Surgical Endoscopy

, Volume 30, Issue 3, pp 819–831 | Cite as

Single-incision laparoscopic cholecystectomy with curved versus linear instruments assessed by systematic review and network meta-analysis of randomized trials

  • Stavros A. AntoniouEmail author
  • Salvador Morales-Conde
  • George A. Antoniou
  • Rudolph Pointner
  • Frank-Alexander Granderath



Single-incision laparoscopic surgery poses significant ergonomic limitations. Curved instruments have been developed in order to address the issue of lack of triangulation. Direct comparison between single-incision laparoscopic surgeries with conventional linear and curved instruments has not been performed to date.


MEDLINE, CENTRAL and OpenGrey were searched to identify relevant randomized trials. A network meta-analysis was applied to compare operative risks, conversion, duration of surgery and the need for placement of an adjunct trocar in single-incision laparoscopic cholecystectomy with linear and curved instruments. The random-effects model was applied for two sets of comparisons, with conventional laparoscopic cholecystectomy as the reference treatment. Odds ratios, mean differences and 95 % confidence intervals were calculated.


Twenty-three randomized trials encompassing 1737 patients were included. The use of curved instruments was associated with increased operative time (mean difference 32.53 min, 95 % CI 24.23–40.83) and higher odds for the use of an adjunct trocar (odds ratio 22.81, 95 % CI 16.69–28.94) compared to the use of linear instruments. Perioperative risks could not be comparatively assessed due to the low number of events.


Single-incision laparoscopic cholecystectomy with curved instruments may be associated with an increased level of operative difficulty, as reflected by the need for auxiliary measures for exposure and increased operative time as compared to the use of linear instruments. Current instrumentation requires further improvement, tailored to the features of single-incision laparoscopic surgery (CRD42015015721).


Single-incision SILS Cholecystectomy Laparoscopic Instruments technical 



Stavros A. Antoniou, Salvador Morales-Conde, George A. Antoniou, Rudolph Pointner and Frank-Alexander Granderath have no competing interests.

Supplementary material

464_2015_4283_MOESM1_ESM.docx (12 kb)
Supplementary material 1 (DOCX 12 kb)
464_2015_4283_MOESM2_ESM.docx (33 kb)
Supplementary material 2 (DOCX 33 kb)
464_2015_4283_MOESM3_ESM.docx (85 kb)
Supplementary material 3 (DOCX 84 kb)


  1. 1.
    Antoniou SA, Antoniou GA, Koutras C, Antoniou AI (2012) Endoscopy and laparoscopy: a historical aspect of medical terminology. Surg Endosc 26(12):3650–3654CrossRefPubMedGoogle Scholar
  2. 2.
    Antoniou SA, Pointner R, Granderath FA (2011) Single-incision laparoscopic cholecystectomy: a systematic review. Surg Endosc 25(2):367–377CrossRefPubMedGoogle Scholar
  3. 3.
    Ahmed I, Paraskeva P (2011) A clinical review of single-incision laparoscopic surgery. Surgeon 9(6):341–351CrossRefPubMedGoogle Scholar
  4. 4.
    Kwag SJ, Kim JG, Oh ST, Kang WK (2013) Single incision vs conventional laparoscopic anterior resection for sigmoid colon cancer: a case-matched study. Am J Surg 206(3):320–325CrossRefPubMedGoogle Scholar
  5. 5.
    Morales-Conde S, Barranco A, Socas M, Méndez C, Alarcón I, Cañete J, Padillo FJ (2012) Improving the advantages of single port in right hemicolectomy: analysis of the results of pure transumbilical approach with intracorporeal anastomosis. Minim Invasive Surg 2012:874172PubMedCentralPubMedGoogle Scholar
  6. 6.
    Allemann P, Demartines N, Schäfer M (2014) Remains of the day: biliary complications related to single-port laparoscopic cholecystectomy. World J Gastroenterol 20(3):843–851PubMedCentralCrossRefPubMedGoogle Scholar
  7. 7.
    Joseph M, Phillips MR, Farrell TM, Rupp CC (2012) Single incision laparoscopic cholecystectomy is associated with a higher bile duct injury rate: a review and a word of caution. Ann Surg 256(1):1–6CrossRefPubMedGoogle Scholar
  8. 8.
    Garg P, Thakur JD, Singh I, Nain N, Mittal G, Gupta V (2012) A prospective controlled trial comparing single-incision and conventional laparoscopic cholecystectomy: caution before damage control. Surg Laparosc Endosc Percutan Tech. 22(3):220–225CrossRefPubMedGoogle Scholar
  9. 9.
    Trastulli S, Cirocchi R, Desiderio J, Guarino S, Santoro A, Parisi A, Noya G, Boselli C (2013) Systematic review and meta-analysis of randomized clinical trials comparing single-incision versus conventional laparoscopic cholecystectomy. Br J Surg 100(2):191–208CrossRefPubMedGoogle Scholar
  10. 10.
    Chamberlain RS, Sakpal SV (2009) A comprehensive review of single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) techniques for cholecystectomy. J Gastrointest Surg 13(9):1733–1740CrossRefPubMedGoogle Scholar
  11. 11.
    University of York, Centre for Reviews and Dissemination. PROSPERO; International Prospective Register of systematic reviews. Accessed January 2014
  12. 12.
    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 62(10):e1–e34CrossRefPubMedGoogle Scholar
  13. 13.
    Robinson KA, Dickersin K (2002) Development of a highly sensitive search strategy for the retrieval of reports of controlled trials using PubMed. Int J Epidemiol 31(1):150–153CrossRefPubMedGoogle Scholar
  14. 14.
    DerSimonian R, Laird N (1986) Meta-analysis in clinical trials. Control Clin Trials 7(3):177–188CrossRefPubMedGoogle Scholar
  15. 15.
    Higgins JP, Altman DG (2008) Assessing risk of bias in included studies. In: Higgins JP, Green S (eds) Cochrane handbook for systematic reviews of interventions. Wiley, West Sussex, pp 187–235CrossRefGoogle Scholar
  16. 16.
    Akethong C, Sawaengtham T (2013) Comparative study: single-incision laparoscopic cholecystectomy and conventional three-ports laparoscopic cholecystectomy. J Med Assoc Thai 96(9):1143–1146PubMedGoogle Scholar
  17. 17.
    Lai EC, Yang GP, Tang CN, Yih PC, Chan OC, Li MK (2011) Prospective randomized comparative study of single incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy. Am J Surg 202(3):254–258CrossRefPubMedGoogle Scholar
  18. 18.
    Zheng M, Qin M, Zhao H (2012) Laparoendoscopic single-site cholecystectomy: a randomized controlled study. Minim Invasive Ther Allied Technol 21(2):113–117CrossRefPubMedGoogle Scholar
  19. 19.
    Saad S, Strassel V, Sauerland S (2013) Randomized clinical trial of single-port, minilaparoscopic and conventional laparoscopic cholecystectomy. Br J Surg 100(3):339–349CrossRefPubMedGoogle Scholar
  20. 20.
    Abd Ellatif ME, Askar WA, Abbas AE, Noaman N, Negm A, El-Morsy G, El Nakeeb A, Magdy A, Amin M (2013) Quality-of-life measures after single-access versus conventional laparoscopic cholecystectomy: a prospective randomized study. Surg Endosc 27(6):1896–1906CrossRefPubMedGoogle Scholar
  21. 21.
    Brown KM, Moore BT, Sorensen GB, Boettger CH, Tang F, Jones PG, Margolin DJ (2013) Patient-reported outcomes after single-incision versus traditional laparoscopic cholecystectomy: a randomized prospective trial. Surg Endosc 27(9):3108–3115CrossRefPubMedGoogle Scholar
  22. 22.
    Khorgami Z, Shoar S, Anbara T, Soroush A, Nasiri S, Movafegh A, Aminian A (2014) A randomized clinical trial comparing 4-port, 3-port, and single-incision laparoscopic cholecystectomy. J Invest Surg 27(3):147–154CrossRefPubMedGoogle Scholar
  23. 23.
    Pan MX, Jiang ZS, Cheng Y, Xu XP, Zhang Z, Qin JS, He GL, Xu TC, Zhou CJ, Liu HY, Gao Y (2013) Single-incision vs three-port laparoscopic cholecystectomy: prospective randomized study. World J Gastroenterol 19(3):394–398PubMedCentralCrossRefPubMedGoogle Scholar
  24. 24.
    Borle FR, Mehra BK, Jain S (2014) Evaluation of pain scores after single-incision and conventional laparoscopic cholecystectomy: a randomized control trial in a rural Indian population. Asian J Endosc Surg 7(1):38–42CrossRefPubMedGoogle Scholar
  25. 25.
    Justo Janeiro JM, Theurel VG, Vázquez de Lara F, de la Rosa Paredes R, Prado OE, Vázquez de Lara LG (2014) One, two, or three ports in laparoscopic cholecystectomy? Int Surg 99(6):739–744PubMedCentralCrossRefPubMedGoogle Scholar
  26. 26.
    Tsimoyiannis EC, Tsimogiannis KE, Pappas-Gogos G, Farantos C, Benetatos N, Mavridou P, Manataki A (2010) Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial. Surg Endosc 24(8):1842–1848CrossRefPubMedGoogle Scholar
  27. 27.
    Bucher P, Pugin F, Buchs NC, Ostermann S, Morel P (2011) Randomized clinical trial of laparoendoscopic single-site versus conventional laparoscopic cholecystectomy. Br J Surg 98(12):1695–1702CrossRefPubMedGoogle Scholar
  28. 28.
    Ma J, Cassera MA, Spaun GO, Hammill CW, Hansen PD, Aliabadi-Wahle S (2011) Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy. Ann Surg 254(1):22–27CrossRefPubMedGoogle Scholar
  29. 29.
    Herrero Fonollosa E, Cugat Andorrà E, García Domingo MI, Camps Lasa J, Porta Castejón R, Carvajal López F, Rodríguez Campos A (2012) A randomised prospective comparative study between laparoscopic cholecystectomy and single port cholecystectomy in a major outpatient surgery unit. Cir Esp. 90(10):641–646CrossRefPubMedGoogle Scholar
  30. 30.
    Sasaki A, Ogawa M, Tono C, Obara S, Hosoi N, Wakabayashi G (2012) Single-port versus multiport laparoscopic cholecystectomy: a prospective randomized clinical trial. Surg Laparosc Endosc Percutan Tech. 22(5):396–399CrossRefPubMedGoogle Scholar
  31. 31.
    Sinan H, Demirbas S, Ozer MT, Sucullu I, Akyol M (2012) Single-incision laparoscopic cholecystectomy versus laparoscopic cholecystectomy: a prospective randomized study. Surg Laparosc Endosc Percutan Tech. 22(1):12–16CrossRefPubMedGoogle Scholar
  32. 32.
    Solomon D, Shariff AH, Silasi DA, Duffy AJ, Bell RL, Roberts KE (2012) Transvaginal cholecystectomy versus single-incision laparoscopic cholecystectomy versus four-port laparoscopic cholecystectomy: a prospective cohort study. Surg Endosc 26(10):2823–2827CrossRefPubMedGoogle Scholar
  33. 33.
    Deveci U, Barbaros U, Kapakli MS, Manukyan MN, Simşek S, Kebudi A, Mercan S (2013) The comparison of single incision laparoscopic cholecystectomy and three port laparoscopic cholecystectomy: prospective randomized study. J Korean Surg Soc. 85(6):275–282PubMedCentralCrossRefPubMedGoogle Scholar
  34. 34.
    Luna RA, Nogueira DB, Varela PS, Rodrigues Neto Ede O, Norton MJ, Ribeiro Ldo C, Peixoto AM, de Mendonça YL, Bendet I, Fiorelli RA, Dolan JP (2013) A prospective, randomized comparison of pain, inflammatory response, and short-term outcomes between single port and laparoscopic cholecystectomy. Surg Endosc 27(4):1254–1259CrossRefPubMedGoogle Scholar
  35. 35.
    Madureira FA, Manso JE, Madureira-Fo D, Iglesias AC (2013) Randomized clinical study for assessment of incision characteristics and pain associated with LESS versus laparoscopic cholecystectomy. Surg Endosc 27(3):1009–1015CrossRefPubMedGoogle Scholar
  36. 36.
    Noguera J, Tejada S, Tortajada C, Sánchez A, Muñoz J (2013) Prospective, randomized clinical trial comparing the use of a single-port device with that of a flexible endoscope with no other device for transumbilical cholecystectomy: LLATZER-FSIS pilot study. Surg Endosc 27(11):4284–4290CrossRefPubMedGoogle Scholar
  37. 37.
    Zapf M, Yetasook A, Leung D, Salabat R, Denham W, Barrera E, Butt Z, Carbray J, Du H, Wang CE, Ujiki M (2013) Single-incision results in similar pain and quality of life scores compared with multi-incision laparoscopic cholecystectomy: a blinded prospective randomized trial of 100 patients. Surgery 154(4):662–670; discussion 670–671Google Scholar
  38. 38.
    Chang SK, Wang YL, Shen L, Iyer SG, Madhavan K (2014) A randomized controlled trial comparing post-operative pain in single-incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy. World J Surg. doi: 10.1007/s00268-014-2903-6 Google Scholar
  39. 39.
    Emre Telciler K, Ilhan E, Yakan S, Cengiz F, Senlikci A, Aktürk Hayat E (2014) Single-port laparoscopic cholecystectomy versus the classical four port laparoscopic cholecystectomy: a randomized prospective clinical trial. Minerva Chir 69(1):1–7PubMedGoogle Scholar
  40. 40.
    Pappas-Gogos G, Tellis CC, Trypsianis G, Tsimogiannis KE, Tsimoyiannis EC, Simopoulos CE, Pitiakoudis M, Tselepis AD (2014) Oxidative stress in multi-port and single-port cholecystectomy. J Surg Res 194(1):101–106CrossRefPubMedGoogle Scholar
  41. 41.
    Madureira FA, Manso JE, Madureira Filho D, Iglesias AC (2013) Inflammation in laparoendoscopic single-site surgery versus laparoscopic cholecystectomy. Surg Innov. 21(3):263–268CrossRefPubMedGoogle Scholar
  42. 42.
    Chang SK, Wang YL, Shen L, Iyer SG, Shaik AB, Lomanto D (2013) Interim report: a randomized controlled trial comparing postoperative pain in single-incision laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy. Asian J Endosc Surg 6(1):14–20CrossRefPubMedGoogle Scholar
  43. 43.
    Tsimogiannis KE, Tellis CC, Tselepis AD, Pappas-Gogos G, Bakola MS, Tsimoyiannis EC, Simopoulos CE, Pitiakoudis M (2012) α-Defensins and hsCRP levels in inflammatory response of standard and laparoendoscopic single-site cholecystectomy. Surg Endosc 26(3):627–631CrossRefPubMedGoogle Scholar
  44. 44.
    Trastulli S, Cirocchi R, Desiderio J, Guarino S, Santoro A, Parisi A, Noya G, Boselli C (2013) Systematic review and meta-analysis of randomized clinical trials comparing single-incision versus conventional laparoscopic cholecystectomy. Br J Surg 100(2):191–208CrossRefPubMedGoogle Scholar
  45. 45.
    Milas M, Deveđija S, Trkulja V (2014) Single incision versus standard multiport laparoscopic cholecystectomy: up-dated systematic review and meta-analysis of randomized trials. Surgeon 12(5):271–289CrossRefPubMedGoogle Scholar
  46. 46.
    Garg P, Thakur JD, Garg M, Menon GR (2012) Single-incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy: a meta-analysis of randomized controlled trials. J Gastrointest Surg 16(8):1618–1628CrossRefPubMedGoogle Scholar
  47. 47.
    McCrory B, Lowndes BR, Wirth LM, de Laveaga AE, LaGrange CA, Hallbeck MS (2012) Ergonomic evaluation of laparoendoscopic single-site surgery ports in a validated laparoscopic training model. Work 41(Suppl 1):1884–1890PubMedGoogle Scholar
  48. 48.
    Koca D, Yıldız S, Soyupek F, Günyeli I, Erdemoglu E, Soyupek S, Erdemoglu E (2014) Physical and mental workload in single-incision laparoscopic surgery and conventional laparoscopy. Surg Innov. doi: 10.1177/1553350614556363 PubMedGoogle Scholar
  49. 49.
    Corker HP, Singh P, Sodergren MH, Balaji S, Kwasnicki RM, Darzi AW, Paraskeva P (2015) A randomized controlled study to establish the effect of articulating instruments on performance in single-incision laparoscopic surgery. J Surg Educ. 72(1):1–7CrossRefPubMedGoogle Scholar
  50. 50.
    Salanti G, Higgins JP, Ades AE, Ioannidis JP (2008) Evaluation of networks of randomized trials. Stat Methods Med Res 17(3):279–301CrossRefPubMedGoogle Scholar
  51. 51.
    Shemilt I, Mugford M, Byford S, Drummond M, Eisenstein E, Knapp M, Mallender J, McDaid D, Vale L, Walker D (2011) Chapter 15: incorporating economics evidence. In: Higgins JPT, Green S (eds) Cochrane handbook for systematic reviews of interventions. Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Stavros A. Antoniou
    • 1
    • 2
    • 6
    Email author
  • Salvador Morales-Conde
    • 3
  • George A. Antoniou
    • 4
  • Rudolph Pointner
    • 5
  • Frank-Alexander Granderath
    • 1
  1. 1.Center for Minimally Invasive SurgeryHospital NeuwerkMönchengladbachGermany
  2. 2.Department of General SurgeryUniversity Hospital of HeraklionCreteGreece
  3. 3.Unit of Innovation in Minimally Invasive Surgery, Unidad de Gestión Clínica de Cirugía General y Aparato DigestivoUniversity Hospital Virgen del RocíoSevilleSpain
  4. 4.Liverpool Vascular and Endovascular ServiceRoyal Liverpool University HospitalLiverpoolUK
  5. 5.Department of General SurgeryHospital Zell am SeeZell Am SeeAustria
  6. 6.Keratea Attikis, AthensGreece

Personalised recommendations