Is smaller necessarily better? A systematic review comparing the effects of minilaparoscopic and conventional laparoscopic cholecystectomy on patient outcomes
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In recent years, minilaparoscopic cholecystectomy (MLC; total size of trocar incision <25 mm) has been increasingly advocated for the removal of the gallbladder, due to potentially better surgical outcomes (e.g., better cosmetic result, reduced pain, shorter hospital stay, quicker return to activity), but an evidence-based approach has been lacking. The current systematic review was undertaken to evaluate the importance of total size of trocar incision in improving surgical outcomes in adult laparoscopic cholecystectomy (LC).
The literature was systematically reviewed using MEDLINE and EmBASE. Only randomized controlled trials in English, investigating minilaparoscopic versus conventional LC (total size of trocar incision ≥25 mm) and reporting pain scores were included. Quantitative analyses (meta-analyses) were performed on postoperative pain scores and other patient outcomes from more than one study where feasible and appropriate. Qualitative analyses consisted of assessing the number of studies showing a significant difference between the techniques.
Thirteen trials met the inclusion criteria. There was a trend towards reduced pain with MLC compared with conventional LC, without reduction in opioid use. Patients in the MLC group had slightly reduced length of hospital stay, but there were no significant differences for return to activity. The two interventions were also similar in terms of operating times and adverse events, but MLC was associated with better cosmetic result (largely patient rated). There was a significantly greater likelihood of conversion to conventional LC or to open cholecystectomy in the MLC group than there was of conversion to open cholecystectomy in the conventional LC group [OR 4.71 (95% confidence interval 2.67–8.31), p < 0.00001].
The data included in this review suggest that reducing the size of trocar incision results in some limited improvements in surgical outcomes after LC. However, it carries a higher risk of conversion to conventional LC or open cholecystectomy.
KeywordsLaparoscopic cholecystectomy Minilaparoscopic cholecystectomy Systematic review
The authors would like to thank Caroline Sharp (M.Sci, Medical Writer, Choice Pharma, Hitchin, UK) for her help with data extraction and entry; Emmanuel Marret (M.D., Departement d’Anesthesie-Reanimation, Hôpital Tenon, Paris, France) for his expert statistical input; Iradj Reza (Ph.D., Biomedical Information Scientist, Pfizer, Sandwich, UK) for his help and expertise in performing literature searches in EmBASE and MEDLINE; and Roseanne Wilkinson (Ph.D., Senior Medical Writer, Choice Pharma), Christine Drewienkiewicz (B.Sc., Scientific Services Director, Choice Pharma), Eva Leung (B.Sc., Account Executive, Choice Pharma), and James Pickford (B.Sc., Editorial Director, Choice Pharma) for editorial assistance.
Financial support: All authors are members or associates of the PROSPECT working group, which is supported by Pfizer Inc., New York, NY, USA. The PROSPECT working group members have been reimbursed by Pfizer Inc. for attending PROSPECT meetings to formulate the consensus recommendations. D.R. is employed by Choice Pharma, which has received funding from Pfizer Inc. to implement PROSPECT activities. This paper makes no specific recommendations about the use of any medical products, drugs or equipment manufactured by Pfizer Inc. or by any of its subsidiaries.
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