| Objective:This study aimed to compare the outcome and morbidity parameters of gasless laparoendoscopic single-site cholecystectomy (GLESC) and conventional laparoscopic cholecystectomy (LC).Materials and Methods:(1) Selection and Surgical groups of patientsSixty-nine patients presenting with gallbladder diseases (36 chronic cholelithiasis and 33 gallbladder polyps) diagnosed by abdominal ultrasound between June 2009 and July 2010 were studied retrospectively at Qilu Hospital of Shandong University. Patients presenting with severe acute attacks of cholecystitis or with history of pancreatitis and having history of operation were excluded from the study. Patients were divided into two groups, gasless laparoscopic single-site cholecystectomy (GLESC) group and the conventional laparoscopic cholecystectomy (LC) group.34 patients whose BMI were under 33kg/m2 were subsumed into GLESC group and another 35 patients were brought into LC group. All the operations were performed by the experienced single surgical team.(2) Surgical technique In the GLESC procedure the subcutaneous abdominal wall lift system was adopted as the method of exposure. The access device was an incision protector named LAP protector. Two kinds of laparoscopes including a common 5-mm one were used in the procedure. Another laparoscope was 5.4mm in diameter and designed with a flexible tip offering 4 directions(up, down, left, right) of motion within 100°.A longer, extensible and articulating dissector and bent instruments including hooks, dissectors, graspers and shears were used during the operation. Hem-O-Lock clips were used for the closure of cystic duct and artery. In the conventional LC group, a 10mm telescope and the standard straight laparoscopic instruments were used.All patients were placed in the supine position under general anesthesia in both groups. In GLESC group, a single infraumbilical semicircular incision approximately 15～20mm was made, then we clamped the inner ring of the LAP protector with an oval forceps and inserted it into the abdominal cavity smoothly. It expands to fill the incision. The abdominal wall lifting system was attached to the operating table. The abdominal wall was then slightly elevated to make an exposure of the operative area, and then the 5-mm laparoscope and bent or the extensible, articulating 5-mm instruments were inserted through the LAP protector. Our conventional LC operation require placement of four abdominal trocars with a 10mm trocar within the umbilicus and three 5mm additional abdominal ports below right costal margin.(3) Main outcome measuresThe BMI, associated disease, operating time, estimated blood loss (EBL),rate for conversion to open procedure, the C-reactive protein (CRP) level, pain scores at 6h and 24h, shoulder and back pain rate, time taken for resumption of oral intake, postoperative hospital stay, wound complications were noted and a retrospective analysis was conducted.(4) Statistical analysis"SPSS11.5 for windows" was applied for statistical analysis. Data were expressed as absolute values and mean±SD. Comparison of categorical variables was performed using x2 test, and continuous variables were assessed by t test. P<0.05 was considered to represent statistical significance for all comparisons.Results:(1) Two cases in the GLESC group were converted to laparoendoscopic single-site cholecystectomy using AWL combined with low-pressure pneumoperitoneum because of high BMI and poor exposure.32 underwent GLESC and 35 underwent LC.(2) The mean operating time was longer in the GLESC group (78.91±24.59) min than in the LC group (46.84±9.60) min (P<0.05). Though the difference did not had the statistical significance (P=0.054), the CRP level of GLESC group (35.75±22.00 mg/L) was higher than LC group (20.22±11.08mg/L).(3) The mean pain scores at 6h were similar in the two groups[(4.96±0.98) for the GLESC group vs. (5.42±1.17) for the LC group; nonsignificant difference].However the pain scores at 24h were significantly lower in the GLESC group (3.39±1.12) than in the LC group(4.84±1.42)(P=0.001). The shoulder and back pain rate of GLESC group was significantly lower than that of LC group (P=0.009). The EBL and the hospital stay were similar in the two groups, respectively.(4) The follow-up period was 48 to 174 days (mean,120days). There were no wound complications such as wound infection or hernia.Conclusion:(1) The GLESC with AWL is safe, effective and feasible in most cases of gallbladder diseases.(2) It appears to be cosmetically superior compared to standard LC and other advantages include less postoperative pain and faster postoperative recovery.(3) It still has some drawbacks such as limited operating area, collisions of instruments and the longer operating time.(4) The techniques provide satisfactory exposure of operative field and an easier access method for patients having certain BMI and height. |
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