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Figure 1.
Miniaturized instruments (A) and access trocars (B) used during a mini-laparoscopic cholecystectomy. Standard 5- and 10-mm ports (B, left) are shown for comparison.

Miniaturized instruments (A) and access trocars (B) used during a mini-laparoscopic cholecystectomy. Standard 5- and 10-mm ports (B, left) are shown for comparison.

Figure 2.
Patient attrition. C-LC indicates laparoscopic cholecystectomy performed conventionally; M-LC, laparoscopic cholecystectomy performed using miniports.

Patient attrition. C-LC indicates laparoscopic cholecystectomy performed conventionally; M-LC, laparoscopic cholecystectomy performed using miniports.

Table 1. 
Port Size and the Instruments Used at Each Site
Port Size and the Instruments Used at Each Site
Table 2. 
Preoperative Indications for Surgery
Preoperative Indications for Surgery
Table 3. 
Postoperative Pain as Assessed by the Patients Using a Visual Analog Scale*
Postoperative Pain as Assessed by the Patients Using a Visual Analog Scale*
Table 4. 
Results of Prospective Randomized Trials Comparing M-LC and C-LC
Results of Prospective Randomized Trials Comparing M-LC and C-LC
1.
Litwin  DEGirotti  MJPoulin  ECMamazza  JNagy  AG Laparoscopic cholecystectomy: trans-Canada experience with 2201 cases. Can J Surg 1992;35291- 296
PubMed
2.
McMahon  AJRussell  ITBaxter  JN  et al.  Laparoscopic versus minilaparotomy cholecystectomy: a randomised trial. Lancet 1994;343135- 138
PubMedArticle
3.
Berggren  UGordh  TGrama  DHaglund  URastad  JArvidsson  D Laparoscopic versus open cholecystectomy: hospitalization, sick leave, analgesia and trauma responses. Br J Surg 1994;811362- 1365
PubMedArticle
4.
Trondsen  EReiertsen  OAndersen  OKKjaersgaard  P Laparoscopic and open cholecystectomy: a prospective, randomized study. Eur J Surg 1993;159217- 221
PubMed
5.
Unger  SWParamo  JCPerez  M Microlaparoscopic cholecystectomy: less invasive gallbladder surgery. Surg Endosc 2000;14336- 339
PubMedArticle
6.
Reardon  PRKamelgard  JIApplebaum  BRossman  LBrunicardi  FC Feasibility of laparoscopic cholecystectomy with miniaturized instrumentation in 50 consecutive cases. World J Surg 1999;23128- 132
PubMedArticle
7.
Ngoi  SSGoh  PKok  KKum  CKCheah  WK Needlescopic or minisite cholecystectomy. Surg Endosc 1999;13303- 305
PubMedArticle
8.
Schwenk  WNeudecker  JMall  JBohm  BMuller  JM Prospective randomized blinded trial of pulmonary function, pain, and cosmetic results after laparoscopic vs microlaparoscopic cholecystectomy. Surg Endosc 2000;14345- 348
PubMedArticle
9.
Look  MChew  SPTan  YC  et al.  Post-operative pain in needlescopic versus conventional laparoscopic cholecystectomy: a prospective randomised trial. J R Coll Surg Edinb 2001;46138- 142
PubMed
10.
Lai  ECFok  MChan  AS Needlescopic cholecystectomy: prospective study of 150 patients. Hong Kong Med J 2003;9238- 242
PubMed
11.
Huang  MTWang  WWei  PLChen  RJLee  WJ Minilaparoscopic and laparoscopic cholecystectomy: a comparative study. Arch Surg 2003;1381017- 1023
PubMedArticle
12.
Bisgaard  TKlarskov  BTrap  RKehlet  HRosenberg  J Microlaparoscopic vs conventional laparoscopic cholecystectomy: a prospective randomized double-blind trial. Surg Endosc 2002;16458- 464
PubMedArticle
13.
Alponat  ACubukcu  AGonullu  NCanturk  ZOzbay  O Is minisite cholecystectomy less traumatic? prospective randomized study comparing minisite and conventional laparoscopic cholecystectomies. World J Surg 2002;261437- 1440
PubMedArticle
14.
Ainslie  WGCatton  JADavides  D  et al.  Micropuncture cholecystectomy vs conventional laparoscopic cholecystectomy: a randomized controlled trial. Surg Endosc 2003;17766- 772
PubMedArticle
15.
Noether  GE Sample size determination for some common nonparametric tests. J Am Stat Assoc 1987;82645- 647Article
16.
Novitsky  YWLDCallery  MP The net immunologic advantage of laparoscopic surgery. Surg Endosc 2004;181411- 1419
PubMedArticle
17.
Kimura  TSakuramachi  SYoshida  MKobayashi  TTakeuchi  Y Laparoscopic cholecystectomy using fine-caliber instruments. Surg Endosc 1998;12283- 286
PubMedArticle
18.
Gagner  MGarcia-Ruiz  A Technical aspects of minimally invasive abdominal surgery performed with needlescopic instruments. Surg Laparosc Endosc 1998;8171- 179
PubMedArticle
19.
Tagaya  NKita  JTakagi  K  et al.  Experience with three-port laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg 1998;5309- 311
PubMedArticle
20.
Leggett  PLBissell  CDChurchman-Winn  R Cosmetic minilaparoscopic cholecystectomy. Surg Endosc 2001;151229- 1231
PubMedArticle
21.
Leggett  PLChurchman-Winn  RMiller  G Minimizing ports to improve laparoscopic cholecystectomy. Surg Endosc 2000;1432- 36
PubMedArticle
22.
Poon  CMChan  KWLee  DW  et al.  Two-port versus four-port laparoscopic cholecystectomy. Surg Endosc 2003;171624- 1627
PubMedArticle
23.
Sherwood  RBerci  GAustin  EMorgenstern  L Minilaparoscopy for blunt abdominal trauma. Arch Surg 1980;115672- 673
PubMedArticle
24.
Mamazza  JSchlachta  CMSeshadri  PACadeddu  MOPoulin  EC Needlescopic surgery: a logical evolution from conventional laparoscopic surgery. Surg Endosc 2001;151208- 1212
PubMedArticle
25.
Tagaya  NRokkaku  KKubota  K Splenectomy using a completely needlescopic procedure: report of three cases. J Laparoendosc Adv Surg Tech A 2002;12213- 216
PubMedArticle
26.
Gill  ISSoble  JJSung  GTWinfield  HNBravo  ELNovick  AC Needlescopic adrenalectomy–the initial series: comparison with conventional laparoscopic adrenalectomy. Urology 1998;52180- 186
PubMedArticle
27.
Chiasson  PMPace  DESchlachta  CMPoulin  ECMamazza  J “Needlescopic” Heller myotomy. Surg Laparosc Endosc Percutan Tech 2003;1367- 70
PubMedArticle
28.
Chiasson  PMPace  DEMustard  RAMamazza  JPoulin  ECSchlachta  CM “Needlescopic” sigmoid resection. Surg Endosc 2002;16715
PubMedArticle
29.
Mostafa  GMatthews  BDSing  RFKercher  KWHeniford  BT Mini-laparoscopic versus laparoscopic approach to appendectomy. BMC Surg 2001;14
PubMedArticle
30.
Yuan  RHLee  WJYu  SC Mini-laparoscopic cholecystectomy: a cosmetically better, almost scarless procedure. J Laparoendosc Adv Surg Tech A 1997;7205- 211
PubMedArticle
31.
Cheah  WKLenzi  JESo  JBKum  CKGoh  PM Randomized trial of needlescopic versus laparoscopic cholecystectomy. Br J Surg 2001;8845- 47
PubMedArticle
32.
Sarli  LIusco  DGobbi  SPorrini  CFerro  MRoncoroni  L Randomized clinical trial of laparoscopic cholecystectomy performed with mini-instruments. Br J Surg 2003;901345- 1348
PubMedArticle
33.
Bisgaard  TKlarskov  BRosenberg  JKehlet  H Characteristics and prediction of early pain after laparoscopic cholecystectomy. Pain 2001;90261- 269
PubMedArticle
34.
Bisgaard  TKlarskov  BTrap  RKehlet  HRosenberg  J Pain after microlaparoscopic cholecystectomy: a randomized double-blind controlled study. Surg Endosc 2000;14340- 344
PubMedArticle
Original Article
December 1, 2005

Advantages of Mini-laparoscopic vs Conventional Laparoscopic CholecystectomyResults of a Prospective Randomized Trial

Author Affiliations

Author Affiliations: Department of Surgery, University of Massachusetts Medical School, Worcester.

Arch Surg. 2005;140(12):1178-1183. doi:10.1001/archsurg.140.12.1178
Abstract

Hypothesis  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).

Design  A patient- and observer-blinded, randomized, prospective clinical trial.

Setting  A tertiary care, university-based hospital.

Patients  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.

Intervention  Laparoscopic cholecystectomy performed with either conventional or miniaturized instruments.

Main Outcome Measures  Patients’ age, sex, operative time, operative blood loss, intraoperative complications, early and late postoperative incisional pain, and cosmetic results.

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).

Conclusions  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 use of laparoscopy has gained widespread popularity in surgical approaches to abdominal wall hernias and intestinal and solid organ resection. However, no other operation has been as profoundly affected by the advent of laparoscopy as cholecystectomy. In fact, laparoscopic cholecystectomy (LC) has clearly become the procedure of choice for routine gallbladder removal. The advantages of this approach include decreased scarring, decreased incisional pain, shorter hospitalization, and faster functional recovery.14

In recent years, many investigators have attempted to further improve on the established technique of LC. Generally, the goal has been to minimize the invasiveness of this procedure by reducing the number and, more commonly, the size of the operating ports and instruments.57 Although several recent trials from Europe and Asia814 provided level I data, the effects of the use of miniaturized instruments for LC are still not well established. In this article, we report the results of a prospective, randomized blinded trial that compared the safety, degree of postoperative pain, and cosmetic results of LC performed conventionally (C-LC) and using miniports (M-LC) (Figure 1).

METHODS
PATIENT SELECTION

All patients scheduled for elective cholecystectomy at the University of Massachusetts Memorial Medical Center in Worchester were offered the opportunity to participate in this trial. The criteria for exclusion were American Society of Anesthesiologists class III or IV, age older than 70 years, liver or coagulation disorders, morbid obesity, previous major abdominal surgical procedures, and acute cholecystitis. Intraoperative evidence of choledocholithiasis mandated a laparoscopic common bile duct exploration and dismissal from the study. Patients were randomly assigned to either the C-LC group or the M-LC group by a study nurse on the basis of a block-randomized computer-generated list. The surgeon was notified of the allocation on the morning of the procedure. The patients and the study nurse remained blinded to the type of instrumentation used until the study was finished.

SURGICAL TECHNIQUE

All operations were performed by experienced laparoscopic surgeons. An intraoperative cholangiogram was used selectively if a patient had a history of abnormal liver function test results, dilated common bile duct on preoperative imaging, or a history of choledocholithiasis or at the discretion of the surgeon.

CONVENTIONAL LC

Patients were placed in a supine position with the operating surgeon on the patient’s left side. The previously described technique for LC was used.1 Briefly, access to the abdominal cavity was gained using a Hasson technique. The abdominal cavity was insufflated to a pneumoperitoneum of 14 mm Hg, and a 10-mm 30° laparoscope was then inserted. The patients were placed in a reverse Trendelenburg position, with the right side elevated approximately 30°. The operating port location and instruments used are listed in Table 1. Under direct vision, a 10-mm bladed trocar (US Surgical, Norwalk, Conn) was placed in the subxiphoid area. Two bladed 5-mm trocars (US Surgical) were then placed in the right subcostal region along anterior axillary and midclavicular lines. The fundus of the gallbladder was retracted above the liver using a 5-mm gallbladder grasper (US Surgical). The cystic duct and artery were dissected with a hook electrocautery and a 5-mm Maryland dissector (Smith and Nephew, Andover, Mass), clipped with three 10-mm clips (EndoClip; US Surgical), and divided with 5-mm endoscopic scissors (EndoShears, US Surgical). The specimen was placed inside the retrieval bag and removed through the umbilical port. The umbilical port site was closed with a 2-0 Vicryl fascial suture; 4-0 Monocryl (Ethicon Inc, Somerville, NJ) interrupted subcuticular sutures were used to reapproximate the skin. Surgical strips (Steri-Strips; 3M, St Paul, Minn) were applied to all port sites.

MINIPORT LC

The C-LC procedure was modified as follows. Two-millimeter subcostal and lateral ports (MiniSite, US Surgical), a 5-mm epigastric port (US Surgical), and a 10-mm umbilical (Hasson) port were used (Table 1). In addition, 2-mm graspers (MiniSite EndoGrasp; US Surgical) were used. A 5-mm clip applier (EndoClip; US Surgical) was used on the cystic artery and duct; a 5-mm 30° laparoscope was placed through the epigastric port to facilitate specimen retrieval.

ANALGESIA AND PAIN ASSESSMENT

Five cubic centimeters of 0.5% bupivacaine hydrochloride was injected in all 4 port sites at the conclusion of the operation. Postoperatively, the patients were given intravenous morphine on an as-needed basis. The patients were usually discharged after 4 to 6 hours of observation. A prescription for an oral narcotic medication (hydrocodone, 5-10 mg, or oxycodone, 5-10 mg) was given to all patients. The standard visual analog scale (VAS) was used for an objective assessment of incisional pain on postoperative days 1, 3, 7, and 28. Patients rated their incisional pain on each of these days from 0 (none) to 10 (worst possible). In addition, all patients completed a VAS form preoperatively to estimate their pain threshold.

COSMESIS ASSESSMENT

Only 10-mm port sites were closed with absorbable subcuticular stitches. Steri-Strips (3M) were applied to all port sites. All incisions were covered by a small sterile dressing for 48 hours. The appearance of each incision was rated on a scale of 1 (worst) to 10 (best) at the 1-month follow-up visit by patients and by a study nurse blinded to the type of instruments used. The cosmesis score was the total of 4 incisions. Both (patient- and nurse-assigned) scores were recorded for each patient.

STATISTICAL ANALYSES

The data are expressed as mean ± SD unless specified otherwise. The sample size was calculated using the formulas derived by Noether.15 Twenty-one people were needed in each group to ensure a power of 80%, with an α of .05 and P(Y>X) = .75, where Y and X are random samples from 2 populations (a treatment vs control group). Under the null hypothesis, = .50. More patients were recruited to account for patients’ attrition. A 2-tailed t test was used to compare normally distributed data. A Wilcoxon rank sum test was used for data not normally distributed and/or ordinal data (VAS and cosmesis scores). A Fisher exact test was used to compare nominal data (absence or presence of incisional pain). ≤ .05 was considered statistically significant. The study was approved by the University of Massachusetts Medical Center institutional review board. Each patient signed an informed consent document before enrollment.

RESULTS

Seventy-nine patients agreed to participate in this study and signed an informed consent document (Figure 2). Eight patients were excluded from the study after they were enrolled owing to an episode of acute cholecystitis (n = 6) and an intraoperative need for a common bile duct exploration (n = 2). Four additional patients (2 in each group) did not undergo an allocated treatment for logistical reasons. Thirty-three C-LCs and 34 M-LCs were performed; the patients in each group were of a similar age (41.8 ± 12.4 vs 46.7 ± 12.1 years, respectively; P = .16; t test) and sex (88% vs 76% women, respectively). The indications for surgery in both groups are summarized in Table 2. No significant difference occurred in the average operative time between C-LC and M-LC (54.9 ± 22.4 vs 50.5 ± 15.4 minutes; P = .33; t test). The average intraoperative blood loss was minimal (<50 mL) in both groups. An intraoperative cholangiogram was performed in 7 patients who had C-LC and 3 patients who had M-LC. There were 8 conversions (24%) to the standard technique in the M-LC group owing to inadequate grasping (n = 5), instrument bending (n = 1), large cystic duct (n = 1), and damage to the trocar (n = 1). These patients were excluded from the analysis of the degree of incisional pain and cosmesis. When the operative times between the groups were compared on an intent-to-treat basis (including patients who were converted to M-LC), there was still no significant difference (54.9 ± 22.4 vs 49.0 ± 17.3 minutes; P = .24; t test). Furthermore, as noted by the operating surgeons, M-LC instruments performed suboptimally in an additional 7 patients (20%). No intraoperative complications and no conversions to open cholecystectomy occurred in either group. One patient in the M-LC group was readmitted for vomiting and dehydration. Otherwise, there were no major postoperative complications in either group.

PAIN

The average pain scores in both groups are summarized in Table 3. Preoperative pain tolerance was equal between C-LC and M-LC groups (6.2 ± 2.3 vs 6.7 ± 1.9; P = .49; Wilcoxon rank sum test). The average pain score on the first postoperative day was significantly less in the M-LC group (3.9 ± 1.5 vs 4.9 ± 1.8; P = .04; Wilcoxon rank sum test). No significant differences occurred in the mean scores for postoperative incisional pain on postoperative day 3, 7, or 28. However, 90% of patients in the M-LC group and only 74% of patients in the C-LC group had no pain (VAS score of 0) at 28 days postoperatively (P = .05; Fisher exact test).

COSMESIS

Cosmetic results were superior in the M-LC group according to both the study nurse and the patients’ assessments. When assessed by a nurse, the mean scores were 38.9 ± 2.1 for the M-LC group and 28.9 ± 5.7 for the C-LC group (P<.001; Wilcoxon rank sum test). Similarly, when assessed by the patients, the mean cosmesis scores were 38.8 ± 1.7 and 33.4 ± 5.7, respectively (P = .001; Wilcoxon rank sum test).

COMMENT

The main advantages of laparoscopic surgery include better cosmetic results, decreased postoperative pain, and faster functional recovery. Although it is unclear whether these benefits stem from a decreased need for retraction and dissection, lack of exposure of the viscera to room air, or smaller-access incisions,16 attempts to further improve surgical outcomes have resulted in a decrease of incision number and size.5,1722 Modern technological advances have armed the surgeon with smaller-caliber laparoscopic instruments, better optics, and better light sources. Although successful use of the mini-laparoscopic technique for diagnostic purposes was reported as early as 1980,23 the smaller instruments have been used only recently in laparoscopic appendectomy, Nissen fundoplication, Heller myotomy, splenectomy, adrenalectomy, thoracic sympathectomy, and segmental colon resections.2429

Most investigative trials evaluating mini-laparoscopic and standard laparoscopic techniques have used LC as their procedure for comparison. After the feasibility and potential benefits of M-LC were established in small series,5,6,17,30 several prospective randomized trials outside the United States produced mixed results (Table 4). In this first prospective, randomized blinded trial conducted in the United States, we evaluated the safety and outcomes of LC performed with smaller epigastric, subcostal, and lateral ports.

Decreased incisional pain is a well-established benefit of laparoscopic surgery. However, the direct link between further reduction in the size of access incisions and decreased pain has not been confirmed, probably because of the multifactorial etiology of incisional pain.33 Nevertheless, several investigators79,11,32 demonstrated that using smaller incisions decreases postoperative pain. Cheah et al31 reported in a prospective randomized trial that using three 2-mm instead of three 5-mm trocars significantly reduced postoperative pain scores and analgesic requirements after LC. Similarly, Bisgaard et al12 found reduced incisional pain at smaller port sites 6 hours postoperatively. The authors also reported decreased total pain scores during the first postoperative week, but mean scores at 1 week were not significantly different. Our study found an early reduction in pain scores in the mini-laparoscopic group. Although we did not document analgesic requirements, VAS scores were significantly lower in the M-LC group on the first postoperative day. Statistically significant differences in pain scores were not seen at other time points in our trial. However, we discovered that a significantly larger proportion of patients in the M-LC group were completely free of incisional pain 1 month postoperatively. Almost a quarter of the patients in the C-LC group had some residual, albeit minor, incisional discomfort. The clinical significance of this late finding is not clear and may be of value to only a small group of patients.

The use of smaller-access incisions has also been suggested to result in minimal scarring and better cosmesis.18,30 However, the evaluation of postoperative cosmetic results is challenged by the absence of a reliable objective scale. The combination of multiple contributing factors, potential observer bias, and variations in patients’ expectations contributes to difficulties in assessing cosmetic results. To minimize bias in our assessment of cosmetic results, we used both patients and blinded observers to evaluate postoperative scars. The comparison between the groups was performed separately for both patient- and study nurse–derived scores. In our series, we observed that both patients and blinded observers scored mini-laparoscopic wounds significantly better with regard to cosmetic appearance. Similar cosmetic benefits were reported by other prospective trials.8,12,13,32 Although the clinical relevance of differential scarring after smaller incisions is debatable in the medical literature, a small cosmetic benefit may be psychologically important to some patients undergoing LC.

Prolonged surgical times often limit implementation of new technologies. Using small instruments in our study did not result in increased duration of the operations. Regardless of the port size, our patients experienced uncomplicated operations with minimal blood loss and same-day discharges. Similarly, other investigators8,13,14,33 reported no significant increase in operative times when mini-laparoscopic techniques were used. In contrast, Huang et al11 reported greater operative times in a prospective randomized trial of C-LC and M-LC techniques. However, this finding occurred only when they used a challenging setup with one 10-mm and three 2-mm ports. Prolonged operative times were not seen when a 5-mm port was substituted for the 2-mm port in the epigastrium.11 Overall, the preponderance of evidence establishes that M-LC techniques do not result in longer operative times for routine LC. In addition, the use of smaller instruments did not prevent us from performing intraoperative cholangiograms in selected patients.

Intraoperative conversions from M-LC to both C-LC and open cholecystectomy have been reported in as many as 23% to 38% of patients.9,13,34 The most common factor contributing to conversions is the presence of chronic cholecystitis with a markedly inflamed, thickened gallbladder and dense adhesions.9,34 Grasping and manipulating the gallbladder in this circumstance may be extremely difficult and may lead to damage of graspers and trocars. In addition, smaller-diameter laparoscopes remain inferior in resolution and clarity when compared with standard laparoscopes.13 Such “instrument failures” in our series occurred in 24% of patients. We discovered that in addition to a thick gallbladder wall, a thick abdominal wall may be a limiting factor as well. It is plausible that with the development of stronger, more durable instruments and better optics and light sources, fewer conversions from M-LC will be necessary. Nevertheless, a conversion from M-LC to C-LC is not a failure by any means. Since the mean operative time of both groups was similar when compared on both intent-to-treat and treatment-rendered bases, conversions from M-LC to C-LC did not prolong the operative times in our series. This may, however, be attributed to timely decisions by experienced laparoscopic surgeons to convert to C-LC in our trial, avoiding prolonged, futile, and possibly unsafe attempts to complete procedures with miniports. Thus, a planned M-LC should be abandoned either after identification of significant right upper quadrant inflammation or scarring on initial diagnostic exploration or when significant limiting factors in anatomical dissection are encountered. In the latter circumstance, the conversion would merely entail upsizing lateral trocars and should not be delayed.

In conclusion, LC 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 and was more likely to result in the absence of late incisional discomfort when compared with conventional LC. In addition, smaller-access incisions resulted in superior cosmetic results according to both patients and blinded observers in this trial. 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.

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Article Information

Correspondence: Yuri W. Novitsky, MD, Carolinas Medical Center, 1000 Blythe Blvd, Department of Surgery, MEB 601, Charlotte, NC 28203 (yuri.novitsky@carolinas.org).

Accepted for Publication: January 1, 2005.

References
1.
Litwin  DEGirotti  MJPoulin  ECMamazza  JNagy  AG Laparoscopic cholecystectomy: trans-Canada experience with 2201 cases. Can J Surg 1992;35291- 296
PubMed
2.
McMahon  AJRussell  ITBaxter  JN  et al.  Laparoscopic versus minilaparotomy cholecystectomy: a randomised trial. Lancet 1994;343135- 138
PubMedArticle
3.
Berggren  UGordh  TGrama  DHaglund  URastad  JArvidsson  D Laparoscopic versus open cholecystectomy: hospitalization, sick leave, analgesia and trauma responses. Br J Surg 1994;811362- 1365
PubMedArticle
4.
Trondsen  EReiertsen  OAndersen  OKKjaersgaard  P Laparoscopic and open cholecystectomy: a prospective, randomized study. Eur J Surg 1993;159217- 221
PubMed
5.
Unger  SWParamo  JCPerez  M Microlaparoscopic cholecystectomy: less invasive gallbladder surgery. Surg Endosc 2000;14336- 339
PubMedArticle
6.
Reardon  PRKamelgard  JIApplebaum  BRossman  LBrunicardi  FC Feasibility of laparoscopic cholecystectomy with miniaturized instrumentation in 50 consecutive cases. World J Surg 1999;23128- 132
PubMedArticle
7.
Ngoi  SSGoh  PKok  KKum  CKCheah  WK Needlescopic or minisite cholecystectomy. Surg Endosc 1999;13303- 305
PubMedArticle
8.
Schwenk  WNeudecker  JMall  JBohm  BMuller  JM Prospective randomized blinded trial of pulmonary function, pain, and cosmetic results after laparoscopic vs microlaparoscopic cholecystectomy. Surg Endosc 2000;14345- 348
PubMedArticle
9.
Look  MChew  SPTan  YC  et al.  Post-operative pain in needlescopic versus conventional laparoscopic cholecystectomy: a prospective randomised trial. J R Coll Surg Edinb 2001;46138- 142
PubMed
10.
Lai  ECFok  MChan  AS Needlescopic cholecystectomy: prospective study of 150 patients. Hong Kong Med J 2003;9238- 242
PubMed
11.
Huang  MTWang  WWei  PLChen  RJLee  WJ Minilaparoscopic and laparoscopic cholecystectomy: a comparative study. Arch Surg 2003;1381017- 1023
PubMedArticle
12.
Bisgaard  TKlarskov  BTrap  RKehlet  HRosenberg  J Microlaparoscopic vs conventional laparoscopic cholecystectomy: a prospective randomized double-blind trial. Surg Endosc 2002;16458- 464
PubMedArticle
13.
Alponat  ACubukcu  AGonullu  NCanturk  ZOzbay  O Is minisite cholecystectomy less traumatic? prospective randomized study comparing minisite and conventional laparoscopic cholecystectomies. World J Surg 2002;261437- 1440
PubMedArticle
14.
Ainslie  WGCatton  JADavides  D  et al.  Micropuncture cholecystectomy vs conventional laparoscopic cholecystectomy: a randomized controlled trial. Surg Endosc 2003;17766- 772
PubMedArticle
15.
Noether  GE Sample size determination for some common nonparametric tests. J Am Stat Assoc 1987;82645- 647Article
16.
Novitsky  YWLDCallery  MP The net immunologic advantage of laparoscopic surgery. Surg Endosc 2004;181411- 1419
PubMedArticle
17.
Kimura  TSakuramachi  SYoshida  MKobayashi  TTakeuchi  Y Laparoscopic cholecystectomy using fine-caliber instruments. Surg Endosc 1998;12283- 286
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