ratio (ORs) and 95% confidence intervals (CIs) were calculated.

MAIN RESULTS

Eighteen studies (6 RCTs, 12 retrospective studies) were included. As compared with CLH, SPLH had a higher failure rate (OR 6.37, 95% CI 3.34-12.14; P<0.001). The frequency of perioperative complications did not differ (OR 0.89, 95% CI 0.45-1.74; P=0.73).

CONCLUSIONS

There is no significant difference in the frequency of perioperative complications between SPLH and CLH. However, the higher rate of procedure failure in SPLH should be taken into consideration.

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.

Comparison of surgical outcomes and cosmetic results between standard and mini laparoscopic pyeloplasty in children younger than 1 year of age

OBJECTIVE

To evaluate safety, efficacy, and cosmetic results after mini laparoscopic (mL) pyeloplasty and standard (sL) pyeloplasty in children younger than 1 year of age with ureteropelvic junction obstruction (UPJO).

MATERIALS AND METHODS

From August 2009 to March 2011, 20 sL pyeloplasties were performed in pediatric patients younger than 1 year of age; afterwards, 20 patients younger than 1 year of age underwent mini laparoscopic (mL) pyeloplasty from June 2011 to August 2012. The patients were followed by urine culture and ultrasonography at 3 and 6 months after surgery. Cosmetic appearance was assessed in all patients in both groups group 3 months after surgery using the Patient Scar Assessment Questionnaire.

RESULTS

Peri and postoperative results revealed that operative time (total and anastomosis of ureteropelvic junction), hospital stay, and overall complication rate were significantly lower in mL than in sL. Persistent hydronephrosis in follow-up imaging and recurrence of obstruction was not observed in any cases. Mean appearance score and consciousness score showed significantly better results in the mL group.

CONCLUSION

We believe that mL pyeloplasty in infant cases with UPJO is more cosmetically pleasing and less invasive than sL pyeloplasty and has similar functional outcomes.

A comparison of open and minimally invasive surgery for hepatic and pancreatic resections using the Nationwide Inpatient Sample

BACKGROUND

The use of minimally invasive surgery (MIS) techniques for pancreatic and liver operations remains ill defined. We sought to compare inpatient outcomes among patients undergoing open versus MIS pancreas and liver operations using a nationally representative cohort.

METHODS

We queried the Nationwide Inpatient Sample database for all major pancreatic and hepatic resections performed between 2000 and 2011. Appropriate International Classification of Diseases, 9th Revision (ICD-9) coding modifiers for laparoscopy and robotic assist were used to categorize procedures as MIS. Demographics, comorbidities, and inpatient outcomes were compared between the open and MIS groups.

RESULTS

A total of 65,033 resections were identified (pancreas, n = 36,195 [55.7%]; liver, n = 28,035 [43.1%]; combined pancreas and liver, n = 803 [1.2%]). The overwhelming majority of operations were performed open (n = 62,192, 95.6%), whereas 4.4% (n = 2,841) were MIS. The overall use of MIS increased from 2.3% in 2000 to 7.5% in 2011. Compared with patients undergoing an open operation, MIS patients were older and had a greater incidence of multiple comorbid conditions. After operation, the incidence of complications for MIS (pancreas, 35.4%; liver, 29.5%) was lower than for open (pancreas, 41.6%; liver, 33%) procedures (all P < .05) resulting in a shorter median length of stay (8 vs 7 days; P = .001) as well as a lower in-hospital mortality (5.1% vs 2.8%; P = .001).

CONCLUSION

During the last decade, the number of MIS pancreatic and hepatic operations has increased, with nearly 1 in 13 HPB cases now being performed via an MIS approach. Despite MIS patients tending to have more preoperative medical comorbidities, postoperative morbidity, mortality, and duration of stay compared favorably with open surgery.

Transvaginal hybrid NOTES cholecystectomy--results of a randomized clinical trial after 6 months

INTRODUCTION

For cholecystectomy (CHE), both the needlescopic three-trocar technique with 2-3-mm instruments (needlescopic cholecystectomy (NC)) and the umbilically assisted transvaginal technique with rigid instruments (transvaginal cholecystectomy (TVC)) have been established for further reduction of the trauma remaining from laparoscopy.

METHODS

To compare the further outcome of both techniques for elective CHE in female patients, we analyzed the secondary end points of a prospective randomized single-center trial (needlescopic versus transvaginal cholecystectomy (NATCH) trial; ClinicalTrials.gov Identifier: NCT0168577), in particular, satisfaction with aesthetics, overall satisfaction, abdominal pain, and incidence of trocar hernias postoperatively at both 3 and 6 months. After 3 months, the domains "satisfaction" and "pain" of the German version of the Female Sexual Function Index (FSFI-d) were additionally evaluated to detect respective complications. A gynecological control examination was conducted in all TVC patients after 6 months.

RESULTS

Forty patients were equally randomized into the therapy and the control groups between February 2010 and June 2012. No significant differences were found for overall satisfaction with the surgical result, abdominal pain, sexual function, and the rate of trocar hernias. However, aesthetics were rated significantly better by TVC patients both after 3 and after 6 months (P = 0.004 and P < 0.001). There were no postoperative pathological gynecological findings.

CONCLUSIONS

Following TVC, there is a significantly better aesthetic result as compared to NC, even at 3 and 6 months after the procedure. No difference was found for sexual function.

Single-incision versus standard multiple-incision laparoscopic cholecystectomy: a meta-analysis of experimental and observational studies

OBJECTIVE

The advantages of single-incision surgery for the treatment of gallstone disease is debated. Previous meta-analyses comparing single-incision laparoscopic cholecystectomy (SILC) and standard laparoscopic multiport cholecystectomy (SLMC) included few and underpowered trials. To overcome this limitation, we performed a meta-analysis of randomized and nonrandomized studies.

METHODS

A MEDLINE, EMBASE, and Cochrane Library literature search of studies published in and comparing SILC with SLMC was performed. The primary outcome was safety of SILC as measured by the overall rate of postoperative complications and biliary spillage. Feasibility was another primary outcome as measured by the conversion and operative time. Postoperative pain, length of hospital stay, perioperative blood loss, time to return to normal activity, and cosmetic satisfaction were secondary outcomes.

RESULTS

We identified 43 studies of which 30 were observational reports and 13 experimental trials, for a total of 7489 patients (2090 SILC and 5389 SLMC). The overall rate of complications was comparable between groups (relative risk [RR] = 1.08; 95% CI = 0.87-1.35; P = .46), as were the rates of biliary spillage (RR = 1.16; 95% CI = 0.73-1.84; P = .53) and conversion rate (RR = 0.88; 95% CI = 0.53-1.46; P = .62). Operative time was in favor of SLMC (weighted mean difference = 0.73; 95% CI = 0.67-0.79; P < .0001). Secondary outcomes favored SILC, but with marginal advantages.

CONCLUSIONS

SILC is a feasible technique but without any significant advantage over SLMC for relevant end points. Although secondary outcomes favored SILC, the small magnitude of the advantage and the low quality of assessment methods question the clinical significance of these benefits.

A prospective, randomized, controlled, trial comparing occult-scar incision laparoscopic cholecystectomy and classic three-port laparoscopic cholecystectomy

BACKGROUND

This study was designed to evaluate the outcome of laparoscopic cholecystectomy by comparing a new technique using occult-scar incision for laparoscopic cholecystectomy (OSLC) with classic three-port laparoscopic cholecystectomy (CLC). In the occult-scar incision, we moved the subcostal and subxiphoid trocar insertion sites to the suprapubic area so that operative scars were hidden in the pubic hairs and below umbilicus.

METHODS

Between July 2009 and 2012, patients undergoing laparoscopic cholecystectomy were randomized to the OSLC or CLC approach after obtaining informed consent. Outcome was measured by operative time, operative complications, hospital length of stay, cost, analgesia required after surgery, and cosmetic outcomes. The patient satisfaction score (PSS) and visual analog score (VAS) also were used to evaluated the level of cosmetic result and postoperative pain.

RESULTS

A total of 75 patients were randomized into CLC (n = 35) and OSLC (n = 40) groups. No patient was converted to an open procedure in either the CLC or OSLC group. No operative complications were reported within 30 days in either group. The PSS of 7 and 30 days after surgery were both significantly higher in the OSLC group than in the CLC group (5.8 ± 1.5 vs. 8.0 ± 1.1, P = 0.03; 6.5 ± 1.2 vs. 9.2 ± 0.8, P = 0.02). The VAS for pain was significantly lower in the OSLC group on postoperative day 3 compared with the CLC group (2.6 ± 1.2 vs. 6.3 ± 0.9, P = 0.01). There was no significant difference in operative time, hospital stay, and cost between the two groups.

CONCLUSIONS

The OSLC is a safe and feasible alternative compared with CLC in experienced hands, and it is superior for outcomes regarding pain control and cosmesis.

Miniports versus standard ports for laparoscopic cholecystectomy

BACKGROUND

In conventional (standard) port laparoscopic cholecystectomy, four abdominal ports (two of 10 mm diameter and two of 5 mm diameter) are used. Recently, use of smaller ports, miniports, have been reported.

OBJECTIVES

To assess the benefits and harms of miniport (defined as ports smaller than the standard ports) laparoscopic cholecystectomy versus standard port laparoscopic cholecystectomy.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until February 2013 to identify randomised clinical trials of relevance to this review.

SELECTION CRITERIA

Only randomised clinical trials (irrespective of language, blinding, or publication status) comparing miniport versus standard port laparoscopic cholecystectomy were considered for the review.

DATA COLLECTION AND ANALYSIS

Two review authors collected the data independently. We analysed the data with both fixed-effect and random-effects models using RevMan analysis. For each outcome we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI).

MAIN RESULTS

We included 12 trials with 734 patients randomised to miniport laparoscopic cholecystectomy (380 patients) versus standard laparoscopic cholecystectomy (351 patients). Only one trial which included 70 patients was of low risk of bias. Miniport laparoscopic cholecystectomy could be completed successfully in more than 80% of patients in most trials. The remaining patients were mostly converted to standard port laparoscopic cholecystectomy but some were also converted to open cholecystectomy. These patients were included for the outcome conversion to open cholecystectomy but excluded from other outcomes. Accordingly, the results of the other outcomes are on 343 patients in the miniport laparoscopic cholecystectomy group and 351 patients in the standard port laparoscopic cholecystectomy group, and therefore the results have to be interpreted with extreme caution.There was no mortality in the seven trials that reported mortality (0/194 patients in miniport laparoscopic cholecystectomy versus 0/203 patients in standard port laparoscopic cholecystectomy). There were no significant differences between miniport laparoscopic cholecystectomy and standard laparoscopic cholecystectomy in the proportion of patients who developed serious adverse events (eight trials; 460 patients; RR 0.33; 95% CI 0.04 to 3.08) (miniport laparoscopic cholecystectomy: 1/226 (adjusted proportion 0.4%) versus standard laparoscopic cholecystectomy: 3/234 (1.3%); quality of life at 10 days after surgery (one trial; 70 patients; SMD -0.20; 95% CI -0.68 to 0.27); or in whom the laparoscopic operation had to be converted to open cholecystectomy (11 trials; 670 patients; RR 1.23; 95% CI 0.44 to 3.45) (miniport laparoscopic cholecystectomy: 8/351 (adjusted proportion 2.3%) versus standard laparoscopic cholecystectomy 6/319 (1.9%)). Miniport laparoscopic cholecystectomy took five minutes longer to complete than standard laparoscopic cholecystectomy (12 trials; 695 patients; MD 4.91 minutes; 95% CI 2.38 to 7.44). There were no significant differences between miniport laparoscopic cholecystectomy and standard laparoscopic cholecystectomy in the length of hospital stay (six trials; 351 patients; MD -0.00 days; 95% CI -0.12 to 0.11); the time taken to return to activity (one trial; 52 patients; MD 0.00 days; 95% CI -0.31 to 0.31); or in the time taken for the patient to return to work (two trials; 187 patients; MD 0.28 days; 95% CI -0.44 to 0.99) between the groups. There was no significant difference in the cosmesis scores at six months to 12 months after surgery between the two groups (two trials; 152 patients; SMD 0.13; 95% CI -0.19 to 0.46).

AUTHORS' CONCLUSIONS

Miniport laparoscopic cholecystectomy can be completed successfully in more than 80% of patients. There appears to be no advantage of miniport laparoscopic cholecystectomy in terms of decreasing mortality, morbidity, hospital stay, return to activity, return to work, or improving cosmesis. On the other hand, there is a modest increase in operating time after miniport laparoscopic cholecystectomy compared with standard port laparoscopic cholecystectomy and the safety of miniport laparoscopic cholecystectomy is yet to be established. Miniport laparoscopic cholecystectomy cannot be recommended routinely outside well-designed randomised clinical trials. Further trials of low risks of bias and low risks of random errors are necessary.

Costs and clinical outcomes of conventional single port and micro-laparoscopic cholecystectomy

Cost for single-port cholecystectomy in the outpatient setting was found to be greater than the cost for micro-laparoscopic or conventional laparoscopic cholecystectomy.

Background and Objective:

This study compares hospital costs and clinical outcomes for conventional laparoscopic, single-port, and mini-laparoscopic cholecystectomy from US hospitals.

Methods:

Eligible patients were aged ≥18 years and undergoing laparoscopic cholecystectomy with records in the Premier Hospital Database from 2009 through the second quarter of 2010. Patients were categorized into 3 groups—conventional laparoscopic, single port, or mini-laparoscopic—based on the International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes and hospital charge descriptions for surgical tools used. A procedure was considered mini-laparoscopic if no single-port surgery products were identified in the charge master descriptions and the patient record showed that at least 1 product measuring <5 mm was used, not more than 1 product measuring >5 mm was used, and the measurements of the other products identified equaled 5 mm. Summary statistics were generated for all 3 groups. Multivariable analyses were performed on hospital costs and clinical outcomes. Models were adjusted for demographics, patient severity, comorbid conditions, and hospital characteristics.

Results:

In the outpatient setting, for single-port surgery, hospital costs were approximately $834 more than those for mini-laparoscopic surgery and $964 more than those for conventional laparoscopic surgery (P < .0001). Adverse events were significantly higher (P < .0001) for single-port surgery compared with mini-laparoscopic surgery (95% confidence interval for odds ratio, 1.38–2.68) and single-port surgery versus conventional surgery (95% confidence interval for odds ratio, 1.37–2.35). Mini-laparoscopic surgery hospital costs were significantly (P < .0001) lower than the costs for conventional surgery by $211, and there were no significant differences in adverse events.

Conclusions:

These findings should inform practice patterns, treatment guidelines, and payor policy in managing cholecystectomy patients.

Recent advances in laparoscopic surgery

Laparoscopic surgery has been widely adopted and new technical innovation, procedures and evidence based knowledge are persistently emerging. This review documents recent major advancements in laparoscopic surgery. A PubMed search was made in order to identify recent advances in this field. We reviewed the recent data on randomized trials in this field as well as papers of systematic review. Laparoscopic cholecystectomy is the most frequently performed procedure, followed by laparoscopic bariatric surgery. Although bile duct injuries are relatively uncommon (0.15%-0.6%), intraoperative cholangiography still plays a role in reducing the cost of litigation. Laparoscopic bariatric surgery is the most commonly performed laparoscopic gastrointestinal surgery in the USA, and laparoscopic Nissen fundoplication is the treatment of choice for intractable gastroesophageal reflux disease. Recent randomized trials have demonstrated that laparoscopic gastric and colorectal cancer resection are safe and oncologically correct procedures. Laparoscopic surgery has also been widely developed in hepatic, pancreatic, gynecological and urological surgery. Recently, SILS and robotic surgery have penetrated all specialties of abdominal surgery. However, evidence-based medicine has failed to show major advantages in SILS, and the disadvantage of robotic surgery is the high costs related to purchase and maintenance of technology. Laparoscopic surgery has become well developed in recent decades and is the choice of treatment in abdominal surgery. Recently developed SILS techniques and robotic surgery are promising but their benefits remain to be determined.

Randomized clinical trial of single-port, minilaparoscopic and conventional laparoscopic cholecystectomy

Background

This three-armed randomized clinical trial, with blinding of patients and outcome assessors, tested the hypothesis that single-port (SP) and/or minilaparoscopic (ML) cholecystectomy are superior to conventional laparoscopic (CL) cholecystectomy.

Methods

Patients eligible for elective laparoscopic cholecystectomy were randomized to SP, ML or CL procedures. The primary outcome was pain measured on a visual analogue scale twice daily during the blinded period. Secondary outcomes included duration of operation, technical performance score, complications, quality of life, cosmesis and patient satisfaction. Postoperative follow-up lasted 1 year.

Results

A total of 105 patients were randomized, 35 in each group. One conversion from a SP to a CL technique was necessary in a patient with chronic cholecystitis. Pain intensity was similar in the three groups, both during the blinded period (day 0 to 3; P = 0·865) and over the whole 7-day evaluation period (P = 0·911). The presence of clinically relevant between-group differences was ruled out (95 per cent confidence interval + 1·0 to − 0·5 for difference in pain scores between SP and CL groups, and − 0·8 to + 0·6 between ML and CL groups). Operating time was significantly longer for SP and ML than for CL cholecystectomy (P = 0·001). Postoperative complications included injury to the diaphragm (1), choledocholithiasis (1), wound infection (5) and hernia (1), all after SP cholecystectomy (P = 0·001). Twelve-month follow-up was complete in 99 patients (94·3 per cent). Cosmesis as rated by patients was significantly better at 6 months after SP and ML procedures (P = 0·043), but no difference was observed at 12 months (P = 0·229).

Conclusion

SP and ML cholecystectomy had no advantage over the CL approach in terms of postoperative outcome. Registration number: DRKS00000302 (German Registry of Clinical Trials).

Internal retraction in single-port laparoscopic cholecystectomy: initial experience and learning curve

INTRODUCTION

We report our experience and learning curve in single-port laparoscopic cholecystectomy (SPLC) using an internal anchored retraction system.

METHODS

Usefulness of the retraction system was analysed in 18 SPLC. The first eight, the following ten SPLC and 20 consecutive four-port laparoscopic cholecystectomies (4PLC) were compared. Duration of operation, burns on nontarget tissue and gallbladder perforations were assessed by reviewing videotapes recorded during the procedures.

RESULTS

Use of the retraction system failed in three out of five patients (60%) with intraoperative signs of chronic inflammation and in one out of 13 (7.1%) without such signs (p = 0.0441). Median operation time was 90 (45-120) in the first eight and 55 (40-180) minutes in the following ten SPLC (p = 0.0361). Whereas the first eight SPLC lasted longer compared to 4PLC (70 (40-140) minutes, p = 0.0435) the difference disappeared after eight procedures (p = 0.2076). Median number of burns to nontarget tissue was seven (1-16) in the first eight and one (0-8) in the following ten SPLC (p = 0.0049). There was no difference in perforation of the gallbladder.

DISCUSSION

Internal retraction enables a safe exposure of the Calot triangle avoiding bile spillage in cholecystectomies without intraoperative signs of inflammation. Familiarisation with SPLC was rapidly achieved. Operation time and dexterity were equal to 4PLC after eight SPLC.

Comparisons of prediction models of quality of life after laparoscopic cholecystectomy: a longitudinal prospective study

BACKGROUND

Few studies of laparoscopic cholecystectomy (LC) outcome have used longitudinal data for more than two years. Moreover, no studies have considered group differences in factors other than outcome such as age and nonsurgical treatment. Additionally, almost all published articles agree that the essential issue of the internal validity (reproducibility) of the artificial neural network (ANN), support vector machine (SVM), Gaussian process regression (GPR) and multiple linear regression (MLR) models has not been adequately addressed. This study proposed to validate the use of these models for predicting quality of life (QOL) after LC and to compare the predictive capability of ANNs with that of SVM, GPR and MLR.

METHODOLOGY/PRINCIPAL FINDINGS

A total of 400 LC patients completed the SF-36 and the Gastrointestinal Quality of Life Index at baseline and at 2 years postoperatively. The criteria for evaluating the accuracy of the system models were mean square error (MSE) and mean absolute percentage error (MAPE). A global sensitivity analysis was also performed to assess the relative significance of input parameters in the system model and to rank the variables in order of importance. Compared to SVM, GPR and MLR models, the ANN model generally had smaller MSE and MAPE values in the training data set and test data set. Most ANN models had MAPE values ranging from 4.20% to 8.60%, and most had high prediction accuracy. The global sensitivity analysis also showed that preoperative functional status was the best parameter for predicting QOL after LC.

CONCLUSIONS/SIGNIFICANCE

Compared with SVM, GPR and MLR models, the ANN model in this study was more accurate in predicting patient-reported QOL and had higher overall performance indices. Further studies of this model may consider the effect of a more detailed database that includes complications and clinical examination findings as well as more detailed outcome data.

Small-incision access retroperitoneoscopic technique (SMART) pyeloplasty in adult patients: comparison of cosmetic and post-operative pain outcomes in a matched-pair analysis with standard retroperitoneoscopy: preliminary report

OBJECTIVES

To present small-incision access retroperitoneoscopic technique pyeloplasty (SMARTp), a novel mini-laparoscopic approach for management of uretero-pelvic junction obstruction (UPJO) in adults including comparison with the standard retroperitoneoscopic technique (SRTp).

METHODS

In a non-randomised study, we matched 12 adult patients treated from August to November 2010 by SMARTp with 12 patients treated with SRTp from January to November 2010. Mini-laparoscopic retroperitoneal space was created with a home-made 6-mm balloon trocar. One 6-mm (for 5-mm 30° telescope) and two 3.5-mm trocars (for 3-mm working instrument) were used. SRTp was performed with 11- and 6-mm trocar. Primary endpoints included evaluation of cosmetic appearance and post-operative pain evaluated respectively by the patient and observer scar assessment scale (POSAS) and analogue visual scale (VAS). Secondary endpoints were comparison between operative and functional parameters.

RESULTS

Cosmetic cumulative results were statistically significant in favour of SMARTp (POSAS: 37.9 vs. 52.4; P = 0.002). A better trend has been shown by post-operative pain (first to fourth day VAS), although not statistically significant (4.2 vs. 4.9, P = 0.891). No differences were recorded in terms of operative time, pre- and post-operative Hb difference, DJ-stent removal and resistive index (RI) improvement. The SMARTp group showed a faster drain removal (2.4 vs. 3.4 day, P = 0.004) and discharge (4.5 vs. 5.4 day P = 0.017).

CONCLUSIONS

Preliminary data support SMARTp as safe procedures in experienced hands, providing better cosmetic results compared to SRTp. Further studies and clinical randomised trial performed in a larger population sample are requested.