Journal of Surgery (ISSN: 2575-9760)

research article

Single-Incision Laparoscopic Cholecystectomy Versus Traditional Laparoscopic Cholecystectomy: A updated Meta-analysis of Randomized Controlled Trials

Weizhong Tang1* Bo Zhao2, Xiaoyong Cai2, Yu Lei2, Jianjun Li2, Yansong Xu1, Yubin Huang2, Fei Huang2, Wenqi Lu2, Wenshu Jiang2, Xiaojian Jin2

1Department of Anal and Colorectal Surgery, The First Affiliated Hospital of Guangxi Medical University, Guangxi, China

2Department of general Surgery, the Second Affiliated Hospital of Guangxi Medical University, Guangxi, China

*Corresponding author: Weizhong Tang, Department of Colorectal Surgery, Hospital of Guangxi Medical University, 6 Shuangyong Road, Nanning 530021, China. Tel: +867715322120; Email: tangweizhong6985@163.com.cn 

Received Date: 07 July, 2017; Accepted Date: 11 July, 2017; Published Date: 18 July, 2017

1. Abstract 

1.1.Objectives: To assess the clinical efficacy of Single-Incision Laparoscopic Cholecystectomy (LESS) compared with Traditional Laparoscopic Cholecystectomy (TLC) based on published literature. 

1.2. Subjects and Methods: An online systematic search Randomized Controlled Trials (RCTs) comparing LESS with TLC were included Pubmed, Embase and the Cochrane Library. The inclusion and extraction of the data were completed by two authors independently. Meta-analysis was performed using version Review Manager 5.1.4 software. The clinical outcomes measures were demographics, postoperative Visual Analog Scale pain score, operative complication rate, intraoperative blood loss, cosmetic score, postoperative hospital stay, operating time, wound length; operating time, quality of life score was evaluated by Odds Ratio (OR) and Standard Mean Difference (SMD) according to the different types of data. A meta-analysis of the outcomes was conducted.

1.3. Results: Fifteen RCTs involving 1069 patients met the predefined inclusion criteria. The cosmetic score of the LESS group was statistically higher than that for TLC. (SMD, 0.55; 95 % CI, 0.20, 0.90; p = 0.002); the postoperative hospital stay of the LESS group was statistically shorter than that for TLC. (SMD, -0.24; 95 % CI, -0.44, -0.04; p = 0.02); the operating time of LESS groups was statistically longer than TLC. (SMD, 0.83; 95 % CI, 0.52, 1.14; p < 0.00001); the wound length of LESS was statistically smaller than TLC. (SMD, -2.90; 95 % CI, - 4.22, -1.58; p < 0.0001); the quality of life of LESS was statistically better than that for TLC. (SMD, 1.17; 95 % CI, 0.06, 2.28; p =0.04); There was no significant difference between the two groups with Visual Analog Scale pain score, intraoperative blood loss, perioperative complication rate.

1.4. Conclusion: LESS is associated with a higher cosmetic score, shorter postoperative hospital stays, smaller wound length, better short-term quality of life compared with TLC.

2.  Keywords: Laparoscopic Cholecystectomy; Meta-Analysis; Single-Incision; Traditional Laparoscopic Cholecystectomy



Figure 1: Meta-analysis of Visual Analog Scale pain score in Laparoendoscopic Single-Site (LESS) cholecystectomy versus Traditional Laparoscopic Cholecystectomy (TLC) patients. CI, confidence interval; SD, Standard Deviation; IV: Inverse Variance.




Figure 2: Meta-analysis of perioperative complication rate in LESS versus TLC patients.


Figure 3: Meta-analysis of intraoperative blood loss in LESS versus TLC patients.


Figure 4: Meta-analysis of cosmetic score in LESS versus TLC patients.


Figure 5: Meta-analysis of postoperative hospital stay in LESS versus TLC patients.



Figure 6: Meta-analysis of operating time in LESS versus TLC patients.


Figure 7: Meta-analysis of wound length in LESS versus TLC patients.



Figure 8: Meta-analysis of QoF in LESS versus TLC patients.

 

 

 

Reference (year)

 

Design

type

Patients (n)

Age (years)

Gender (M/F)

Journal

Comparison

Measured

outcomes

LESS

TL

LESS

TL

LESS

TL

Lai, et al. (2011) [9]

RCT

 

27

24

54.3±12.0

51.7±13.3

16/8

16/11

The American Journal of Surgery

Four-port TL VS. LESS

1, 3, 4, 5,7

Ostlie, et al. (2012) [10]

RCT

 

30

30

13.3±3.3

14.0±3.2

24/6

24/6

Journal of Pediatric Surgery

Four-port TL VS. LESS

1,5,6,8

Aprea, et al. (2010) [11]

RCT

25

25

44.0±10.0

45.5± 9.4

-

-

Journal of Surgical Research

Four-port TL VS. LESS

1,4,5,6

Evangelos, et al. (2010) [12]

RCT

 

20

20

47.9± 9.8

49.2±16.9

13/12

19/6

Surg Endosc

 

Four-port TL VS. LESS

1,2,3

Phillips, et al. (2012) [13]

RCT

 

117

80

45.6

 

44.1

28/29

23/56

Surg Endosc

 

Four-port TL VS. LESS

1,2,4,6

Madureira, et al. (2013) [14]

RCT

28

29

50

56

28/89

23/56

Surg Endosc

Four-port TL VS. LESS

1,2,6,7

Renato, et al. (2013) [15]

RCT

 

20

20

-

-

-

-

Surg Endosc

 

Four-port TL VS. LESS

1,6

Jun, et al. (2011) [16]

RCT

 

21

22

57.3±16.0

45.8±11.9

-

-

Annals of Surgery

 

Four-port TL VS. LESS

1,2,4,6

Saad, et al. (2012) [17]

RCT

35

35

49±14

45±17

26/9

28/7

British Journal of Surgery

Four-port TL VS. LESS

2,4,5,6

Sasaki, et al. (2012) [18]

RCT

 

27

27

56.6 (14.2)

 

/58.2 (12.3)

14/13

14/13

Surg Laparosc Endosc Percutan Tech

Four-port TL VS. LESS

1,2,3,4,5,6

Zhan Guo Cao, et al. (2011) [19]

RCT

 

57

51

62.2±5.1

 

59.7±4.4

23/34

21/29

Surg Laparosc Endosc Percutan Tech

Four-port TL VS. LESS

1,2,3,5,6,7

Bucher, et al. (2011) [20]

RCT

 

75

75

42

44

-

-

British Journal of Surgery Society

Four-port TL VS. LESS

 

Asakuma, et al. (2011) [21]

RCT

 

24

25

57

66

11/13

13/12

British Journal of Surgery

Four-port TL VS. LESS

1,5,6

MingweiZheng, et al. (2012) [22]

RCT

 

30

30

43.6± 11.3

46.8± 14.4

13/17

16/14

Informa Healthcare

 

Four-port TL VS. LESS

1,4,6

Lirici, et al. (2011) [23]

RCT

20

20

-

-

-

-

The American Journal of Surgery

Four-port TL VS. LESS

1,6

Table 1: Baseline Characteristics of Studies Included.

 

 

Reference (year)

 

Randomization

Blinding

Withdrawals and dropouts

Jadad score

Setting

Lai, et al. (2011) [9]

Yes

Double-blind

Clearly reported

4

Single center

Aprea, et al. (2010) [11]

Yes

Single-blind

Clearly reported

4

Single center

Evangelos, et al. (2010) [12]

Yes

Single-blind

Clearly reported

4

Single center

Phillips, et al. (2012) [13]

Yes

Single-blind

Clearly reported

4

Multicenter

Madureira, et al. (2013) [14]

Yes

Single-blind

Clearly reported

4

Single center

Renato, et al. (2013) [15]

Yes

Single-blind

Clearly reported

4

Single center

Jun, et al. (2011) [16]

Yes

Double-blind

Clearly reported

4

Single center

Saad, et al. (2012) [17]

Yes

Double-blind

Clearly reported

4

Single center

Sasaki, et al. (2012) [18]

Yes

Double-blind

Clearly reported

4

Single center

Zhan Guo Cao, et al. (2011) [19]

Yes

Double-blind

Clearly reported

4

Single center

Bucher, et al. (2011) [20]

Yes

Not stated

Clearly reported

3

Single center

Mingwei Zheng, et al. (2012) [22]

Yes

Double-blind

Clearly reported

4

Single center

Lirici, et al. (2011) [23]

Yes

Single-blind

Clearly reported

4

Multicenter

Asakuma, et al. (2011) [21]

Yes

Single-blind

Clearly reported

4

Single center

Daniel J. Ostlie, et al. (2012) [10]

Yes

Single-blind

Clearly reported

4

Single center

 

Table 2: Quality Assessment of Studies Included.

  1. Keus F, De Jong J, Gooszen H, Van Laarhoven C (2006) Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev 2006: 4.
  2. Bueno LJ, Planells RM, Arnau BC, Sanahuja SA, Oviedo BM, et al. (2006) Outpatient laparoscopic cholecystectomy: a new gold standard for cholecystectomy. Revista espanola de enfermedades digestivas: organo oficial de la Sociedad Espanola de Patologia Digestiva 98: 14-24.
  3. Schirmer BD, Edge SB, Dix J, Hyser MJ, Hanks JB, et al. (1991) Laparoscopic cholecystectomy. Treatment of choice for symptomatic cholelithiasis. Annals of surgery 213: 665.
  4. Johansson M, Thune A, Nelvin L, Stiernstam M, Westman B, et al. (2005) Randomized clinical trial of open versus laparoscopic cholecystectomy in the treatment of acute cholecystitis. British journal of surgery 92: 44-49.
  5. Forgione A, Maggioni D, Sansonna F, Ferrari C, Di Lernia S, et al. (2008) Transvaginal endoscopic cholecystectomy in human beings: preliminary results. Journal of Laparoendoscopic & Advanced Surgical Techniques 18: 345-351.
  6. Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D, et al. (2007) Surgery without scars: report of transluminal cholecystectomy in a human being. Archives of Surgery 142: 823-826.
  7. Zorron R, Maggioni L, Pombo L, Oliveira A, Carvalho G, et al. (2008) NOTES transvaginal cholecystectomy: preliminary clinical application. Surgical endoscopy 22: 542-547.
  8. Tacchino R, Greco F, Matera D (2009) Single-incision laparoscopic cholecystectomy: surgery without a visible scar. Surgical endoscopy 23: 896-899.
  9. Lai EC, Yang GP, Tang CN, Yih PC, Chan OC, et al. (2011) Prospective randomized comparative study of single incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy. The American Journal of Surgery 202: 254-258.
  10. Ostlie DJ, Adibe David, Juang OO, Iqbal CW, Sharp SW, Snyder CL, et al. (2013) Single incision versus standard 4-port laparoscopic cholecystectomy: a prospective randomized trial. Journal of pediatric surgery 48: 209-214.
  11. Aprea G, Coppola Bottazzi E, Guida F, Masone S, Persico G (2011) Laparoendoscopic Single Site (LESS)< i> Versus Classic Video-Laparoscopic Cholecystectomy: A Randomized Prospective Study. Journal of Surgical Research 166: e109-e112.
  12. Tsimoyiannis EC, Tsimogiannis KE, Pappas-Gogos G, Farantos C, Benetatos N, et al. (2010) Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial. Surgical endoscopy 24: 1842-1848.
  13. Phillips MS, Marks JM, Roberts K, Tacchino R, Onders R, et al. (2012) Intermediate results of a prospective randomized controlled trial of traditional four-port laparoscopic cholecystectomy versus single-incision laparoscopic cholecystectomy. Surgical endoscopy 26: 1296-1303.
  14. Madureira FAV, Manso JEF, Fo DM, Iglesias ACG (2013) Randomized clinical study for assessment of incision characteristics and pain associated with LESS versus laparoscopic cholecystectomy. Surgical endoscopy 27: 1009-1015.
  15. Luna RA, Nogueira DB, Varela PS, Neto EdOR, Norton MJR, et al. (2013) A prospective, randomized comparison of pain, inflammatory response, and short-term outcomes between single port and laparoscopic cholecystectomy. Surgical endoscopy 27: 1254-1259.
  16. Ma J, Cassera MA, Spaun GO, Hammill CW, Hansen PD, et al. (2011) Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy. Annals of surgery 254: 22-27.
  17. Saad S, Strassel V, Sauerland S (2013) Randomized clinical trial of singleport, mini laparoscopic and conventional laparoscopic cholecystectomy. British journal of surgery 100: 339-349.
  18. Sasaki A, Ogawa M, Tono C, Obara S, Hosoi N, et al. (2012) Single-port versus multiport laparoscopic cholecystectomy: a prospective randomized clinical trial. Surgical Laparoscopy Endoscopy & Percutaneous Techniques 22: 396-399.
  19. Cao ZG, Cai W, Qin MF, Zhao HZ, Yue P, et al. (2011) Randomized clinical trial of single-incision versus conventional laparoscopic cholecystectomy: short-term operative outcomes. Surgical Laparoscopy Endoscopy & Percutaneous Techniques 21: 311-333.
  20. Bucher P, Pugin F, Buchs N, Ostermann S, Morel P (2011) Randomized clinical trial of laparoendoscopic singlesite versus conventional laparoscopic cholecystectomy. British journal of surgery 98: 1695-1702.
  21. Asakuma M, Hayashi M, Komeda K, Shimizu T, Hirokawa F, et al. (2011) Impact of singleport cholecystectomy on postoperative pain. British journal of surgery 98: 991-995.
  22. Zheng M, Qin M, Zhao H (2012) Laparoendoscopic single-site cholecystectomy: a randomized controlled study. Minimally Invasive Therapy & Allied Technologies 21: 113-117.
  23. Lirici MM, Califano AD, Angelini P, Corcione F (2011) Laparo-endoscopic single site cholecystectomy versus standard laparoscopic cholecystectomy: results of a pilot randomized trial. The American Journal of Surgery 202: 45-52.
  24. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJM, et al. (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Controlled clinical trials 17: 1-12.
  25. Kjaergard LL, Villumsen J, Gluud C (2001) Reported methodologic quality and discrepancies between large and small randomized trials in meta-analyses. Annals of Internal Medicine 135: 982-989.
  26. Collaboration C (2008) Review Manager (RevMan) Version 5.0. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration [Computer programme] 2008.
  27. Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ: British Medical Journal 327: 557.
  28. Cuesta MA, Berends F, Veenhof AA (2008) The “invisible cholecystectomy”: a transumbilical laparoscopic operation without a scar. Surgical endoscopy 22: 1211-1213.
  29. Sarli L, Iusco D, Gobbi S, Porrini C, Ferro M, et al. (2003) Randomized clinical trial of laparoscopic cholecystectomy performed with miniinstruments. British journal of surgery 90: 1345-1348.