Pain after microlaparoscopic cholecystectomy. A randomized double-blind controlled study. Is minisite cholecystectomy less traumatic? Prospective randomized study comparing minisite and conventional laparoscopic cholecystectomies. Microlaparoscopic vs conventional laparoscopic cholecystectomy: a prospective randomized double-blind trial. Sympathetic nervous system activity during laparoscopic and needlescopic cholecystectomy. Minilaparoscopic and laparoscopic cholecystectomy: a comparative study. Randomized clinical trial of laparoscopic cholecystectomy performed with mini-instruments. Minimizing ports to improve laparoscopic cholecystectomy. Micropuncture cholecystectomy vs conventional laparoscopic cholecystectomy: a randomized controlled trial. Randomized trial of needlescopic versus laparoscopic cholecystectomy. Advantages of mini-laparoscopic vs conventional laparoscopic cholecystectomy: results of a prospective randomized trial. Prospective randomized blinded trial of pulmonary function, pain, and cosmetic results after laparoscopic vs. microlaparoscopic cholecystectomy. Early minilaparoscopic cholecystectomy in patients with acute cholecystitis. Post-operative pain in needlescopic versus conventional laparoscopic cholecystectomy: a prospective randomised trial.
Laparoscopic cholecystectomy (LC) is traditionally performed with two 10-mm and two 5-mm trocars. The effect of smaller port incisions on pain has not been established in controlled studies.
                In a double-blind controlled study, patients were randomized to LC or cholecystectomy with three 2-mm trocars and one 10-mm trocar (micro-LC). All patients received a multimodal analgesic regimen, including incisional local anesthetics at the beginning of surgery, NSAID, and paracetamol. Pain was registered preoperatively, for the first 3 h postoperatively, and daily for the 1st week.
                The study was discontinued after inclusion of 26 patients because five of the 13 patients (38%) randomized to micro-LC were converted to LC. In the remaining 21 patients, overall pain and incisional pain intensity during the first 3 h postoperatively increased in the LC group (n = 13) compared with preoperative pain levels (p<0.01), whereas pain did not increase in the micro-LC group (n = 8).
                Micro-LC in combination with a prophylactic multimodal analgesic regimen reduced postoperative pain for the first 3 h postoperatively. However, the micro-LC led to an unacceptable rate of conversion to LC (38%). The micro-LC instruments therefore need further technical development before this surgical technique can be used on a routine basis for laparoscopic cholecystectomy. The main objectives of minisite cholecystectomy (MC) are to have smaller incisions, better cosmetic results, less trauma, and a lower morbidity rate. This prospective randomized study compares MC with conventional laparoscopic cholecystectomy (CLC) in terms of surgical trauma and cosmetic results in 44 patients. Conversion from MC to CLC was required in five patients. No conversion to open surgery was needed in the CLC group. The average operating time was slightly longer in the MC group, but the difference was not statistically significant (81 minutes versus 72 minutes, p = 0.22). The population characteristics, postoperative respiratory function measurements, pain scores, and analgesic requirements were similar in the two groups. The average score for scar tissue was significantly lower in the MC group (0.73 versus 1.93, p = 0.0045). Only the cosmetic results of MC were superior to CLC. This technique could be a feasible alternative procedure in patients seeking better cosmetic results. However, further studies with larger sample sizes are needed to evaluate the postoperative morbidity of MC. Downsizing the port incisions may reduce pain after laparoscopic cholecystectomy.
                In a double-blind controlled study, 60 patients were randomized to undergo either microlaparoscopic cholecystectomy using one 10-mm and three 3.5-mm trocars (3.5-mm LC) or traditional laparoscopic cholecystectomy using two 10-mm and two 5-mm trocars (LC). Incisional pain at each port incision and overall pain were recorded for 1 week after the operation. Fatigue, nausea and vomiting, pulmonary function, and cosmetic results were also measured.
                Data from 52 patients were analyzed; eight patients were excluded from the study for various reasons. One patient was converted from 3.5-mm LC to LC due to technical problems with the 3.5-mm optic. In the 3.5-mm LC group (n = 25), incisional pain was significantly decreased in the 1st postoperative week as compared with the LC group (n = 27) (p <0.01). In both groups, pain scores at the supraumbilical 10-mm port were significantly higher compared with other port sites (p <0.05). The cosmetic results were significantly better in the 3.5-mm LC group (p <0.01). There were no significant differences in any of the other variables.
                The use of 3.5-mm trocars is feasible in LC, and it both reduces incisional pain and improves the cosmetic result. It is difficult to quantify the impact of surgical trauma on patients with conventional measurement techniques. We report our preliminary experience with the determination of sympathetic nervous system activity during laparoscopic and needlescopic cholecystectomy.
                The electroconductivity of representative dermatomes (24 measuring points) was recorded prior, during, and after performing laparoscopic and needlescopic cholecystectomy on 40 consecutive patients according to the method of Nakatani (Ryodoraku). Fifty-five healthy adults served as a control group.
                Median age in the two groups was 52.4 and 54.1 years, respectively. Prior to the operation and on the 1st postoperative day, sympathetic nervous activity was equal in both groups. In the needlescopic patients, sympathetic activity was lesser at 30 min after the start of the laparoscopic procedure (p <0.05).
                The measurement of electroconductivity is a useful noninvasive technique for the evaluation of sympathetic nervous activity. As far as activation of sympathetic nervous system is concerned, the needlescopic technique was found to be superior. To evaluate the feasibility and safety of the minilaparoscopic cholecystectomy (MLC) and to compare the clinical benefits experienced by patients who undergo MLC with those who undergo laparoscopic cholecystectomy (LC) or 5-mm laparoscopic cholecystectomy (5-mm LC).
                Prospective consecutive study.
                A tertiary referral center.
                From September 1, 2000, through June 30, 2001, 90 patients with symptomatic gallstones were randomized to undergo 1 of these 3 procedures.
                Minilaparoscopic cholecystectomy, LC, and 5-mm LC.
                Duration of surgery, loss of blood, length of hospital stay, resumption of solid food intake, quantity of analgesic dosage administered, development of complications, degree of pain at ports 24 and 48 hours after surgery, and overall cosmetic result.
                Subsequent to excluding 6 patients who were converted to LC, there were 30 patients in the LC group, 29 patients in the 5-mm LC group, and 25 patients in the MLC group. The MLC necessitated a longer time to complete the procedure than was the case for the other 2 procedures. There was no notable difference in the mean dosage of the meperidine hydrochloride (Pethidine) administered between the LC and MLC groups, but an apparent increase in the analgesia requirements for the 5-mm LC group was noted when compared with those of the other 2 groups. There was no remarkable difference in terms of blood loss, resumption of solid food intake, hospital stay subsequent to surgery, or surgical-related complication between these 3 groups. The MLC group did have a lower pain score in the subxyphoid port only at 24 hours after surgery compared with the other 2 groups. The cosmetic results were evaluated and no notable difference was noted at 1 week, 1 month, and 6 months after surgery.
                Although this study has demonstrated the feasibility and safety of the MLC, it does require a longer surgical time and reflects a reasonably high possibility for the conversion to LC. Furthermore, the MLC did not provide any notable clinical benefit for the tested patients compared with those patients in the LC group. We concluded that there is no reason for the MLC to become the universally accepted mode of treatment for symptomatic gallstones before further improvements are made in the technique and instrumentation. The outcomes after traditional laparoscopic cholecystectomy (LC; one 10-mm port, one 12-mm port and two 5-mm ports) and minilaparoscopic cholecystectomy (MLC; three 3-mm ports and one 12-mm port) for gallstone disease were compared.
                The study was a randomized, single-blind trial comparing LC with MLC. Only elective patients were eligible for inclusion. LC was a routine procedure at the institution in which the study was performed, whereas MLC was introduced after a short training period. The randomization period was from January to December 2001.
                Of 175 patients who had elective minimal access cholecystectomy during the randomization period, 135 entered the trial: 68 underwent LC and 67 underwent MLC. The groups were matched for age, sex and preoperative characteristics. Median (range) operating times for LC and MLC were similar (45 (20-120) and 50 (20-170) min respectively). Intraoperative and postoperative complication rates, the time for the patient to resume walking, eating and passing stools, and median hospital stay were the same in the two groups. The level of postoperative pain was lower in the MLC group at 1 h (P = 0.011), 3 h (P = 0.012), 6 h (P = 0.003), 12 h (P = 0.052) and 24 h (P = 0.034). Patients who had MLC received fewer injections of analgesic (P = 0.036) and more patients in this group expressed satisfaction with the cosmetic result (P = 0.001).
                MLC took a similar time to perform and caused less postoperative pain than the standard laparoscopic procedure. Reducing the port size further enhanced the advantages of laparoscopic over open cholecystectomy.
                Copyright 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. Minimizing the number and scope of ports used to perform laparoscopic cholecystectomy attempts to build on the improvements in postoperative pain control, rapid return to activity and work, patient satisfaction, and cosmetic result achieved by the laparoscopic method.
                We studied 141 patients in two sequential studies: the first a prospective randomized trial with 41 patients, and the second an examination of the more minimal procedure in 100 patients. In the randomized trial, patients underwent laparoscopic cholecystectomy with three ports: three 5-mm ports or two 10-mm ports and one 5-mm port. The 100 patients underwent the three 5-mm port procedure.
                In the randomized trial, differences were not statistically significant. However, on the average, the group with three 5-mm ports required less medication over less time, had less postoperative pain, and took less time to return to activity than the second group with larger ports. A statistically significant difference was found in incisional pain between the smaller group (21 patients) with two 10-mm ports and one 5-mm port and the larger group (100 patients) with three 5-mm ports, whether the measure was overall incisional pain (p = 0.014) or a comparison based on specific ports (p = 0.001). The percentage of cases requiring port enlargement to remove the gallbladder was not significantly different between the groups. There were no conversions to an open procedure, no fourth trocars added, and no complications. No patient required overnight hospitalization.
                Reducing the number and size of ports in laparoscopic cholecystectomy sustains or enhances the improvements initiated by performing laparoscopic rather than open cholecystectomy. In a comparison of microlaparoscopic procedures, patients undergoing the procedure with the shorter incisions experienced significantly less pain. The aim of this study was to compare micropuncture laparoscopic cholecystectomy (MPLC), with three 3.3-mm cannulas and one 10-mm cannula with conventional laparoscopic cholecystectomy (CLC).
                Patients were randomized to undergo either CLC or MPLC. The duration of each operative stage and the procedure were recorded. Interleukin-6 (IL-6), adrenocorticotropic hormone (ACTH), and vasopressin were sampled for 24 h. Visual analogue pain scores (VAPS) and analgesic consumption were recorded for 1 week. Pulmonary function and quality of life (EQ-5D) were monitored for 4 weeks. Statistical analysis was performed using the Mann-Whitney test or Fisher's exact test. Results are expressed as median (interquartile range).
                Forty-four patients entered the study, but four were excluded due to unsuspected choledocholithiasis (n = 3) or the need to reschedule surgery (n = 1). The groups were comparable in terms of age, duration of symptoms, and indications for surgery. Total operative time was similar (CLC, 63 [52-81] min vs MPLC 74 [58-95] min; p = 0.126). However, time to place the cannulas after skin incision (CLC, 5:42 [3:45-6:37] min vs MPLC, 7:38 [5:57-10:15] min; p = 0.015) and to clip the cystic duct after cholangiography (CLC, 1:05 [0:40-1:35] min vs MPLC, 3:45 [2:26-7:49] min; p <0.001) were significantly longer for MPLC. Six CLC patients and one MPLC patient required postoperative parenteral opiates (p = 0.04). Oral analgesic consumption was similar in both groups (p = 0.217). Median VAPS were lower at all time points for MPLC, but this finding was not significant (p = 0.431). There were no significant differences in postoperative stay, IL-6, ACTH or vasopressin responses, pulmonary function, or EQ-5D scores.
                The thinner instruments did not significantly increase the total duration of the procedure. MPLC reduced the use of parenteral analgesia postoperatively, which may prove beneficial for day case patients, but it did not have a significant impact on laboratory variables, lung function or quality of life. Several studies have reported the feasibility of using 'needlescopic' instruments with a diameter less than 3 mm in minimally invasive surgery. This study reports a comparison of needlescopic cholecystectomy and laparoscopic cholecystectomy.
                Seventy-five patients with symptomatic chronic cholelithiasis were randomized to needlescopic (n = 37) or laparoscopic (n = 38) cholecystectomy.
                The duration of surgery in the two groups was similar. Patients in the needlescopic group had less pain (mean visual analogue score 2.2 versus 3.6; P < 0.003) and had smaller scars (median length 17.0 versus 25.0 mm; P < 0.001). In addition, patients in the needlescopic group tended to require fewer intramuscular pethidine injections (P = 0.05). However, oral analgesic requirements in the two groups were similar. There were no complications in either group.
                Needlescopic cholecystectomy resulted in less postoperative pain and a smaller surgical scar than laparoscopic cholecystectomy in patients with chronic cholecystitis. The use of smaller instruments during laparoscopic cholecystectomy (LC) has been proposed to reduce postoperative pain and improve cosmesis. However, despite several recent trials, the effects of the use of miniaturized instruments for LC are not well established. We hypothesized that LC using miniports (M-LC) is safe and produces less incisional pain and better cosmetic results than LC performed conventionally (C-LC).
                A patient- and observer-blinded, randomized, prospective clinical trial.
                A tertiary care, university-based hospital.
                Seventy-nine patients scheduled for an elective LC who agreed to participate in this trial were randomized to undergo surgery using 1 of the 2 instrument sets. The criteria for exclusion were American Society of Anesthesiologists class III or IV, age older than 70 years, liver or coagulation disorders, previous major abdominal surgical procedures, and acute cholecystitis or acute choledocholithiasis.
                Laparoscopic cholecystectomy performed with either conventional or miniaturized instruments.
                Patients' age, sex, operative time, operative blood loss, intraoperative complications, early and late postoperative incisional pain, and cosmetic results.
                Thirty-three C-LCs and 34 M-LCs were performed and analyzed. There were 8 conversions (24%) to the standard technique in the M-LC group. No intraoperative or major postoperative complications occurred in either group. The average incisional pain score on the first postoperative day was significantly less in the M-LC group (3.9 vs 4.9; P = .04). No significant differences occurred in the mean scores for pain on postoperative days 3, 7, and 28. However, 90% of patients in the M-LC group and only 74% of patients in the C-LC group had no pain (visual analog scale score of 0) at 28 days postoperatively (P = .05). Cosmetic results were superior in the M-LC group according to both the study nurse's and the patients' assessments (38.9 vs 28.9; P<.001, and 38.8 vs 33.4; P = .001, respectively).
                Laparoscopic cholecystectomy can be safely performed using 10-mm umbilical, 5-mm epigastric, 2-mm subcostal, and 2-mm lateral ports. The use of mini-laparoscopic techniques resulted in decreased early postoperative incisional pain, avoided late incisional discomfort, and produced superior cosmetic results. Although improved instrument durability and better optics are needed for widespread use of miniport techniques, this approach can be routinely offered to many properly selected patients undergoing elective LC. The size of laparoscopic instruments has been reduced for use in abdominal video endoscopic surgery. However, it has yet to be proven that microlaparoscopic surgery will actually result in clinically relevant benefits for patients.
                Fifty patients were randomized in a blinded fashion to receive either elective laparoscopic (MINI), (n = 25) or microlaparoscopic (MICRO) (n = 25) cholecystectomy. Pulmonary function (FVC, FEV (1)), analgesic consumption during patient-controlled analgesia (PCA), pain perception by visual analogue score (VAS), and the cosmetic result (by the patient's self-assessment) were evaluated postoperatively as clinically relevant end points.
                Age, sex, body mass index (BMI), preoperative pulmonary function, pain perception, and operative time were similar for the two groups. At 8:00 PM on the day of surgery, FVC (MINI: 1.96 L [range, 1.48-2.48]; MICRO: 2.13 L) [(range, 1.61.-2.50)] and FEV (1) (MINI: 1.17 L/sec) [range, 0.87-1. 48]; MICRO: 1.34 L/sec [range, 1.05.-2.14] were also similar (each p = 0.5). From surgery to the 3rd postoperative day, cumulative PCA morphine doses were comparable (MINI: 0.15 mg/kg bw [range, 0.09-0. 23]; MICRO: 0.21 mg/kg bw [range, 0.10-0.42]; p = 0.4), but overall VAS scores for pain while coughing were higher in the laparoscopic group (406 [range, 358-514]) than in the microlaparoscopic group (365 [range, 215-427]; p = 0.02). The cosmetic result was judged to be slightly superior by the microlaparoscopic patients (10 [range, 9-10]), as compared to those in the laparoscopic (9 [range, 8-10]) group (p = 0.04).
                Because microlaparoscopic cholecystectomy has some minor advantages over laparoscopic surgery, it should be considered for use in selected patients. Recently, techniques using fine-caliber instruments (2 or 3 mm in diameter) for laparoscopic cholecystectomy, called minilaparoscopic cholecystectomy (MLC), were reported to be superior to conventional LC (CLC, using 5 mm instruments) in postoperative course and cosmetic outcome. However, the use of MLC to date has been largely restricted to uncomplicated situations. Since CLC has been proved to be a safe and efficient technique for acute cholecystitis especially if conducted early, this study tests the feasibility and safety of MLC for acute cholecystitis.
                Sixty-nine consecutive patients with acute cholecystitis were prospectively randomized to minilaparoscopic (n = 38) or conventional laparoscopic (n = 31) cholecystectomy, and the operations were conducted within 2 days of admission whenever possible. Despite different operative techniques, both groups of patients received identical preoperative preparation, evaluation and postoperative care. The two groups were compared for patient characteristics, results of laboratory tests, predictive score for LC difficulties, operative time, operative complications, hospitalization days and need for meperidine injection for wound pain.
                The conversion rate was 7.9% (3 of 38) for the MLC group and 6.5% (2 of 31) for the CLC group. Nine patients in the MLC group and 7 in the CLC group had concomitant choledocholithiasis and underwent endoscopic stone retrieval before operation. The age, sex, predictive score for LC difficulties, preoperative leukocyte count, length of hospital stay and requirement of intramuscular meperidine injections were similar for both groups of patients, while, the operative times were marginally longer in the MLC group (113.8 +/- 30.8 versus 98.2 +/- 33.2 minutes, P = 0.056). No major complications occurred in either group.
                The results of cholecystectomy for acute cholecystitis by MLC are as good as those of CLC if the operation is performed early, with obvious smaller incisions and minimal complications. MLC is a safe and effective procedure for patients with acute cholecystitis, and has an acceptable low conversion rate. Needlescopic cholecystectomy (NC) utilises instruments and ports smaller than 3 mm in diameter compared with the 5 mm ones used in conventional laparoscopic cholecystectomy (LC). Post-operative pain control and recovery has been thought to be superior in NC, when compared with historical controls with LC, but has not been proven in a prospective fashion.
                A prospective randomised trial of NC versus LC for patients with symptomatic gallstone disease, with standardisation of post-operative analgesia and daily assessment of post-operative pain, using a 5-point visual analogue scale.
                There were 64 eligible patients randomised into NC (28) and LC (36). Four patients who had NC were converted to LC due to technical problems. Another three and six patients from the NC and LC groups, respectively, had conversion to open surgery. Post-operative pain scores were low in both groups. Mean pain scores for those with successful NC and LC were: 1.24 versus 1.43 for the day of operation (P = 0.49), 0.86 versus 0.83 for the first day post-operatively (P = 0.92) and 0.75 versus 0.81 for the second post-operative day (P = 0.87). The mean number of intra-muscular analgesic injections required were 0.76 versus 0.83 after NC and LC, respectively (P = 0.93). There were no significant differences between the two groups in the time taken to return to feeding, eating a normal diet and discharge from hospital.
                There is no advantage of NC over LC in terms of post-operative pain or recovery. Nevertheless, NC can be performed safely and expediently and has an excellent cosmetic outcome and high patient acceptability.
Miniport laparoscopic cholecystectomy can be completed successfully in more than 85% of patients. Patients, in whom elective miniport laparoscopic cholecystectomy was completed successfully, had lower pain than those who underwent standard laparoscopic cholecystectomy. However, because of the lack of information on its safety, miniport laparoscopic cholecystectomy cannot be recommended outside well-designed, randomised clinical trials.