Surgical Endoscopy

, Volume 25, Issue 2, pp 367–377

Single-incision laparoscopic cholecystectomy: a systematic review

Authors

    • Department of General and Visceral Surgery, Center for Minimally Invasive SurgeryHospital “Maria v. d. Aposteln” Neuwerk
  • Rudolph Pointner
    • Department of General SurgeryHospital Zell am See
  • Frank A. Granderath
    • Department of General and Visceral Surgery, Center for Minimally Invasive SurgeryHospital “Maria v. d. Aposteln” Neuwerk
Review

DOI: 10.1007/s00464-010-1217-5

Cite this article as:
Antoniou, S.A., Pointner, R. & Granderath, F.A. Surg Endosc (2011) 25: 367. doi:10.1007/s00464-010-1217-5

Abstract

Background

Laparoscopic techniques induced a tremendous revolution in surgery of the biliary tract, mainly due to improved results compared with the open approach and secondary because of their cosmetic advantage. A trend toward even more minimally invasive approaches has led to techniques of single-incision and natural orifice laparoscopic surgery. Because the evaluation of single-incision laparoscopic cholecystectomy (SILC) is rather fragmentary by single-institution small patient series, this article intends to examine the success and the risks of the technique, and attempts to determine its potential limitations.

Methods

A systematic review of the literature was performed to identify relevant articles. Studies enrolling at least ten patients who underwent SILC and reporting on analytical complication data were considered for inclusion.

Results

The literature search identified 29 studies, which included a total of 1,166 patients. Success and complication rates were 90.7% and 6.1%, respectively. Mean adjusted operative time was 70.2 min and mean adjusted hospital stay was 1.4 days. Analysis of outcome exhibited higher complication rates for studies with a mean patient age older than 45 years (p = 0.04), and higher operative time for studies with a mean body mass index >30 kg/m2 (83.4 vs. 74.5 min) and female percentage lower than 70% (78.7 vs. 68.5 min). Acute cholecystitis as inclusion criterion was a factor for technical failure (success rate 59.9 vs. 93.0%, p = 0.005) and resulted in an increase of operative time (78.1 vs. 70.6 min). Suture suspension of the gallbladder yielded significantly lower complication rates compared with instrument usage (3.3 vs. 13.3%, p < 0.0001).

Conclusions

The clinical application of SILC exhibited satisfactory results. Cases of acute cholecystitis and older patients should be approached with caution, whereas improvement of the instrumentation is necessary.

Keywords

Laparoscopic cholecystectomySingle-incisionSingle-port accessTransumbilicalSingle-incision laparoscopic surgery

Surgery of the biliary tract underwent a radical revolution with the introduction of minimally invasive techniques in gallbladder diseases during the 1980s. Erich Mühe performed in 1985 the first laparoscopic cholecystectomy [1], and Perissat published in 1990 the first 157 cases [2]. Within the first years after this initial report, the technique gained enormous popularity due to its significant advantages compared with the open approach and is now considered the procedure of choice for the vast majority of benign diseases of the biliary tract. Laparoscopic cholangiography, choledochotomy, and common bile duct exploration are routine procedures in many centers and limit the open approach to extremely rare cases.

A second revolution in the history of gallbladder surgery seemed to occur during the past years, with the first cases of cholecystectomy through the vagina and the colon being described [3, 4]. A few years after the first reports, these techniques are performed by very few centers and still on an experimental basis. Some of the drawbacks for surgeons to adopt the so-called “natural orifice transluminal endoscopic surgery” (NOTES) include hesitation of transgressing sensitive mucosal barriers, de facto technical challenges, as well as the scarcity of the instrumentation.

Earlier, Navarra et al. [5] hypothesized that laparoscopic cholecystectomy through a single umbilical incision may be technically feasible and could be proved advantageous in selected patients. Two case series by Bresadola et al. and Piskun and Rajpal [6, 7] were followed by a decade of absence of the single-incision approach of laparoscopic cholecystectomy in the literature. From 2008 and thereafter, single-incision laparoscopic cholecystectomy (SILC) gained popularity and several reports examined its feasibility and safety.

Because SILC is currently performed occasionally by several surgical teams with its results not having been adequately studied yet, a systematic review of the literature seems reasonable, to examine the feasibility, safety, and results of SILC, and define, if possible, the limitations of this technique.

Materials and methods

Search strategy

A literature search confined to studies published in English and German was performed using the electronic database of Medline through mid February 2010. The keywords used were “laparoendoscopic single site”; “LSS”; “single port access”; “SPA”; “single port surgery”; “SPS”; “transumbilical endoscopic surgery”; “TUES”; “laparoendoscopic single site surgery”; “single incision laparoscopic surgery”; “SILS”; “transumbilical single port”; “TUSP”; “single incision multiport”; and “cholecystectomy” in all possible combinations. A second-level search included manual search of the reference lists of the retrieved articles.

Study selection

Studies were considered for inclusion provided the following criteria were fulfilled: (1) the study included ten or more patients who underwent SILC, (2) no additional incisions besides the umbilical were performed, and (3) they reported analytical conversion and complication data.

Data abstraction

The following data were abstracted from each study, if available: study type (prospective/retrospective), number of patients, inclusion and exclusion criteria, success rate, female/male ratio, mean age, mean body mass index (BMI), number and type of trocars used, type of optical, type of instruments (rigid/roticulating), method of gallbladder anchorage, reason for failure, intraoperative complications, postoperative complications, mean operative time, and mean hospital stay.

Statistical analysis

The chi-square test (χ2) was used to evaluate the differences in success and complication rates according to demographic and operative study data. A p value <0.05 was considered statistically significant.

Results

Literature search results

The search of the literature identified 141 articles; 30 of these articles fulfilled the inclusion criteria [534]. The reasons for exclusion were (Fig. 1): not related articles (n = 75), non-English/non-German articles (n = 12), no. of patients <10 (n = 11), technical notes/videos (n = 4), animal studies (n = 4), reviews (n = 2), letters to the editor/commentaries (n = 2), and inadequate complication data (n = 1). Two single-center studies from the same author team were thought to contain duplicate cases [12, 34]; the report satisfying the inclusion criteria was included in the final analysis [12]. The 29 recruited studies with details on their characteristics are summarized in Table 1.
https://static-content.springer.com/image/art%3A10.1007%2Fs00464-010-1217-5/MediaObjects/464_2010_1217_Fig1_HTML.gif
Fig. 1

Search history

Table 1

Study characteristics

Study

Year

Study type

No. of patients

Inclusion criteria

Exclusion criteria

Success rate (%)

Navarra et al. [5]

1997

NR

30

NR

NR

100

Bresadola et al. [6]

1999

Prospective

28

NR

Acute cholecystitis

53.6

Piskun and Rajpal [7]

1999

NR

10

NR

NR

100

Cuesta et al. [8]

2008

NR

10

Symptomatic cholecystolithiasis

Acute cholecystitis

100

Rao et al. [9]

2008

NR

20

Symptomatic cholecystolithiasis

Acute cholecystitis, history of pancreatitis

85

Binenbaum et al. [10]

2009

Prospective

11

Symptomatic cholecystolithiasis

Acute and chronic cholecystitis

100

Bucher et al. [11]

2009

Prospective

11

Symptomatic cholecystolithiasis, history of cholecystitis, biliary pancreatitis

NR

100

Chow et al. [12]

2009

Retrospective

14

NR

NR

100

Dominguez et al. [13]

2009

NR

40

Symptomatic cholecystolithiasis, gallbladder polyp

Acute cholecystitis, pregnancy, implanted pacemaker

100

Dunning and Kohli [14]

2009

Retrospective

12

NR

Acute cholecystitis, large chololiths

100

Hernandez et al. [15]

2009

NR

100

NR

NR

93

Hong et al. [16]

2009

NR

15

Symptomatic cholecystolithiasis

Acute cholecystitis, complicated cholecystolithiasis, cirrhosis, peritonitis, previous upper abdominal surgery, severe obesity, high-risk for anesthesia

100

Kirschniak et al. [17]

2009

NR

38

Symptomatic cholecystolithiasis

Acute cholecystitis, cholestasis

100

Kravetz et al. [18]

2009

Retrospective

22

Symptomatic cholecystolithiasis, biliary dyskinesia, acute cholecystitis

NR

90.9

Kuon Lee et al. [19]

2009

NR

37

NR

Previous upper abdominal surgery, acute cholecystitis, suspicion of malignancy

86.5

Langwieler et al. [20]

2009

NR

14

NR

NR

100

Petrotos et al. [21]

2009

NR

10

Symptomatic cholecystolithiasis

Acute cholecystitis

100

Philipp et al. [22]

2009

Retrospective

29

Symptomatic cholecystolithiasis, biliary dyskinesia, acute cholecystitis, chronic cholecystitis, biliary pancreatitis

NR

48.3

Rivas et al. [23]

2009

Retrospective

100

NR

NR

100

Roberts et al. [24]

2009

NR

56

Symptomatic cholecystolithiasis, acute cholecystitis, biliary pancreatitis

Pregnancy, ASA score III and IV

96.4

Romanelli et al. [25]

2009

Retrospective

22

Symptomatic cholecystolithiasis, chronic cholecystitis, biliary dyskinesia

NR

95.5

Schlager et al. [26]

2009

NR

20

Symptomatic cholecystolithiasis, history of cholecystitis, history of biliary pancreatitis

BMI >35 m2/kg, acute cholecystitis, elevated liver enzymes, ASA III and IV

95

Tacchino et al. [27]

2009

NR

12

NR

NR

100

Vidal et al. [28]

2009

NR

19

NR

NR

73.7

Zhu et al. [29]

2009

NR

10

NR

NR

100

Brody et al. [30]

2010

NR

59

NR

NR

76.3

Curcillo et al. [31]

2010

Retrospective

297

NR

NR

88.6

Erbella and Bunch [32]

2010

NR

100

Symptomatic cholecystolithiasis, biliary dyskinesia

Acute cholecystitis, biliary pancreatitis

98

Ersin et al. [33]

2010

NR

20

Symptomatic cholecystolithiasis

Acute cholecystitis

95

Total

  

1166

  

90.7a

NR not reported, ASA scoring system of the American Society of Anesthesiologists, BMI body mass index

aMean cumulative success rate

Study characteristics

The main study characteristics are summarized in Table 1. The included articles enrolled a cumulative number of 1,166 patients. Most authors did not define the prospective or retrospective character of the study, whereas many did not report on the inclusion and exclusion criteria or follow-up data. The most common indication for the application of SILC was symptomatic uncomplicated cholecystolithiasis, whereas patients with acute cholecystitis often were excluded from the study population. Success rates ranged from 53.6–100% with a cumulative success rate of 90.7%.

Demographic characteristics

Demographic characteristics of the study population are listed in Table 2. The percentage of the female study population ranged from 60–100% and the age of the included patients was rather young, with the mean ranging from 33–53.8 years. Patients with a lower body mass index more often were considered as suitable candidates as indicated by the range of the value of BMI (22.3–32.7 kg/m2).
Table 2

Demographic characteristics of the study population

Study

Female (%)

Mean age (year)

Mean BMI

Navarra et al. [5]

NR

NR

NR

Bresadola et al. [6]

67.9

42

NR

Piskun and Rajpal [7]

90

NR

NR

Cuesta et al. [8]

100

36

23

Rao et al. [9]

60

NR

NR

Binenbaum et al. [10]

91.7

33

NR

Bucher et al. [11]

NR

NR

NR

Chow et al. [12]

64.3

40

26.5

Dominguez et al. [13]

77.5

48

28

Dunning and Kohli [14]

NR

NR

NR

Hernandez et al. [15]

75

46

29

Hong et al. [16]

73.3

39

25.2

Kirschniak et al. [17]

81.6

53.8

27.8

Kravetz et al. [18]

80

43.9

30.2

Kuon Lee et al. [19]

64.9

47.5

22.3

Langwieler et al. [20]

NR

NR

NR

Petrotos et al. [21]

80

NR

NR

Philipp et al. [22]

86

NR

NR

Rivas et al. [23]

85

33.8

29.8

Roberts et al. [24]

88.7

41

30.2

Romanelli et al. [25]

68.2

40

32.7

Schlager et al. [26]

90

40.7

27

Tacchino et al. [27]

75

42

30

Vidal et al. [28]

84.2

41

NR

Zhu et al. [29]

70

38

NR

Brody et al. [30]

71.2

45

29.2

Curcillo et al. [31]

80.8

46

NR

Erbella and Bunch [32]

NR

NR

NR

Ersin et al. [33]

90

44.9

26.5

BMI body mass index, NR not reported

Technical details

A wide variation of technical methods was described with regard to the number, type, and size of the trocars, the instrumentation, and the preferred method of gallbladder anchorage and exposure of the Calot’s triangle (Table 3). The two most common methods included either insertion of two umbilical ports and gallbladder anchorage with two or three percutaneous sutures, or three umbilical ports and gallbladder suspension with a grasper. Multiport systems were used in only five studies [9, 18, 2325], whereas innovative methods creatively utilized surgical gloves to insert multiple instruments through a single fascial incision [16, 19]. An author described the technique of extracorporeal magnetic retracting system with magnet forceps attached to the gallbladder [13]. Many surgeons noted discomfort using roticulating instruments, because the right hand operates the left-sided instrument at the site of the gallbladder and vice versa. Furthermore, clashing of rigid instruments was not reported to be a significant technical problem; handling of the instruments was, however, rather uncomfortable. Routine intraoperative cholangiography was performed in two studies, with success rates of 87 and 100% [11, 30]. Insertion of an endo-bag for retraction of the gallbladder was unfeasible with 5-mm ports, and thus replacement with a 10-mm or a 12-mm port was required.
Table 3

Technical details

Author

No. of trocars

Type of trocars

Optical

Type of instruments

Gallbladder anchorage

Navarra et al. [5]

2

10 mm, 10 mm

10 mm 0° or 30° Laparoscope

Conventional

Percutaneous anchorage with 3 sutures

Bresadola et al. [6]

2

10 mm, 5 mm

10 mm 30° Laparoscope

Conventional

Percutaneous anchorage with 2 sutures

Piskun and Rajpal [7]

2

5 mm, 5 mm

5 mm 0° or 30° Laparoscope

Conventional

Percutaneous anchorage with 2 sutures

Cuesta et al. [8]

2

5 mm, 5 mm

5 mm 30° Laparoscope

Conventional

Percutaneous anchorage with 1 suture

Rao et al. [9]

1

Mutiport system (10 mm, 5 mm or 5 mm, 5 mm, 5 mm)

5 mm 30° Laparoscope

Roticulating

Roticulating instrument, n = 10; suture anchorage, n = 7

Binenbaum et al. [10]

2

12 mm, 5 mm

Laparoscope, gastroscope

Roticulating

Conventional instrument, percutaneous anchorage with 1 suture

Bucher et al. [11]

1

12 mm

10 mm 0 Aparoscope with a 6 mm working channel

Conventional

Percutaneous anchorage with 2 sutures

Chow et al. [12]

2–3

12 mm, 5 mm, 5 mm

5 mm 30° Laparoscope

Roticulating

Percutaneous anchorage with 1 suture

Dominguez et al. [13]

1

12 mm

11 mm 0° Laparoscope with a 6 mm working channel

Conventional

Magnetic forceps controlled extracorporeally

Dunning and Kohli [14]

2

5 mm, 5 mm

5 mm 0° and 5 mm 30° Laparoscope

Conventional

Percutaneous anchorage with 2 sutures

Hernandez et al. [15]

2

5 mm, 5 mm

NR

Roticulating

Percutaneous anchorage with 2 sutures

Hong et al. [16]

1

12 mm and 2 pipes through a surgical glove

5 mm 30° Laparoscope

Conventional

Conventional instrument

Kirschniak et al. [17]

3

5 mm, 5 mm, 5 mm

5 mm 30° Laparoscope

Conventional

Conventional instrument

Kravetz et al. [18]

1

Multiport system (12 mm, 5 mm, 5 mm)

5 mm 30° Laparoscope

Roticulating

Conventional instrument; additional percutaneous anchorage with one suture in 90% of the cases

Kuon Lee et al. [19]

3

5 mm, 5 mm, 5 mm

5 mm Laparoscope

Roticulating

Conventional or roticulating instrument

Langwieler et al. [20]

1

12 mm, 5 mm, 5 mm

5 mm 30° Laparoscope

Conventional

Conventional instrument

Petrotos et al. [21]

3

5 mm, 5 mm, 5 mm

5 mm 30° Laparoscope

Roticulating

Conventional instrument

Philipp et al. [22]

2–3

NR

5 mm Angulated or flexible-tip laparoscope

Conventional

Percutaneous anchorage with 1–3 sutures

Rivas et al. [23]

1–3

Multiport system or 5 mm trocars

5 mm 30° Laparoscope, n = 99; flexible tip andoscope, n = 1

Conventional and/or roticulating

Percutaneous or internal anchorage with 2 or 3 sutures

Roberts et al. [24]

3, n = 38; 1, n = 18

5 mm, 5 mm, 5 mm or multiport system

NR

Roticulating

Percutaneous suture anchorage

Romanelli et al. [25]

1–3

Multiport system or 12 mm, 5 mm, 5 mm or 12 mm

NR

Roticulating

Percutaneous anchorage with 1 or 2 sutures

Schlager et al. [26]

1–3

15 mm or 5 mm, 5 mm, 5 mm

Gastroscope or 5 mm 30° laparoscope

Roticulating

Percutaneous anchorage with 1 suture or internal anchoring device

Tacchino et al. [27]

3

5 mm, NR

5 mm 30° Laparoscope

Roticulating

Percutaneous anchorage with 2 sutures

Vidal et al. [28]

3

12 mm, 5 mm, 5 mm

5 mm or 10 mm 30° Laparoscope

Roticulating

Roticulating instrument

Zhu et al. [29]

3

5 mm, 3 mm, 3 mm

5 mm 30° Laparoscope

Conventional

Conventional instrument

Brody et al. [30]

3

5 mm, 5 mm, 5 mm

5 mm 45° Laparoscope

Conventional

Percutaneous or internal anchorage with 1 suture

Curcillo et al. [31]

3 and additional instrument without trocar

5 mm, 5 mm, 5 mm

5 mm 30° Laparoscope

Conventional and roticulating

Conventional instrument or percutaneous anchorage with 1 suture

Erbella and Bunch [32]

2

5 mm, 5 mm

5 mm 0° Laparoscope

Roticulating instruments

Percutaneous anchorage with 3 sutures

Ersin et al. [33]

3

5 mm, 5 mm, 5 mm

5 mm 30° Laparoscope

Roticulating grasper, roticulating dissector

Percutaneous anchorage with 1 suture

NR not reported

Technical failure and morbidity

Completion of SILC was unsuccessful in 9.3% of the patients; the most common reasons for technical failure were obscure anatomy of the Calot’s triangle due to adhesions, acute or chronic inflammation (5.2%), inadequate exposure of the Calot’s triangle due to insufficient gallbladder retraction (2.6%), and inability to maintain pneumoperitoneum due to proximity of the ports (1.4%; Table 4). Conversion to open surgery was required for five patients (0.4%).
Table 4

Reasons for failure

 

No. of patients (ratio %)

Rate (%)

Inflammation/adhesions/unclear anatomy

18 (47.4)

5.2

Inadequate visualization of the Calot’s triangle

9 (23.7)

2.6

Inability to maintain pneumoperitoneum

5 (13.2)

1.4

Choledocholithiasis

2 (5.3)

0.6

Bleeding

2 (5.3)

0.6

Insufficient length of instruments

1 (2.6)

0.3

Failure of trocar insertion

1 (2.6)

0.3

Total

38

11

Intraoperative complication rates ranged from 0–20% with a cumulative rate of 2.7% (Table 5). Most common intraoperative complications were gallbladder perforation/bile spillage (2.2%) and hemorrhage (0.3%; Table 6). Postoperative complications included wound infection and hematoma (2.1%), bile leakage (0.4%), residual choledocholithiasis (0.3%), and single cases of incisional hernia, intra-abdominal hematoma, and biliary stricture (Table 6). The cumulative postoperative complication rate was 3.4%.
Table 5

Complications, operative time, and hospital stay

Study

Intraoperative complications, n (%)

Postoperative complications, n (%)

Mean operative time, min (range)

Mean hospital stay, days (range)

Navarra et al. [5]

0

0

123 (NR)

1.8 (NR)

Bresadola et al. [6]

0

0

94 (NR)

NR

Piskun and Rajpal [7]

0

0

NR

1 (NR)

Cuesta et al. [8]

1 (10)

0

70 (65–85)

<1 (NR)

Rao et al. [9]

0

0

40 (19–100)

1 (NR)

Binenbaum et al. [10]

0

0

149.5 (99–240)

<1 (NR)

Bucher et al. [11]

0

0

52; median (40–77)

<1 (median) (0–1)

Chow et al. [12]

0

1 (7.1)

142.9 (100–276)

<1 (0–2)

Dominguez et al. [13]

2 (5)

1 (2.5)

93 (55–130)

NR

Dunning and Kohli [14]

0

0

NR

NR

Hernandez et al. [15]

1 (1)

1 (1)

72 (NR)

1 (1–10)

Hong et al. [16]

4 (2.7)

0

79 (35–165)

1.6 (1–2.5)

Kirschniak et al. [17]

0

2 (5.3)

67.1 (45–114)

4.4 (3–6)

Kravetz et al. [18]

0

0

73.1 (70–160)

1.2 (1–4)

Kuon Lee et al. [19]

12 (32.4)

0

83.6 (30–210)

2.7

Langwieler et al. [20]

0

0

NR (53–115)

NR

Petrotos et al. [21]

2 (20)

0

85 median (42–159)

1 (1)

Philipp et al. [22]

0

6 (20.1)

85 (median) (52–138)

0 (median) (0–1)

Rivas et al. [23]

0

1 (1)

50.8 (23–120)

NR

Roberts et al. [24]

0

3 (5.4)

80 (41–186)

0.3 (0–2)

Romanelli et al. [25]

0

1 (4.5)

80.8 (51–156)

NR

Schlager et al. [26]

0

1 (5)

136 (78–230)

NR

Tacchino et al. [27]

0

2 (16.7)

NR

2.4 (2–7)

Vidal et al. [28]

0

0

62 (35–95)

<1 (0–1)

Zhu et al. [29]

1 (1)

0

62 (45–110)

2 (2)

Brody et al. [30]

1 (1.7)

1 (1.7)

92.6 (NR)

1.2 (NR)

Curcillo et al. [31]

7 (2.4)

20 (6.7)

71 (NR)

1.5 (NR)

Erbella and Bunch [32]

1 (1)

0

30 (22–75)

1 (1)

Ersin et al. [33]

0

0

94 (70–130)

1 (1)

Total

32

40

70.2a

1.4a

NR not reported

aMean cumulative adjusted values

Table 6

Morbidity data

Complications

No. of patients (ratio %)

Rate %

Intraoperative complications

 Gallbladder perforation/bile spillage

26 (81.2)

2.2

 Hemorrhage

4 (12.5)

0.3

 Bile duct injury

1 (2.9)

0.09

 Other

2 (3.1)

0.2

 Total

32a

2.7

Postoperative complications

 Wound complications

25 (62.5)

2.1

 Bile leakage

5 (12.5)

0.4

 Residual choledocholithiasis

4 (10)

0.3

 Intra-abdominal hematoma

1 (2.5)

0.09

 Incisional hernia

1 (2.5)

0.09

 Biliary stricture

1 (2.5)

0.09

 Other

3 (7.5)

2.6

 Total

40

3.4

aTwo complications occurred in a single patient

Mean operative time ranged from 30–150 min with a mean adjusted cumulative operative time of 70 min. A decrease of operative times with increasing experience with the technique was noticed by several authors [12, 23, 30, 32]. The mean cumulative adjusted hospital stay was 1.4 (range, 0–4.4) days.

Analysis of outcome

Comparative data of morbidity, success rates, and operative times according to demographic and study population characteristics are summarized in Tables 7 and 8. The statistical analysis indicated significantly lower complication rates for studies enrolling patients with a mean age lower than 45 years (p = 0.04), whereas no difference in morbidity and success rates was noted with regard to sex distribution and mean BMI. However, operative times tended to be longer in studies enrolling patients with a BMI >30 kg/m2 (83.4 vs. 74.5 min) and female percentage lower than 70% (78.7 vs. 68.5 min).
Table 7

Analysis of outcome according to cumulative demographic characteristics

 

Mean age (year)

Gender

Mean BMI (kg/m2)

<45

≥45

p Value

Female >70%

Female ≤70%

p Value

<30

≥30

p Value

Complication rate (%)

4.2

8.1

0.04

6.5

11.5

NS

6.4

5.4

NS

Success rate (%)

93

98.4

NS

92.1

83.2

NS

96.9

95.5

NS

Operative time (min)

78

75.5

NA

74.5

83.4

NA

68.5

78.7

NA

BMI body mass index, NS not significant, NA not applicable

Table 8

Analysis of outcome according to operative data

 

Acute cholecystitis

Gallbladder anchorage

Instruments

As inclusion criterion

As exclusion criterion

p Value

Suture(s)

Instrument

p Value

Rigid

Articulating

p Value

Complication rate (%)

6.1

6.9

NS

3.3

13.3

<0.0001

6.2

5.4

NS

Success rate (%)

59.9

93.0

0.005

93.4

93

NS

90.9

93.7

NS

Operative time (min)

78.1

70.6

NA

71.4

72.5

NA

67.2

67.8

NA

NS not significant, NA not applicable

Acute cholecystitis as an inclusion criterion did not significantly affect complication rates, but technical success was greater if patients with acute cholecystitis were excluded from the single incision approach (59.9 vs. 93%, p = 0.005). Furthermore, operative times tended to be longer in studies that included patients with acute cholecystitis (78.1 vs. 70.6 min). The type of instrumentation did not affect morbidity, success rate, or operative time, whereas gallbladder anchorage with sutures seems to provide improved operative field exposure, as it significantly affected complication rates (p < 0.0001).

Discussion

Single-incision laparoscopic surgery (SILS) seems to be a further evolution of minimally invasive surgical techniques. To date, single-incision laparoscopic appendectomy [35], colectomy [36], adrenalectomy [37], splenectomy [38], sleeve gastrectomy [39], gastric bypass [40], fundoplication, and Heller myotomy (unpublished data) have been performed. These procedures seem to be feasible; their safety, however, has yet to be determined. The hypothesis of the exponents of single-incision laparoscopic procedures is that reduction of the number of the incisions may result in decreased postoperative pain, less wound-related complications, and improved cosmesis.

The apparent advantage of SILS is the excellent cosmetic result. SILC requires an intraumbilical or a subumbilical incision of 1.5–2.5 cm length. Transcutaneous suture suspension of the gallbladder does not result in a significant subcostal scar, and trocar insertion through the single incision seems to be feasible even in obese patients.

Wound complications do not seem to be a significant problem of standard laparoscopic cholecystectomy. A meta-analysis of 78,747 patients exhibited a wound infection rate of 1.1% and wound hematoma rate of 0.6% [41]. Additionally, trocar-site incisional hernia has an incidence of 0.77% [42]. In the present review, wound complications occurred in 2.1% (25/1,166) of patients; furthermore, incisional hernia was reported for one patient (0.09%). Due to the fact that many authors had short follow-up periods or omitted to report on time of follow-up, we would approach these results with caution. The effect of multiple fascial incisions in a narrow area is unpredictable and has not been subject of study to date. Some authors prefer to connect the two or three fascial incisions to a single incision and then proceed to the closure of the fascia; this approach additionally allows easier extraction of the gallbladder even without an endo-bag. Additionally, concerns regarding chronic wound complications, such as umbilical fistula and hernia with the placement of a drainage tube through the single incision and skin necrosis when the incision is made through the poorly blood-supplied umbilicus, are reasonable.

Unfortunately, adequate data on postoperative pain could not be traced in the literature. Bresadola et al. reported significantly lower postoperative pain scores for single-incision patients [6], whereas Philipp et al. noticed a trend toward increased postoperative pain for SILC compared with standard laparoscopic cholecystectomy [22]. The only study that examined postoperative pain was published recently by Tsimoyiannis et al. and observed lower pain scores for SILC in their randomized series of 40 patients, whereas ropivacaine infusion in the right suprahepatic area preceded and followed the procedures [43]. The fact that patients who undergo SILC complain of umbilical and subcostal pain [15] suggests that irritation of the Glisson’s capsule also contributes to postoperative pain apart from incisions of the skin, the fascia, and the peritoneum.

Technical challenges of SILC include retraction of the gallbladder and exposure of the Calot’s triangle, clashing of the instruments, inadequate length of the instrumentation, and the “mirror-effect” concerning the handling of roticulating instruments. The latter problem is expected to be solved with the evolution of novel instrumentation, roticulating in the contralateral direction of the handgrip articulation, and the “lockup” at a specific angle. Utilization of longer instruments will render gallbladder retraction more effective and improve the “critical view.” Novel trocars also are expected to minimize intra- and extra-abdominal clashing and allow simultaneous gas insufflation and suction to avoid smoke entrapment in the abdominal cavity.

The selection of patients suitable for SILC in the included articles did not allow subjective comparison of operative data and morbidity with standard laparoscopic cholecystectomy. Raw comparison of the present results with early reports of laparoscopic cholecystectomy exhibited similar morbidity rates [44, 45]. Nevertheless, whereas the only apparent advantage of SILC to date is the improved cosmesis, safety should not be sacrificed. For this reason, patients groups more suitable for the single-incision approach should be identified and the technical details of the procedure should be improved according to current data.

Our analysis exhibited significantly lower complication rates for articles with a younger study population. Young patient age in combination with cosmetic requests may indicate the application of SILC. Because gender and BMI seem to affect operative times, difficult surgical conditions should be expected in men and obese patients; because complications and success rates are not affected, the exclusion of these patients from the single-incision approach does not seem reasonable for now. Furthermore, acute cholecystitis was a significant factor for failure in the present review, with a cumulative success rate of 59.9 versus 93% for studies excluding patients with acute cholecystitis. The use of anchoring sutures instead of instruments for suspension of the gallbladder also significantly affected complication rates (13.3 vs. 3.3%). The length and utilization of rigid or articulating instruments should be reevaluated to ensure patient safety.

Laparoscopic treatment of gallbladder diseases was adopted due to lower complication rates, shorter hospital stay, and reduced postoperative pain; alone the cosmetic advantage does not justify the performance of SILC on a routine basis according to current data. As prophetically highlighted by Cuesta et al., patient request for improved cosmesis will impel surgeons toward the application of SILC [8]; ethical considerations and knowledge of current evidence should be sufficient to weigh the relative advantages and risks of the procedure. Marketing terms as “scarless surgery” and “invisible incision” are not proper for the surgical community; we feel that patient safety should be highlighted until the results of the procedure are well established.

The efficacy of SILC is adequately studied, as indicated by the volume of articles reporting on the success of the technique; evaluation of its safety is a matter of time. Until the results of the procedure are well established, cases of acute cholecystitis and older patients should be approached with caution. Furthermore, conventional instrumentation seems to be insufficient for the single-incision approach.

Acknowledgment

The authors highly appreciate the contribution of Ms. Aggeliki Zachou of the Papageorgiou University Hospital Medical Library.

Disclosures

Drs. S. A. Antoniou, R. Pointner, and F. A. Granderath have no conflicts of interest or financial ties to disclose.

Copyright information

© Springer Science+Business Media, LLC 2010