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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 50  |  Issue : 5  |  Page : 169-174

A retrospective comparison of two-, three-, and four-port laparoscopic cholecystectomies


1 Department of Medicine, School of Medicine, Fu-Jen Catholic University, New Taipei; Department of General Surgery, Cathay General Hospital, Taipei, Taiwan
2 Department of General Surgery, Cathay General Hospital, Taipei, Taiwan

Date of Submission18-Nov-2016
Date of Decision10-Jan-2017
Date of Acceptance04-Aug-2017
Date of Web Publication9-Oct-2017

Correspondence Address:
Heng Hui Lien
Department of General Surgery, Cathay General Hospital, 280, Section 4, Jen-Ai Road, Taipei
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_128_17

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  Abstract 


Purpose: A total of 1276 laparoscopic cholecystectomies (LCs) using two-, three-, and four-port methods were analyzed to evaluate the feasibility and effectiveness of two and three-port LCs in management for acute or elective gallstone disease when compared with four-port LC.
Materials and Methods: A between-group comparison was performed on the difference of operation time, postsurgery admission days, postsurgery daily pain score between acute or elective surgery or different procedures.
Results: Proportion of four-port LC was significant high in acute then in elective surgery (93.3% vs. 79.0%; P = 0.001). In elective surgeries, difference among mean operative time of two-, three-, and four-port LC (36.76, 34.72, and 27.32 min, respectively) was statistically significant (P = 0.001). Three-port LC showed a significant lowest mean pain score (1.887; 1 to 10 point pain score) on the first-day post-LC.(P = 0.04) Difference on the mean post-LC hospitalization of two-, three-, and four-port LCs (2.158, 2.141 and 2.412 days, respectively) were significant in elective (P = 0.001) while not significant in acute surgery (two-, three-, and four-port LCs: 2.75, 2.778, and 3.097 days, respectively; P = 0.237).
Conclusions: Four-port LC was the procedure of choice in acute surgery. The operative time was the shortest for four and longest for two-port LC. Three-port LC could be adopted using strategic selection (elective surgery) and conversion (with adding port) as safety guard for the benefits of less wound pain, decreased post-LC admission days.

Keywords: Cholecystectomy, laparoscopic, port


How to cite this article:
Lien HH, Huang CC, Huang CS. A retrospective comparison of two-, three-, and four-port laparoscopic cholecystectomies. Formos J Surg 2017;50:169-74

How to cite this URL:
Lien HH, Huang CC, Huang CS. A retrospective comparison of two-, three-, and four-port laparoscopic cholecystectomies. Formos J Surg [serial online] 2017 [cited 2022 May 26];50:169-74. Available from: https://www.e-fjs.org/text.asp?2017/50/5/169/216232




  Introduction Top


Over 10,000 laparoscopic cholecystectomies (LCs) have been performed at our hospital since 1990. Our previous studies focused on the complication prevention and management,[1],[2],[3] safety and quality improvement [4],[5] of LC were reported elsewhere. Recently techniques for smaller and lesser wounds for LC like mini LC [6],[7],[8],[9] or the two- or single-port method for LC [10],[11] were developed for less pain, better cosmetic, quick recovery while such modified procedures were also reported with increased difficulty; lacks evidence-based approval of safety control and cost-effectiveness.[12] We examined the experiences on two-, three-, and four-port LCs to evaluate the feasibility and effectiveness of two and three-port LCs in management of acute or elective gallstone disease when compared with four-port LC.


  Materials and Methods Top


This retrospective study was approved by the Institutional Review Board of the Cathay General Hospital; patient records were anonymized and de-identified prior analysis. 1276 continuous LCs from 2011 to 2014 using two-, three- and four-port methods were analyzed. Among these LCs, number of four-port LC was 1062, three- and two-port LC were 103 and 109 separately. We categorized three operative time intervals (15–30, 30–45, and 45–60 min) for analyze the correlations among procedures, operative time, and acute or elective surgery. The visual analog scale was used to assess level of postoperation wound pain. The incidence of major bile duct injury was collected for the between-group comparisons of surgical complication.

Setting for two-port laparoscopic cholecystectomies

Transverse skin incision was made approximately 20 mm over the subumbilical area, using Veress needle to create pneumoperitoneum. An 11-mm trocar (Endopath, Xcel, Ethicon) was introduced and the surgical field was first observed for decision-making whether two-port LC go ahead, the trocar was then removed and the wound was dilated for indwelling of the extra-small wound retractor (Alexis wound retractor X-Small, Applied Medical, Rancho Santa Margarita, CA, USA). A surgical glove was attached and using its finger parts to connect an 11- and a 5-mm trocars. Another 5-mm trocar was indwelled at the subxiphoid area thus complete the setting [Figure 1]. No traction sutures as mentioned elsewhere [11],[13],[14] was used, and the following steps were similar to 3-port method. Initial one hundred two-port LCs were not included in the 1276 cases for clear the confounding effect of learning curve.
Figure 1: Setting of two-port laparoscopic cholecystectomy. (a) Size of umbilical wound. (b) Indwell of wound retractor. (c) Attach of surgical glove to wound retractor. (d) Complete setting of two-port laparoscopic cholecystectomy

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Setting for three-port laparoscopic cholecystectomies

Transverse skin incision was made approximately 10 mm over subumbilical area and pneumoperitoneum created with Veress needle. An 11-mm trocar was introduced; the second 5-mm trocar was indwelled over the subxiphoid and the third 5-mm trocar was indwelled over transverse umbilical line across the mid-clavicle line thus complete the setting.

Statistic methods

The Chi-square test was used to compare factors: Procedures (two-, three-, and four-port LC), timing of surgery (acute or elective), conversion rate, and the operative time among study groups. Operative time was calculated from skin incision to skin close. The t-test was used to compare the pain scores among procedures (two-, three-, and four-port LCs) after surgery. Due to data were not normal distributed, the nonparametric tests were used. The Wilcoxon rank-sum test was used for comparing between two groups and the Kruskal–Wallis test was used for comparing among three groups and used the significant variable to compare the risk of conversion in the acute or elective group and to determine the level of risk involved.

Ethical approval

The study was conducted in accordance with the Declaration of Helsinki and was approved by the local ethics committee of the institute. Informed written consent was obtained from all patients before their enrollment in this study.


  Results Top


Of the 390 acute cases, the number and rate that adopted two-, three-, or four-port LC procedure, contained missing data, were 8 (2.1%), 18 (4.6%), and 363 (93.3%), respectively. Of the 886 elective cases that adopted two-, three-, or four-port LC, those that contained missing values were 101 (11.4%), 85 (9.6%), and 699 (79.0%), respectively. The data showed that for both acute and elective surgery, the number of four-port LC surgeries was higher than that of the two- or three-port surgeries. Between the acute or elective surgery, the probability of adopting a four-port LC procedure was higher for acute surgeries (93.3%) than for elective surgeries (79.0%). A statistically significant difference was observed between the surgical procedure and the acute-elective type (P = 0.001), and these parameters were highly correlated [Table 1].
Table 1: Surgical procedure and timing of surgery were highly correlated

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A total of 1276 LCs comprising 390 acute and 886 elective LCs were examined. Of the 390 acute and 886 elective cases, 93 and 115 had missing data, respectively. Among the acute surgeries, 101 (34.0%) had an operation time between 15 and 30 min, 101 (34.0%) had an operation time between 31 and 45 min, and 95 (32.0%) had an operation time between 46 and 60 min. Among the elective surgeries, 461 (63.1%) had an operation time between 15 and 30 min, 184 (25.2%) had an operation time between 31 and 45 min, and 86 (11.8%) had an operation time between 46 and 60 min. Clearly, most of the elective surgeries were completed within 30 min, and the operation time for the acute surgeries was higher than that of the elective surgeries. A statistically significant difference (P = 0.001) was observed between the operation time and the timing of surgery, and these two parameters were highly correlated [Table 1].

We further compare the difference of mean operative time among different groups of procedures and timing of surgery. A nonparametric analysis was conducted to determine the correlation between the operative time and surgical procedures as well as the timing of surgery. Regarding the patients who underwent two-, three-, and four-port LCs, the mean operation times were 38.71 ± 15.993, 37.07 ± 17.505, and 30.85 ± 18.708 min, respectively. The Kruskal–Wallis test indicated significant difference between these procedures (P = 0.001). We further stratified acute or elective surgery to determine the correlation between operative time and procedures as well as timing of surgery. For elective surgeries, the mean and median operative time of two-, three-, and four-port LCs were 36.76 ± 12.555 min and 35 (27.8, 45) min, 34.72 ± 15.367 min and 30 (25, 40) min, 27.32 ± 15.608 min and 25 (20, 30) min, respectively. The Kruskal–Wallis test indicated a statistically significant difference between these parameters (P = 0.001). The results indicated that the operative time was the shortest for the four-port surgeries and the longest for the two-port surgeries. For the acute surgery, two-, three-, and four-port surgeries had a mean and median operation time of 66.43 ± 31.633 min and 60 (41, 92.5) min, 50.58 ± 23.13 min and 43.5 (40, 60) min, and 45.8 ± 23.006 min and 40 (30, 60) min, respectively. The Kruskal–Wallis test indicated that the operative time for acute surgeries did not differ significantly (P = 0.148). A stratified analysis was conducted to determine the correlation between the operation time and surgical procedures as well as the different timing of surgery. The results showed that for elective surgeries, significant differences were observed in the mean operation time between the four- and three-port surgeries (P< 0.001) and between four- and two-port surgeries (P< 0.001). No statistically significant differences were observed between three- and two-port surgeries (P = 0.663). For the acute surgeries, no statistically significant differences were observed in the mean operation time for all the three types of surgical procedures (three port-two port: P =0.339; four port-two port: P = 0.072; four port-three port: P = 0.789).

Conversion

Twelve cases among this series had to convert primary procedure included one two-port LC convert to three-port LC, three three-port LCs convert to 4-port LCs, and eight four-port LCs convert to laparotomic cholecystectomy. The 12 cases that underwent conversion during surgery, 4 (33.3%) were elective surgeries and 8 (66.7%) were acute surgeries. Of the 1264 cases that did not undergo conversion during the surgery, 882 (69.8%) were elective surgeries and 382 (30.2%) were acute surgeries. The results clearly indicated the rate of conversion was higher in acute than in elective surgery; a statistically significant difference was observed (P = 0.016). The correlation analysis between the surgical procedure and conversion showed that of the 12 cases that underwent conversion, 1 (8.3%), 3 (25%), and 8 (66.7%) cases were the two-, three-, and four-port surgeries, respectively. Of the 1264 cases that did not undergo conversion, 108 (8.6%), 100 (7.9%), and 1056 (83.5%) cases were the two-, three-, and four-port surgeries, respectively. The data indicated that the four-port LCs had a higher conversion rate than that of the two- and three-port surgeries. However, no statistically significant difference was observed (P = 0.095) between the surgical procedure and the surgery results. The results revealed that conversion or not was unaffected by the type of surgical procedure; however, situational needs dominated the choice of conversion.

Subsequently, we analyzed the increase in the risks of conversion for the patients who underwent the elective and acute surgeries and the conversion odds ratio for the different types of surgical procedures. For the 886 elective surgeries, 882 underwent no conversion, whereas 4 did. The risk of conversion for the patients not exposed to acute surgeries was 0.0045. The risk of conversion for the patients exposed to acute surgeries was 0.02. The overall risk of conversion was 0.01. The attributable risk equal to 0.02 suggests that exposure to acute surgeries increased the risk of conversion by 2%. The risk of conversion for the patients exposed to acute surgery was 4.54 folds higher than those of elective surgery, which indicated that approximately one in 62.51 patients exposed to acute surgeries would undergo conversion.

Pain score postsurgery (a pain score of 0–10)

Analysis of the pain score of patients (0–10 pain score) on the day of the surgery (PS0) for 2-, 3-, 4-port LCs showed that the mean and median of pain score were 1.575 ± 2.042 and 0 (0, 3), 2.092 ± 2.307 and 2 (0, 4), and 1.987 ± 2.107 and 2 (0, 3), respectively. The Kruskal–Wallis test revealed P = 0.146, indicating no statistically significant differences. Analysis of the pain score on the first day after surgery (PS1) for two-, three-, four-port LCs showed that the mean of pain score was 2.209 ± 1.48, 1.887 ± 1.567, and 2.324 ± 1.73, respectively. The Kruskal–Wallis test revealed P = 0.04, indicating statistically significant differences. Analysis of the pain score on the second day after the surgery (PS2) for two-, three-, four-port LC showed that the mean and median pain scores of patients were 1.581 ± 1.395 and 1 (0, 2), 1.322 ± 1.49 and 1 (0, 2), and 1.578 ± 1.448 and 2 (0, 2), respectively. The Kruskal–Wallis test result revealed a P = 0.134, indicating no statistically significant differences [Table 2]. The pain scores did not differ significantly between the three- and two-port surgeries (P = 0.406) as well as between the four- and two-port surgeries (P = 0.820). However, significant differences were observed between the four- and three-port surgeries (P = 0.042).
Table 2: Significance on the difference of postoperative daily pain score for three procedures

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Procedure and postsurgery hospitalization

Analysis of the surgical procedure and postsurgery hospitalization showed that the mean and median values for the postsurgery hospitalization duration for the patients who underwent two-, three-, and four-port surgeries were 2.2 ± 0.661 and 2 (2, 2) days, 2.252 ± 1.274 and 2 (2, 2) days, and 2.65 ± 1.299 and 2 (2, 3) days, respectively. The Kruskal–Wallis test result indicated a P = 0.001, which was statistically significant, and the postsurgery hospitalization duration differed when the type of surgical procedure differed. The results of a stratified analysis conducted for the two timing of surgeries (elective and acute) showed that in the patients who received elective surgeries that adopted two-, three-, and four-port procedures, the mean and median postsurgery hospitalization duration were 2.158 ± 0.644 and 2 (2, 2) days, 2.141 ± 1.167 and 2 (2, 2) days, and 2.412 ± 1.08 and 2 (2, 3) days, respectively. The Kruskal–Wallis test result revealed P = 0.001, which was statistically significant, and for elective surgeries, the postsurgery hospitalization duration differed when the type of surgical procedure differed. The mean and median postsurgery hospitalization duration for the patients who received surgeries under acute disease that adopted two-, three-, and four-port procedures were 2.75 ± 0.707 and 2 (2, 3) days, 2.778 ± 1.629 and 2 (2, 3) days, and 3.097 ± 1.542 and 3 (2, 3) days, respectively. The Kruskal–Wallis test result showed a P = 0.237, which was not statistically significant, and that for acute-type surgeries, the postsurgery hospitalization duration was unaffected by the type of surgical procedure performed.

Complications

Two common bile duct injuries occurred in this series (2/1276; 0.16%). Both cases were treated with Roux-en-Y hepaticojejunostomy with a fair short-term outcome. Both these injuries occurred in patients who underwent the acute surgery using the four-port procedure. There were neither other mortalities nor major complications in this series.


  Discussion Top


This paper collects 1276 cases of LCs in a single institute and reflects what likely current practice in a high-volume hospital. Not randomized case selection was the major limitation of this study, while it clearly reflects the safety principles of applying two- or three-port LC in the clinical situations. Single-port LC was not involved in this study because of suboptimal visual effect of 5-mm scope, increased obviously surgical difficulty and larger size of umbilical wound needed.

Our data showed a significant difference in the pain scores and admission days after surgery between these procedures. the three-port approach reveal lowest pain score at the first day after LC and that four-port LC got longest postoperation admission days (less than one-fourth of a hospital day). Our results revealed that conversion or not were unaffected by the types of procedur e; however, the risk of conversion for the patients exposed to acute surgeries was obvious higher than those exposed to elective surgeries. We found two major disadvantages of three-port LC; it needs more procedure steps and larger umbilical wound when compare with three- and four-port LC. We also confirm that the four-port LC was the most commonly used in most situations, given its speed and reliability, especially for situations of acute cholecystitis.

After completion of this study, our general practice of LC was using three-port procedure in elective disease and four-port method for acute disease or time saver. Decreased selection of two-port method was mainly due to increased procedure steps and operation time that derived from port setting system. Criteria of using two-, three-, or four-port methods basically follow the safety principle that Dr. Strasberg mentioned; increasing the number of trocars before conversion to open surgery.[15] We could not agree more the safety consideration of Dr. Rawling, to place patient safety over evolution of minimally LC[16] and Dr. Wendy A Rogers to aware the ethical oversight aims to protect patients by minimizing risks.[12]

It should report that during the study period, the 5 mm-shaft clip applicator had replaced 10 mm-shaft applicator for most LC in our institute; after that all the wound size of subxiphoid were reduced from 10 mm to 5 mm. The 2.4 mm grasper (double action upward curved needle-like forceps; Endo Relief™; Hirata Precisions Co.) was routinely used in our three-port LC, thus change sizes of wounds to become 11, 5, and 2 mm. We are looking forward to modify our future mini-LC use such instruments. It would be interesting to compare results between single LC and three-port LC with 10, 2, and 2 mm wound. It was expected that through such improvements in the procedure, technique and instruments without compromise of surgical convenience, effect, cost, and safety.[12],[17],[18]


  Conclusion Top


Four-port LC was the major procedure of choice for acute surgery and suitable for most surgeons in most conditions. Prolonged operation time was observed in two- and three-port LC. Three-port LC could be adopted using strategic selection (elective surgery) and conversion (with adding port) as safety guard for the benefits of less wound pain, decreased post-LC admission days.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lien HH, Huang CS. Male gender: A risk factor for severe symptomatic cholelithiasis. World J Surg 2002;26:598-601.  Back to cited text no. 1
    
2.
Lien HH, Huang CS, Shi MY, Chen DF, Wang NY, et al. Management of bile leakage post laparoscopic cholecystectomy according to etiological classification. Surg Today 2004;34:326-30.  Back to cited text no. 2
    
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Huang CS, Lien HH, Tai FC, Wu CH. Long-term results of major bile duct injury associated with laparoscopic cholecystectomy. Surg Endosc Other Interv Tech 2003;17:1362-7.  Back to cited text no. 3
    
4.
Lien HH, Huang CC, Liu JS, Shi MY, Chen DF, Wang NY, et al. System approach to prevent common bile duct injury and enhance performance of laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 2007;17:164-70.  Back to cited text no. 4
    
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Lien HH, Huang CC, Wang PC, Huang CS, Chen YH, Lin TL, et al. Changes in quality-of-life following laparoscopic cholecystectomy in adult patients with cholelithiasis. J Gastrointest Surg 2010;14:126-30.  Back to cited text no. 5
    
6.
Slim K, Pezet D, Stencl J Jr., Lechner C, Le Roux S, Lointier P, et al. Laparoscopic cholecystectomy: An original three-trocar technique. World J Surg 1995;19:394-7.  Back to cited text no. 6
    
7.
Yuan RH, Lee WJ, Yu SC. Mini-laparoscopic cholecystectomy: A cosmetically better, almost scarless procedure. J Laparoendosc Adv Surg Tech A 1997;7:205-11.  Back to cited text no. 7
    
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Sarli L, Costi R, Sansebastiano G. Mini-laparoscopic cholecystectomy vs. laparoscopic cholecystectomy. Surg Endosc Other Interv Tech 2001;15:614-8.  Back to cited text no. 8
    
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Lee PC, Lai IR, Yu SC. Minilaparoscopic (needlescopic) cholecystectomy: A study of 1011 cases. Surg Endosc Other Interv Tech 2004;18:1480-4.  Back to cited text no. 9
    
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Navarra G, Pozza E, Occhionorelli S, Carcoforo P, Donini I. One-wound laparoscopic cholecystectomy. Br J Surg 1997;84:695.  Back to cited text no. 10
    
11.
Ramachandran CS, Arora V. Two-port laparoscopic cholecystectomy: An innovative new method for gallbladder removal. J Laparoendosc Adv Surg Tech A 1998;8:303-8.  Back to cited text no. 11
    
12.
Rogers WA, Lotz M, Hutchison K, Pourmoslemi A, Eyers A. Identifying surgical innovation: A qualitative study of surgeons' views. Ann Surg 2014;259:273-8.  Back to cited text no. 12
    
13.
Lee PC, Lo C, Lai PS, Chang JJ, Huang SJ, Lin MT, et al. Randomized clinical trial of single-incision laparoscopic cholecystectomy versus minilaparoscopic cholecystectomy. Br J Surg 2010;97:1007-12.  Back to cited text no. 13
    
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Poon CM, Chan KW, Lee DW, Chan KC, Ko CW, Cheung HY, et al. Two-port vs. four-port laparoscopic cholecystectomy. Surg Endosc Other Interv Tech 2003;17:1624-7.  Back to cited text no. 14
    
15.
Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg 2010;211:132-8.  Back to cited text no. 15
    
16.
Rawlings A, Hodgett SE, Matthews BD, Strasberg SM, Quasebarth M, Brunt LM. Single-incision laparoscopic cholecystectomy: Initial experience with critical view of safety dissection and routine intraoperative cholangiography. J Am Coll Surg 2010;211:1-7.  Back to cited text no. 16
    
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Allemann P, Schafer M, Demartines N. Critical appraisal of single port access cholecystectomy. Br J Surg 2010;97:1476-80.  Back to cited text no. 17
    
18.
McCloy R, Randall D, Schug SA, Kehlet H, Simanski C, Bonnet F, et al. Is smaller necessarily better? A systematic review comparing the effects of minilaparoscopic and conventional laparoscopic cholecystectomy on patient outcomes. Surg Endosc Other Interv Tech 2008;22:2541-53.  Back to cited text no. 18
    


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