Laparoscopic cholecystectomy (LC) has been the standard treatment for benign gallbladder disease since 1985.^1–3 The procedure has been conducted to relieve postoperative pain, improve the length of hospital stay, and reduce scarring of the surgery site in comparison with conventional open cholecystectomy.^4,5

Technological advances and development of new surgical instruments have increased minimally invasive surgical methods, including single incision LC (SILC), first published in 1997.^1,2,6 However, SILC still has several limitations for the surgeon such as repeated conflict between operating instruments, lack of perception caused by the collision of surgical instruments, and reduced visualization of key point for performing the cholecystectomy. To overcome these disadvantages, we used a needlescopic grasper (Minilap Grasper, Stryker, San Jose, CA) for adequate traction of the gallbladder and recovery of instrument triangulation. The procedure was defined as needlescopic grasper-assisted single incision laparoscopic cholecystectomy (nSILC).¹

The indications for each surgical procedure are similar regardless of whether the case is elective or urgent.⁶ SILC has been mostly used in select patients with exclusion criteria such as obesity, acute cholecystitis, gallbladder empyema, and history of previous abdominal operation.^7,8 Furthermore, nSILC allows for an expansion of SILC indications to cases with acute inflammation including acute cholecystitis, gangrenous cholecystitis, gallbladder empyema, and obesity.^2,7

In this study, we aimed to demonstrate the adequacy and operative feasibility of nSILC by comparing the surgical outcomes to pure SILC (pSILC) and conventional three-port laparoscopic cholecystectomy (TPLC).

This retrospective study enrolled 103 patients who underwent LC for benign gallbladder disease (gallbladder stone, gallbladder polyp, adenomyomatosis) at Uijeongbu St. Mary’s Hospital, Korea, between January 2013 and January 2015. Among them, 33 patients underwent pSILC, 35 underwent nSILC, and 35 underwent TPLC. All patients were older than 18 years of age who were classified as American Society of Anesthetists (ASA) classification 1 to 3 and excluded emergency gallbladder disease.

We collected patient demographic information and medical data from the patient medical charts including operation time, inoperative blood loss, visual analogue scale score, conversion to open, postoperative complications, ASA classification, and length of hospital stay.

This study was approved by Institutional Review Board (IRB) and assigned study number UC19RESI0068. All analyses were done with IBM SPSS statistics version 13.0 program. Continuous and categorical values were presented as the number (%) and mean±standard deviation. The results were statistically significant difference when the p value was less than 0.05.

Operation techniques

Patient characteristics according to surgery group are shown in Table 1. Age was similar between the pSILC group (42.9±12.3) and the nSILC group (41.4±10.6). However, the mean age of patients in the TPLC group (46.1±13.5) was older than in those in other groups. The pSILC group consisted of 4 male and 29 female patients, the nSILC group consisted of 4 male and 31 female patients, and the TPLC group consisted of 19 male and 16 female patients. Women and younger patients were more likely to undergo SILC over TPLC. The body mass index, diagnosis, and ASA classification were not statistically significant between the groups.

The surgical outcomes of patient groups are shown in Table 2. There were statistical differences between all groups in skin to skin operation mean time (pSILC: 65.2±19.1 min, nSILC: 49.7±12.9 min, and TPLC: 43.4±14.7 min, p<0.001), and major procedure mean time (pSILC: 42.2±18.7 min, nSILC: 25.9±8.9 min, and TPLC: 23.4±12.7 min, p<0.001). The TPLC group mean operation time was shorter than that of the pSILC and nSILC groups.

Between-group comparison results of the visual analogue scale scores (pSILC: 2.2±0.8, nSILC: 2.6±1.4, and TPLC: 2.6±0.9, p=0.161), length of hospital stay (pSILC: 2.6±1.6, nSILC: 2.3±0.9, and TPLC: 2.1±0.5, p=0.185), and intraoperative blood loss (pSILC: 32.7±13.7, nSILC: 31.8±20.8, and TPLC: 37.0±22.0, p=0.495) were not statistically different.

Since 1985, LC has been an important development in general surgery. As minimally invasive laparoscopic surgery is preferred, SILC was introduced in the 1990s.³ SILC is less invasive as it requires fewer ports than TPLC.^1,2,10 Moreover, pSILC was a surgical option with the goal of reducing postoperative pain and improving cosmetic effect with non-visible scar. However, pSILC has some difficulties because of the limitation of obtaining a CVS and inappropriate traction of the gallbladder. Surgeons have used a snake liver retractor and needlescopic grasper to overcome unclear exposure of the triangle of Calot.² This technique is nSILC and was allowed for CVS due to needlescopic grasper for lateral traction and snake liver retractor for cephalad space traction of gallbladder during SILC.¹ At present, a comparative study of three surgical methods is needed.

This study was performed to compare the surgical outcomes of nSILC, pSILC and TPLC. There were no significant differences in pain according to visual analogue scale score, length of hospital stay, or postoperative complications, while gender, age, and operative time showed significant differences between groups.

The mean age was similar between the pSILC and nSILC groups, but TPLC group was older than the other groups. It can be seen that young people prefer SILC. In terms of gender composition, women prefer SILC to men.

It is generally known that pSILC is a more desirable method for patients than TPLC because of the reduced postoperative pain.^3,5,11,12 In contrast, a systematic review reported no statistically significant difference in postoperative pain scores for pSILC versus 4-Port LC.⁶ Moreover, previous studies have showed no difference in pain scores between nSILC and TPLC groups.^7,8,13 There were no significant differences visual analogue scale scores of the three groups in this study.

A previous study described a statistically significant shorter length of hospital stay for patients who underwent SILC⁶ and another study reported that these patients experienced improved recovery and shortened length of hospitalization compared with conventional open cholecystectomy.¹³ On the other hand, one study reported no difference in length of hospital stay between patients undergoing SILC and TPLC.³ This study showed that the days of hospitalization between the three groups were not significantly different. This may vary depending on the nature of the hospital and the characteristics of the patient.

Previous studies have reported post-operative complications such as bile leakage, bile duct injury, surgical site bleeding, urinary and pulmonary infection, wound infection, seroma, hematoma, incisional hernia, and duodenal perforation.^12,14–16 Like the present study, many studies have found no significant difference in complication rate between SILC and conventional laparoscopic cholecystectomy.^3,13,14 Conversely, one study showed that the incidence of postoperative complications in patients who underwent SILC was lower in conventional laparoscopic cholecystectomy.¹² Recently, some articles have been published to report the feasibility and safety of SILC compared to conventional laparoscopic cholecystectomy.^2,11 In this study, there were 4 out of 135 (two cases in the pSILC group, one case in the nSILC group, and one case in the TPLC group) postoperative complications. Postoperative complications may be due to differences in operative capacity, operative environment, or patient status.

Most clinical features and surgical outcomes were similar between pSILC and nSILC.¹ However, there was a difference in operation time. Results of this study show that nSILC operation time was longer than that of TPLC, but shorter than that of pSILC. The operation time for nSILC was 1.15 times that of TPLC but was 0.76 times less than that of pSILC. The same results were found in other studies.^2,6,10 Kim et al.² reported that the nSILC group had longer operative times than the TPLC group. Another study described that operative time was significantly longer in the pSILC group than in the four-port LC group.^6,10 Van der Linden et al.³ reported that the disadvantages of single-port surgery were often referred to as time-consuming surgery. Although nSILC method takes longer than TPLC, nSILC has an anatomical view that is an advantage of TPLC. That is, nSILC overcomes the disadvantage of not achieving anatomical vision of pSILC. Therefore, nSILC feasible surgical procedure in patients with benign gallbladder disease compared with TPLC and it is an effective approach to overcome the limitations of pSILC. Recently, single incision robotic cholecystectomy (SIRC) has been introduced to improve the merit of minimally invasive surgery. The operation time (skin to skin) of SIRC is similar to that of SILC. SIRC is just as safe and effective as SILC. However, the total cost of SIRC is significantly higher than that of SICL.^17,18 Therefore, it is expected that SILC will be mainly performed in small and medium hospitals in the future.

This study has several limitations to consider. Because it was a retrospective, single institutional research study, data from only a small sample size could be collected. Thus, this limits the generalizability of our findings. Data from a larger sample size will be needed to determine the true rate of postoperative complications, postoperative pain, and length of hospital stay. Future prospective randomized controlled trials will be required to significantly determine the efficacy and safety of nSILC.

Conceptualization: KHK. Formal analysis: SHL. Methodology: KHK, CWK. Writing-original draft: KHK, CWK. Writing-review and editing: KHK.

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