Comparative Evaluation Of Post.docx

COMPARATIVE EVALUATION OF POST-OPERATIVE PAIN & COSMETIC OUTCOME BETWEEN CONVENTIONAL LAPAROSCOPIC CHOLECYSTECTOMY & SINGLE INCISION LAPAROSCOPIC CHOLECYSTECTOMY Dr. R. S. Jhobta, Dr. Ashok Kaundal, Dr. Sanjay Kumar. Department of General Surgery, IGMC Shimla.

ABSTRACT AIM: - Comparative analysis of post-operative pain and cosmetic outcome between Single Incision Laparoscopic Cholecystectomy and conventional Laparoscopic Cholecystectomy. Method: - Patients suffering from symptomatic cholelithasis were randomly subjected to Single Incision Laparoscopic Cholecystectomy (SILC) and conventional four ports Laparoscopic Cholecystectomy (cLC). Data analyzed included duration of surgery, postoperative pain and cosmetic results. For assessment of post-operative pain numeric pain scale scoring system was used and pain scoring done at four hours, twelve hours and twenty-four hours post-operatively. Cosmetic results of the surgery were assessed using validated Cosmesis and Body Image scoring system evaluated twelve weeks post-operatively. Results: - The study included fifty patients operated upon from June, 2014 to May, 2014. Twenty-five patients were subjected to SILC and rest of the twenty-five underwent cLC. Preoperative characteristics of two groups were similar and there was no significant difference between two groups based on age, sex and Body Mass Index. Mean operative time for SILC was significantly higher than cLC 40.20 ± 14.03 minutes versus 22.80 ± 5.82 minutes (pvalue < 0.0001). Post-operative pain score was higher for cLC compared to SILC at four, twelve and twenty-four hours post-operatively. The mean pain score at four hours was 4.64 ± 1.89 for SILC versus 7.72 ± 0.84 for cLC (p-value < 0.0001). While the score at twelve and twenty-four hours were 2.96 ± 1.88 and 1.80 ± 1.44 for SILC compared to 5.08 ± 1.15 and 3.80 ± 1.11 for cLC respectively. The cosmetic score for SILC was significantly better than cLC twelve weeks post-operatively 40.76 ± 2.77 versus 38.28 ± 1.97 (p-value < 0.0001). Conclusion: - Although SILC has longer operative time compared to cLC however SILC is superior to cLC compared to post-operative pain and aesthetic results of SILC is significantly better than conventional four ports LC as per our study.

1

1.) INTRODUCTION: - Diseases of

so far1, the SILS has met more favourable

the gall bladder constitute a major portion

acceptance in surgical community. Its

of digestive tract disorders. Among these,

feasibility and safety have been proved in

gall stone disease is the most common

a number of surgical procedures including

pathology requiring surgical intervention

cholecystectomy 2, 3.

for total cure. Females are three times

Conventional laparoscopic

more prone to develop gall stones than

cholecystectomy is done using four ports.

men.

With an effort to minimize the number of Scar less surgery is

ports, single-incision laparoscopic surgery

the Holy Grail of surgery and the very

(SILS) has come into practice2. SILS is a

raison d'être of minimal access surgery

rapidly

was the reduction of scars and thereby pain

complementing traditional laparoscopy in

and suffering of patients. The work of

selected fields and patients3,4. It has also

Muhe and Mouret in the late 80s, paved

been suggested as a bridge between

the way for mainstream laparoscopic

traditional laparoscopy and natural orifice

procedures and it rapidly became the

transluminal

method

(NOTES)5.

of

choice

for

many

intra-

evolving

abdominal procedures.

that

endoscopic

is

surgery

SILC is perhaps the most

Over the last 20 years,

method

conventional

common SILS procedure, used to treat

laparoscopic

patients with gall stone disease. It is being

cholecystectomy (cLC) as less invasive

considered as no-scar surgery because the

method,

incision is placed within the umbilical scar

has

replaced

cholecystectomy in

open of

that is not visible7,8 . SILC has also shown

gallstone

to have reduced postoperative pain as

disease. In recent years, a search for even

compared to four-port cholecystectomy in

more minimally invasive approaches has

a recent randomized study, although the

led to innovative techniques of single

sample size was small.

patients

with

the treatment

symptomatic

incision laparoscopic surgery (SILS) and

Single

natural orifice transluminal endoscopic surgery

(NOTES).

While

cholecystectomy

substantial

challenges

and

scarcity

(SILC)

laparoscopic has

been

projected to have better cosmetic outcome

drawbacks of NOTES technique including technical

incision

compared with conventional laparoscopic

of

cholecystectomy (cLC). However, there

instrumentation, have limited its adoption

are scarce data that have objectively 2

compared the patient's perception of

conventional

cosmetic outcome after SILC and CLC.9

Unlike

laparoscopic

instruments.

multiport

laparoscpic

the

been

cholecystectomy (LC), a standardized

devised and described in literature for

technique and detailed description of the

single

operative steps of SILC is lacking in the

Various

techniques

incision

cholecystectomy.

has

laparoscopic Many

literature.

special

instruments6 and ports10,11 are available now

for

SILC.

But

cost

of

The objective of this study is to

these

evaluate post-operative pain and cosmetic

instruments is very high making SILC to

outcome

between

conventional

be a costly operation. Keeping this fact in

laparoscopic cholecystectomy and SILC.

mind we had performed SILC with only

2). AIMS AND OBJECTIVES:1. To assess the post-operative pain in

2. To evaluate the cosmetic outcome in

patients undergoing conventional

patients

laparoscopic cholecystectomy and

cholecystectomy

single

laparoscopic cholecystectomy.

incision

laparoscopic

cholecystectomy.

3

of

conventional and

laparoscopic

single

incision

2. MATERIAL The

present

AND METHODS:prospective

study

investigations

were

recorded

as

per

included ultrasonographically proved 50

proforma attached (annexure 1). Consent of

patients of symptomatic cholelithiasis posted

all these patients was taken as per consent

for elective cholecystectomy. These patients

form (annexure 2). All the patients were

were admitted in Surgical Wards of Indira

subjected

Gandhi Medical College, Shimla. SILC was

antibiotics, perioperative analgesics and

performed on 25 (50% of patients) and

intravenous fluids. SILC was done by infra-

conventional laparoscopic cholecystectomy

umbilical incision and conventional LC

conducted in rest of 25 (50%) patients. The

done by four Trocars Technique.

patients were selected randomly. Relevant

.

history,

clinical

examination

to

same

general

anesthesia,

and

Patients having following conditions

5

were excluded from the study.

Patients

on

Contraceptive

Oral Pills

or

pregnant. 1. Acute

Cholecystitis

6

/Pancreatitis. 2

Choledocholithiasis

3

Jaundice

requiring

intra-

operative blood transfusion. 7

/Hypoproteinemia

Conversion of conventional LC to OC.

/Malignancy 4

Patients

8

History of Allergy , taking

Intra

operative

injury

adjacent organs/structures.

Steroids and Chemotherapy

9

4

Cholecystoenteric fistulae.

to

assistant’s rachet ( with lock ) grasper by

CONVENTIONAL LAPAROSCOPIC CHOLECYSTECTOMY:-

5mm stab incisions.

The laparoscopic

With the laparoscope through

procedure was carried out in the standard

the umbilical port, a grasper was introduced

fashion after cleaning & draping of the

through the lateral 5mm trocar to grasp the

abdomen,

any

fundus of the gall bladder. The assistant

technique.

applied traction upward and backward, to

Pneumoperitoneum was established by close

establish optimal exposure. The orientation

technique in which CO2 was insufflated into

of the laparoscope was kept parallel to that

peritoneal cavity through Veress needle &

of the cystic duct with fundus elevated,

intraperitoneal pressure will be kept at

whereas the instruments placed through the

12mm Hg. There after 10 mm umbilical port

other three ports entered the abdomen at

was put in and through which laparoscope

right angles to this plane. Cystic duct and

inserted into abdomen and the patient placed

cystic artery were identified, doubly clipped

in reverse trendelenburg position of 30

and cut. Gall bladder was be separated from

degree while rotating the table to left by 15

bed with the help of cautery and extracted

degree. The second trocar was placed under

out through 10mm epigastric port.

with

modifications

of

4

ports

without

American

direct laparoscopic vision in the midline between the xiphoid and the umbilicus through a 10mm incision, after ensuring its entry into abdominal cavity right to the falciform ligament. Also the trocar was

SINGLE INCISION LAPAROSCOPIC

directed towards the gall bladder, so that no

CHOLECYSTECTOMY:-

reposition will be required throughout the Equipment

procedure.

We Two 5mm ports were placed, one in

used

and

Instruments:

conventional

laparoscopic

instruments and equipment for performing

the subcostal region, in the midclavicular

SILC. We used 5mm (30°) 51mm long

line for atraumatic grasper for the left hand

laparoscope for performing the procedure.

of the surgeon, and another at the level of

Use of a long laparoscope helped moving

umbilicus along anterior axillary line for the 5

the hand of the camera person about 8-10

Placement of ports: We gave

inches away from the abdominal wall, thus

infraumbilical curved (smiling) incision.

reducing the crowding. A sharp image that

The umbilicus was everted and held with

allows clear distinction between tissue

two-toothed forceps in a cephalic and caudal

planes and tissue textures is essential for

position prior to making an incision of

safe dissection and this principle was kept in

length 2-2.5 cm. This was deepened through

mind while performing SILC. For the

the fat and the flaps were undermined to

purpose of introduction of instruments one

expose the fascia over a distance of 2-2.5

10mm and one 5mm trocar (Covidien Versa

cm. A Veress needle was then introduced

Port 5mm Bladeless Trocar with Fixation

through this incision and after confirmation

Canula) were used.

of

Position

of

the

patient,

team,

its

intraperitoneal

position;

CO2 pneumoperitoneum was induced and

and

maintained at 12 mm Hg. We used two ports

equipment:

one five mm port for camera and another ten

The patient was positioned supine on

mm

the operating table with the legs split apart.

working

port

through

which

laparoscopic needle holder, left curve and

Both arms of the patient placed on arm

extractor were introduced at the various

boards at an angle less than 90º to the

steps of SILC procedure. The camera port

torso. The operating surgeon stood on the

was at left margin (patient’s) of the 10mm

left side of the patient, with the assistant

port.

opposite to him during the placement of the

Placement of traction sutures:

first port. For rest of the procedure, the surgeon stood between the legs and the

This was the key step of our SILC

camera person to his right (near the left leg

technique. At

of the patient). The monitor trolley was

procedure, a grasper or a dissector was used

placed above the patient's right arm. The

to move the omentum away from the right

diathermy pedal placed near the surgeon's

upper quadrant so as to obtain a view of the

left foot and all tubes and cables were fixed

fundus of the gallbladder. Flimsy omental

such that they did not interfere with the

adhesions, if present, were teased off at this

camera person.

stage. We used a strand of No. 1 or 1.0

the

beginning

of

the

vicryl on a 60-mm straight needle for placing the traction sutures. The needle was 6

introduced laterally through one of the

cystic duct were skeletonised - the endpoint

intercostal spaces above the level of the

of this dissection was obtaining a "critical

costal margin on right side. A laparoscopic

view".

needle holder brought the needle into the

Control of the cystic artery:

peritoneal cavity. The needle was then be The cystic artery was identified

taken through the fundus of gall bladder and doubly

driven out through the same intercostal

clipped

and

divided

as

in

conventional laparoscopic cholecystectomy.

space. The suture was then pulled out

Control of the cystic duct:

leaving two ends of 5-6 cm. A haemostat applied to both ends of suture close to the

The cystic duct was then identified

skin, resulting in elevation of the gallbladder

doubly clipped and divided.

fundus. Another traction suture was taken in

Dissection of the gallbladder:

which the needle was introduced from the epigastric

region

just

below

Alternating

the

medial

and

lateral

xiphisternum .This needle was then passed

rotation of the gallbladder using the ends of

through the Hartmann’s pouch with the help

the suture placed on Hartmann's pouch was

of needle holder and then a knot was taken

done to dissect the gallbladder from the liver

at Hartmann’s pouch, the other end of suture

bed using a diathermy hook. Prior to the

brought out through subcostal parietal wall

final

at anterior axillary line. This mechanism

meticulous haemostasis in the liver bed was

was crux of the puppeteer technique used

ensured and the subhepatic space was

during dissection of callot’s triangle. Both

lavaged

ends were held with hemostats.

Specimen extraction:

detachment

with

of

saline

the

if

gallbladder,

required.

Gall bladder was then be held at

Dissection of the Calot's Triangle:

neck with the grasper and extracted through The

dissection

was

started

at

the umbilical 10 mm port.

posterior peritoneum to free the Hartmann’s pouch and cystic duct. This was followed by further dissection of the anterior and

Closure of the incision:

posterior peritoneal leaves overlying the

Careful closure of the fascial incision

Calot's triangle with the help of a right

was done to prevent formation of port-site

angled dissector. The cystic artery and the 7

hernia. The edges of the fascial incision

Evaluation of Cosmetic Outcome:

were identified, grasped and elevated using

The

cosmetic

outcome

evaluation

fine Kelly’s haemostat. Rectus sheath was

between

closed using vicryl no.1 suture. The fascia

cholecystectomy and SILC group was done

and the skin were infiltrated with a local

using Body Image Questionnaire consisting

anaesthetic and the skin closed using

of body image score (items 1 to 5) and

Monocryl 3-0 subcuticular sutures.

cosmetic score (items 6 to 8)

conventional

laparoscopic

filled 12

weeks following surgery.

Body Image Questionnaire:Evaluation of Post-operative Pain:

1. Are you less satisfied with your body

Post-operative pain among the study

since the operation?

groups was assessed using numeric pain

□ 1 = yes, extremely

scale scoring system. Operationally the scale

□ 2 = quite a bit

is usually a horizontal line, with scaling

□ 3 = a little bit

done from 0 to 10 as illustrated in figure

□ 4 = no, not at all

below. The patient is asked to score his/her pain on scale from 0 to 10; a higher score

2. Do you think the operation has damaged

signifies severer pain perceived by patient.

your body?

Both set of patients were prescribed standard

□ 1 = yes, extremely

analgesics post-operatively. The pain

□ 2 = quite a bit

scoring was done at four hours, twelve hours

□ 3 = a little bit

and twenty four hours following surgery.

□ 4 = no, not at all

3. Do you fell less attractive as a result of your operation? □ 1 = yes, extremely □ 2 = quite a bit □ 3 = a little bit □ 4 = no, not at all

8

□ 2 = quite revolting 4. Do you feel less feminine/masculine as a

□ 3 = a bit revolting

result of your operation?

□ 4 = not revolting/not beautiful

□ 1 = yes, extremely

□ 5 = a bit beautiful

□ 2 = quite a bit

□ 6 = quite beautiful

□ 3 = a little bit

□ 7 = very beautiful

□ 4 = no, not at all

5. Is it difficult to look at yourself naked?

8. Could you score your own scar(s) on a scale from 1 to 10?

□ 1 = yes, extremely □ 2 = quite a bit □ 3 = a little bit

(1 = ugliest scar imaginable, 10 = almost scarless)

□ 4 = no, not at all

6. On a scale from 1 to 7, how satisfied are you with your scar(s)?

…………………………………………………………………

□ 1 = very unsatisfied □ 2 = quite unsatisfied □ 3 = a bit unsatisfied □ 4 = not unsatisfied/not satisfied

Body Image Score:-

□ 5 = a bit satisfied □ 6 = quite satisfied Cosmetic Score:-

□ 7 = very satisfied

7. On a scale from 1 to 7, how would you describe your scar(s)? □ 1 = revolting

The results were noted as per proforma

by Chi Square test and t test. All statistical

attached, statistically evaluated and analyzed

analysis were conducted by using SPSS

9

statistical software. The level of significance

set

at

0.05.

3). RESULTS:The

present

study

was

GROUP:-

conducted in the Department of Surgery,

The age of patients in the present study

IGMC, Shimla over a period of 1 year from

ranged from 15 to 65 years. In SILC group,

1st July, 2013 to 30th June, 2014 on 50

the age ranged from 15 to 65 years and the

patients who were admitted for elective cholecystectomy.

These

patients

mean age was 35.92±14.248 (standard

were

deviation) years, whereas in cLC group, the

alternatively divided into two groups of 25

age ranged from 21 to 63 years and the

patients each. Group ‘A’ included patients in

mean age was 37.76±11.377 (standard

whom SILC was done and Group ‘B’

deviation) years. Patients were grouped as:

included patients who underwent cLC.

below 30 years, 30-45 years and more than

Detailed history was taken, thorough clinical

45 years. In SILC group majority of patients

examination was done and appropriate

were 30-45 year group accounting for 40%

investigations were carried out in each case

of

which was recorded in the proforma

patients

laparoscopic

attached. The following observations were

while

in

conventional

cholecystectomy

group

majority of patients fall in below 30 years

made:

group accounting for 44% of patients. The youngest patient in SILC group was 15years of age, whereas in cLC group, youngest

1:- AGE DISTRIBUTION IN SINGLE

patient was of 21 years (see master charts).

INCISION AND CONVENTIONAL

The p value for age of patients between

LAPAROSCOPIC CHOLECYSTECTOMY

SILC and cLC groups was 0.616. (Table

Group

N

Mean

Std. Deviation

Std. Error Mean

SILC

25

35.92

14.248

2.850

cLC

25

37.76

11.377

2.275

1a,1b and figure 1a,1b ) .

Table no 1a :- GROUP STATISTICS (AGE)

10

p-value = 0.616 ( p > 0.05 insignificant ) FIGURE1b:-

FIGURE 1a:45 40 No. of patients (n=25) 35 %age

30 25

No. of patients (n=25)

20

%age

15 10 5 0 <30

30-45

>45

2:- SEX DISTRIBUTION:Table no 1b:- Age Distribution Out of 50 patients, 44 patients (88%) Age (years) <30 30-45 >45

SILC No. of patients (n=25) 8 10 7

Clc %age No. of patients (n=25) 32 11 40 8 28 6

were female and 6 patients (12%) were

%age

male. In the SILC group 21 patients (84%) were female and only 4 patients (16%) were

44 32 24

male, whereas in the cLC 23 patients (92%) were females and 2 patients (8%) were females. (Table 2, Figure 2) 11

showing that BMI of the two study group is not a confounding factor.

Table no 2 :- Sex Distribution SILC (n=25) %age 4 16

Sex Male Female

21

84

cLC (n=25) %age 8 2 23 92

Table no 3:- BASAL METABOLIC INDEX (BMI):-

p value= 0.37 ( p >0.05- insignificant )

SILC c LC No. of %age No. of %age BMI(Kg/m2) patients patients (n=25) (n=25) <20 2 8 0 0 20-23 7 28 3 12 23-26 1 4 6 24 26-29 7 28 8 32 >29 8 32 8 32 MEAN 26.308 27.448

FIGURE 2:100 90 80 70 60 50

Male

40

Female

30 20

p value= 0.321 ( p >0.05- insignificant)

10 0 (n=25)

%age

(n=25)

%age

Figure: - 3 35

30

3:-BASAL METABOLIC INDEX (BMI):-

No. of patients 25 %age

The BMI in my study groups ranged

20

from 19.2 to 34.5 kg/m2. Mean BMI of

No. of patients 15

patients was 26.308 and 27.448 in the SILC %age

and

cLC

groups

respectively.

10

For

standardisation patients were sub grouped

5

into five categories and compared (Table 3, 0

figure 3). P value for the comparison is

<20

0.321 which is statistically insignificant

12

20-23

23-26

26-29

>29

comparison is 0.001 which depicts that Time (in minut es)

SILC GROUP

cLC GROUP

No. of patient s

No. of patients

%Ag e

significantly more time is required to complete SILC compared to cLC.

%Age

(Table 4 & Figure 4)

(n =25)

(n =25) <20

0

0

5

20

20-39

11

44

20

80

40-59

11

44

0

0

>60

3

12

0

0

MEA N

40.20

Table 4:- COMPARISON OF DURATION OF SURGERY (DOS):-

p-value = <.001 (p <0.05- significant).

22.80

FIGURE 4 :80 70 No. of patients 60

4:- COMPARISON OF DURATION OF SURGERY (DOS):-

50

%Age

40

No. of patients

30

Time taken for completing conventional

%Age 20

laparoscopic cholecystectomy varied from 10

fifteen minutes to thirty minutes while that

0 <20

in SILC group was from twenty five minutes

20-39

40-59

>60

to ninety minutes. The time elapsed during the surgery were divided into four intervals for comparison viz :- less than 20 minutes, 5: COMPARISON OF PAIN:-

20-39 minutes, 40-59 minutes and more than

Pain experienced by patients following

60 minutes. The mean time taken for

surgery is compared between two groups

conventional lap cholecystectomy was 22.80

using numeric pain rating scale. Patients

minutes while that for SILC was as high as 40.20

minutes.

The

p-value

for

were asked to score the pain experience by

the

them on scale of 0 to 10, four hours, twelve 13

hours and twenty four hours post-surgery, a higher

score

signifies

greater

were

given

standard

n=25

%age

n=25

%age

≤3

11

44

0

0

4-6

10

40

2

8

≥7

4

16

23

92

pain

experienced by patient. Both group of patient

Score

NSAIDs

(Diclofenac) post-operatively.

Mean

7.72 ±

4.64 ± 1.89 0.843

5.1: PAIN COMPARISON AFTER FOUR HOURS:-

p-value = 0.0001( p-value < 0.05; signifiacant.)

In SILC group numeric pain score four hours after surgery ranged from 3 to 9 while that for cLC group ranged from 6 to 9. For

Figure 5.1:

comparison the pain score is sub-grouped into three categories viz: score less than or

100

equal to 3, score between 4-6 and score

90 80

equal to or more than 7. Mean pain score for

70

the SILC group is 4.64 ± 1.89 while that for

n=25

60 %age

50

the cLC group is 7.72 ± 0.843. p-value for

40

the comparison is 0.0001 which depicts that

n=25

30 %age

20

there is significant difference in the pain

10 0

between the groups. Clearly the pain

≤ 3.0

4.0-6.0

≥ 7.0

experienced by the SILC group is significantly lower than the cLC group

5.2: PAIN COMPARISON AFTER 12 HOURS:-

(Figure 5.1 & Table 5.1).

The numeric pain score following 12 hours of surgery ranged from 1 to 9 in SILC group Table 5.1:-

while that form cLC group ranged from 3 to SILC

7. The pain scoring is sub-grouped into three

Clc

categories. Mean score for SILC group is

14

2.96 ± 1.881 while that for cLC group is

Figure 5.2:-

5.08 ± 1.152. p-value for the comparison is 80

0.0001 that signifies that there is significantly lower pain felt by patients

70

undergoing SILC twelve hours after surgery

60

(Figure 5.2 & Table 5.2).

50

n=25

%age

n=25 40 %age 30

20

10

0

Table 5.2:-

≤ 3.0

SILC Score

n=25

%age

4.0-6.0

≥ 7.0

cLC n=25

%age

≤3

20

80

2

8

4-6

3

12

20

80

5.3: PAIN COMPARISON AFTER 24 HOURS:The numeric pain score following 24 hours of surgery ranged from 1 to 7 in SILC group

≥7

2

8

3

12

while that form cLC group ranged from 2 to 7. The pain scoring is sub-grouped into three

2.96 ± 5.08 ± 1.881 1.152 p-value = 0.0001 (value < 0.05 ; significant) Mean

categories same as pain scoring comparison at 4 and 12 hours. Mean score for SILC group is 1.80 ± 1.443 while that for cLC group is 3.80 ± 1.118. p-value for the comparison is 0.0001 that signifies that there is significantly lower pain experienced by patients undergoing SILC vis-à-vis cLC, twenty four hours after surgery (Figure 5.3 & Table 5.3).

15

6: COSMETIC COMPARISON BETWEEN SILC & cLC:Table 5.3:The cosmetic end point between SILC & SILC

cLC

cLC is compared using a validated Cosmesis and Body Image Score that was previously

Score

n=25

%age

n=25

%age

≤3

23

92

9

36

4-6

1

4

15

60

used in surgery for Crohn’s disease and donor nephrectomy. The score is calculated on an eight item multiple choice type questionnaire ranging between 8 to 48 points. On follow up patients were asked to

≥7

1

4

1

4

fill the questionnaire following twelve weeks of surgery. For comparison between

1.80 ± 3.80 ± 1.443 1.118 p-value = 0.0001 (value < 0.05 ; significant) Mean

two groups the body image score is subgrouped into five categories. The body image score for SILC group ranged from 30 to 44 with mean score of 40.76 ± 2.773 while that for cLC group ranged from 33 to

Figure: 5.3:-

42 with mean score of 38.28 ± 1.969. pvalue for the comparison stands 0.001 which

100 90 80

shows that patients undergoing SILC had

n=25

better cosmetic perception of their body

70 %age

60

image compared to cLC group (Table 6 &

50

Figure 6).

n=25 40 30

%age

20 10 0 ≤ 3.0

4.0-6.0

≥7

16

Table: 6 Cosmesis and body image score

Figure: 6 SILC N=25

%age

n=25

cLC

100

%age

90 80 n=25

0

8-16 17-24 25-32 33-40

0 1 9

0

0

0

0

4

0

36

24

0

70

0 0

60

%age

50

n=25

40

%age

30

96

20

41-48

15

60

Mean

40.76 ± 2.773

1

4

10 0

38.28 ± 1.969

8.0-16

17-24

25-32

33-40

41-48

p-value = 0.0001 (value < 0.05 ; significant)

4). DISCUSSION:-

Laparoscopic cholecystectomy (three or four

step toward these objectives, because it

trocars) is known to be a gold standard for

cannot be overstated that every incision and

cholecystectomy63,64.

trocar placement poses a risk of bleeding,

As

a

result

of

66,67.

development of new surgical technique and

organ damage and incisional hernia.

highly sophisticated technologies, surgical

SILC has attracted wide attention because of

approach to gallbladder has tendency to

its potential cosmetic results. It may even be

become less invasive by reducing number

possible for this approach to become a gold

and size of operative ports and instruments

standard for cholecystectomy. However,

63,65,66

there is still a long way to go before this

; with intention of less postoperative

pain, shorter hospitalization time and better

approach

cosmetic

Single-incision

standardization, safety, and the cosmetic

laparoscopic (SILC) cholecystecomy is a

results of SILC require validation. Although

results.

17

is

a

gold

standard,

as

recent reports have focused on comparisons

2. SEX DISTRIBUTION:-

between SILC and multi-port LC, the safety,

In the present study 88% of the

better cosmetic results and faster recovery

total patients were females and 12 % were

following SILC have been agreed, however,

males (Table 2, Figure 2). There was 4 male

SILC has not been standardized and there is

(16%) and 21 females (84%) in the SILC

much technical variation.

and 2 males (8%) and 23 females (92%) in

We compared post-operative pain

the cLC group. The study of H. Rivas et al60

and cosmetic outcome between SILC and

in which 80 women (85%) and 15 men

cLC by randomly subjecting 25 patients to

(15%) were included in SILC group and

SILC and 25 patients to cLC. Both group of

female to male ratio was 16:3.

patients were given NSAIDs (Diclofenac) 3. BASAL METABOLIC INDEX (BMI):-

post-operatively as and when required. Patients were asked to score their pain

The BMI ranged from 19.2 to

perception at 4, 12 and 24 hour post-

35.2 kg/m2. Mean was 26.308 in the SILC

operatively based on numeric pain scale. In

and 27.448 in the cLC group respectively.

order

a

The p value for the comparison is 0.321

questionnaire is adopted form cosmesis and

which was statistically insignificant. (Table

body image score earlier used in surgery for

3, Figure 3).

to

compare

cosmetic

results

crohn’s disease and donor’s nephrectomy.

The BMI in the study of Asakuma et al70 was 22 ± 2kg/m2 in both SILC and 4 port LC group.

1. AGE DISTRIBUTION IN SINGLE INCISION AND 4PORT LAPAROSCOPIC CHOLECYSTECTOMY GROUP:-

4. COMPARISON OF DURATION OF

The age of patients included in

SILC were operated in time interval 20-39

the study ranged from 15 years to 64 years.

minutes while same numbers of patients

The mean age was 35.92 years in the SILC

were operated in time interval 40-59 minutes

and

group

on the other hand 20 (80%) patients

statistically

undergoing cLC were operated in time

37.76

years

respectively,which

in is

cLC

SURGERY (DOS):11 (44%) patients undergoing

interval 20-39 minutes. Mean time required

insignificant(p value=0.616).

18

for SILC is 40.2 minutes while that required

surgery. Mean score for SILC group was

for cLC is 22.8 minutes. p-value for the

2.96 while that for cLC group was 5.08. p-

comparison is 0.001 which shows that there

value for the comparison stands < 0.0001

is significantly more time required in

which signifies that the patients undergoing

completing SILC compared to cLC.

SILC had considerably less pain compared to their counterparts in cLC group twelve hours following surgery.

5.

PAIN

COMPARISON

AFTER

4

HOURS:-

7. 11 (44%) patients in SILC

PAIN

Twenty four hours following

had score between 4 to 6 while only 4 (16%)

surgery

patients had score ≥ 7. On the other hand

patients

23(92%)

score from 4 to 6. Mean score for SILC

majority of patient 23 (92%) had score ≥ 7

group was 1.80 while that for cLC group

four hours after surgery. Mean score for

was 2.80. p-value for the comparison stands

SILC group was 4.64 while that for cLC

< 0.0001 which signifies that the patients

group was 7.72. p-value for the comparison

undergoing

stands < 0.0001 which depicts that there is

SILC

had

experienced

substantially less pain compared to those in

experienced by

cLC group twenty four hours following

patients undergoing SILC compared to cLC

surgery.

four hours following surgery.

COMPARISON

of

cLC group majority of patients 15(60%) had

only 2 (8%) had score from 4-6 while

PAIN

majority

undergoing SILC had score ≤ 3 while in

none patient in the cLC group had score ≤ 3,

6.

AFTER

TWENTY FOUR HOURS:-

group had pain score ≤ 3, 10 (40%) patients

significantly low pain

COMPARISON

8. COSMETIC SCORE COMPARISON:-

AFTER

TWELVE HOURS:-

Cosmesis and body image score

Majority of patients 20(80%)

was evaluated following 12 weeks after

undergoing SILC had score ≤ 3 while in

surgery. Majority of patients 15(60%) in

cLC group majority of patients 20(80%) had

SILC group had score in range 41 to 48 on

score between 4 to 6, twelve hours after

the other hand majority of patients 24(96%) in cLC group had score in range 33 to 40. 19

Mean score in for SILC patients was 40.76

their body image significantly better than

while that for cLC group was 38.28. p-value

those patients undergoing cLC.

for the comparison is < 0.0001 which shows that patients undergoing SILC perceived

CONCLUSION:SILS

is

a

of

SILC has steeper learning curve compared

laparoscopic

to cLC which accounts for more operative

cholecystectomy. The main advantage of

time required in SILC but after adequate

SILC over cLC comes in terms of less post-

experience the operative time can also be

operative pain and better cosmetic results.

reduced

conventional

promising four

ports

alternative

substantially.

Although this fact cannot be ignored that

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