RESEARCH ARTICLE

https://doi.org/10.5005/jp-journals-10033-1482
World Journal of Laparoscopic Surgery
Volume 14 | Issue 3 | Year 2021

Laparoscopic Cholecystectomy: Single-port vs Traditional Procedure: Our Experience

Selmy Mohamed Awad^{1https://orcid.org/0000-0002-2724-5599}, Ibrahim Dawoud², Waleed Althobiti³, Shaker Alfaran⁴, Saleh Alghamdi⁵, Saleh Alharthi⁶, Khaled Alsubaie⁷, Soliman Ghedan⁸, Rayan Alharthi⁹, Majed Asiri¹⁰, Azzah Alzahrani¹¹, Nawal Alotaibi¹², Mohamed Shetiwy¹³

^1,2,13Department of General Surgery, Mansoura University Hospitals, Mansoura, Egypt

^3–12Department of General Surgery, King Faisal Medical Complex, Taif, Saudi Arabia

Corresponding Author: Selmy Mohamed Awad, Department of General Surgery, Mansoura University Hospitals, Mansoura, Egypt, Phone: 0556466097, e-mail: selmysabry2007@yahoo.com

How to cite this article: Awad SM, Dawoud I, Althobiti W, et al. Laparoscopic Cholecystectomy: Single-port vs Traditional Procedure: Our Experience. World J Lap Surg 2021;14(3):221–226.

Source of support: Nil

Conflict of interest: None

ABSTRACT

Background: Laparoscopic surgery is widely accepted as a reliable alternative to the open approach across surgical disciplines. Benefits of single-incision laparoscopic surgery (SILS), as exemplified here by single-port laparoscopic cholecystectomy (SPLC), have yet to be formally proved. However, the hypothesized benefits of SILS would include those of standard traditional laparoscopic surgery plus improved esthetic outcomes, with surgery being performed through a single hidden incision.

Methods: All patients who had chronic calcular cholecystitis at the General Surgery Department at Mansoura University Hospital between May 2014 and May 2018 were eligible for this study to compare SPLC with multiport laparoscopic cholecystectomy (MPLC). Operative and perioperative outcomes, including cosmesis, were analyzed.

Results: SPLC had been performed in Group A (40 patients), mean age was 37.35 ± 10.72, 80% were females, and mean BMI was 30.15 ± 4.53. MPLC was performed in Group B (40 patients), mean age was 40.70 ± 9.71, 75% were females, and mean BMI was 28.35 ± 2.83. The average duration of postoperative hospital stay in SPLC cases was 24 hours and in MPLC group was 25.20 hours, with p = 0.330, which was insignificant. In the SPLC group, the mean operative time was 95.75 minutes whereas in the MPLC group the mean operative time was 42.10 minutes. Therefore, the mean operative time in the SPLC group was significantly higher than in the MPLC group (p <0.01). Esthetic results were better in the SPLC group than in the MPLC group.

Conclusion: Based on the current findings, SPLC seems to be a safe procedure in uncomplicated cholecystitis with rapid recovery, less postoperative pain, less wound infection, and better cosmesis. The operative time was long. However, patients should be aware of the risks of port-site incisional hernia and instructed to avoid heavy work and exercises during the first three postoperative months.

Keywords: Laparoscopic cholecystectomy, Single-port, Traditional.

INTRODUCTION

Laparoscopic surgeries are special techniques by which surgeons perform the operations via several tiny holes in the abdomen with the help of a camera. It is known also as minimally invasive surgery (MIS). These incisions are much smaller than traditional surgical techniques.¹

Diminished postoperative pain, fast recovery, improved esthetic outcomes, and short hospital stay are the documented benefits across a spectrum of surgical procedures. Many procedures have been done safely with laparoscopy. These include laparoscopic cholecystectomy that has supplanted open cholecystectomy for most gallbladder pathologies.^2,3

Laparoscopic cholecystectomy is a widely accepted procedure that causes less postoperative pain and a shorter postoperative length of stay (LoS) than open surgery.^4–8 Traditional laparoscopic cholecystectomy is done in >90% of elective cholecystectomies and 70% of urgent cholecystectomies.^9,10

The concept of SILS is to do the procedure through a single skin incision, usually the umbilicus through multichannel (trocar) ports. The umbilicus is the common site for basic procedures such as laparoscopic cholecystectomy and appendectomy. The incision can be periumbilical or transumbilical.^11,12

SILS is a quickly growing procedure as a union between traditional laparoscopic techniques and Natural orifice transluminal endoscopic surgery (NOTES). The current trend has been about the development of SILS to further reduce the invasiveness of laparoscopic surgeries by minimizing the number of skin violations.^13,14

Since 1985, many efforts have been on in the laparoscopy field to reduce the invasiveness of laparoscopic approaches, with operators developing new technology and techniques to minimize postoperative pain and improve esthetic outcome by small-sized ports or smaller numbers. At present, SILS has gained tremendous focus for the treatment of many surgical diseases.^5,15–17

The difficulties of SILS include limited triangulation between straight instruments, restricted movements, close proximity between the instruments, and narrow visual axis and operative field.^18–20

However, there are no clear indications for SILS until now, and its applicability and feasibility have grown throughout many of the surgical fields. The applicability of this approach has been observed in gynecologic, urologic, pediatric, gastrointestinal, and bariatric surgery.¹³

PATIENTS AND METHODS

All patients who had chronic calcular cholecystitis at the General Surgery department 7 at Mansoura University Hospital between May 2014 and May 2018 were eligible for this study to compare between SPLC and MPLC. Operative and perioperative outcomes, including cosmesis and quality of life, were analyzed. Candidates were randomly assigned into two groups: Group A consisted of 40 cases (single-port laparoscopic cholecystectomy) and Group B consisted of 40 cases (traditional multiport laparoscopic cholecystectomy).

Inclusion criteria: (1) age: ≥15 years, (2) sex: male and female, (3) ultrasound finding of gallbladder stones, (4) biliary colic, and (5) BMI <40.

Exclusion criteria: (1) age: <15 years, (2) acute pancreatitis, (3) common bile duct stones, (4) contraindications for single-port cholecystectomy, namely, ASA classification of 3 or 4 indicating pregnancy, and (5) BMI >40.

All candidates underwent proper history taking, thorough clinical examination, radiological, and full laboratory investigation stressing on liver status.

Follow-up of the patients: Follow-up of the patients included operative time, periprocedural operative complications (bleeding, bile leak, visceral injury, conversion to MPLC or open cholecystectomy). Postoperative follow-up included postoperative bleeding, bile leak, hospital stay, wound infection, incisional hernia, and cosmesis for one year. All of these data were collected, tabulated, and analyzed carefully using SPSS version 26.

RESULTS

This comparative prospective research was performed on all eligible candidates who were classified into two groups: Group A consisted of patients who underwent single-port laparoscopic cholecystectomy and Group B consisted of patients who underwent multiport laparoscopic cholecystectomy.

Demographic Criteria and Clinical Characteristics of the Patients

Demographic and clinical characteristics of the patients are shown in Table 1. Patients in both groups had same abdominal sonography finding, such as normal liver, gallbladder stones, normal common bile duct diameter with no stones impacted, and so on. Laboratory investigations for patients in both groups were normal including serum bilirubin, serum alkaline phosphatase, liver enzymes, bleeding profile, and hemoglobin level. All cases with symptomatic cholelithiasis and all surgeries were elective.

**Table 1:** Demographic and clinical characteristics of the patients
	SPLC group (n = 40)		MPLC group (n = 40)		t	p
Age (mean ± SD), years	37.35 ± 10.72		40.70 ± 9.71		1.036	0.307
BMI (mean ± SD)	30.15 ± 4.53		28.35 ± 2.83		1.506	0.140
Sex	No.	%	No.	%
Male	8	20%	10	25%	0.143^#	0.705
Female	32	80%	30	75%
Recent attack of acute cholecystitis or pancreatitis	6	15%	4	10%	0.229	0.633

Operative time: In Group A, the mean operative time in minutes was 95.75 ± 18.37 (Table 2) whereas in the MPLC group, it was 42.10 ± 5.04, so that the mean operating time in Group B was significantly lower than in the SPLC group (p <0.01).

**Table 2:** Operative time in SPLC group and MPLC group
	Group A (n = 40)	Group B (n = 40)	t	p
Operative time (mean ± SD)	95.75 ± 18.37	42.10 ± 5.04	12.594	<0.01^*

Operative times and learning curve: The operative time was significantly higher in Group A (Fig. 1). An important reduction in the operative time was achieved as the number of cases undergoing SPLC had increased. In the first 20 cases, the average operative time was 100 minutes whereas in the second 20 patients, it was 80 minutes (Fig. 2).

Fig. 1: postoperative time in SPLC and MPLC groups

Fig. 2: Operative time and learning curve in SPLC group

Intraoperative complications: In the SPLC group, we encountered intraoperative bleeding in one case. The source of bleeding was a cystic artery, and we had to convert to MPLC to control the bleeding whereas in the MPLC group there was no intraoperative bleeding (p = 0.311) which is insignificant (Fig. 3). There was no intraoperative viscus injury or bile leakage in both groups.

Fig. 3: Intraoperative complications of both groups

Conversion to MPLC: In the SPLC group (Fig. 4), the conversion to MPLC was mandated in five patients. In one patient, it was due to uncontrolled bleeding from a cystic artery. In two patients, conversion was due to a tense gallbladder with pericholecystic adhesions and exposure of Calot’s triangle was difficult. Both patients were male and had a history of recent attack of acute cholecystitis. In one patient, there was a caterpillar hump anomaly of the right hepatic artery occupying most of the cholecystohepatic triangle and so we had to convert for better delineation of Calot’s triangle and safe cholecystectomy. In one patient, we converted to MPLC then to open procedure due to a thick gallbladder with an impacted large stone at the cystic duct.

Fig. 4: Conversion to MPLC in SPLC group

Postoperative complications (bleeding, bile leak): In both groups, we did not have postoperative bleeding or bile leak.

Postoperative pain and need for additional analgesia: All patients in both groups received the same postoperative analgesia (paracetamol injection 8 hourly). In the SPLC group, the number of patients requiring additional analgesia in the form of NSAIDS was 16 (40%) whereas in the MPLC group, the number of patients requiring additional analgesia was 30 (75%) (p = 0.025), indicating that postoperative pain in SPLC is not significantly less than in the MPLC group. The data are shown in Table 3.

**Table 3:** Post-procedural pain in the two groups
	SPLC group (n = 40)		MPLC group (n = 40)
	No.	%	No.	%	x²	p
Need for NSAIDS	16	40%	30	75%	5.013	0.025

Postoperative of LoS: The mean duration of LoS in Group A was 24 hours whereas in Group B it was 25.20 hours (Table 4); p was 0.330 which is insignificant.

**Table 4:** Postoperative LoS in SPLC and MPLC groups
	SPLC group (n = 40)	MPLC group (n = 40)	t	p
Hospital stay (mean ± SD)	24.00 ± 0.00	25.20 ± 5.37	1.000	0.330

Postoperative wound infection: In the SPLC group, we observed wound infection in two patients (5%) whereas in the MPLC group wound infection occurred in eight patients (p = 0.151). In the SPLC group, the wound infection was mild and managed by oral antibiotics whereas in the MPLC group wound infection was at the site of the epigastric port (Fig. 5). In the eight patients, port-site wound infections were observed because the gallbladder had been perforated during specimen extraction and it was resolved with oral antibiotics.

Fig. 5: Postoperative wound infection in SPLC and MPLC groups

Port-site incisional hernia: In the SPLC group, port-site incisional hernia developed in two patients whereas in the MPLC group no patient developed port-site incisional hernia within the six-month follow-up period (p = 0.147). Two patients had port-site incisional hernia within the first six months postoperatively (Table 5), so patients should be informed to avoid heavy exertion and exercises during the first three months postoperatively.

**Table 5:** Incidence of postoperative port-site incisional hernia in both groups
	SPLC group (n = 40)		MPLC group (n = 40)
	No.	%	No.	%	X²	p
Port-site incisional hernia	2	5%	0	0%	2.105	0.147

Cosmetic results: Esthetic outcomes were higher in the first group having one incision concealed in the umbilicus rather than having four separate incisions as in the MPLC group (Fig. 6).

Figs 6A and B: (A) The transumbilical incision immediately after surgery; (B) The transumbilical incision 6 months postoperatively

DISCUSSION

SILS is one of the most advanced innovation in the field of MIS. The collaboration between the biomedical industry, technology research, and surgical experts is the guiding force to add more patient-friendly techniques to the field of surgery. The target of SILS is to minimize surgical invasiveness of port access and provide surgery with no scar as the slit of port access is most often concealed within the umbilicus.^21–24

The latest invention in SILS is use of the single-access device. This technique accommodated the introduction of three or four instruments through a single access device via an opening in the umbilicus. The latest devices that are available let the surgeon to insert more than two instruments and an optic with or without trocars through one port. Triangulation can be gained through articulating prebent instruments.^25–28

We will now discuss the advantages, disadvantages, and difficulties that we faced during our own experience of SPLC at the General Surgery department at Mansoura University Hospital.

A recent revolution in MIS for the majority of surgical specialties has been the rapid recovery times with shorter hospitalization, fewer wound-related complications post-operatively, and better esthetic results. However, MPLC is still associated with more tissue trauma due to the size and number of ports utilized.^18,29–31

In our study, the postoperative pain in both groups was compared using the number of patients who required additional analgesia for breakthrough pain (NSAIDS). Analysis of these two items showed that postoperative pain was more in the MPLC group. According to Prasad A et al., Group A patients experienced less postoperative pain than those of the other group.^12,32

SILS is a maneuver to minimize multiple incisions by using a small hidden intraumbilical slit, thereby making SPLC seems like a scarless operation to the candidate.^33–36 According to the patients’ own assessment in our study, those who underwent SPLC had better esthetic outcome and more candidate satisfaction than those in the MPLC group.

According to a study, SPLC patients were cosmetically superior than MPLC cases and were also higher in the same group in terms of patient satisfaction scores; thus cases in Group A were more satisfied with the overall outcomes of the technique.³⁷

According to a study of SPLC conducted in 107 cases of which 81 (76%) were done successfully, the LoS of the SPLC group vs that for the MPLC group was statistically different. The successful SPLC cases had a mean LoS of 1.1 ± 0.35 days compared with 1.4 ± 1.3 days for the MPLC group.³⁸ In our current research, the average postoperative LoS for successful SPLC was 24 hours and for the MPLC group (25 ± 5.37 hours) there was insignificant difference between the two groups.

In our study, port-site wound infection occurred in two patients of the SPLC group whereas in the MPLC group it occurred in eight cases. According to Lee et al.’s study, the incidence of postoperative port-site wound infection was less in the SPLC group.³⁷ In the current research, the average operative time was 100 minutes in the first 10 patients in the SPLC group and it decreased to 80 minutes in the second 10 patients denoting that the operative time reduces with an improved learning curve.

The experience with SPLC is manifest in the cholecystectomy trial of Tacchino et al. as the operative time reduced from 180 minutes for the first patient to 105 minutes for the second patient and remained at an average of 50 minutes finally. Some researchers concluded no learning curve for this technique when transabdominal sutures were used for clear exposure from the start. To enhance the learning curve, laboratory training on dry porcine models was advised.³¹

SPLC is an advanced laparoscopic technique, and it should be done basically by surgeons with enough experience in traditional laparoscopy. Surgeons face a learning curve in using the instruments with a limited range of motion. The operators also are in need of frequent adjustment of the vision due to simultaneous movement of both the laparoscope and instruments. This mandates skilled laparoscopists with superior coordination and harmony between the surgeon and the assistant, which increases with experience.^{31,34–36,39}

SPLC can be done safely with standard straight laparoscopic instruments. In our study 10 patients out of 40 were operated by the standard laparoscopic instruments and all were completed successfully. According to Cantore et al.’s study of 20 candidates (16 women, 4 men) of SILC, 4 (20%) had had previous abdominal surgery (appendectomy in all patients). Traditional straight laparoscopic instruments were used. All patients were successfully operated without additional skin slits. This study concluded that SILC with traditional straight laparoscopic instruments is feasible and safe.⁴⁰

In recent years, SILS and NOTES have received attention for both clinical and industrial aspects. The key advantages in favor of these two techniques are the esthetic outcome, fast recovery of patients, and reduced need for analgesia.^18–20 SILS is considered superior to other NOTES because it does not involve manipulation of instruments through internal hollow organs such as the stomach or vagina.^31,32,37

In our present research, the mean operative time in the first group as a new procedure was 95.75 minutes, which was significantly higher than in the MPLC group (42.10 minutes). According to one research, which was carried out on 60 patients divided into two equal groups of 30 candidates each, Group I was offered MPLC and in Group II, SILC was done. Length of stay, pain score, operative time, and wound infection rates were compared between the two groups. Operative times in Group I and Group II were 38.50 ± 8.92 minutes and 80.17 ± 30.16 minutes, respectively. p value was 0.0001, which indicates an important difference between the two groups.⁴¹

As the number of cases undergoing SPLC increased, there was an important reduction in the operative time with improvement of the learning curve. In our current study, operative time after first 20 SPLC techniques showed a significant reduction. This correlates with the recorded “learning curve” in other research studies.²⁴

In one study, the postoperative incidence of port-site incisional hernia in the 1st group was higher postoperatively (2 cases out of 20). An issue that many operators expressed about SILS is the probability of a high occurrence of port-site incisional umbilical hernias postoperatively. The concern behind this query was that SILS requires a bigger fascial incision (20–30 mm) to accept a multichannel port device. So careful closure of the fascial defect and postoperative instructions to avoid heavy work and exercises within the first three months post-operatively are obligatory.^24,39,42

In our study, the instrumental cost of the SPLC using a commercial port and curved instruments was significantly higher than the cost for MPLC. According to a previous experience, two consecutive series of cases with SILC were assessed and revealed that the instrumental cost of SILC using a commercial port was significantly higher (median $1123) than the cost for MPLC (median $441, p = 0005).⁴³ SPLC has secondary advantages including improved esthetic outcomes, LoS, and a rapid return to work Therefore, the cost of the SPLC procedure should not be the reason to reject the technique.

Major technical difficulties with this novel procedure are the sacrifice that have to be made in terms of ergonomics and comfort. Because all camera and instruments are accommodated through the same slit, the triangulation of instruments around the target was lost. In our current research, this resulted in an initial significant increase in the operative time. However, in our study with an improvement of the learning curve of the technique, operative times have been minimized significantly and are now very near to the mean time taken for traditional laparoscopy. Future technical improvements in instrumental technology may guide minimizing of the operative times further.^41,43,44

Another issue that must be understood with SILS is cross-handedness. Early in our current study, we struggled with hand placement outside the abdomen as the sphere of space that the external components of the instrumentation and the surgeons’ hands inhabit is decidedly smaller.^45,46

In general aspects, case results and safety from any operative technique may be affected by three various, but equally significant, items: the patients’ health (or disease); surgeons (expertise, training, and his/her surgical team); and technology used.⁴⁷ In our current research, simple cases with straightforward diseases are the most proper cases for this procedure. Thus, one might think that patients who are morbidly obese, those with previous abdominal surgeries (especially ventral hernia repairs with mesh), very tall candidates, or cases with multiple comorbidities may be excluded (at least at an early time of experience with an operator’s single-port use).

In general, all periprocedural complications linked to laparoscopy will also be potential concerns in SILS. At present, most clinical research studies have not reported a higher complication rate, or more serious entities of complications, after SILS. In fact, the available experience has revealed the same results with SILS as compared to conventional laparoscopic approach, with the addition of many of its proposed and unique benefits, such as improved esthetic outcomes from virtually hidden scars.^45,46

There may be a subset of potential complications, which may prove to be more common with SILS as compared with other traditional procedures. Of particular concern is that electrical injuries could be more prone to occur, at least in theory. These may occur as a result of the near proximity of laparoscopic instruments, with close contact, to each other. However, it did not occur in our study.⁴⁶

CONCLUSION

SILS allowed for better cosmesis, less pain and faster recovery, less wound infections, ease of tissue retrieval, combination procedure, and patient acceptance. Standard instruments can be used, and natural orifices need not be violated. SPLC can be done safely with standard straight laparoscopic instruments. With improvement of the learning curve of the technique, operative times have been minimized significantly.

ORCID

Selmy Mohamed Awad https://orcid.org/0000-0002-2724-5599

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