Three-port versus four-port technique for laparoscopic cholecystectomy: systematic review and meta-analysis

Abstract

Background: The four-port laparoscopic technique is the standard approach for cholecystectomy. A three-port technique has been described, but there is no consensus over the outcomes and efficacy of this approach. The aim was to perform a systematic review and meta-analysis to compare the three- and four-port techniques in laparoscopic cholecystectomy for benign diseases of the gallbladder.

Methods: The review was conducted according to a predefined protocol registered on PROSPERO. Two authors independently conducted an electronic database search of CENTRAL, MEDLINE, Embase, CINAHL, WHO International Clinical Trials Registry, and ClinicalTrials.gov. Outcomes are reported as risk ratios (RR), mean difference (m.d.), or standardized mean difference (s.m.d.) with 95 per cent confidence intervals.

Results: Eighteen trials were included with 2085 patients. Length of hospital stay and postoperative analgesia requirement favoured the three-port group (m.d. -0.29, 95 per cent c.i. -0.43 to -0.16 (P < 0.001); and s.m.d. -0.68, 95 per cent c.i. -1.03 to -0.33 (P < 0.001), respectively). There were no differences in length of procedure or success rate between the two groups (m.d. 0.90, 95 per cent c.i. -3.78 to 5.58 (P = 0.71) and RR 0.99, 95 per cent c.i. 0.97 to 1.01 (P = 0.17), respectively). There were no differences in adverse events. The overall quality of evidence was low.

Conclusion: The three-port technique for laparoscopic cholecystectomy is an option for appropriately trained surgeons who perform it regularly. However, the decision to use three ports should not be at the expense of safe dissection of Calot's triangle.

Fig. 1

Port placement and sizes of each port for the standard four-port technique

Fig. 2

The same equipment is used in the three-port technique but the 5 mm port in the anterior axillary line is absent

Fig. 3

Study flow diagram showing the number of records identified and excluded at each stage

Fig. 4

Risk of bias summary

Fig. 5

Risk of bias summary

Fig. 6

Forest plot for length of hospital stay

Fig. 7

Forest plot for length of procedure

Fig. 8

Forest plot for postoperative analgesia requirement

Fig. 9

Forest plot for success rate

Fig. 10

Forest plots for the following secondary outcomes

Fig. 10

Forest plots for the following secondary outcomes

Fig. 11

Summary of findings table for our primary outcomes