Single-Incision Versus Conventional Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis
Background: This review aims to evaluate the feasibility and safety of single-incision laparoscopic cholecystectomy (SILC) as compared to conventional laparoscopic cholecystectomy (CLC). Methods: A literature search for studies comparing the feasibility and safety of SILC with CLC was performed. Perioperative complications, postoperative pain, cosmetic satisfaction, conversion rates operative time, length of stay (LOS), estimated blood loss (EBL), total incision length, time to return to work / normal activity, and cost of stay were extracted. Weighted mean differences (WMDs) and odds ratios (ORs) were calculated for continuous and dichotomous variables, respectively. Results: Forty-three studies, including 2291 cases for SILC and 2281 cases for CLC, were included. Our analysis showed that compared with CLC, SILC was associated with significantly reduced postoperative pain on the day of surgery (WMD, -0.47; p = 0.005), lower rate of analgesic use (26.5% vs. 36.1%; p = 0.004), better cosmetic satisfaction scores (WMD, 0.84; p = 0.0006), shorter LOS (WMD, -0.18d; p = 0.03), and shorter incision length (WMD, -9.67 mm; p = 0.004). However, SILC was associated with significantly longer operative time compared to CLC (WMD, 13.65min; p < 0.00001). No significant differences were observed in perioperative complications, analgesic requirement, conversions to open surgery, EBL, time to return to work / normal activity, or cost of stay. Conclusions: In this analysis, which included the largest number of patients thus far, SILC appeared to be feasible and safe. Whether SILC benefits LOS over CLC remains to be further investigated, as well as cost of stay.
Laparoscopic Cholecystectomy, Single-Incision, Single-Port Access, Laparoendoscopic Single-Site, Single-Incision Laparoscopic Surgery
Reynolds Jr W. The first laparoscopic cholecystectomy. JSLS 2001; 5:89.
Litynski GS. Profiles in laparoscopy: Mouret, Dubois, and Perissat: the laparoscopic breakthrough in Europe (1987-1988). JSLS 1999; 3:163.
Keus F, de Jong JA, Gooszen HG, et al. Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev 2006(4): CD006231.
Keus F, de Jong JA, Gooszen HG, et al. Laparoscopic versus small-incision cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev 2006(4): CD006229.
Schirmer BD, Edge SB, Dix J, et al. Laparoscopic cholecystectomy. Treatment of choice for symptomatic cholelithiasis. Ann Surg 1991; 213: 665.
Navarra G, Pozza E, Occhionorelli S, et al. One-wound laparoscopic cholecystectomy. Br J Surg 1997; 84: 695.
Bresadola F, Pasqualucci A, Donini A, et al. Elective transumbilical compared with standard laparoscopic cholecystectomy. Eur J Surg 1999; 165: 29.
Piskun G, Rajpal S. Transumbilical laparoscopic cholecystectomy utilizes no incisions outside the umbilicus. J Laparoendosc Adv Surg Tech A 1999; 9: 361.
Garg P, Thakur JD, Garg M, et al. Single-incision laparoscopic cholecystectomy vs. conventional laparoscopic cholecystectomy: a meta-analysis of randomized controlled trials. J Gastrointest Surg 2012; 16: 1618.
Pisanu A, Reccia I, Porceddu G, et al. Meta-analysis of prospective randomized studies comparing single-incision laparoscopic cholecystectomy (SILC) and conventional multiport laparoscopic cholecystectomy (CMLC). J Gastrointest Surg 2012; 16: 1790.
Sajid MS, Ladwa N, Kalra L, et al. Single-Incision Laparoscopic Cholecystectomy Versus Conventional Laparoscopic Cholecystectomy: Meta-analysis and Systematic Review of Randomized Controlled Trials. World J Surg 2012; 36: 2644.
Joseph M, Phillips MR, Farrell TM, et al. Single incision laparoscopic cholecystectomy is associated with a higher bile duct injury rate: a review and a word of caution. Ann Surg 2012; 256:1.
Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 2009; 62: 1006.
Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000; 283:2008.
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240: 205.
Higgins JPT, Altman DG. Assessing risk of bias in included studies. In: Higgins JPT, Green S, eds. Cochrane handbook for systematic reviews of interventions Version 5.0.0. New York: John Wiley and Sons; 2008.
Wells GA, Shea B, O'Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa, Canada. Available at: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed January 4, 2013.
Phillips B, Ball C, Sackett D, et al. Levels of evidence and grades of recommendation. Oxford Centre for Evidence-based Medicine Web site. Available at: http://www.cebm.net/index.aspx?o=1025. Accessed January 10, 2013.
Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ 2003; 327:557.
Dupont WD, Plummer WD Jr. Power and sample size calculations. A review and computer program. Control Clin Trials 1990; 11:116.
Beck C, Eakin J, Dettorre R, et al. Analysis of perioperative factors and cost comparison of single-incision and traditional multi-incision laparoscopic cholecystectomy. Surg Endosc 2013; 27:104.
Cao LP, Que RS, Zhou F, et al. Transumbilical single-port laparoscopic cholecystectomy using traditional laparoscopic instruments: a report of thirty-six cases. J Zhejiang Univ Sci B 2011; 12:862.
Chang SK, Tay CW, Bicol RA, et al. A case-control study of single-incision versus standard laparoscopic cholecystectomy. World J Surg 2011; 35:289.
Chow A, Purkayastha S, Aziz O, et al. Single-incision laparoscopic surgery for cholecystectomy: a retrospective comparison with 4-port laparoscopic cholecystectomy. Arch Surg 2010; 145:1187.
Fronza JS, Linn JG, Nagle AP, et al. A single institution’s experience with single incision cholecystectomy compared to standard laparoscopic cholecystectomy. Surgery 2010; 148:731.
Hernandez JM, Morton CA, Ross S, et al. Laparoendoscopic single site cholecystectomy: the first 100 patients. Am Surg 2009; 75:681.
Hodgett SE, Hernandez JM, Morton CA, et al. Laparoendoscopic single site (LESS) cholecystectomy. J Gastrointest Surg 2009; 13:188.
Jacob D, Raakow R. Single-port versus multi-port cholecystectomy for patients with acute cholecystitis: a retrospective comparative analysis. Hepatobiliary Pancreat Dis Int 2011; 10:521.
Joseph S, Moore BT, Sorensen GB, et al. Single-incision laparoscopic cholecystectomy: a comparison with the gold standard. Surg Endosc 2011; 25:3008.
Karim MA, Ahmed J, Mansour M, et al. Single incision vs. conventional multiport laparoscopic cholecystectomy: a comparison of two approaches. Int J Surg 2012; 10:368.
Khaimook A. Single-incision versus conventional multiple-incision laparoscopic cholecystectomy at Hat Yai Hospital. J Med Assoc Thai 2012; 95:771.
Kim BS, Kim KC, Choi YB. A comparison between single-incision and conventional laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A 2012; 22:443.
Love KM, Durham CA, Meara MP, et al. Single-incision laparoscopic cholecystectomy: a cost comparison. Surg Endosc 2011; 25:1553.
Philipp SR, Miedema BW, Thaler K. Single-incision laparoscopic cholecystectomy using conventional instruments: early experience in comparison with the gold standard. J Am Coll Surg 2009; 209:632.
Rasić Z, Schwarz D, Nesek VA, et al. Single incision laparoscopic cholecystectomy--a new advantage of gallbladder surgery. Coll Antropol 2010; 34:595.
Sasaki K, Watanabe G, Matsuda M, et al. Single-incision laparoscopic cholecystectomy: comparison analysis of feasibility and safety. Surg Laparosc Endosc Percutan Tech 2012; 22:108.
Wu SD, Han JY, Tian Y. Single-incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy: a retrospective comparative study. J Laparoendosc Adv Surg Tech A 2011; 21:25.
Barband A, Fakhree MB, Kakaei F, et al. Single-incision laparoscopic cholecystectomy using glove port in comparison with standard laparoscopic cholecystectomy SILC using glove port. Surg Laparosc Endosc Percutan Tech 2012; 22:17.
Gangl O, Hofer W, Tomaselli F, et al. Single incision laparoscopic cholecystectomy (SILC) versus laparoscopic cholecystectomy (LC)-a matched pair analysis. Langenbecks Arch Surg 2011; 396:819.
Garg P, Thakur JD, Singh I, et al. A prospective controlled trial comparing single-incision and conventional laparoscopic cholecystectomy: caution before damage control. Surg Laparosc Endosc Percutan Tech 2012; 22:220.
Han HJ, Choi SB, Kim WB, et al. Surgical stress response and clinical outcomes of single port laparoscopic cholecystectomy: prospective nonrandomized study. Am Surg 2012; 78:485.
Khambaty F, Brody F, Vaziri K, et al. Laparoscopic versus single-incision cholecystectomy. World J Surg 2011; 35:967.
McGregor CG, Sodergren MH, Aslanyan A, et al. Evaluating systemic stress response in single port vs. multi-port laparoscopic cholecystectomy. J Gastrointest Surg 2011; 15:614.
Prasad A, Mukherjee KA, Kaul S, et al. Postoperative pain after cholecystectomy: Conventional laparoscopy versus single-incision laparoscopic surgery. J Minim Access Surg 2011; 7:24.
Rupp CC, Farrell TM, Meyer AA. Single incision laparoscopic cholecystectomy using a "two-port" technique is safe and feasible: experience in 101 consecutive patients. Am Surg 2011; 77:916.
Solomon D, Shariff AH, Silasi DA, et al. Transvaginal cholecystectomy versus single-incision laparoscopic cholecystectomy versus four-port laparoscopic cholecystectomy: a prospective cohort study. Surg Endosc 2012; 26:2823.
Thapa PB, Maharjan DK, Singh DR. Single incision laparoscopic cholecystectomy vs conventional cholecystectomy in developing country. JNMA J Nepal Med Assoc 2010; 49:216.
Vidal O, Valentini M, Ginestà C, et al. Single-incision versus standard laparoscopic cholecystectomy: comparison of surgical outcomes from a single institution. J Laparoendosc Adv Surg Tech A 2011; 21:683.
Wong JS, Cheung YS, Fong KW, et al. Comparison of postoperative pain between single-incision laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy: prospective case-control study. Surg Laparosc Endosc Percutan Tech 2012; 22:25.
Aprea G, Coppola Bottazzi E, Guida F, et al. Laparoendoscopic single site (LESS) versus classic video-laparoscopic cholecystectomy: a randomized prospective study. J Surg Res 2011; 166:109.
Bucher P, Pugin F, Buchs NC, et al. Randomized clinical trial of laparoendoscopic single-site versus conventional laparoscopic cholecystectomy. Br J Surg 2011; 98:1695.
Cao ZG, Cai W, Qin MF, et al. Randomized clinical trial of single-incision versus conventional laparoscopic cholecystectomy: short-term operative outcomes. Surg Laparosc Endosc Percutan Tech 2011; 21:311.
Lai EC, Yang GP, Tang CN, et al. Prospective randomized comparative study of single incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy. Am J Surg 2011; 202:254.
Lee PC, Lo C, Lai PS, et al. Randomized clinical trial of single-incision laparoscopic cholecystectomy versus minilaparoscopic cholecystectomy. Br J Surg 2010; 97:1007.
Leung D, Yetasook AK, Carbray J, et al. Single-Incision Surgery Has Higher Cost with Equivalent Pain and Quality-of-Life Scores Compared with Multiple-Incision Laparoscopic Cholecystectomy: A Prospective Randomized Blinded Comparison. J Am Coll Surg 2012; 215:702.
Lirici MM, Califano AD, Angelini P, et al. Laparo-endoscopic single site cholecystectomy versus standard laparoscopic cholecystectomy: results of a pilot randomized trial. Am J Surg 2011; 202:45.
Ma J, Cassera MA, Spaun GO, et al. Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy. Ann Surg 2011; 254:22.
Phillips MS, Marks JM, Roberts K, et al. Intermediate results of a prospective randomized controlled trial of traditional four-port laparoscopic cholecystectomy versus single-incision laparoscopic cholecystectomy. Surg Endosc 2012; 26:1296.
Sinan H, Demirbas S, Ozer MT, et al. Single-incision laparoscopic cholecystectomy versus laparoscopic cholecystectomy: a prospective randomized study. Surg Laparosc Endosc Percutan Tech 2012; 22:12.
Tsimoyiannis EC, Tsimogiannis KE, Pappas-Gogos G, et al. Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial. Surg Endosc 2010; 24:1842.
Vilallonga R, Barbaros U, Sümer A, et al. Single-port transumbilical laparoscopic cholecystectomy: A prospective randomised comparison of clinical results of 140 cases. J Minim Access Surg 2012; 8:74.
Zheng M, Qin M, Zhao H. Laparoendoscopic single-site cholecystectomy: a randomized controlled study. Minim Invasive Ther Allied Technol 2012; 21:113.
Asakuma M, Hayashi M, Komeda K, et al. Impact of single-port cholecystectomy on postoperative pain. Br J Surg 2011; 98:991.
Hey J, Roberts KJ, Morris-Stiff GJ, et al. Patient views through the keyhole: new perspectives on single-incision vs. multiport laparoscopic cholecystectomy. HPB (Oxford) 2012; 14:242.
Bignell M, Hindmarsh A, Nageswaran H, et al. Assessment of cosmetic outcome after laparoscopic cholecystectomy among women 4 years after laparoscopic cholecystectomy: is there a problem? Surg Endosc 2011; 25:2574.
Monkhouse SJ, Court EL, Beard LA, et al. A retrospective wound review of standard four-port laparoscopic cholecystectomy: is there need for single-port laparoscopic surgery? Surg Endosc 2012; 26:255.
Blinman T. Incisions do not simply sum. Surg Endosc 2010; 24:1746.
Hernandez J, Ross S, Morton C, et al. The learning curve of laparoendoscopic single-site (LESS) cholecystectomy: definable, short, and safe. J Am Coll Surg 2010; 211:652.
Joseph M, Phillips M, Rupp CC. Single-incision laparoscopic cholecystectomy: a combined analysis of resident and attending learning curves at a single institution. Am Surg 2012; 78:119.
Chauhan A, Mehrotra M, Bhatia PK, et al. Day care laparoscopic cholecystectomy: a feasibility study in a public health service hospital in a developing country. World J Surg 2006; 30:1690.
Bal S, Reddy LG, Parshad R,et al. Feasibility and safety of day care laparoscopic cholecystectomy in a developing country. Postgrad Med J 2003; 79:284.
Love KM, Durham CA, Meara MP, et al. Single-incision laparoscopic cholecystectomy: a cost comparison. Surg Endosc 2011; 25:1553.