European Journal of Cardiovascular Medicine

Laparoscopic cholecystectomy has become the gold standard for the surgical management of symptomatic gallstone disease, offering reduced postoperative pain, shorter hospital stay, and faster return to normal activities compared to open cholecystectomy [1]. Since its introduction in the late 1980s, the conventional multi-port laparoscopic cholecystectomy (CMLC) technique, typically employing four ports, has been the most widely adopted approach worldwide [2]. Over time, surgical innovation has driven the development of minimally invasive techniques aimed at further reducing postoperative discomfort and improving cosmetic outcomes without compromising safety [3].

Single-incision laparoscopic cholecystectomy (SILC) emerged as one such advancement, utilizing a single umbilical incision to introduce all laparoscopic instruments and the camera [4]. The potential benefits of SILC include improved cosmesis, less postoperative pain, and faster convalescence, while its drawbacks may involve longer operative times, increased technical difficulty, and the need for specialized instruments [5,6]. Moreover, concerns persist regarding the potential for higher rates of port-site complications, such as incisional hernia, due to the enlargement of the umbilical incision [7].

Although multiple randomized controlled trials and meta-analyses have compared SILC and CMLC, the evidence remains inconclusive regarding their equivalence in safety and efficacy [8]. Some studies suggest that SILC is associated with better postoperative pain scores and cosmetic satisfaction, while others report negligible differences or highlight increased operative complexity [9]. Additionally, most available data come from high-volume centers with experienced surgeons, raising questions about the reproducibility of results in varied clinical settings [10].

Given these uncertainties, further comparative evaluation in real-world clinical practice is warranted to clarify whether SILC provides meaningful advantages over CMLC in terms of operative performance, postoperative recovery, and complication rates. The present study aims to compare the perioperative outcomes of SILC versus CMLC in patients undergoing elective laparoscopic cholecystectomy for benign gallbladder disease in a tertiary care setting.

Study Design and Setting

This was a prospective, comparative observational study conducted in the Department of General Surgery, Gulbarga Institute of Medical Sciences, Kalaburagi, from August 2023 to July 2024. The study compared the outcomes of single-incision laparoscopic cholecystectomy (SILC) with conventional multi-port laparoscopic cholecystectomy (CMLC) in patients undergoing elective cholecystectomy for benign gallbladder disease.

Study Population

A total of 100 patients were enrolled, with 50 patients assigned to the SILC group and 50 to the CMLC group. Inclusion criteria were:

• Age between 18 and 65 years
• Diagnosis of symptomatic cholelithiasis, gallbladder polyps <1 cm, or chronic cholecystitis confirmed on ultrasonography
• ASA physical status I or II

Exclusion criteria included:

• Acute cholecystitis, empyema, or gallbladder perforation
• Common bile duct stones or history of ERCP
• Previous upper abdominal surgery
• Severe cardiopulmonary comorbidities (ASA III or higher)
• Pregnancy

Ethical Considerations

The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Ethics Committee. Written informed consent was obtained from all participants prior to enrollment.

Surgical Techniques

All procedures were performed by surgeons with a minimum experience of 50 prior cases in each technique.

• SILC: A 2–3 cm transumbilical incision was made, through which a specialized multi-channel port was inserted. A 10-mm 30° laparoscope and straight or articulating instruments were introduced. Standard dissection of Calot’s triangle was performed, followed by cystic duct and artery ligation and gallbladder removal via the umbilical incision.
• CMLC: Four standard ports (one umbilical, one epigastric, and two lateral) were placed. Dissection and ligation steps were identical to SILC, with gallbladder retrieval via the umbilical port.

Data Collection

Data were collected prospectively and included:

1. Demographics: Age, sex, body mass index (BMI)
2. Primary outcomes: Operative time (minutes), intraoperative blood loss (mL), conversion to open surgery
3. Secondary outcomes: Postoperative pain assessed using a Visual Analogue Scale (VAS) at 6 and 24 hours, length of hospital stay (days), postoperative complications (wound infection, bile leak, port-site hernia, nausea/vomiting)
4. Cosmetic satisfaction: Not formally scored but recorded qualitatively during follow-up visits.

Statistical Analysis

• Data analysis was performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD) and compared using the Student’s t-test. Categorical variables were expressed as frequencies and percentages and compared using the Chi-square or Fisher’s exact test, as appropriate. A p-value of <0.05 was considered statistically significant.

Table 1: Demographic Characteristics

Table 2: Primary Outcome Measures

Table 3: Secondary Outcomes

Table 4: Postoperative Complications

Fig 1: Primary and Key secondary outcomes

The demographic characteristics of the study population were comparable between the two groups. The mean age was 42.6 ± 10.3 years in the SILC group and 43.8 ± 9.7 years in the CMLC group (p=0.54). Gender distribution showed a similar pattern, with males comprising 36.0% in the SILC group and 40.0% in the CMLC group (p=0.68). The mean BMI was 26.1 ± 3.4 kg/m² for SILC and 26.4 ± 3.6 kg/m² for CMLC (p=0.72), indicating no statistically significant difference in baseline characteristics.

In terms of primary outcomes, the mean operative time was significantly longer in the SILC group (62.4 ± 8.9 minutes) compared to the CMLC group (55.2 ± 7.8 minutes) (p=0.001). Intraoperative blood loss was slightly lower in the SILC group (48.6 ± 12.3 mL) than in the CMLC group (52.8 ± 14.1 mL), but this difference did not reach statistical significance (p=0.09). Conversion to open surgery occurred in 1 patient (2.0%) in the SILC group, while no conversions were required in the CMLC group (p=0.31).

Among secondary outcomes, the SILC group reported significantly lower mean VAS pain scores at both 6 hours (3.8 ± 0.9 vs 4.5 ± 1.0, p=0.002) and 24 hours (2.1 ± 0.7 vs 2.8 ± 0.8, p=0.001) postoperatively. The length of hospital stay was shorter in the SILC group (1.6 ± 0.5 days) compared to the CMLC group (2.1 ± 0.6 days), and this difference was statistically significant (p=0.0005).

Postoperative complication rates were low and did not significantly differ between groups. Wound infection occurred in 4.0% of SILC patients and 6.0% of CMLC patients (p=0.65). Bile leaks were seen in 2.0% of SILC cases and none in the CMLC group (p=0.31). Port-site hernia was reported in 2.0% of SILC cases, with none in the CMLC group (p=0.31). Postoperative nausea/vomiting was noted in 16.0% of SILC patients and 24.0% of CMLC patients (p=0.32).

DISCUSSION

This prospective comparative study evaluated single-incision laparoscopic cholecystectomy (SILC) against conventional multi-port laparoscopic cholecystectomy (CMLC) in terms of operative performance, recovery, and safety outcomes. Our findings showed that while SILC had a significantly longer operative time, it was associated with reduced postoperative pain and shorter hospital stay, with no significant difference in complication rates.

The mean operative time in our study was 62.4 ± 8.9 minutes for SILC compared to 55.2 ± 7.8 minutes for CMLC (p=0.001). Marks et al. [11] reported similar results, with SILC requiring 65.1 ± 9.3 minutes versus 54.7 ± 8.6 minutes for CMLC, attributing the difference to instrument crowding through a single access site. Chow et al. [12] also found SILC operative times to be longer (63.4 ± 7.8 vs 55.9 ± 7.2 minutes).

Intraoperative blood loss in our series was 48.6 ± 12.3 mL for SILC and 52.8 ± 14.1 mL for CMLC (p=0.09). Ma et al. [13] reported comparable figures of 50.2 ± 11.8 mL and 53.7 ± 13.4 mL, while Frutos et al. [14] recorded 47.5 ± 13.1 mL versus 51.6 ± 14.2 mL.

Conversion to open surgery occurred in 2.0% of SILC cases in our study versus 0.0% for CMLC, which is consistent with the 1.9% vs 0.0% rates reported by Frutos et al. [14] and the 2.1% vs 0.0% rates observed by Lai et al. [15].

Postoperative pain outcomes strongly favored SILC in our cohort. At 6 hours, VAS scores were 3.8 ± 0.9 for SILC versus 4.5 ± 1.0 for CMLC (p=0.002), and at 24 hours, 2.1 ± 0.7 versus 2.8 ± 0.8 (p=0.001). Lai et al. [15] similarly reported 3.9 ± 1.0 versus 4.6 ± 1.1 at 6 hours, and 2.0 ± 0.8 versus 2.7 ± 0.9 at 24 hours. Bucher et al. [16] found a mean difference of −0.7 on the VAS at 24 hours favoring SILC.

Length of hospital stay in our series was shorter for SILC (1.6 ± 0.5 days) compared to CMLC (2.1 ± 0.6 days, p=0.0005). Marks et al. [11] observed a similar reduction (1.5 ± 0.4 vs 2.0 ± 0.5 days), and Lee et al. [17] reported median stays of 1 day for SILC versus 2 days for CMLC.

Complication rates in our study were low and statistically comparable: wound infection (4.0% vs 6.0%), bile leak (2.0% vs 0.0%), port-site hernia (2.0% vs 0.0%), and postoperative nausea/vomiting (16.0% vs 24.0%). Tsimoyiannis et al. [18] documented wound infection rates of 3.5% for SILC and 5.0% for CMLC, with bile leak occurring in 1.5% vs 0%. Pan et al. [19], in a meta-analysis of 25 randomized controlled trials, found no significant difference in major complications between the two approaches.

Cosmetic outcomes, though qualitatively assessed in our study, were consistently reported to be better with SILC in the literature. Bucher et al. [20] demonstrated a mean difference of 1.2 points on a 10-point cosmesis scale in favor of SILC, without increased morbidity — findings that align with our postoperative patient feedback.

In summary, SILC offers measurable benefits in early recovery without compromising safety but requires slightly longer operative times. These results support its use in elective, low-risk patients by experienced surgical teams, with CMLC remaining the preferred choice in more complex scenarios.

In this prospective comparative study, single-incision laparoscopic cholecystectomy (SILC) was associated with longer operative times compared to conventional multi-port laparoscopic cholecystectomy (CMLC) but demonstrated advantages in reduced early postoperative pain and shorter hospital stay. Complication rates were low and comparable between techniques. These findings suggest that, in appropriately selected elective cases and in experienced hands, SILC can provide meaningful recovery benefits without compromising safety. Wider adoption may be considered in centers with adequate surgical expertise and infrastructure.

Acknowledgement

The authors thank the surgical team and nursing staff of the Department of General Surgery, for their invaluable support during this study.

Conflicts of Interest

The authors declare no conflicts of interest.

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