Comparison of Double-Incision Laparoscopic Cholecystectomy and Needlescopic Cholecystectomy

doi:10.4236/ss.2013.412103

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Surgical Science, 2013, 4, 530-534

Published Online December 2013 (http://www.scirp.org/journal/ss)

http://dx.doi.org/10.4236/ss.2013.412103

Open Access SS

Comparison of Double-Incision Laparoscopic

Cholecystectomy and Needlescopic Cholecystectomy

Kenju Ko*, Shigetoshi Yamada, Ken Hayashi,

Akira Tsunoda, Hiroshi Kusanagi, Nobuyasu Kano

Department of Surgery, Kameda Medical Center Kamogawa, Chiba, Japan

Email: *[email protected]

Received November 5, 2013; revised November 25, 2013; accepted December 2, 2013

permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In accordance of

ABSTRACT

Purpose: Recently, reduced port surgery is becoming popular for laparoscopic surgery. “Reduced” means reducing the

size or number of ports, but it is controversial as to which procedure is better. We evaluated double-incision laparo-

scopic cholecystectomy (DILC) and needlescopic cholecystectomy (NC) as reducing number or size of ports, respec-

tively. Method: Patient records for 51 patients undergoing DILC and 22 patients undergoing NC were retrospectively

evaluated. The p atien t and operatio n r elated var iab les of DILC and NC were co mpared by ag e, gend er , body mass index

(BMI), operative time, blood loss, length of postoperative hospital stay, numerical rating scale (NRS) pain score, and

frequency to administer NSAIDs postoperatively for three days. Results: The operative times of both groups were simi-

lar (DILC 106 ± 31 min, NC 103 ± 35 min). Blood loss did not show any difference and each of them was small in

amount (DILC 14 ± 29 ml, NC 22 ± 31 ml). Length of postoperative hospital stay of DILC (3.2 ± 0.4 days) was signifi-

cantly shorter than that of NC (3.5 ± 0.7 days). Regarding postoperative pain, frequency to administer NSAIDs and pain

score for three days postoperatively showed no significant difference. Conclusion: It is thought that DILC and NC have

the same operative difficulty. As far as early postoperative pain was concerned, both procedures did not have any difference.

Keywords: Double Incision Laparoscopic Cholecystectomy; Single Incision Laparoscopic Cholecystectomy;

Thin Forceps; Needlescopic Cholecystectomy

1. Introduction

Recently, laparoscopic cholecystectomy (LC) by single

por t has come to be performed for cosmetic impro v e me n t.

Single-incision LC has been proved to be superior in

cosmetics, body image, and quality of life [1]. Mean-

while, single-incision LC has a disadvantage as a surgical

procedure in comparison with conventional LC. Some

devices, including additional ports, are often used to keep

safety. Additional devices or ports indicate a surgeon’s

carefulness, and not a failure to perform an elegant pro-

cedure [2,3]. We perform DILC, which has an additional

3.5 mm port with single-incision LC, for more safety.

On the oth er hand, thin fo rceps are often use d for cos-

metics without losing operability of conventional LC. We

also have performed NC because operative safety of LC

with thinner forceps than conventional LC is reported [4].

In our hospital, both DILC and NC are performed for

better cosmetics after all. It is thought that DILC is more

cosmetic but more difficult than NC. But it is not obv ious

that which procedure is superior because there are no re-

ports comparing with postoperative pain, operability, and

the others.

Therefore, we retrospectively analyzed and compared

clinical outcomes of DILC and NC.

2. Patients and Methods

2.1. Patients

In this retrospective study, data of 73 patients who had

undergone DILC or NC were analyzed. All patients were

treated between June 2010 and October 2012 at Kameda

Medical Center. The cases given a diagnosis as being

severe or moderate acute cholecystitis by the Tokyo

guidelines [5] or performed with some kind of preopera-

*Corresponding a uthor.

K. KO ET AL. 531

tive drainage were excluded. DILC and NC group in-

clude 51 case and 22 cases, respectively. Both group pa-

tients were completely informed ab out the technique and

had the opportunity to choose the conventional LC pro-

cedure.

2.2. Methods

All procedures were performed by some experienced

surgeons who have been trained for more than three

years. Decision for the procedure either DILC or NC

depended on surgeon’s preference and experience.

In case of DILC, the operation was started by placing a

22 mm longitudin al incision through the u mbilicus. After

cutting fascia and peritoneum, multi-channel port

(LAPPROTECTORTM and EZ ACCESSTM, Hakko, Ja-

pan) was constructed. Additionally, a 3.5-mm port was

constructed at right hypochondrium (Figure 1).

In case of NC, the operation was started by placing a

smaller longitudinal incision than DILC through the um-

bilicus. A 12-mm umbilical port, a 5-mm subxyphoid

port, and two 3.5-mm hypochondriac ports were con-

structed (Figure 1).

In both procedures, epidural anesthesia was not given

and total 20 ml of 0.75% ropivacaine was injected into

each wound during the operation for relieving postopera-

tive pain. Postoperative pain was managed only with

non-steroidal anti-inflammatory drugs (NSAIDs) via the

oral or intravenous route if patient complained of pain.

The patient- and operation-related variables of DILC

and NC were retrospectively compared by age, gender,

body mass index (BMI), operative time, blood loss, length

of postoperative hospital stay, numerical rating scale

(NRS) pain score, and frequency to administer NSAIDs

postope ra t ively fo r 3 da ys.

Figure 1. DILC has a 22-mm umbilical multi-channel port

and 3.5-mm additional port at right hopochondrium. NC

has a 12-mm at umbilicus, a 5-mm at subxyphoid, and two

3.5-mm ports at hypochondrium.

2.3. Statistical Analysis

Results are expressed as means ± standard error of mean.

The statistical difference was determined by Student’s t

test or the Cochran-Cox test. Dichotomous variables of

independence were evaluated by the x2 test. The results

were considered significant when the P value were P <

0.05.

3. Results

The DILC included 16 (31%) male and 35 (6 9%) female

with a median age of 55.9 ± 2.0 years, whereas 8 (36%)

male and 14 (64%) female were in the NC with a median

age of 57.7 ± 2.9 years. Comparison of each group never

showed a significant difference in gender and age. The

median BMI in the DILC was 23.9 ± 0.43 and in the NC

was 23.9 ± 0.70. Each preoperative severity of inflam-

mation (none/grade I) was 41/10 for DILC and 14/8 for

NC according to Tokyo guideline criteria for acute cho-

lecystitis (Table 1).

The operative times of each group (106 ± 4.4 min for

DILC vs. 103 ±7.5 min for NC) were similar. Blood loss

did not show any difference and each of them was small

in amount (14 ± 4.1 ml for DILC vs. 22 ± 6.6 ml for NC).

Length of postoperative hospital stay of DILC was sig-

nificantly shorter than NC (Table 2).

Regarding postoperative pain, frequency to administer

NSAIDs for postoperative three days showed no signifi-

cant difference as 2.0 ± 0.25 fo r DILC and 2.1 ± 0.47 for

NC. The pain score each day postoperatively for three

days did not have any difference although both of them

decrease as time passed (Figure 2).

One patient in DILC suffered wound infection of um-

bilicus and took treatment cons ervatively.

4. Discussion

Single-incision LC had been described even a decade ago

[6] and became popular with the recent development of

surgical technologies. Single-incision LC has less inci-

sion and higher cosmetic efficiency in comparison with

conventional LC. The high cosmetic value made sin-

gle-incision LC become more popular. On the other hand,

single-incision LC has the disadvantage of operative dif-

ficulty because of conflict between forceps. The proce-

dure becomes difficult to perform safely except for ex-

perienced surgeons.

It is still controversial regarding the advantages and

disadvantages although many reports compare between

single-incision and conventional LC [7 -11]. For now, the

significant difference has not statistically shown which

procedure is superior.

Convention al LC basically needs four ports in total in-

cluding three for manipulation and one for laparoscope.

Single-incision LC, however, has just two channels for

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K. KO ET AL.

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532

Table 1. Characteristics of the patients.

DILC (n = 51) NC (n = 22) P

Sex (male/fem ale) 16/35 8/14 0.68

Age (years) 55.9 ± 2.0 57.7 ± 2.9 0.31

BMI (kg/m2) 23.9 ± 0.43 23.9 ± 0.70 0.48

Tokyo guideline criteria for acute cholecystitis (none/grade I) 41/10 14/8 v

DILC: doubl e-incision laparo s copic c h ol ecystec t o my; NC: needlescopic cholecy s t ectomy.

Table 2. Comparison of the perioperative data.

DILC (n = 51) NC (n = 22) P

Operative time (min) 106 ± 4.4 103 ± 7.5 0.362

Blood loss (ml) 14 ± 4.1 22 ± 6.6 0.134

Length of postoperative hospital stay (days) 3.2 ± 0.06 3.5 ± 0.14 0.021

Frequency to administer NSAIDs for postoperative three days 2.0 ± 0 .25 2.1 ± 0.47 0.426

Pain score

Postoperative day 1 3.8 ± 0.30 3.3 ± 0.38 0.168

Postoperative day 2 2.8 ± 0.23 3.0 ± 0.30 0.251

Postoperative day 3 1.3 ± 0.25 1.7 ± 0.33 0.214

Complication (cases) 1 (wound infection) none

DILC: doubl e-incision laparo s copic c h ol ecystec t o my; NC: needlescopic cholecy s t ectomy; NSAIDs: non-steroidal anti-inflammatory drugs.

ventional LC [13-16]. A certain report described that

operation time became longer by thin forceps and the

other did not clarify the merit of thin forceps. However,

two systematic reviews concluded that LC with thin for-

ceps can be superior in pain and cosmetics compared

with conventional LC [17,18].

Briefly, even if the size of the port is reduced for cos-

metic purposes, the operability is secured by the same

number of usable forceps as conventional LC. We also

have performed LC changing the port 10 mm to 5 mm

and 5 mm to 3.5 mm as NC based on this concept. The

use of 3.5 mm forceps is an appropriate decision because

Tagaya concluded that the most important factor for re-

ducing operative time and achieving a low conversion

rate is the use of at least a 3 - 5 mm port for NC [19].

Figure 2. Relation of the pain score and postoperative days.

Both of pain score didn’t show any significant difference

although they decreased as time passed.

manipulation because the umbilical port has only three

channels in total. It is a natural consequence that single-

incision LC, operating through one port, became more

difficult because of a smaller number of forceps than

conventional LC. Some kind of supporting device such

as additional forceps or endoscopic retractors is some-

times used for this problem and we chose a thin 3.5 mm

forceps for assistance. It is reasonable to add a forceps

because single port LC has just only two usable forceps

for handling. It is reported that an additional forceps re-

duces difficulty of single-incision LC [12]. Furthermore,

we placed importance on cosmetics by using thinner 3.5

mm forceps than 5 mm for conventional LC.

There are not any reports that compared these different

operations (DILC and NC) in consideration for operabil-

ity and cosmetics. Our study never showed any differ-

ence by age, gender, BMI, and degree of preoperative

inflammation. The op erativ e ti me an d bloo d lo ss as index

of the operative difficulty did not show any difference.

This result showed that the operative difficulty of DILC

and NC was almost same. It has been reported [17] that

NC has longer operative time than conventional LC

while there is not the comparison the operative time be-

tween DILC and conventional LC. It is known that the

operative time of single incision LC is longer than con-

ventional LC [7]. But it is doubtful whether additional

forceps for single incision LC can shorten operative time

On the other hand, some trials downsizing ports are

reported without reducing the number of ports for con-

K. KO ET AL. 533

the same as conventional LC. Perhaps DILC is expected

having longer operation time in comparison with con-

ventional LC. Therefore, it is natural that DILC and NC

needed almost same operative time as a result of our

study.

However, the surgeon’s experience had an effect on

the decision of operative procedure in our study, and it

might have caused no difference of operative time. The

amount of blood loss was a minimal and no differences

were seen in either procedure. It was supposed that DILC

and NC have almost same operative difficulty although

the surgeon’s experience differed between these proce-

dures.

Length of hospital stay of DILC group was signifi-

cantly shorter than NC, but th e cause is not clear because

NC had no complications which extended hospital stay.

For the case which is expected to be difficult, NC might

have been chosen because decision of the procedure de-

pended on surgeon’s preference and experience.

Regarding postoperative pain, single incision LC was

expected to be less painful because of a smaller number

of wounds than conventional LC at first. Recently, some

reports have shown that single incision LC is more pain-

ful than conventional LC [8,9]. However, there is no re-

port found including a comparative review about postop-

erative pain of DILC and NC like in our report. Our

study compared frequency of administrating NSAIDs

and pain scale for the evaluation of the pain and, as a

result, it did not show any significant difference.

There is a report that postoperative analgesia require-

ments for the LC with needlescopic instruments, which

has smaller ports, were 70% lower than for the conven-

tional LC [20]. It is expected that a slightly bigger wound

to construct multichannel port for DILC caused strong

pain, but our study showed a different result. The effect

of number or size of ports on postoperative pain remains

an open que st ion.

Regarding complications, no major complications oc-

curred and both procedures seemed to be almost safe.

5. Conclusion

It is thought that DILC and NC have the same operative

difficulties on account of no difference with operative

time and blood loss. Moreover, both procedures can be

performed safely without any serious complication. Re-

garding early postoperative pain, both procedures did not

show any difference.

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