Is single port laparoscopic cholecystectomy superior to standard cholecystectomy in post-operative pain?

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: is single port laparoscopic cholecystectomy superior to standard cholecystectomy in post-operative pain? Using the reported search, 8083 papers were found. 8 studies were deemed to be suitable to answer the question. The outcomes assessed were post-operative pain differ in single or standard laparoscopic cholecystectomy, all study used VAS (visual analogue scale). The evidence showed no difference in post-operative pain for patients went for single laparoscopic in compared with standard laparoscopic cholecystectomy.


Introduction
A Best Evidence Topic was constructed based on a structured protocol. This is described by the International Journal of Surgery.

Clinical scenario
As general surgeon concerning regarding post-operative pain for patients going to laparoscopic cholecystectomy, should we go with singe port rather than standard lap chole with advance of surgical technique?

Three-part question
In (a patient undergoing a cholecystectomy) is (single port laparoscopic cholecystectomy) superior to (standard laparoscopic cholecystectomy in post op pain)?

Search strategy
A. Medline using the PubMed interface: The results were limited to English articles and human studies.

Search outcome
A total of 8083 papers were found using OVID and 39 using the PubMed interface. A total of 8044 papers were identified after we removed duplicates. Out of these 8044 papers were excluded because they were irrelevant based on titles and abstracts. 8036 full-text articles were screened and assessed for eligibility. From these, 8 papers were identified that provided the best evidence to answer the question eligible articles were defined as those articles that compared the post-operative pain among patients who underwent single port laparoscopic cholecystectomy or standard laparoscopic cholecystectomy techniques, please refer to fig. 1.

Result
(please refer to the Table 1).

Discussion
Phillips et al. conducted a small randomized controlled trial multicenter, single-blind in 2011 they included 197 patients who underwent laparoscopic cholecystectomy. (117) 59.3% of the laparoscopic cholecystectomy were single incision and 40.6% (80) were multiple. The author concluded that single incision laparoscopic cholecystectomy is associated with increased early postoperative pain and was shown to be an independent variable in worst and average pain scores, (6.3-4.8) (worst-average pain) (P = 0.914-0.350) in single incision group compared to (6.2-4.5) (worst-average pain) (P = 0.914-0.350) in 4 ports laparoscopic cholecystectomy group [1].
In contrast, Wong et al., in 2012, conducted a small sample size, From August 2009 to July 2010, 20 consecutives patients who underwent SILC (SILC group) were compared with a prospective cohort of 20 patients who underwent conventional 4-port laparoscopic cholecystectomy (LC group) during the same period. The author concluded that single incision laparoscopic cholecystectomy resulted in significantly less postoperative pain than conventional laparoscopic cholecystectomy (P < 0.01) (2.9 ± 1.6) (4.8 ± 1.5) [2].
Furthermore, pan et al., in 2013 reached single incision laparoscopic cholecystectomy was superior in postoperative pain after they conducted a Single center, prospective randomized control trial which included 102 who randomized to single incision laparoscopic cholecystectomy (n = 49) 48% and triple port laparoscopic cholecystectomy (n = 53) 51.9%. The author noticed postoperative pain in single incision group was (2.0 ± 1.5) and triple ports (3.5 ± 1.6) with P-value 0.0000) [3].
Nevertheless, despite these contradicting findings, another four randomized control trials and one cohort study showed no statically significant difference in post-operative pain between single post laparoscopic cholecystectomy and standard laparoscopic cholecystectomy.
Those are the study which were conducted by Bingener et al. [4] In 2015, which was a randomized controlled trial that included 110 patients who had symptomatic cholelithiasis underwent laparoscopic cholecystectomy, large Multicentric randomized controlled trial in 2016 by Arezzo et al. [5] which included 600 patients who underwent laparoscopic cholecystectomy, on 2017 Tyagi et al. did Single center, randomized control trial that included 75 patients who had symptomatic cholelithiasis underwent laparoscopic cholecystectomy [6], and also casaccia et al., 2019 [7] did single center small cohort study that included 40 patients who had symptomatic cholelithiasis underwent laparoscopic cholecystectomy recently in 2020 klein et al. [8]. Performed a single center retrospective randomized controlled study including 193 patients who underwent laparoscopic cholecystectomy, our message from this review single port laparoscopic cholecystectomy comparing to standard multiple port laparoscopic cholecystectomy no difference in post-operative pain.

Clinical bottom line
In minimal invasive surgery especially in laparoscopic cholecystectomy single port may differ in hospital stay and cosmesis but not for post-operative pain so our advice if your main concern is post-operative pain evidence not supporting any technique over other.

Ethical approval
Not applicable.

Sources of funding
None.

Author contribution
TA: conducted the literature search and wrote the paper. SA: assisted in writing the paper. RI: assisted in the literature search, editing and Writing the paper.

Declaration of competing interest
None. Difference in two groups in term of pain post laparoscopic cholecystectomy.
In their study, according to visual analogue scale evaluation, the pain profile was similar but SPLC group was associated with more analgesic's requirement.
Single center, small sample size, disadvantage of this study were short period and small sample size.