Classic Laparoscopy Technique Still Preferred for Gallbladder Surgery

With traditional laparoscopic cholecystectomy, the gallbladder is removed with instruments placed in four small incisions in the abdomen. When laparoscopic surgery is not an option because of complications such as inflammation, scar tissue, injury, or bleeding, an open cholecystectomy is performed and the gallbladder is removed through an approximately six-inch long incision that cuts through fat and muscles in the abdomen.

Given the choice between the two methods, physicians and patients alike quickly agree that laparoscopic surgery is the way to go. With laparoscopic cholecystectomy, hospital stays are shorter, recovery times are quicker, there is less risk of infection, less pain and less scarring.

Now, some surgeons recommend single-port cholecystectomy as an even better method of removing the gallbladder. One incision is better than four, right? Not necessarily.

In my experience, which is backed up by findings from a recent clinical study conducted by an Oregon team, the single-port method takes longer, causes more post-operative problems (particularly hernias), and results in more pain. It also increases the cost of surgery.

So, when should the single-port method be considered? I recommend it for purely cosmetic purposes and only for routine gallbladder surgery on younger women with very little body fat. When performing the procedure, instead of using one large incision and instrument, I use two tiny holes and 2 mm graspers. It speeds up the operation and is a safer method.

Delving Deeper

Medscape.com recently published an article regarding the study conducted by Dr. Paul D. Hansen and colleagues at Providence Portland Medical Center. The article, summarized below, agrees with my findings.

Article Overview

A study that compared single-port and four-port laparoscopic cholecystectomy, randomizing 43 patients to surgery with one or the other approach, resulted in the following findings:

  • Procedure times are longer and complications more frequent with single-port laparoscopic cholecystectomy than with the traditional four-port technique.
  • The two groups had similar results for intraoperative complications, blood loss or length of stay, and there were no conversions to open laparotomy.
  • Mean operative time was twice as long with the single-port technique (89 vs. 45 minutes). Over the course of the study, mean operative time with the single-port device fell from 100 to 82 minutes, suggesting a learning-curve effect, but the difference wasn’t statistically significant.
  • Postoperative pain scores at discharge were slightly higher in the single-port group than the 4-port group (2.7 vs. 1.8; p=0.06). Patient satisfaction with the procedure was 8.9 on a 10-point scale for the single-port procedure and 9.2 for the classic technique (p=0.59), and corresponding satisfaction rates for the cosmetic results were 9.3 vs. 8.9.
  • Three patients in each group had wound infections requiring oral antibiotics, but other complications occurred only in the single-port group; these included one case each of retained bile duct stone, port-site hernia, and a port-site postop hemorrhage, the investigators report.

Summary of findings:

“In summary, on the basis of our randomized controlled trial, single-port laparoscopic cholecystectomy had a longer operative time and seemed to incur more postoperative complications, which may be related to the learning curve,” Dr. Hansen and colleagues conclude. “However, both single-port laparoscopic cholecystectomy and classic laparoscopic cholecystectomy produced similar levels of patient satisfaction and pain, as well as patient-perceived functional health status.”

They add, “Larger randomized trials performed later in the learning curve with single-port laparoscopic cholecystectomy may identify more subtle advantages of one method over another.”

For reference: http://www.medscape.com/viewarticle/742149?src=mp&spon=14

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