Skip to main content
SpringerLink
Log in

Single-incision laparoscopic cholecystectomy is responsible for increased adverse events: results of a meta-analysis of randomized controlled trials

  • Review
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Over the last decade, single-incision laparoscopic cholecystectomy (SLC) has gained popularity, although it is not evident if benefits of this procedure overcome the potential increased risk. Aim of the study is to compare the outcome of SLC with conventional multi-incision laparoscopic cholecystectomy (MLC) in a meta-analysis of randomized controlled trials only.

Methods

A systematic Medline, Embase, and Cochrane Central Register of Controlled Trials literature search of articles on SLC and MLC for any indication was performed in June 2017. The main outcomes measured were overall adverse events, pain score (VAS), cosmetic results, quality of life, and incisional hernias. Linear regression was used to model the effect of each procedure on the different outcomes.

Results

Forty-six trials were included and data from 5141 participants were analysed; 2444 underwent SLC and 2697 MLC, respectively. Mortality reported was nil in both treatment groups. Overall adverse events were higher in the SLC group (RR 1.41; p < 0.001) compared to MLC group, as well severe adverse events (RR 2.06; p < 0.001) and even mild adverse events (RR 1.23; p = 0.041). This was confirmed also when only trials including 4-port techniques (RR 1.37, p = 0.004) or 3-port techniques were considered (RR 1.89, p = 0.020). The pain score showed a standardized mean difference (SMD) of − 0.36 (p < 0.001) in favour of SLC. Cosmetic outcome by time point scored a SMD of 1.49 (p < 0.001) in favour of SLC. Incisional hernias occurred more frequently (RR 2.97, p = 0.005) in the SLC group.

Conclusions

Despite SLC offers a better cosmetic outcome and reduction of pain, the consistent higher rate of adverse events, both severe and mild, together with the higher rate of incisional hernias, should suggest to reconsider the application of single incision techniques when performing cholecystectomy with the existing technology.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10

Similar content being viewed by others

References

  1. Navarra G, Pozza E, Occhionorelli S, Carcoforo P, Donini I (1997) One-wound laparoscopic cholecystectomy. Br J Surg 84(5):695–695

    Article  PubMed  CAS  Google Scholar 

  2. Allemann P, Schafer M, Demartines N (2010) Critical appraisal of single port access cholecystectomy. Br J Surg 97(10):1476–1480

    Article  PubMed  CAS  Google Scholar 

  3. Joseph M, Phillips MR, Farrell TM, Rupp CC (2012) Single incision laparoscopic cholecystectomy is associated with a higher bile duct injury rate: a review and a word of caution. Ann Surg 256(1):1–6

    Article  PubMed  Google Scholar 

  4. Markar SR, Karthikesalingam A, Thrumurthy S, Muirhead L, Kinross J, Paraskeva P (2012) Single-incision laparoscopic surgery (SILS) vs. conventional multiport cholecystectomy: systematic review and meta-analysis. Surg Endosc 26(5):1205–1213

    Article  PubMed  CAS  Google Scholar 

  5. Garg P, Thakur JD, Garg M, Menon GR (2012) Single-incision laparoscopic cholecystectomy vs. conventional laparoscopic cholecystectomy: a meta-analysis of randomized controlled trials. J Gastrointest Surg Off J Soc Surg Aliment Tract 16(8):1618–1628

    Article  Google Scholar 

  6. Milas M, Deveđija S, Trkulja V (2014) Single incision versus standard multiport laparoscopic cholecystectomy: up-dated systematic review and meta-analysis of randomized trials. Surg J R Coll Surg Edinb Irel 12(5):271–289

    Google Scholar 

  7. Trastulli S, Cirocchi R, Desiderio J, Guarino S, Santoro A, Parisi A, Noya G, Boselli C (2013) Systematic review and meta-analysis of randomized clinical trials comparing single-incision versus conventional laparoscopic cholecystectomy. Br J Surg 100(2):191–208

    Article  PubMed  CAS  Google Scholar 

  8. Gurusamy KS, Vaughan J, Rossi M, Davidson BR (2014) Fewer-than-four ports versus four ports for laparoscopic cholecystectomy. Cochrane Database Syst Rev 20(2):CD007109

    Google Scholar 

  9. Evers L, Bouvy N, Branje D, Peeters A (2016) Single-incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy: a systematic review and meta-analysis. Surg Endosc 31(9):3437–3448

    Google Scholar 

  10. Arezzo A, Passera R, Bullano A, Mintz Y, Kedar A, Boni L, Cassinotti E, Rosati R, Fumagalli Romario U, Sorrentino M, Brizzolari M, Di Lorenzo N, Gaspari AL, Andreone D, De Stefani E, Navarra G, Lazzara S, Degiuli M, Shishin K, Khatkov I, Kazakov I, Schrittwieser R, Carus T, Corradi A, Sitzman G, Lacy A, Uranues S, Szold A, Morino M (2017) Multi-port versus single-port cholecystectomy: results of a multi-centre, randomised controlled trial (MUSIC trial). Surg Endosc 31(7):2872–2880

    Article  PubMed  Google Scholar 

  11. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration (2011). http://www.cochrane-handbook.org. Accessed 01 Jan 2012

  12. Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications. Ann Surg 240(2):205–213

    Article  PubMed  PubMed Central  Google Scholar 

  13. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700

    Article  PubMed  PubMed Central  Google Scholar 

  14. Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5(1):13

    Article  PubMed  PubMed Central  Google Scholar 

  15. DerSimonian R, Laird N (1986) Meta-analysis in clinical trials. Control Clin Trials 7(3):177–188

    Article  PubMed  CAS  Google Scholar 

  16. Schwarzer G (2007) Meta: an R package for meta-analysis. R News 7:40–45

    Google Scholar 

  17. Review Manager (RevMan) (2014) [Computer program] Version 5.3 Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration

  18. Lee PC, Lo C, Lai PS, Chang JJ, Huang SJ, Lin MT, Lee PH (2010) Randomized clinical trial of single-incision laparoscopic cholecystectomy versus minilaparoscopic cholecystectomy. Br J Surg 97(7):1007–1012

    Article  PubMed  Google Scholar 

  19. Mehmood Z, Subhan A, Rasul S (2011) Singleincision laparoscopic cholecystectomy (SILS). Pak J Med Sci 27:38–40

    Google Scholar 

  20. Tsimoyiannis EC, Tsimogiannis KE, Pappas-Gogos G, Farantos C, Benetatos N, Mavridou P, Manataki A (2010) Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial. Surg Endosc 24(8):1842–1848

    Article  PubMed  Google Scholar 

  21. Aprea G, Coppola Bottazzi E, Guida F, Masone S, Persico G (2011) Laparoendoscopic single site (LESS) versus classic video-laparoscopic cholecystectomy: a randomized prospective study. J Surg Res 166(2):e109–e112

    Article  Google Scholar 

  22. Bucher P, Pugin F, Buchs NC, Ostermann S, Morel P (2011) Randomized clinical trial of laparoendoscopic single-site versus conventional laparoscopic cholecystectomy. Br J Surg 98(12):1695–1702

    Article  PubMed  CAS  Google Scholar 

  23. Cao ZG, Cai W, Qin MF, Zhao HZ, Yue P, Li Y (2011) Randomized clinical trial of single-incision versus conventional laparoscopic cholecystectomy: short-term operative outcomes. Surg Laparosc Endosc Percutan Tech 21(5):311–313

    Article  PubMed  Google Scholar 

  24. Lai ECH, Yang GPC, Tang CN, Yih PCL, Chan OCY, Li MKW (2011) Prospective randomized comparative study of single incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy. Am J Surg 202(3):254–258

    Article  PubMed  Google Scholar 

  25. Lirici MM, Califano AD, Angelini P, Corcione F (2011) Laparo-endoscopic single site cholecystectomy versus standard laparoscopic cholecystectomy: results of a pilot randomized trial. Am J Surg 202(1):45–52

    Article  PubMed  Google Scholar 

  26. Ma J, Cassera MA, Spaun GO, Hammill CW, Hansen PD, Aliabadi-Wahle S (2011) Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy. Ann Surg 254(1):22–27

    Article  PubMed  Google Scholar 

  27. Herrero Fonollosa E, Cugat Andorrà E, Domingo G, Isabel M, Camps Lasa J, Porta Castejón R, Rodriguez Campos A (2012) Estudio prospectivo aleatorizado comparativo entre colecistectomía laparoscópica versus colecistectomía por puerto único en régimen ambulatorio. Cir Esp 90(10):641–646

    Article  PubMed  Google Scholar 

  28. Sasaki A, Ogawa M, Tono C, Obara S, Hosoi N, Wakabayashi G (2012) Single-port versus multiport laparoscopic cholecystectomy: a prospective randomized clinical trial. Surg Laparosc Endosc Percutan Tech 22(5):396–399

    Article  PubMed  Google Scholar 

  29. Sinan H, Demirbas S, Ozer MT, Sucullu I, Akyol M (2012) Single-incision laparoscopic versus laparoscopic cholecystectomy: a prospective randomized study. Surg Laparosc Endosc Percutan Tech 22(1):12–16

    Article  PubMed  Google Scholar 

  30. Zheng M, Qin M, Zhao H (2012) Laparoendoscopic single-site cholecystectomy: a randomized controlled study. Minim Invasive Ther Allied Technol MITAT Off J Soc Minim Invasive Ther 21(2):113–117

    Article  Google Scholar 

  31. Abd Ellatif ME, Askar WA, Abbas AE, Noaman N, Negm A, El-Morsy G, El Nakeeb A, Magdy A, Amin M (2013) Quality-of-life measures after single-access versus conventional laparoscopic cholecystectomy: a prospective randomized study. Surg Endosc 27(6):1896–1906

    Article  PubMed  Google Scholar 

  32. Brown KM, Moore BT, Sorensen GB, Boettger CH, Tang F, Jones PG, Margolin DJ (2013) Patient-reported outcomes after single-incision versus traditional laparoscopic cholecystectomy: a randomized prospective trial. Surg Endosc 27(9):3108–3115

    Article  PubMed  Google Scholar 

  33. Deveci U, Barbaros U, Kapakli MS, Manukyan MN, Simsek S, Kebudi A, Mercan S (2013) The comparison of single incision laparoscopic cholecystectomy and three port laparoscopic cholecystectomy: prospective randomized study. J Korean Surg Soc 85(6):275–282

    Article  PubMed  PubMed Central  Google Scholar 

  34. Luna RA, Nogueira DB, Varela PS, Rodrigues Neto Ede O, Norton MJ, Ribeiro Ldo C, Peixoto AM, de Mendonca YL, Bendet I, Fiorelli RA, Dolan JP (2013) A prospective, randomized comparison of pain, inflammatory response, and short-term outcomes between single port and laparoscopic cholecystectomy. Surg Endosc 27(4):1254–1259

    Article  PubMed  Google Scholar 

  35. Madureira FAV, Manso JEF, Madureira Fo D, Iglesias ACG (2013) Randomized clinical study for assessment of incision characteristics and pain associated with LESS versus laparoscopic cholecystectomy. Surg Endosc 27(3):1009–1015

    Article  PubMed  Google Scholar 

  36. Marks JM, Phillips MS, Tacchino R, Roberts K, Onders R, DeNoto G, Gecelter G, Rubach E, Rivas H, Islam A, Soper N, Paraskeva P, Rosemurgy A, Ross S, Shah S (2013) Single-incision laparoscopic cholecystectomy is associated with improved cosmesis scoring at the cost of significantly higher hernia rates: 1-year results of a prospective randomized, multicenter, single-blinded trial of traditional multiport laparoscopic cholecystectomy vs single-incision laparoscopic cholecystectomy. J Am Coll Surg 216(6):1037–1047

    Article  PubMed  Google Scholar 

  37. Pan MX, Jiang ZS, Cheng Y, Xu XP, Zhang Z, Qin JS, He GL, Xu TC, Zhou CJ, Liu HY, Gao Y (2013) Single-incision vs three-port laparoscopic cholecystectomy: prospective randomized study. World J Gastroenterol 19(3):394–398

    Article  PubMed  PubMed Central  Google Scholar 

  38. Saad S, Strassel V, Sauerland S (2013) Randomized clinical trial of single-port, minilaparoscopic and conventional laparoscopic cholecystectomy. Br J Surg 100(3):339–349

    Article  PubMed  CAS  Google Scholar 

  39. Singh M, Mehta KS, Yasir M, Kaur A, Aiman A, Sharma A, Kaur N (2015) Single-incision laparoscopic cholecystectomy using conventional laparoscopic instruments and comparison with three-port cholecystectomy. Indian J Surg 77(Suppl 2):546–550

    Article  PubMed  Google Scholar 

  40. Yilmaz H, Arun O, Apiliogullari S, Acar F, Alptekin H, Calisir A, Sahin M (2013) Effect of laparoscopic cholecystectomy techniques on postoperative pain: a prospective randomized study. J Korean Surg Soc 85(4):149–153

    Article  PubMed  PubMed Central  Google Scholar 

  41. Zapf M, Yetasook A, Leung D, Salabat R, Denham W, Barrera E, Butt Z, Carbray J, Du H, Wang CE, Ujiki M (2013) Single-incision results in similar pain and quality of life scores compared with multi-incision laparoscopic cholecystectomy: a blinded prospective randomized trial of 100 patients. Surgery 154(4):662–670

    Article  PubMed  Google Scholar 

  42. Borle FR, Mehra B, ranjan Singh A (2015) Comparison of cosmetic outcome between single-incision laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy in rural indian population: a randomized clinical trial. Indian J Surg 77(Suppl 3):877–880

    Article  PubMed  Google Scholar 

  43. Emre Telciler K, Ilhan E, Yakan S, Cengiz F, Senlikci A, Aktürk Hayat E (2014) Single-port laparoscopic cholecystectomy versus the classical four port laparoscopic cholecystectomy: a randomized prospective clinical trial. Minerva Chir 69(1):1–7

    PubMed  CAS  Google Scholar 

  44. Jørgensen LN, Rosenberg J, Al-Tayar H, Assaadzadeh S, Helgstrand F, Bisgaard T (2014) Randomized clinical trial of single- versus multi-incision laparoscopic cholecystectomy. Br J Surg 101(4):347–355

    Article  PubMed  Google Scholar 

  45. Justo-Janeiro JM, Vincent GT, Vazquez de Lara F, de la Rosa Paredes R, Orozco EP, Vazquez de Lara LG (2014) One, two, or three ports in laparoscopic cholecystectomy? Int Surg 99(6):739–744

    Article  PubMed  PubMed Central  Google Scholar 

  46. Khorgami Z, Shoar S, Anbara T, Soroush A, Nasiri S, Movafegh A, Aminian A (2014) A randomized clinical trial comparing 4-port, 3-port, and single-incision laparoscopic cholecystectomy. J Invest Surg 27(3):147–154

    Article  PubMed  Google Scholar 

  47. Rizwi F, Saleem M, Abid KJ (2014) Outcome of single incision laparoscopic cholecystectomy (SILC) versus conventional four port laparoscopic cholecystectomy for cholelithiasis—a randomized control trial. Pak J Med Sci 8:243–246

    Google Scholar 

  48. Bingener J, Skaran P, McConico A, Novotny P, Wettstein P, Sletten DM, Park M, Low P, Sloan J (2015) A double-blinded randomized trial to compare the effectiveness of minimally invasive procedures using patient-reported outcomes. J Am Coll Surg 221(1):111–121

    Article  PubMed  PubMed Central  Google Scholar 

  49. Chang SKY, Wang YL, Shen L, Iyer SG, Madhavan K (2015) A randomized controlled trial comparing post-operative pain in single-incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy. World J Surg 39(4):897–904

    Article  PubMed  Google Scholar 

  50. Dabbagh N, Soroosh A, Khorgami Z, Shojaeifard A, Jafari M, Abdehgah AG, Mahmudzade H (2015) Single-incision laparoscopic cholecystectomy versus mini-laparoscopic cholecystectomy: a randomized clinical trial study. J Res Med Sci 20(12):1153–1159

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  51. Guo W, Liu Y, Han W, Liu J, Jin L, Li JS, Zhang ZT (2015) Randomized trial of immediate postoperative pain following single-incision versus traditional laparoscopic cholecystectomy. Chin Med J (Engl) 128(24):3310–3316

    Article  Google Scholar 

  52. He GL, Jiang ZS, Cheng Y, Lai QB, Zhou CJ, Liu HY, Gao Y, Pan MX, Jian ZX (2015) Tripartite comparison of single-incision and conventional laparoscopy in cholecystectomy: a multicenter trial. World J Gastrointest Endosc 7(5):540–546

    Article  PubMed  PubMed Central  Google Scholar 

  53. Lurje G, Raptis DA, Steinemann DC, Amygdalos I, Kambakamba P, Petrowsky H, Lesurtel M, Zehnder A, Wyss R, Clavien PA, Breitenstein S (2015) Cosmesis and body image in patients undergoing single-port versus conventional laparoscopic cholecystectomy: a multicenter double-blinded randomized controlled trial (SPOCC-trial). Ann Surg 262(5):728–734

    Article  PubMed  Google Scholar 

  54. Partelli S, Barugola G, Sartori A, Crippa S, Falconi M, Ruffo G (2016) Single-incision laparoscopic cholecystectomy versus traditional laparoscopic cholecystectomy performed by a single surgeon: findings of a randomized trial. Surg Today 46(3):313–318

    Article  PubMed  Google Scholar 

  55. Sulu B, Yildiz BD, Ilingi ED, Gunerhan Y, Cakmur H, Anuk T, Yildiz B, Koksal N (2015) Single port vs. four port cholecystectomy–randomized trial on quality of life. Adv Clin Exp Med 24(3):469–473

    Article  PubMed  Google Scholar 

  56. Ye G, Qin Y, Xu S, Wu C, Wang S, Pan D, Wang X (2015) Comparison of transumbilical single-port laparoscopic cholecystectomy and fourth-port laparoscopic cholecystectomy. Int J Clin Exp Med 8(5):7746–7753

    PubMed  PubMed Central  Google Scholar 

  57. Goel A, Chaubey P, Gupta A, Gupta S, Agarwal A, Bhardwaj D (2016) Comparative study of single-incision laparoscopic cholecystectomy with four port conventional laparoscopic cholecystectomy: a single-center experience. World J Lap Surg 9(1):9–12

    Google Scholar 

  58. Hajong R, Hajong D, Natung T, Anand M, Sharma G (2016) A comparative study of single incision versus conventional four ports laparoscopic cholecystectomy. J Clin Diagn Res JCDR 10(10):PC06–PC09

    PubMed  Google Scholar 

  59. Sarwar G, Jan MA, Sheikh TH (2016) Comparison of single versus four port laparoscopic cholecystectomy. Park J Med Sci 10(2):646–648

    Google Scholar 

  60. Tyagi S, Sinha R, Tyagi A (2017) Single incision laparoscopic cholecystectomy: less scar, less pain. J Minim Access Surg 13(2):118–123

    PubMed  PubMed Central  Google Scholar 

  61. Zhao L, Wang Z, Xu J, Wei Y, Guan Y, Liu C, Xu L, Liu C, Wu B (2016) A randomized controlled trial comparing single-incision laparoscopic cholecystectomy using a novel instrument to that using a common instrument. Int J Surg 32:174–178

    Article  PubMed  Google Scholar 

  62. Omar MA, Redwan AA, Mahmoud AG (2017) Single-incision versus 3-port laparoscopic cholecystectomy in symptomatic gallstones: a prospective randomized study. Surgery 162(1):96–103

    Article  PubMed  Google Scholar 

  63. Haueter R, Schütz T, Raptis DA, Clavien P-A, Zuber M (2017) Meta-analysis of single-port versus conventional laparoscopic cholecystectomy comparing body image and cosmesis. Br J Surg 104(9):1141–1159

    Article  PubMed  CAS  Google Scholar 

  64. Arezzo A, Scozzari G, Famiglietti F, Passera R, Morino M (2013) Is single-incision laparoscopic cholecystectomy safe? Results of a systematic review and meta-analysis. Surg Endosc 27(7):2293–2304

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We would like to acknowledge Lorenzo Causarano and Nicoletta Colombi for helping us in determining the correct syntax for the search strategy. The authors declare no grant equipment and drugs.

Funding

The authors declare not having received funding for this work from any of the following organizations: National Institutes of Health (NIH); Wellcome Trust; Howard Hughes Medical Institute (HHMI); or other(s).

Author information

Authors and Affiliations

  1. Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Turin, Italy

    A. Arezzo, R. Passera, E. Forcignanò, L. Rapetti & M. Morino

  2. Department of Surgical Sciences, University of Perugia, Terni, Italy

    R. Cirocchi

Authors
  1. A. Arezzo
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. R. Passera
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. E. Forcignanò
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. L. Rapetti
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. R. Cirocchi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. M. Morino
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors equally contributed to study conception and design and data acquisition. All authors participated in interpreting the data, drafting the article and revising it critically for intellectual content, and gave their final approval of the version submitted for publication.

Corresponding author

Correspondence to A. Arezzo.

Ethics declarations

Disclosures

A Arezzo, R Passera, E Forcignanò, E Rapetti, R Cirocchi and M Morino have no conflicts of interest or financial ties to disclose.

Appendix

Appendix

See Table 4.

Table 4 Search strategy
Full size table

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Arezzo, A., Passera, R., Forcignanò, E. et al. Single-incision laparoscopic cholecystectomy is responsible for increased adverse events: results of a meta-analysis of randomized controlled trials. Surg Endosc 32, 3739–3753 (2018). https://doi.org/10.1007/s00464-018-6143-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-018-6143-y

Keywords

Search

Navigation