Single incision versus conventional laparoscopic cholecystectomy outcomes: a meta-analysis of randomized controlled trials

Abstract

Background: Previous meta-analyses that compared the outcome of SILC and CLC have not presented consistent conclusions. This meta-analysis was performed after adding many recent RCTs, to clarify this issue.

Methods: Relevant articles published in English were identified by searching PubMed, Embase, Web of Knowledge, and the Cochrane Controlled Trial Register from January 1997 to February 2013. Reference lists of the retrieved articles were reviewed to identify additional articles. Primary outcomes (postoperative pain scores, cosmetic score, and length of incision) and secondary outcomes (operating time, blood loss, conversion rates, postoperative complications, postoperative hospital stay, time to initial oral intake, and time to resume work) were pooled. Quantitative variables were calculated using the weighted mean difference (WMD), and qualitative variables were pooled using odds ratios (OR).

Results: 25 appropriate RCTs were identified from 2128 published articles. 1841 patients were treated, 944 with SILC and 897 with CLC. SILC was superior to CLC in cosmetic score (WMD = 1.155, P<0.001), shorter length of incision (WMD = -3.285, P = 0.029), and postoperative pain within 12 h (VAS in 3-4 h, WMD = -0.704, P = 0.026; VAS in 6-8 h, WMD = -0.613, P = 0.010). CLC was superior to SILC in operating time (OT) (WMD = 13.613, P<0.001) and need of additional instruments (OR = 7.448, P<0.001). Other secondary outcomes were similar.

Conclusions: SILC offered a better cosmetic result and less postoperative pain for patients with uncomplicated cholelithiasis or polypoid lesions of the gallbladder. However, SILC was associated with a longer OT and required additional instruments.

Figure 1. PRISMA flow diagram of the systematic article selection process.

Figure 2. Forest plots for primary outcomes included postoperative pain scores from four time points(A) cosmetic score (B) and length of incision (C).

CI: confidence interval; WMD: weighted mean difference. Random effects models based on the DerSimonian & Laird methods were used as heterogeneity existed in all primary outcomes.

Figure 3. Forest plots for intraoperative outcomes included operating time

(A) blood loss (B) conversion rate (C). CI: confidence interval; WMD: weighted mean difference; OR: odds ratio. A fixed effect model was used as no statistical heterogeneity across conversion rate (C) was observed. Random effects models were used as heterogeneity existed in operating time (A) and blood loss (B).

Figure 4. Forest plots for postoperative complications included wound complications, incisional hernia, bile leak, retained stones, bile duct injury and bleeding.

CI: confidence interval; OR: odds ratio. A fixed effects model was used as no statistical heterogeneity across complications were observed.

Figure 5. Forest plots for recovery outcomes included length of postoperative hospital stay (A), time to initial oral intake (B) and time to resume work (C).

CI: confidence interval; WMD: weighted mean difference. Random effects models based on the DerSimonian & Laird methods were used as heterogeneity existed in hospital stay (A) and time to resume work (C). A fixed effect model was used as no statistical heterogeneity across initial oral intake (B) was observed.