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Systematic Review

Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials

[version 1; peer review: 1 approved, 1 approved with reservations]
Reno Rudiman
https://orcid.org/0000-0001-6826-6313
1, Ricarhdo Valentino Hanafi2, Alma Wijaya1
Reno Rudiman
https://orcid.org/0000-0001-6826-6313
1, Ricarhdo Valentino Hanafi2, Alma Wijaya1
PUBLISHED 06 Jul 2022
Author details Author details
OPEN PEER REVIEW
REVIEWER STATUS

Abstract

Background: Conventional multi-port laparoscopic cholecystectomy (CMLC) has become the current ‘gold standard’ technique in gallbladder disease. Single-incision laparoscopic cholecystectomy (SILC) has gained attention due to its benefits in improving patient cosmetic results and pain reduction. We aim to assess the latest evidence on the feasibility, safety and surgical outcomes of SILC and CMLC.
Methods: We conducted searches for randomized controlled trials (RCTs) in PubMed, PubMed Central (PMC), and Europe PMC between December 2011 and 2021. The latest search was conducted in January 2022. We analyzed several outcomes, including perioperative complications, estimated blood loss, operation time, conversion to open surgery, hospital stay, pain score, cosmesis, and days of return to work. Cochrane Risk of Bias (RoB) 2.0 tool was used to evaluate quality of studies. Mantel-Haenszel's formula and Inverse Variance method were conducted to synthesize results. This study was accomplished in accordance with the PRISMA guidelines.
Results: A total of 37 studies were eligible, with a total of 2,129 and 2,392 patients who underwent SILC and CMLC. Our study demonstrated a superiority of SILC for the visual analog score (VAS) at six hours post-operation [mean difference (MD) -0.58 (95% CI -1.11, -0.05), p=0.03], cosmesis one-month post-operation [standard MD 2.12 (95% CI 1.10, 3.13), p<0.0001], and cosmesis six months post-operation [standard MD 0.53 (95% CI 0.06, 0.99), p<0.0001]. Meanwhile, SILC showed a longer operation time [MD 10.45 (95% CI 6.74, 14.17), p<0.00001]. In terms of VAS at four time points (4, 8, 12, and 24 hours), perioperative complications, estimated blood loss, conversion to open surgery, hospital stay and days to return to work, SILC did not differ from CMLC.
Conclusions: SILC is a safe, feasible and favorable procedure in terms of pain reduction and cosmetic results. The option between both procedures is based on surgeon preferences.
Registration: PROSPERO (CRD42022306532; 23 February 2022).

Keywords

Cholecystectomy, laparoscopic surgery, meta-analysis, minimal invasive surgery, systematic review

Corresponding author: Reno Rudiman
Competing interests: No competing interests were disclosed.
Grant information: The author(s) declared that no grants were involved in supporting this work.
Copyright:  © 2022 Rudiman R et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Rudiman R, Hanafi RV and Wijaya A. Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials [version 1; peer review: 1 approved, 1 approved with reservations]. F1000Research 2022, 11:754 (https://doi.org/10.12688/f1000research.122102.1) First published: 06 Jul 2022, 11:754 (https://doi.org/10.12688/f1000research.122102.1) Latest published: 18 Nov 2024, 11:754 (https://doi.org/10.12688/f1000research.122102.2)

Introduction

For decades, conventional multi-port laparoscopic cholecystectomy (CMLC) has been a favored procedure in gall bladder diseases.1 This technique differs from any laparoscopic surgery, which requires advanced technology and skill. The gains in CMLC aggregate the learning curve and surgical aftermaths.2 Many adjustments and modifications are made in CMLC; fundamentally, CMLC consists of four ports. The adaptations may be a reduced port size, such as 10 mm to 5 mm or 5 mm to 2/3 mm, or reduced port numbers. These changes intend to amend patient outcomes in any aspect.3

The curiosity about single-incision laparoscopic cholecystectomy (SILC) has increased in the past years. A single incision implies when many ports are inserted at a single site (umbilicus). Many studies have demonstrated technical difficulty and increasing complications.4,5 A recent study indicated a feasible and valuable technique with superior cosmetic outcomes, pain reduction, and nil complications.6 We speculate that knowledge about SILC will improve in the following years.

Pros and cons remain disputable in many systematic reviews.7–12 We would like to update the recent randomized controlled trials (RCTs) regarding these techniques because there has not been a newer systematic review to analyze the latest amendment. The latest meta-analysis by Lyu et al.,12 determined that a limitation of their study was that only three and four ports of instruments, plus non-RCT were included; thus, our study addresses the limitations of the latest research and expects different outcomes. Our hypothesis is that SILC is superior to CMLC in all aspects. Consequently, this study aimed to assess and evaluate the latest evidence on the feasibility, safety, and surgical outcomes of SILC and CMLC.

Methods

Eligibility criteria

We conducted a systematic review and meta-analysis study from clinical trial studies. We registered this systematic review in PROSPERO (CRD42022306532) on 23 February 2022. Articles were included in this systematic review and meta-analysis if they fulfilled the Population, Intervention, Comparison, Outcomes and Study (PICOS) framework as follows:

  • • P - Population: Adults aged >18 years old with body mass index (BMI) <35 kg/m2 with uncomplicated gall bladder disease who were eligible to undergo either SILC or CMLC with the American Society of Anesthesiology (ASA) Score I-III.13

  • • I - Intervention: Patients who underwent SILC to treat their gall bladder diseases.

  • • C - Comparator: Patients who underwent CMLC as surgical treatment for gall bladder diseases.

  • • O - Outcomes: Bile duct injury (BDI), bile leakage, gallbladder perforation, wound infection, incisional hernia, total intraoperative complications, total post-operative complications, conversion to open cholecystectomy, operating time, estimated blood loss volume, length of hospital stay, cosmesis (satisfactory quantitative scores) at one month and six months post-operation, days to return to work, and post-operative pain score assessed by a visual analog score (VAS) at five-time points (4, 6, 8, 12, and 24 hours post-procedure).

  • • S - Study design: Randomized clinical trials

All studies besides original articles (correspondence, letter to editor, or review articles), observational studies (cohort or case-control designs), case series, case report studies, studies reported in a language other than English, research focusing on pregnant women and populations below the age of 18 years were excluded.

Search strategy and study selection

We conducted systematic literature searches in three databases: PubMed (RRID:SCR_004846), PubMed Central (PMC) (RRID:SCR_004166), and Europe PubMed Central (EuroPMC) (RRID:SCR_005901) from December 2011 until December 2021. The latest search was conducted in January 2022. To filter the intended studies, combined keywords were used, but were not limited to, the following: “single-incision”, “single-port”, “single access”, “conventional”, “standard”, “multi-port”, “laparoscopic cholecystectomy”. Two researchers (RR and RVH) independently screened the titles and abstracts to find the eligible articles. Additional evaluation of references from eligible studies was also conducted to search for more potential articles. Full-text articles were then assessed independently according to the inclusion and exclusion criteria. This study is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines63 and the PRISMA diagram shows the strategy we employed during our study (Figure 1).

ff0fee1c-942e-4684-adb3-47e36ad78ef5_figure1.gif

Figure 1. PRISMA flowchart.

RISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; EuroPMC, Europe PubMed Central; RCT, randomised controlled trial.

Data extraction and quality assessment

Two researchers (RR and RVH) independently conducted the data extraction process. An extraction form was developed to list information about the study, such as the study’s general information (title, authors, year of publication, study design), population characteristics, and outcomes measured. The data were then extracted through Covidence (RRID:SCR_016484). Conflicts in data abstraction were resolved by consensus and referring to the original article.

Two authors (RR and RVH) assessed the quality of each study involved in this review independently. The Cochrane Risk of Bias (RoB) 2.0 tool was used to evaluate the quality of clinical trial studies. This tool is comprised of five domains, including (1) bias arising from the randomization process; (2) bias due to deviations from intended interventions; (3) bias due to missing outcome data; (4) bias in measurement of the outcome; and (5) bias in the selection of the reported results. The final judgments of each domain were categorized as low risk, some concerns, or high risk. The summarized five domains of RoB were concluded by RR and RVH, whereas a discussion with AW resolved any discrepancies in the judgments to reach the final consensus.

Statistical analysis

Meta-analysis was done using Review Manager 5.4 (Cochrane Collaboration) and Comprehensive Meta-Analysis version 3 software. The Mantel-Haenszel formula was used to obtain the risk ratio (RR) and 95% confidence interval (CI). At the same time, the Inverse Variance method was used to obtain the mean difference (MD), standardized mean difference (SMD), and standard deviation (SD). We used the random-effects model for all outcomes of interest in this study, regardless of heterogeneity. This meta-analysis assessed heterogeneity between studies by I-squared (I2; inconsistency). The I2 statistic with a value of <25% is considered a low degree of heterogeneity, 26-50% is a moderate degree of heterogeneity, and >50% is considered a high degree of heterogeneity. Funnel plot analysis was utilized to assess the qualitative risk of publication bias, while Egger’s regression method was used to evaluate the quantitative risk of publication bias.

Results

Study selection and study characteristics

The initial search generated 222 records, in which 37 RCTs were included for qualitative synthesis (systematic review) following the screening, removing duplication, and excluding of several studies (Figure 1).14–50 These final included RCTs yielded 2,129 and 2,392 patients who underwent SILC and CMLC. All patients had uncomplicated gall bladder diseases with ASA grade I-III and were eligible to undergo both techniques. The types of surgical ports ranged from conventional instruments to specific models. Three studies were double-blind RCTs, one was a single-blind RCT, and the remaining RCTs did not elaborate on the blinding method. A total of 10 studies were excluded due to including BMI >35 kg/m2, age <18 years old, and retrospective study.51–60 The full details of data characteristics are available in Table 1.

Table 1. Data characteristics.

AuthorsYearType of port(s)Sample size, nAge, years, mean (SD)Male sex, n (%)BMI, kg/m2, mean (SD)ASA grade, mean (SD)
SILCCMLCSILCCMLC
Arezzo et al.142017Singe-port device10 mm port and two 2 mm port26327848.3 (15.8)NR26.9 (4.1)NR
Bingener et al.152016TriPort™ (Olympus)Two 10 mm and two 5 mm port555548.4 (16.2)21 (19.1%)31.7 (6.1)1.95 (0.5)
Borle et al.162014Conventional instrumentsTwo 11 mm and two 5 mm port303041.25 (13.09)17 (28.3%)23.2 (1.7)NR
Brown et al.172013SILS® port (Covidien)One 11 mm and three 5 mm port403945 (13.9)18 (22.8%)29.8 (6.0)NR
Bucher et al.182011TriPort™ (Olympus)Two 10 mm and two 5 mm port757546.12 (10.03)NR35.3 (2.5)2 (0.3)
Cao et al.192011Conventional instrumentsTwo 10 mm and one 5 mm port575161.0 (4.9)45 (41.7%)28.3 (4.7)1.85 (0.6)
Chang et al.202015SILS® port (Covidien)10 mm port (Genicon)505050.3 (12.9)39 (39%)25.5 (5.5)1.65 (0.5)
Deveci et al.212013SILS® port (Covidien)Two 10 mm and one 5 mm port505041.4 (12.1)12 (12%)28 (5.02)1.75 (0.5)
Ellatif et al.222013Conventional instrumentsTwo 10 mm and two 5 mm port12512547.3 (10.9)67 (26.8%)28.2 (5.7)1.55 (0.3)
Goel et al.232016Conventional instrumentsNR303038.5 (7.8)11 (18.3%)NRNR
Guo et al.242015Conventional instrumentsTwo 10 mm and one or two 5 mm port13841443.9 (12.1)137 (24.8%)24.9 (2.7)NR
Hajong et al.252016Conventional instrumentsTwo 10 mm and two 5 mm port3232NR12.50%NRNR
He et al.262015Conventional instrumentsOne 10 mm and two 5 mm port10010040.6 (13.3)99 (49.5%)26.1 (7.1)1.6 (0.5)
Ito et al.272019Single device (EZ ACCESS)One 12 mm and three 5 mm port585357.4 (12.5)47 (42.3%)24.5 (3.7)NR
Jorgensen et al.282014SILS® port (Covidien)One 12 mm and two 5 mm port606045.1 (5.4)NR25.7 (1.6)1.35 (0.5)
Justo-Janeiro et al.292014SILS® port (Covidien)Two 10 mm and one 5 mm port171743.4 (16.4)5 (14.7%)27.8 (3.9)1.5 (0.25)
Khorgami et al.302014Conventional instrumentsOne 10 mm and three 5 mm port303042.6 (11.8)17 (28.3%)27.3 (4.1)NR
Klein et al.312020TriPort™ or TriPort+™ (Olympus)Two 10 mm and one 5 mm port989547.2 (15.4)64 (33.1%)28.6 (6.1)1.6 (0.3)
Koirala et al.322019Conventional instrumentsTwo 10 mm and two 5 mm port10010041 (14.2)41 (20.5%)NRNR
Lai et al.332011SILS® port (Covidien)One 10 mm and three 5 mm port242753.1 (12.6)19 (37.3%)24.7 (2.9)1.5 (0.5)
Leung et al.342012NRNR364347.5 (19.2)25.70%28.5 (6.4)NR
Lirici et al.352011TriPort™ (Olympus)Two 12 mm and two 5 mm port202046.2 (13.2)12 (30%)24.8 (2.9)1.9 (0.5)
Luna et al.362013SITRACC deviceTwo 10 mm and two 5 mm ports2020NRNRNRNR
Lurje et al.372015SILS® port (Covidien)NR484846.0 (14.0)62 (64.6%)25.0 (4.0)1.5 (0.3)
Noguera et al.382013SILS® port (Covidien)One 1 mm and two 5 mm port202054.5 (7.1)7 (17.5%)29.0 (3.1)1.6 (0.5)
Partelli et al.392016Single Site Laparoscopic Access SystemTwo 10 mm and two 5 mm port302944.8 (12.9)22 (37.2%)24.2 (3.4)NR
Qu et al.402019Single portTwo 10 mm and two 5 mm port494246.4 (9.8)41 (45.1%)23.3 (2.7)NR
Rizwi et al.412014NRNR10010041.7 (8.3)84 (42%)NRNR
Saad et al.422013SILS® port (Covidien)Two 10 mm and two 5 mm port353547.0 (15.6)54 (77.1%)25.4 (2.8)1.6 (0.5)
Sasaki et al.432012SILS® port (Covidien)One 12 mm and three 5 mm port272757.4 (13.2)28 (51.8%)24.7 (3.2)NR
Solomon et al.442012SILS® port (Covidien)One 11 mm and three 5 mm port221137.4 (3.8)NR31.7 (1.7)NR
Subirana et al.452021TriPort+™ (Olympus)Two 10 mm and two 5 mm port373638.1 (10.3)9 (12.3%)26.3 (3.8)1.35 (0.3)
Sulu et al.462015SILS® port (Covidien)Two 5 mm and two 2 mm port303046.3 (9.7)21 (35%)29.4 (5.0)1.6 (0.5)
Ye et al.472015Single 5mm portNR100100NRNRNRNR
Yilmaz et al.482013SILS® port (Covidien)NR434049.7 (10.7)61 (73.4%)23.8 (3.6)2.0 (0.5)
Zhao et al.492016Single Site Laparoscopic Access SystemNR505048.1 (8.9)32 (32%)24.9 (3.8)NR
Zheng et al.502012A single Tri-port (Advanced Surgical Concept)Two 10 mm and one 5 mm port303045.2 (12.9)29 (48.3%)25.3 (3.8)NR

Risk of bias in studies

The Cochrane RoB 2.0 tool was applied to determine the quality of RCTs. A total of 33 studies were categorized as low risk of bias studies. Two studies were determined to have some concerns because the long-term follow-up results could not be fully concluded. The other two studies were evaluated for having a high risk of bias due to having a higher percentage of loss to follow-up and a high risk of false-positive results. The evaluation of RoB is summarized in Figure 2.

ff0fee1c-942e-4684-adb3-47e36ad78ef5_figure2.gif

Figure 2. The overall judgment of included studies.

Outcome effects

Bile duct injury

A total of 17 studies (n=2,114) reported the BDI outcome. Our pooled analysis showed that the SILC procedure did not differ from the CMLC procedure in terms of risk for BDI [RR 0.83 (95% CI 0.17–4.04), p=0.82, I2=0%, random-effect modeling] (Figure 3A).

ff0fee1c-942e-4684-adb3-47e36ad78ef5_figure3.gif

Figure 3. Forrest plots of SILC vs. CMLC.

(A) Bile duct injury. (B) Bile leakage. (C) Gall bladder perforation. (D) Wound infection. SILC, single-incision laparoscopic cholecystectomy; CMLC, conventional multi-port laparoscopic cholecystectomy.

Bile leakage

A total of 16 studies (n=2,363) reported on the bile leakage outcome. Our pooled analysis showed that the SILC procedure did not differ from the CMLC procedure in terms of risk for bile leakage incidence [RR 1.31 (95% CI 0.72–2.39), p=0.38, I2=0%, random-effect modelling] (Figure 3B).

Gallbladder perforation

Nine studies (n=1,874) reported on the gallbladder perforation outcome. Our pooled analysis showed that the SILC procedure did not differ from the CMLC procedure in terms of gallbladder perforation incidence [RR 0.94 (95% CI 0.71–1.26), p=0.68, I2=0%, random-effect modelling] (Figure 3C).

Wound infection

A total of 24 studies (n=2,926) reported on the wound infection outcome. Our pooled analysis showed that the SILC procedure did not change the risk of wound infection incidence when compared with the CMLC procedure [RR 1.20 (95% CI 0.72–2.03), p=0.48, I2=0%, random-effect modelling] (Figure 3D).

Incisional hernia

A total of 28 studies (n=3,788) reported on the incisional hernia outcome. Our pooled analysis showed that the SILC procedure did not change the risk of incisional hernia incidence when compared with the CMLC procedure [RR 1.43 (95% CI 0.75–2.74), p=0.28, I2=0%, random-effect modelling] (Figure 4A).

ff0fee1c-942e-4684-adb3-47e36ad78ef5_figure4.gif

Figure 4. Forrest plots of SILC vs. CMLC.

(A) Incisional hernia. (B) Total intra-operative complications. (C) Total post-operative complications. SILC, single-incision laparoscopic cholecystectomy; CMLC, conventional multi-port laparoscopic cholecystectomy.

Total intra-operative complications

A total of 26 studies (n=3,717) reported on the total intra-operative outcome. Our pooled analysis showed that the SILC procedure did not differ from the CMLC procedure in terms of the incidence of total intra-operative complications [RR 1.22 (95% CI 0.93–1.59), p=0.15, I2=0%, random-effect modelling] (Figure 4B).

Total post-operative complications

A total of 30 studies (n=3,882) reported on the total post-operative outcome. Our pooled analysis showed that the SILC procedure did not differ from the CMLC procedure in terms of the incidence of total post-operative complications [RR 1.04 (95% CI 0.93–1.59), p=0.15, I2=0%, random-effect modelling] (Figure 4C).

Estimated blood loss

A total of 12 studies (n=1,416) reported on the estimated blood loss outcome. Our pooled analysis showed that the SILC procedure did not differ from the CMLC procedure in terms of estimated blood loss volume [MD 1.29 (95% CI -0.85, 3.43), p=0.24, I2=86%, random-effect modelling] (Figure 5A).

ff0fee1c-942e-4684-adb3-47e36ad78ef5_figure5.gif

Figure 5. Forrest plots of SILC vs. CMLC.

(A) Estimated blood loss. (B) Operation time. (C) Conversion to open surgery. (D) Hospital stay. SILC, single-incision laparoscopic cholecystectomy; CMLC, conventional multi-port laparoscopic cholecystectomy.

Operation time

A total of 34 studies (n=3,972) reported on the operation time outcome. Our pooled analysis showed that the SILC procedure significantly increased the length of operation time when compared with the CMLC procedure [MD 10.45 (95% CI 6.74, 14.17), p<0.00001, I2=97%, random-effect modelling] (Figure 5B).

Conversion to open cholecystectomy

A total of 27 studies (n=3,701) reported on the conversion to open cholecystectomy outcome. Our pooled analysis showed that the SILC procedure did not differ from the CMLC procedure in terms of conversion to open cholecystectomy rate [RR 1.07 (95% CI 0.53–2.19), p=0.84, I2=0%, random-effect modelling] (Figure 5C).

Length of hospital stay

A total of 26 studies (n=3,868) reported on the length of hospital stay outcome. Our pooled analysis showed that the SILC procedure did not differ from the CMLC procedure in terms of length of hospital stay [MD -0.11 (95% CI -0.26, 0.05), p=0.18, I2=90%, random-effect modelling] (Figure 5D).

VAS at four hours post-operation

Five studies (n=537) reported on VAS at the four-hour post-operative observation. Our pooled analysis showed that the SILC procedure did not offer benefits in VAS at four hours post-operation when compared with the CMLC procedure [MD -0.70 (95% CI -1.89, 0.49), p=0.25, I2=95%, random-effect modelling] (Figure 6A).

ff0fee1c-942e-4684-adb3-47e36ad78ef5_figure6.gif

Figure 6. Forrest plots of SILC vs. CMLC.

VAS at (A) 4, (B) 6, (C) 8, (D) 12 and 24 hours post-operation. Cosmesis at (F) one month and (G) six months post-operation. (H) Days to return to work. SILC, single-incision laparoscopic cholecystectomy; CMLC, conventional multi-port laparoscopic cholecystectomy; VAS, visual analog score.

VAS at six hours post-operation

Nine studies (n=1,204) reported on VAS at the six-hour post-operative observation. Our pooled analysis showed that the SILC procedure offered benefits in reducing the VAS at six hours post-operation when compared with the CMLC procedure [MD -0.58 (95% CI -1.11, -0.05), p=0.03, I2=93%, random-effect modelling] (Figure 6B).

VAS at eight hours post-operation

Five studies (n=573) reported on VAS at the eight-hour post-operative observation. Our pooled analysis showed that the SILC procedure did not offer benefits in VAS at eight hours post-operation when compared with the CMLC procedure [MD -0.50 (95% CI -1.17, 0.17), p=0.15, I2=95%, random-effect modelling] (Figure 6C).

VAS at 12 hours post-operation

Four studies (n=459) reported on VAS at the 12-hour post-operative observation. Our pooled analysis showed that the SILC procedure did not offer benefits in VAS at 12 hours post-operation when compared with the CMLC procedure [MD -0.86 (95% CI -2.02, 0.30), p=0.15, I2=95%, random-effect modelling] (Figure 6D).

VAS at 24 hours post-operation

A total of 29 studies (n=4,096) reported on VAS at the 24-hour post-operative observation. Our pooled analysis showed that the SILC procedure did not offer benefits in VAS at 24 hours post-operation when compared with the CMLC procedure [MD -0.14 (95% CI -0.42, 0.14), p=0.32, I2=94%, random-effect modelling] (Figure 6E).

Cosmesis at one month

Five studies (n=1,196) reported on the outcome of cosmesis one-month post-operation. Our pooled analysis showed that the SILC procedure offered benefits in increasing the cosmesis score one-month post-operation when compared with the CMLC procedure [SMD 2.12 (95% CI 1.10, 3.13), p<0.0001, I2=98%, random-effect modelling] (Figure 6F).

Cosmesis at six months

Three studies (n=446) reported on the outcome of cosmesis six months post-operation. Our pooled analysis showed that the SILC procedure offered benefits in increasing the cosmesis score at six months post-operation compared with the CMLC procedure [SMD 0.53 (95% CI 0.06, 0.99), p=0.03, I2=81%, random-effect modelling] (Figure 6G).

Days to return to work

Eight studies (n=771) reported on the days to return to work outcomes. Our pooled analysis showed that the SILC procedure did not differ from the CMLC procedure in terms of the number of days it took to return to work [MD 0.00 (95% CI -1.42, 1.43), p=1.00, I2=96%, random-effect modelling] (Figure 6H).

Meta-regression

Meta-regression was performed to identify risk factors that influence the relationship between SILC procedure and statistically significant outcomes, consisting of the operation time, VAS at six hours post-operation, cosmesis score at one-month post-operation, and cosmesis score at six months post-operation. The results of the meta-regression analyses can be found as Extended data.63 Our meta-regression revealed that variability in those outcomes in patients who underwent the SILC procedure compared with the CMLC procedure was explained by known patient factors associated with predictors of abdominal surgery outcomes. From our meta-regression analysis, it was revealed that the length of operation time in patients who underwent the SILC procedure compared with the CMLC procedure was not significantly influenced by age (p=0.1133), sex (p=0.1936), BMI (p=0.4407), and ASA score (p=0.0557). In terms of VAS at six hours post-operation, a statistically significant association was present for BMI (beta coefficient: -0.1120; 95% CI: -0.2161, -0.0079; p=0.0350). However, other factors such as age (p=0.7800), sex (p=0.8660), and ASA score (p=0.0976) did not significantly affect the relationship between the SILC procedure compared with the CMLC procedure on the VAS at six hours post-operation. Meanwhile, in terms of cosmesis at one-month post-operation, a statistically significant association was also present for BMI (beta coefficient: -1.2241; 95% CI: -1.7181, -0.7302; p<0.0001). Our meta-regression also revealed that cosmesis at one-month post-operation was not significantly influenced by age (p=0.2866), and sex (p=0.9090). Lastly, for cosmesis at six months post-operation, the meta-regression analysis could not be performed as there were too many included studies in the analysis.

Publication bias

We used Funnel plot analysis for the assessment of publication bias in each outcome of interest. This analysis showed a relatively symmetrical inverted plot for all outcomes of interest in this study, indicating no publication bias.63 Furthermore, the Egger regression test results were also not statistically significant for all outcomes of interest, confirming the results from funnel plot analysis in which no sign of publication bias was found (Table 2).

Table 2. Summary of publication bias analysis.

OutcomesFunnel-plotEgger’s test
Bile duct injurySymmetricalp=0.93632
Bile leakageSymmetricalp=0.42522
Gallbladder perforationSymmetricalp=0.28977
Wound infectionSymmetricalp=0.62726
Incisional herniaSymmetricalp=0.27176
Total intra-operative complicationsSymmetricalp=0.71848
Total post-operative complicationsSymmetricalp=0.14619
Estimated blood lossSymmetricalp=0.57188
Operation timeSymmetricalp=0.82622
Conversion to open cholecystectomySymmetricalp=0.54945
Length of hospital staySymmetricalp=0.38360
VAS at four hours post-operationSymmetricalp=0.83937
VAS at six hours post-operationSymmetricalp=0.59750
VAS at six hours post-operationSymmetricalp=0.28533
VAS at 12 hours post-operationSymmetricalp=0.18789
VAS at 24 hours post-operationSymmetricalp=0.47530
Cosmesis at one-month post-operationSymmetricalp=0.08651
Cosmesis at six months post-operationSymmetricalp=0.95798
Days to return to workSymmetricalp=0.95410

Discussion

The current ‘gold standard’ for cholecystectomy is laparoscopic cholecystectomy. This well-known technique has superseded the open approach for routine cholecystectomy since the 1990s. Multiple studies have demonstrated that conventional laparoscopic (three or four ports) is feasible, safe, and favourable for cholecystectomy.61 Advancements in surgical technology are accelerating; thus, the single incision approach was introduced in 1997 to improve post-operative pain and cosmetic results. At present, SILC and CMLC are the current options for cholecystectomy with various considerations, and many RCTs showed the strengths and limitations of each technique, although the conclusion remains contentious.1

A recent systematic review by Lyu et al.,12 stated that SILC did not offer advantages over CMLC. The overall results of our study showed that SILC improved post-operative pain and cosmetic results with no higher incidence of perioperative complications, blood loss, conversion to open cholecystectomy, extended hospital stay, and days return to work compared to CMLC. On the other hand, longer operation time is still a major issue of SILC.

Perioperative complications are the current issue and remain disputable in every study. Evers et al.,7 in 2017 demonstrated that SILC was inferior to CMLC [RR 3.00 (95% CI 1.05–8.58)]. Another systematic review conducted by Hall et al.,11 further supported the inferiority of SILC regarding overall complications. Meanwhile, our study showed that biliary duct injuries, bile leakage, gall bladder perforation, wound infection, and incisional hernia did not differ between SILC and CMLC. These statements are parallel with other systematic reviews.9,13,62 Our suppositions are that the enhanced knowledge and advancement in single incision port have minimized the potential complications. Hence, SILC is considered as feasible as CMLC.

The learning curve that remains to be overcome for SILC is operation time. Our study demonstrated a longer time in SILC with a significant p-value. None of the other systematic reviews showed a quicker time in SILC than CMLC.7,9,11,13 Many aspects can hinder the operation time of SILC, including the peculiar technique, type of instruments, camera angle perspective, and instruments crossing. These issues can be overcome by surgical experience and the development of advanced instruments. Thus, the operation time may be equal in both approaches.

Post-operative pain was calculated using the VAS at four time points (4, 6, 8, 12 and 24 hours). Our study showed a significant pain reduction at pain score six hours post-operation; however, VAS at 4, 8, 12 and 24 hours did not differ in both groups. The studies were done by Hall et al.,11 and Arezzo et al.,9 stated the VAS did not differ significantly. Meanwhile, Lirici et al.,62 demonstrated an improvement in VAS after day one, although the pain score on day one did not show any differences between SILC and CMLC. On the other hand, Evers et al.,7 revealed a superior VAS outcome in the SILC group at 24 hours. The opposite outcomes were reported by Lyu et al.,,12 in which SILC remained inferior for post-operative pain reduction at 6, 8, 12 and 24 hours. The heterogeneity of VAS was influenced by many elements, including the type of anaesthetic drugs, length of incision, and psychological factors. Thus, our study reported a high degree of heterogeneity.

In terms of cosmesis, the superiority of SILC was undoubtedly observed. Our study reported better cosmetic results at both the one-month and six-month post-operative outcomes. Multiple studies have also supported our results.7,9,11,62 The advantage of having a single incision at the umbilical creates a seamless scar, increasing the patient’s satisfaction. The definition of cosmesis was varied in every study; consequently, heterogeneity was high.

Our study did not find any differences between SILC and CMLC concerning blood loss, conversion to open surgery, hospital stay, and days to return to work. Supporting studies also stated equivalent results, which SILC did not enhance the outcome of those categories.7,9,11,62

The limitations regarding this study are that we only included studies in English, a high degree of heterogeneity of several aspects, numerous RCTs with a high risk of bias, and inconsistent definitions of every outcome measured. We suggest an equal scoring for pain and cosmesis score to minimize the heterogeneity, as well as a more precise definition of perioperative complications and operation time to unify the outcome measurement. Hence, large-scale, double-blinded, well-designed RCTs are recommended.

Conclusions

SILC is a safe, feasible and favourable approach. In terms of pain reduction and cosmetic results, SILC offers promising results. Thus, SILC may be an option for cholecystectomy depending on the surgeon’s experience.

Data availability

Underlying data

All data underlying the results are available as part of the article and no additional source data are required.

Extended data

Zenodo: Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials. https://doi.org/10.5281/zenodo.6416832.63

This project contains the following extended data:

  • - ROB2_IRPG_beta_v9_Sysrev.xlsm (dataset)

  • - Supplementary Figure 1.pdf

  • - Supplementary Figure 2.pdf

  • - Supplementary Figure 3.pdf

  • - Supplementary Figure 4.pdf

  • - Supplementary Table 1.docx

  • - Search Strategy.docx

Reporting guidelines

Zenodo: PRISMA checklist for ‘Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials.’ https://doi.org/10.5281/zenodo.6416832.63

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

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Rudiman R, Hanafi RV and Wijaya A. Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials [version 1; peer review: 1 approved, 1 approved with reservations]. F1000Research 2022, 11:754 (https://doi.org/10.12688/f1000research.122102.1)
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Reviewer Report 06 Nov 2024
Yunushan Furkan Aydoğdu, Department of General Surgery, Bandırma Training and Research Hospital, Balıkesir, Turkey 
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https://doi.org/10.5256/f1000research.134047.r335341
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Subject and Objective: The study focused on the comparison of SILC and CMLC techniques. The purpose of the research is clearly defined and targets existing gaps in the literature. This draws the reader's attention.

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Aydoğdu YF. Reviewer Report For: Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials [version 1; peer review: 1 approved, 1 approved with reservations]. F1000Research 2022, 11:754 (https://doi.org/10.5256/f1000research.134047.r335341)
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    Reno Rudiman, Division of Digestive Surgery, Department of General Surgery, School of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, 40161, Indonesia
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    Dear Dr. Yunushan Furkan Aydoğdu,

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    Reno Rudiman, Division of Digestive Surgery, Department of General Surgery, School of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, 40161, Indonesia
    08 Nov 2024
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    Dear Dr. Yunushan Furkan Aydoğdu,

    Thank you for your insightful recommendations on our manuscript. Therefore, we will proceed to revise based on the details you have provided.

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Vicky Sumarki Budipramana, Department of Surgery, Premier Surabaya Hospital, Surabaya, Indonesia;  Airlangga University, Surabaya, East Java, Indonesia 
Andro Pramana Witarto, Airlangga University, Surabaya, East Java, Indonesia 
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Budipramana VS and Pramana Witarto A. Reviewer Report For: Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials [version 1; peer review: 1 approved, 1 approved with reservations]. F1000Research 2022, 11:754 (https://doi.org/10.5256/f1000research.134047.r155047)
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  1. Vicky Sumarki Budipramana, Premier Surabaya Hospital, Surabaya, Indonesia; Airlangga University, Surabaya, Indonesia
    Andro Pramana Witarto, Airlangga University, Surabaya, Indonesia
  2. Yunushan Furkan Aydoğdu, Bandırma Training and Research Hospital, Balıkesir, Turkey
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    Alongside their report, reviewers assign a status to the article:
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