|Year : 2016 | Volume
| Issue : 4 | Page : 311-314
A comparative study of two-port versus three-port laparoscopic cholecystectomy
Ranendra Hajong, Peter DS Khariong
Department of General Surgery, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, Meghalaya, India
|Date of Submission||24-Aug-2015|
|Date of Acceptance||02-Oct-2015|
|Date of Web Publication||8-Sep-2016|
Department of General Surgery, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong - 793 018, Meghalaya
Source of Support: None, Conflict of Interest: None
Background: Conventionally, laparoscopic cholecystectomy (LC) is performed by using three or four ports of various sizes. As cosmesis is an important aspect of LC, the trend is now towards use of fewer ports, thereby resulting in better cosmesis for patients. The aim of this study was to compare three-port against two-port LC techniques and to see whether there is any advantage in using one technique over the other. Settings and Design: The study was conducted in the Department of General Surgery of North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS) hospital in Northeast India. A prospective comparative type of study was designed. An odd number of patients were operated on by using the three-port technique (Group A), whereas an even number of patients were operated on by the two-port technique (Group B). Materials and Methods: Sixty patients with symptomatic gallstone disease were included in the study after obtaining informed consent from each of the patients. All patients were operated on under general anaesthesia. Statistical Analysis Used: Statistical analysis was done using SPSS software version 22. Results: There were 51 female patients and 9 male patients. The mean patient age was 38.67 years. There was less operative time in group A but less postoperative pain in group B. Cosmetic appearance and patient satisfaction for the scar were better in group B. Conclusions: The two-port method appeared to have better acceptability among patients due to lower pain score and better cosmesis.
Keywords: Cholecystectomy, laparoscopic, three-port, two-port
|How to cite this article:|
Hajong R, Khariong PD. A comparative study of two-port versus three-port laparoscopic cholecystectomy. J Min Access Surg 2016;12:311-4
| ¤ Introduction|| |
Since its foundation in 1987 by Philip Mouret of Lyon, France, laparoscopic cholecystectomy (LC) has been the procedure of choice for symptomatic gall bladder disease. Short length of hospital stay, immediate regaining of physical activity, low prevalence of postoperative pain, morbidity and mortality, and good cosmetic outcomes contribute to the benefits of LC. This operation is conventionally performed by using four ports into the abdomen: One for the camera, two for manipulation of tissues and another for retraction. With increasing surgeon experience, LC has undergone many refinements including reduction in port size. Three trocars and even two trocars have been used to perform LC,, as were mini-instruments; the authors of these new techniques claimed that these techniques took similar time to perform and caused less postoperative pain than the standard LC., Two-port LC has been reported in the international literature to be safe and feasible. The aim of this study was to compare two-port LC with three-port LC and demonstrate whether there are any extra benefits with two-port LC.
| ¤ Materials and Methods|| |
The study was conducted in the Department of General Surgery, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS) Hospital, Shillong, Meghalaya between January 2013 and June 2014. Sixty adult patients with symptomatic cholelithiasis were enrolled into this study after obtaining due informed consent. An odd number of patients were operated on by using the three-port technique (Group A), whereas an even number of patients were operated on by the two-port technique (Group B). Ethical clearance was obtained from the Institute Ethics Committee.
The three-port technique was done by using one 10-mm umbilical port for camera, one 10-mm operating port in the epigastrium, one 5-mm port in the right hypochondrium for retraction at gall bladder neck [Figure 1]. The fundus of the gall bladder was tied with a suture passed from the anterior axillary line [Figure 2].
|Figure 2: Figure showing gall bladder being retracted with the fundal suture|
Click here to view
In the two-port technique, one 10-mm port was passed in the umbilicus for camera and one 10-mm port passed in the epigastrium for operation. One suture was passed in the right hypochondrium in the anterior axillary line for retracting the gall bladder fundus [Figure 3]. One more suture was passed in the anterior axillary line about 5 cm below the previous suture and tied to the neck of the gall bladder for lateral traction during dissection at Calot's triangle [Figure 4].
|Figure 3: Figure showing trocar and traction suture positions in two-port technique|
Click here to view
Postoperative pain was measured using the Visual Analogue Scale, which consists of a line, usually 100 mm long, whose ends are labelled as the extremes ('no pain' and 'pain as bad as it could be'). The patient is asked to put a mark on the line indicating his/her pain intensity.
Cosmetic appearance was assessed using the Hollander Wound Evaluation Scale  which addresses the following six clinical items:
- Step-off borders,
- Contour irregularities,
- Scar width,
- Edge inversion,
- Excess inflammation and
- Overall cosmetic appearance.
Each of these items was graded between 0 and 1; the optimal score was 6, and any score lower than this was considered suboptimal.
| ¤ Results|| |
There were 51 female patients and 9 male patients. The mean patient age was 38.67 years (range 18-60 years). The mean follow-up time was 9.24 months (range 5-18 months). The mean operative time was 38.346 min for Group A and 41.243 min for Group B. No statistically significant difference in initiation of oral feeds between the two study groups. The mean hospital stay was 2 days for Group A and 1.862 days for Group B. The severity of postoperative pain in group A was mild in 8 patients (26.67%), moderate in 18 patients (60.00%) and severe in 4 patients (13.33%). As regards Group B, the severity of postoperative pain was mild in 20 patients (66.67%), moderate in 9 patients (30.00%) and severe in 1 patient (3.33%). Conversion to open surgery was not done for any group. No port-site hernia was observed in both groups. Cosmetic appearance and patient satisfaction for the scar were excellent in 20 patients (66.67%) and good in 10 patients (33.33%) in Group A, whereas in Group B, it was excellent in 27 patients (90.00%) and good in 3 patients (10.00%). [Table 1] shows patient characteristics and follow-up results. The two-port method appeared to have better acceptability among patients, judging by the lower pain score and better cosmesis.
| ¤ Discussion|| |
Traditional LC is performed using a four-port technique., Reducing the number and size of ports further enhanced the advantages of laparoscopic over open cholecystectomy. These modifications actually reduced the pain and analgesia requirement. Poon et al. conducted a randomised study on 120 patients for comparison of four-port and two-port LC. They found that two-port LC involved less operative time, less port-site pain, similar clinical outcomes and fewer surgical scars. The phenomenon of reduced pain due to reduced number and sizes of the ports has been established by researchers such as Cheah et al. and Bisgaard et al.,
The value of the lateral (fourth) trocar in the American technique used to hold the gall bladder fundus has been challenged., Recently published data , showed that the three-port technique did not compromise the procedure's safety.
In the new era of minimal access surgery, the preferred outcomes under consideration are not only safety, but also quality, which is often defined by pain and cosmetic results. Scarless surgery is the ultimate goal for both surgeons and patients. Minimally invasive surgical techniques continue to evolve. Advancement in instrumentation has allowed more complex surgeries to be performed laparoscopically.
Two-port LC has shown a higher patient satisfaction score. A randomised study evaluating postoperative pain in patients undergoing three- versus four-trocar cholecystectomy demonstrated less analgesic use in the three-trocar group. A report on two-port LC has already shown that all patients would choose this technique over a four-port approach, as the postoperative pain is significantly reduced and the procedure outcome is cosmetically more acceptable to the patients.
Intraperitoneal spillage of gall bladder contents during LC is found in about 29% of cases and is associated with an increased risk of intra-abdominal abscess. None of the patients in our study had any intra-abdominal abscess, even though bile spillage was seen in some of the cases. The reason for this may be the saline irrigation that was done in those cases.
There were no reported complications at the needle puncture sites in the abdominal wall in any of the patients undergoing two-port and two-thread LC, similar to our findings.
Two-port LC has been reported to be safe and feasible, but it is technically difficult even in expert hands because of the limited operative field. However, whether it offers any additional advantages remains controversial.
| ¤ Conclusion|| |
Two-port cholecystectomy is technically feasible and may further improve surgical outcomes in terms of postoperative pain and better cosmetic value. This technique can be used only for simple and uncomplicated cases of cholelithiasis. It has been associated with better patient satisfaction.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
| ¤ References|| |
Espiner HJ, Keen G, Farndon J. Operative Surgery and Management. 3rd
ed. Oxford: Butterworth-Heinemann Ltd; 1994. p. 304-7.
Sari YS, Tunali V, Tomaoglu K, Karagöz B, Güneyi A, Karagöz I. Can bile duct injuries be prevented? “A new technique in laparoscopic cholecystectomy”. BMC Surg 2005;5:14.
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.
Osborne D, Boe B, Rosemurgy AS, Zervos EE. Twenty-millimeter laparoscopic cholecystectomy: Fewer ports results in less pain, shorter hospitalization, and faster recovery. Am Surg 2005;71:298-302.
Poon CM, Chan KW, Lee DW, Chan KC, Ko CW, Cheung HY, et al
. Two-port versus four-port laparoscopic cholecystectomy. Surg Endosc 2003;17: 1624-7.
Sarli L, Costi R, Sansebastiano G. Mini-laparoscopic cholecystectomy vs laparoscopic cholecystectomy. Surg Endosc 2001;15:614-8.
Leggett PL, Bissell CD, Churchman-Winn R, Ahn C. Three-port microlaparoscopic cholecystectomy in 159 patients. Surg Endosc 2001; 15:293-6.
Bombardier C. Glossary of terms. Spine 2000;25:3100-202.
Ong CCP, Jacobsen AS, Joseph VT. Comparing wound closure using tissue glue versus subcuticular suture for pediatric surgical incisions: A prospective, randomised trial. Pediatr Surg Int 2002;18:553-5.
Olsen DO. Laparoscopic cholecystectomy. Am J Surg 1991;161:339-44.
Litynski GS. Profiles in laparoscopy: Mouret, Dubois, and Perissat: The laparoscopic breakthrough in Europe (1987-1988). JSLS 1999;3:163-7.
Cheah WK, Lenzi JE, So JB, Kum CK, Goh PM. Randomized trial of needlescopic versus laparoscopic cholecystectomy. Br J Surg 2001;88:45-7.
Bisgaard T, Klarskov B, Trap R, Kehlet H, Rosenburg J. Microlaparoscopic vs conventional laparoscopic cholecystectomy: A prospective randomized double-blind trial. Surg Endosc 2002;16:458-64.
Otani T, Kaji T, Fukasawa T, Osawa T, Seki F, Yokoyama T, et al
. A flower-shaped cannula for three-incision laparoscopic cholecystectomy. Surg Endosc 1998;12:179-80.
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.
Trichak S. Three-port vs standard four-port laparoscopic cholecystectomy. Surg Endosc 2003;17:1434-6.
Waqar SH, Zahid MA. Two port laparoscopic cholecystectomy: An early experience. J Surg Pak 2009;14:179-81.
Kroh M, Rosenblatt S. Single-port, laparoscopic cholecystectomy and inguinal hernia repair:First clinical report of a new device. J Laparoendosc Adv Surg Tech A 2009;19:215-7.
Poon CM, Chan KW, Ko CW, Chan KC, Lee DW, Cheung HY, et al
. Two-port laparoscopic cholecystectomy: Initial results of a modified technique. J Laparoendosc Adv Surg Tech A 2002:12:259-62.
Leung KF, Lee KW, Cheung TY, Leung LC, Lau KW. Laparoscopic cholecystectomy: Two-port technique. Endoscopy 1996;28:505-7.
Rice DC, Memon MA, Jamison RL, Agnessi T, Ilstrup D, Bannon MB, et al
. Long-term consequences of intraoperative spillage of bile and gallstones during laparoscopic cholecystectomy. J Gastrointest Surg 1997;1:85-90.
Nashed GA, Helmy H, Shaaban N, Yehia M. Comparison between single incision laparoscopic cholecystectomy [SILS] and the novel Two Ports, Two Threads Mini-laparoscopic Cholecystectomy; A Prospective Study. Kasr El Eini J Surg 2011;12:67-73.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]