|Year : 2014 | Volume
| Issue : 2 | Page : 72-77
Two-port and four-port laparoscopic cholecystectomy: Differences in outcome
Mumtaz Wani, Hilal Wani, Muddassir Shahdhar, Shahid Hameed, Shabir Mir, Mudasir Magray
Department of Surgery, Shri Maharaja Hari Singh Hospital, Srinagar, Jammu and Kashmir, India
|Date of Web Publication||16-Oct-2014|
Department of Surgery, Shri Maharaja Hari Singh Hospital, Srinagar - 190 001, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: Laparoscopic cholecystectomy has several advantages over open cholecystectomy. The purpose of this study was to compare the outcome between two-port and four-port laparoscopic cholecystectomy.
Patients and Methods: Between October 2011 and September 2013, 200 patients with calculous cholecystitis were prospectively consecutively selected into two groups of 100 patients each for two-port and four-port laparoscopic cholecystectomy, respectively.
Results: There were 39 males and 161 females. The mean operative time required in the two-port group was 46.66 ± 14.47 minutes and in four-port group was 48.79 ± 8.336 minutes (P value = 0.1297). Three patients were converted to four-port laparoscopic cholecystectomy in the two-port group. There were 25 minor complications (14 in the two-port group and 11 in the four-port group). The VAS scores were statistically significant at 1, 12, and 24 hours. An average requirement of 0.73 doses of analgesia in the two-port group and 1.36 doses in the four-port cohort was observed. The hospital stay was significantly shorter in the two-port group.
Conclusion: The two-port laparoscopic cholecystectomy is safe and preferable due to fewer requirements of analgesics, better cosmesis, cost-effectiveness, shorter hospital stay, and reduced labor.
Keywords: Four port, gallbladder disease, laparoscopic cholecystectomy, suspension sutures, two port
|How to cite this article:|
Wani M, Wani H, Shahdhar M, Hameed S, Mir S, Magray M. Two-port and four-port laparoscopic cholecystectomy: Differences in outcome
. Arch Int Surg 2014;4:72-7
|How to cite this URL:|
Wani M, Wani H, Shahdhar M, Hameed S, Mir S, Magray M. Two-port and four-port laparoscopic cholecystectomy: Differences in outcome
. Arch Int Surg [serial online] 2014 [cited 2020 Oct 24];4:72-7. Available from: https://www.archintsurg.org/text.asp?2014/4/2/72/143082
| Introduction|| |
The enthusiasm of having minimal surgical trauma without compromising on the final result yet having a broader view of all the organs has led to the evolution of laparoscopic surgery. Ever since Philip Mouret  performed his first laparoscopic cholecystectomy (LC), there has been a rapid evolution in this field. LC has rapidly replaced open cholecystectomy for treatment of patients with gall bladder diseases.  LC is associated with shorter hospital stay and convalescence, lesser pain and scarring, and lower rates of postoperative surgical site infections than open cholecystectomies. Reduced incidence of adhesion formation, wound dehiscence and incisional hernia are other advantages  LC has been performed by standard four-port technique since its introduction. With increasing experience, it has been shown that LC can be safely performed using three ports also, and recently, two-port technique and single incision LC ,, has been shown to be feasible. These new techniques took similar time to perform operation and caused less postoperative pain, reducing analgesic requirement and had cosmetic benefits.  The two-port LC has been reported to be safe and feasible with higher patient satisfaction score than the conventional four-port LC.  Nevertheless, the two-port technique is technically more demanding because of limited operative field and space and should only be used to remove simple, uncomplicated gall bladder. The surgeon should always be prepared to insert more trocars or convert to open procedures when necessary.  The aim of our study was to compare the outcome between two-port and four-port LC in terms of safety of procedure, operating time, postoperative pain, hospital stay, cosmesis, and need for conversion to open surgery.
| Patients and Methods|| |
This prospective study was conducted between October 2011 and October 2013 in the Postgraduate Department of Surgery, SMHS Hospital Srinagar, a tertiary care centre in northern India. Approval of the hospital ethics committee was obtained. The study comprised of 200 cases; 100 were subjected to two-port LC and 100 to four-port LC. The study population included all patients with gallstone disease regardless of their gender. Inclusion criteria for the study were patients with normal gall bladder (GB) wall thickness, normal bile duct on ultrasound, and virgin abdomen. Patients with history of jaundice or suspicion of GB malignancy were excluded from the study. An informed consent was obtained from each patient after explaining the advantages and potential complications of the procedure. Patients allocated to two-port or four-port group consecutively. Observations and results were tabulated and subjected to appropriate statistical analysis to calculate the P value using Fischer's exact test or unpaired 't' test as and when needed. A P value of <0.05 was taken as significant.
Pneumoperitoneum was established by blind puncture using veress needle. A 10-mm canula was inserted through the same incision used for veress needle (subumbilical or supraumbilical). Telescope was introduced through the same cannula and peritoneoscopy was performed. Another 10-mm trocar was inserted 3 cm below the xiphestenum [Figure 1]. The operating surgeon performs the procedure from the left side of the patient. The camera-holding assistant remains on the same side, while TV monitor was located on the right side of the patient. The operating surgeon holds the dissecting instruments with the right hand through a 10-mm working port. The gall bladder is manipulated through two or three strategically placed traction sutures, passed through fundus, the body, and the neck area of the gall bladder, respectively, using laparoscopic straight needle holder [Figure 2]. The fundal suture was placed higher up in the right hypochondrium just below the tip of 9 th costal cartilage. It was fixed by either tying a knot or by hemostatic clips. The second suture was placed through the body of gallbladder and was placed below the fundal suture in the same fashion. The other traction suture was placed in the right flank at a lower level to hold the neck of gallbladder. This was the main traction suture and was kept free to adjust the level of traction during different steps of procedure. Cystic duct and cystic artery were separately clipped. L-Hook/spatula was used to dissect GB from liver bed. GB was extracted through the subxephesternal port.
|Figure 1: Showing position of two ports (umblical and epigastric) with placement of traction sutures|
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|Figure 2: Intraabdominal view of gallbladder being held by traction sutures (one at fundus and other at neck of gb)|
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The severity of pain during the first 2 postoperative days was assessed daily by the patient using a VAS scale of 0 to 10. Feeding was resumed as soon as tolerated. Intravenous ceftriaxone 1 gm was used as an antibiotic prophylaxis. Patients were monitored and discharged from hospital on clinical grounds. After discharge, all patients were seen at surgical outpatient department at one week, at second week, and then every four weeks for three months. The four-port approach was conducted by the standard method.
| Results|| |
The age distribution in both the groups was comparable with no statistically significant difference observed. The mean age in two-port group was 39.55 ± 14.117 years and in four-port group was 38.89 ± 11.394 years (P value = 0.9268). Out of 200 cases, 39 were males and 161 were females with male to female ratio of 1:4.2. In 55 patients, ultrasonography revealed a single calculus in the gallbladder (22 in the two-port and 33 patients in the four-port group); the rest of the patients had multiple stones (78 in two-port and 67 patients in two-port group). As regards the wall thickness, 5 patients had a wall thickness of >4 mm (2 in two-port group and 3 in four-port group). The size of common bile duct was normal in both the study groups. The operative time was recorded from the insertion of veress needle until the closure of the ports externally. The difference in the mean operative time in the two groups was statistically insignificant (P value = 0.1297). The intraoperative parameters are shown in [Table 1]. The differences were statistically insignificant.
There were 25 minor complications in the study (14 in the two-port group and 11 in the four-port group) shown in [Table 2].
The postoperative pain was assessed using the visual analogue scale (VAS). Patients were informed that pain may be represented by a straight line that was calibrated from 0-10 cm, extremes of which correspond to no pain "0" at one end and worst pain at other end "10". Patients were assessed to rate their pain depending on the severity. The scores were calculated at 1, 12, and 24 hours postoperatively. The results were statistically significant at 1, 12, and 24 hours with P values = 0.019, <0.0001, and <0.0001, respectively [Table 3].
Pain was quantified by the number of doses of analgesic required in the postoperative period and VAS. A 75-mg injection of diclofenac was set as one analgesic dose. In general, two-port LC cohort patients were more comfortable in the postoperative period with an average requirement of 0.73 doses, while as it was 1.36 doses in the four-port cohort [Table 4].
|Table 4: Comparison of distribution of cases according to dose of analgesic|
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The mean time for resumption of diet in two-port and four-port groups was 6.04 ± 0.7236 hours and 7.55 ± 0.9431 hours, respectively, and this difference was statistically significant (P value < 0.0001) .The hospital stay was shorter in the two-port group (1.68 ± 0.7769 days) as compared to four-port group (2.09 ± 0.2876 days), and the results were statistically significant (P value < 0.0001). In the follow-up period of one month, scars were evaluated for cosmetic outcome by an independent evaluator. The mean VAS score in the two-port group was 77.10 ± 0.7013 mm and in the four-port group was 71.41 ± 0.6379 mm. The difference was statistically significant (P value < 0.001).
| Discussion|| |
In the present times, improvements in minimal access surgery are sought after in terms of reducing the number and the size of the ports. Patients undergoing LC with a reduced number and size of ports experienced significantly less pain.  Two-port LC with two 10-mm ports (umbilical and epigastric) and percutaneous traction suture was first reported by Leung and associates in 1996.  Since then, the two-port technique has been modified using a microendoscope or multiple traction sutures. With improvements in laparoscopic instrumentation, mini LC was introduced with the advantage of improved cosmesis.  Two-port LC has shown a higher patient's satisfaction score.  However, whether it offers any additional advantages over the conventional four-port remained controversial for a longer time. Trichak  in 2003 published a report on three-port LC depicting that all patients would choose this technique over the four-port approach, as the postoperative pain is significantly reduced and the procedure is cosmetically more acceptable to the patients. In our study the difference in age of the patients between the two groups was not statistically significant (P >0.05). For the two-port group, the male to female ratio in our study was 1:4 and for the four-port group the male to female ratio was 1:5. The predominance of females in our study is similar to the results of Peters et al.  in which the male to female ratio was 1:5. Twenty-two (22%) patients in two-port group had a single stone in gall bladder while as 78 (78%) had multiple stones. In the four-port group, 33 (33%) patients were harboring a single stone in contrast to 67 (67%) patients who had multiple stones. Furthermore, 5 patients had a wall thickness of >4 mm. Two (2%) patients in the two-port group and three (3%) patients in the four-port group had no clinical evidence of acute cholecystitis. The size of the bile duct was normal in both groups. All the differences were statistically insignificant with P value > 0.05. Our results are comparable to those obtained by Udwadia et al.,  in their study, multiple stones were present in 72% of patients and solitary stone in 28% of patients. The mean operative time required in the two-port group was 46.66 ± 14.473 minutes and in four-port group was 48.79 ± 8.336 minutes. This difference was statistically insignificant with p value of 0.1297. Lomanto, David et al.  obtained the same results with mean operating time of 42 minutes for two-port LC. Poon et al.  reported similar results in their study with mean operating time of 54.6 ± 24.7 minutes for the two-port group and 66.9 ± 33.1 minutes for the four-port group. There were no need of additional sutures in the two-port group. An additional port (5 mm) was needed in only one patient in the two-port group because the gallbladder was too long and would often come in the field of surgery, but there was no need of an additional port in any patient in the four-port group (P value = 1). Three (3%) patients were converted to four-port LC in the two-port group. In one patient, the gall bladder was long and would often come in the field of surgery and in another 2 patients because of dense adhesions it was difficult to define Calot's triangle, as keeping gall bladder at stretch by a clamp holding fundus, the dissection become easier but there was no need for an additional port in any patient in the four-port group (P value = 0.246). There was one right diaphragmatic injury (right-sided pneumothorax) in the two-port group for which right-sided chest tube drainage was done. The chest tube drain was removed on 3 rd postoperative day and the postoperative course was uneventful.
There were 11 gallbladder perforations in our study, 7 gall bladder perforations in the two-port group, and 4 gall bladder perforations in the four-port group. Sub-hepatic drains were placed in 5 patients in the two-port group and in 7 patients in the four-port group. Due to difficult dissection in view of adhesions and increased wall thickness, the gall bladder perforations during surgery caused spillage of bile and stones. After saline washes and retrieval of stones a drain was left in the sub-hepatic region in all these patients (P value = 0.7673). Four patients developed bleeding from liver bed in two-port group and 4 patients in the four-port group (P value = 1), out of total 8 patients, 6 patients had intrahepatic gall bladder, three (3%) in the two-port group and 3 in the four-port group. Two patients had difficulty in dissection of gall bladder bed, resulting in bleeding from liver bed, one from the two-port and one from the four-port group. In 7 patients, bleeding was controlled using diathermy and postoperative period was uneventful. Two patients (2%) were converted to open LC in the two-port group and 2 patients (2%) in the four-port group. One patient from the two-port group was converted to open LC because of bleeding from gall bladder bed, which was obscuring the operating field, while another patient from the two-port group was converted to open LC due to dense adhesions around Calot's triangle. Two patients in the four-port group were converted to open procedure; both patients had dense adhesions around the Calot's triangle. Our results are consistent with the results obtained by Chi-Ming Poon.  In their study, two patients required one additional 5-mm port or a traction suture because of dense adhesions. In the study by Tadashi Kagaya et al.  , an additional 5-mm trocar was inserted in 3 patients while performing two-port LC because of difficulty in removing the gall bladder from the gall bladder fossa. Twenty-five minor complications occurred in our study (14 in the two-port group and 11 in the four-port group), with no statistical significance. Three (3%) patients developed port site infection in the two-port group and mean VAS score for pain was 3.71 ± 1.409 and 4.77 ± 1.96 for two-port LC and four-port LC, respectively, at 12 hour, with a P value of <0.0001, which was statistically significant. The mean VAS score for pain was 2.2 ± 0.8165 and 2.98 ± 1.295 for two-port LC and four-port LC, respectively, at 24 hours, with a P value of <0.0001, which was statistically significant. Poon CM et al.  reported similar results in their study; the VAS pain score was significantly low in the two-port group than the four-port group. The analgesic used in our study was intramuscular injection of diclofenac sodium (75 mg), which was given on demand. The mean analgesic requirement in our study was (0.73 mg) for the two-port group and 1.36 mg for the four-port group. The P value was <0.05, which was statistically significant. In our study, no dose (0 dose) of intramuscular injection of diclofenac sodium (75 mg) was given in 48 patients in the two-port group and 26 patients in the four-port group. Though it is said that the epigastric port is the main contributor to pain in LC, in our study we observed that the two 5-mm ports also contribute to pain in LC. AL Nafeh et al.  reported similar results in their study with requirement of intramuscular NSAID for the four-port group (1.3 ± 0.7 mg) doses. The mean time for resumption of diet in the two-port and four-port groups was 6.04 ± 0.7236 hours and 7.55 ± 0.9431 hours, respectively, and this difference was statistically significant with P value < 0.0001. Mean hospital stay in the two-port group was 1.68 ± 0.7769 days, while in the four-port group it was 2.09 ± 0.2876 days. This difference was statistically significant with a P value < 0.0001. Ray Hwang Yuan, Wei Jei Lee et al.  reported similar results in their study. The mean hospital stay was 1.57 days for mini LC. Cosmesis was assessed by the number and the size of the surgical scars. Patients in both the groups were operated laparoscopically by a single surgeon; however, in the two-port group, there were two less scars than that in the four-port group. The average scar size was 2.1 cm in the four-port group (11 mm epigastric and two 5-mm port scars), whereas the average scar size was only 1.1 cm in epigastric in the two-port group. Furthermore, scars in two-port LC get hidden in female patients (epigastric scar under bra and umbilical scar hidden in the umbilical pit), and therefore are hardly visible after healing. Overall, patients in the two-port group were highly satisfied over the cosmetic outcomes of their surgery [Figure 3]. All procedures were completed successfully without any mortality or major morbidity. None of the patients in our study had major bile duct injury. The operative field was quite clear and comparable to that in standard four-port cases. Although in some cases of the two-port group, the liver and gallbladder hindered the operative field and consumed slightly more time.
| Conclusion|| |
Two-port LC requires no special but conventional laparoscopic instruments. It is a feasible and safe procedure when performed by an experienced surgeon. It reduces the labor required for the procedure as there is no need of a second assistant.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]