Single-incision versus four-port laparoscopic cholecystectomy in an ambulatory surgery setting: A prospective randomised double-blind controlled trial

Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials

Background

Conventional multi-port laparoscopic cholecystectomy (CMLC) has become the current 'gold standard' technique in gallbladder disease. Single-incision laparoscopic cholecystectomy (SILC) has gained attention due to its benefits in improving patient cosmetic results and pain reduction. We aim to assess the latest evidence on the feasibility, safety and surgical outcomes of SILC and CMLC.

Methods

We conducted searches for randomized controlled trials (RCTs) in PubMed, PubMed Central (PMC), and Europe PMC between December 2011 and 2021. The latest search was conducted in January 2022. We analyzed several outcomes, including perioperative complications, estimated blood loss, operation time, conversion to open surgery, hospital stay, pain score, cosmesis, and days of return to work. Cochrane Risk of Bias (RoB) 2.0 tool was used to evaluate quality of studies. Mantel-Haenszel's formula and Inverse Variance method were conducted to synthesize results. This study was accomplished in accordance with the PRISMA guidelines.

Results

A total of 37 studies were eligible, with a total of 2,129 and 2,392 patients who underwent SILC and CMLC. Our study demonstrated a superiority of SILC for the visual analog score (VAS) at six hours post-operation [mean difference (MD) -0.58 (95% CI -1.11, -0.05), p=0.03], cosmesis one-month post-operation [standard MD 2.12 (95% CI 1.10, 3.13), p<0.0001], and cosmesis six months post-operation [standard MD 0.53 (95% CI 0.06, 0.99), p<0.0001]. Meanwhile, SILC showed a longer operation time [MD 10.45 (95% CI 6.74, 14.17), p<0.00001]. In terms of VAS at four time points (4, 8, 12, and 24 hours), perioperative complications, estimated blood loss, conversion to open surgery, hospital stay and days to return to work, SILC did not differ from CMLC.

Conclusions

SILC is a safe, feasible and favorable procedure in terms of pain reduction and cosmetic results. The option between both procedures is based on surgeon preferences. Registration: PROSPERO ( CRD42022306532; 23 February 2022).

Evaluation of Safety and Feasibility of Using LigaSure During Clipless Single-Incision Laparoscopic Cholecystectomy: A Prospective Clinical Study

Background: Single-incision laparoscopic cholecystectomy (SILC) is a minimally invasive procedure designed to minimize the number and size of the incisions needed for cholecystectomy. Titanium clips are traditionally used to close the cystic duct and artery. Although it is considered safe, dislodgement can result in bleeding and biliary leakage. Using LigaSure for duct sealing is still controversial. The aim of this study was to evaluate the safety and feasibility of using LigaSure to close the cystic duct during SILC. Methods: A prospective study over two years was conducted at the General Surgery Department, Mansoura University Hospital, on 102 patients, 51 in each group. They underwent SILC using LigaSure (Group 1) or titanium clips (Group 2) to control the cystic duct and artery. Results: The data analyzed included demographic data, operative time, intra- and postoperative complications, postoperative pain, and hospital stay. The operative time was significantly shorter in LigaSure group (68.5 ± 9.8 versus 72.9 ± 10.6 minutes in the clips group, P .03). There was no significant difference between the two groups regarding postoperative bile leak or bleeding. However, two cases in Group 1 and four cases in Group 2 were converted to multiple port laparoscopic cholecystectomy; this was statistically nonsignificant. Postoperative pain and hospital stay showed no significant difference between the two groups. Two patients in each group developed port-site incisional hernia. Conclusions: Clipless SILC using LigaSure is a feasible and safe procedure with acceptable morbidity with shorter operative time than SILC using clips. Nevertheless, the risk of port-site incisional hernia should be explained to the patients.

Pain management after laparoscopic cholecystectomy: A systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations

Laparoscopic cholecystectomy can be associated with significant postoperative pain that is difficult to treat. We aimed to evaluate the available literature and develop updated recommendations for optimal pain management after laparoscopic cholecystectomy. A systematic review was performed using the procedure-specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials and systematic reviews published in the English language from August 2017 to December 2022 assessing postoperative pain after laparoscopic cholecystectomy using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. From 589 full text articles, 157 randomised controlled trials and 31 systematic reviews met the inclusion criteria. Paracetamol combined with NSAIDs or cyclo-oxygenase-2 inhibitors should be given either pre-operatively or intra-operatively, unless contraindicated. In addition, intra-operative intravenous (i.v.) dexamethasone, port-site wound infiltration or intraperitoneal local anaesthetic instillation are recommended, with opioids used for rescue analgesia. As a second-line regional technique, the erector spinae plane block or transversus abdominis plane block may be reserved for patients with a heightened risk of postoperative pain. Three-port laparoscopy, a low-pressure pneumoperitoneum, umbilical port extraction, active aspiration of the pneumoperitoneum and saline irrigation are recommended technical aspects of the operative procedure. The following interventions are not recommended due to limited or no evidence on improved pain scores: single port or mini-port techniques, routine drainage, low flow insufflation, natural orifice transluminal endoscopic surgery (NOTES), infra-umbilical incision, i.v. clonidine, nefopam and regional techniques such as quadratus lumborum block or rectus sheath block. Several interventions provided better pain scores but are not recommended due to risk of side effects: spinal or epidural anaesthesia, gabapentinoids, i.v. lidocaine, i.v. ketamine and i.v. dexmedetomidine.

Day-case laparoscopic cholecystectomy in the management of gallbladder disease: a literature review

BACKGROUND

Day-case laparoscopic cholecystectomy (DCLC) has gained traction globally due to its benefits, including shorter hospital stays, reduced costs, and enhanced patient experience. While concerns about patient safety, particularly related to bleeding and bile duct injury persist, the literature supports the efficacy and advantages of DCLC highlighting the need for its wider adoption in healthcare settings to optimise resources and improve patient outcomes.

METHODS

This was a literature review that aims to assess the feasibility and safety of day-case laparoscopic cholecystectomy for symptomatic gallstone patients, focusing on incidence and aetiology of unexpected admissions and readmissions, as well as conversion-to-open rates. PubMed was searched for all studies focusing on DCLC between 2014 and 2024. The timeframe was specifically selected to identify recent trends and practices in this evolving field. By focusing on this specific period, the review aims to provide a comprehensive analysis of current practices, emerging trends, and the evolving standard of care in this area.

RESULTS

This review highlights that the main causes of unexpected admission post DCLC were postoperative nausea, vomiting, and pain, while the implementation of anaesthetic pathways notably increased day-case rates. Studies addressing complication rates postoperatively consistently found no significant difference between day-case and in-patient procedures.

CONCLUSIONS

DCLC for symptomatic gallstone patients is supported by research as safe and effective, with high success rates and patient satisfaction. Studies show minimal complications and acceptable readmission rates, suggesting that DCLC can be the standard approach for selective patients, improving outcomes and healthcare efficiency.

Single-port laparoscopic pancreaticoduodenectomy

BACKGROUND

Performing a single-port laparoscopic pancreatectomy is technically challenging. Single-port laparoscopic pancreaticoduodenectomy (SPLPD) is rarely reported in English literature.

METHODS

Eighty-seven cases of laparoscopic pancreaticoduodenectomy (LPD) were performed by a single surgical team in the Department of Pancreatic Surgery, West China Hospital, Sichuan University between February 2020 and December 2020. Among these, 13 cases of LPD (group 1) were performed using a single-port device. Basing on the same inclusion and exclusion criteria, 68 cases of LPD performed using traditional 5-trocar were included as a control group (group 2). The patient's demographic characteristics, intraoperative, and postoperative variables were prospectively collected and retrospectively analyzed.

RESULTS

Five men and eight women were included in the SPLPD group. The median age of these patients was 57 years. The patients who underwent SPLPD required a longer operative time (332.7 ± 38.1 min vs. 305.8 ± 64.7 min; p = 0.03) than those in the LPD group. The estimated blood loss, conversion rate, blood transfusion rate, time to oral intake, postoperative hospital stays, and perioperative complications were comparable between the two groups. The short-term oncological outcomes, such as R0 rate and lymph node harvested, were comparable between the two groups. The 90-day mortality of all patients was zero.

CONCLUSIONS

SPLPD is a safe and feasible procedure for well-selected patients in an experienced minimally invasive pancreatic surgery team. SPLPD may provide several potential advantages, such as the requirement of fewer trocars, fewer abdominal complications, and reduced participation of assistants than conventional LPD.

Evidence-based surgery for laparoscopic cholecystectomy

Background

Laparoscopic cholecystectomy is frequently performed for acute cholecystitis and symptomatic cholelithiasis. Considerable variation in the execution of key steps of the operation remains. We conducted a systematic review of evidence regarding best practices for critical intraoperative steps for laparoscopic cholecystectomy.

Methods

We identified 5 main intraoperative decision points in laparoscopic cholecystectomy: (1) number and position of laparoscopic ports; (2) identification of cystic artery and duct; (3) division of cystic artery and duct; (4) indications for subtotal cholecystectomy; and (5) retrieval of the gallbladder. PubMed, EMBASE, and Web of Science were queried for relevant studies. Randomized controlled trials and systematic reviews were included for analysis, and evidence quality was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation framework.

Results

Fifty-two articles were included. Although all port configurations were comparable from a safety standpoint, fewer ports sometimes resulted in improved cosmesis or decreased pain but longer operative times. The critical view of safety should be obtained for identification of the cystic duct and artery but may be obtained through fundus-first dissection and augmented with cholangiography or ultrasound. Insufficient evidence exists to compare harmonic-shear, clipless ligation against clip ligation of the cystic duct and artery. Stump closure during subtotal cholecystectomy may reduce rates of bile leak and reoperation. Use of retrieval bag for gallbladder extraction results in minimal benefit. Most studies were underpowered to detect differences in incidence of rare complications.

Conclusion

Key operative steps of laparoscopic cholecystectomy should be informed by both compiled data and surgeon preference/patient considerations.

Comparison of outcomes of single incision robotic cholecystectomy and single incision laparoscopic cholecystectomy

Backgrounds/Aims

Multiport laparoscopic cholecystectomy is the standard surgical procedure for symptomatic gallbladder diseases. However, as a result of the ongoing trend toward minimally invasive laparoscopy, single-incision laparoscopic cholecystectomy (SILC) has evolved. Single-incision robotic cholecystectomy (SIRC) can overcome several limitations of manual SILC. The purpose of this study is to evaluate and compare the safety and feasibility of SIRC and SILC.

Methods

This study retrospectively reviewed data for all patients who underwent SIRC or SILC from March 2018 to July 2019 in a single institution. The following variables were analyzed: age, sex, body mass index, pain scale, length of stay, and complications. The data were analyzed using the Independent two sample t-test or the Fisher’s exact test.

Results

A total of 343 patients underwent SIRC or SILC during the study period. After excluding patients with acute cholecystitis, 197 SIRC and 103 SILC patients were analyzed in this study. The surgery time and postoperative hospital stay did not differ between SIRC and SILC. However, the SIRC patients experienced less bile spillage during the surgery than did the SILC patients (SIRC vs. SILC: 24 (23.3%) vs. 11 (5.6%) cases, respectively; p<0.001). Although there was no difference in the incidence of postoperative complications between procedures, additional pain control was administered more frequently in SILC patients (SILC 1.08±0.893, SIRC 0.58±0.795; p<0.001).

Conclusions

While both SILC and SIRC are effective for single-incision cholecystectomy, SIRC was superior to SILC in terms of technical stability. Moreover, it has the advantage of postoperative pain control.