Laparoscopic cholecystectomy (LC) is widely regarded as the premier method for gallbladder removal, celebrated for its enhanced cosmetic outcomes, reduced postoperative discomfort, and swifter return to normal activity¹. Cutting-edge approaches like Natural Orifice Endoscopic Surgery (NOTES), Single-Incision Laparoscopic Surgery (SILS)², as well as two-port³ and three-port techniques, have been employed to make gallbladder surgery less invasive than the traditional four-port method. These advancements usher in nearly scarless operations, diminished pain, superior cosmetic results, and accelerated recovery. SILS, also known as Single-Port-Access (SPA), promises exceptional cosmesis by concealing the incision within the umbilicus, yet it presents technical hurdles: instrument clashing, disrupted triangulation, limited visibility, and constrained dissection depth. Specialized equipment—large ports, angled tools, and scopes—is required, steepening the learning curve and elevating the risk of wound complications like hernias⁴.

Typically, LC is conducted with four trocars, but advancements have proven it can be safely executed with three ports, two ports, or even a single incision⁵. The two-port LC is noted for its safety and feasibility, boasting higher patient satisfaction than the conventional four-port approach. This technique relies on two traction sutures or alligator graspers—one at the gallbladder fundus and another at Hartmann’s pouch. However, its technical complexity, due to a restricted operative field, limits its application to straightforward, uncomplicated cases⁶. Introduced by Mouret in 1987, LC offers shorter hospital stays, less pain, smaller, more attractive scars, and cost-effectiveness compared to open surgery. A 1992 NIH consensus conference in Bethesda affirmed LC as the optimal treatment for cholelithiasis, establishing it as the most common procedure among general surgeons today.

Despite its merits, LC can encounter challenges, including issues with anesthesia, peritoneal access, pneumoperitoneum, surgical exploration, thermocoagulation, and an increased risk of iatrogenic injury to organs like the biliary tract. Anatomical distortions from acute or chronic inflammation may complicate matters further, prompting surgeons to opt for open surgery in difficult cases as a reliable, albeit more invasive, means to avert complications. Laparoscopes equipped with operational channels render two-port LC viable, with case series underscoring its advantages in patient satisfaction and pain reduction⁶. Compared to SILS, two-port and four-port LC restore triangulation, ease the learning curve, minimize abdominal trauma, reduce postoperative pain, and deliver comparable cosmesis⁷.

AIM

To study and compare the surgical and cosmetic outcomes of two port Laparoscopic. Cholecystectomy with Standard four port Laparoscopic cholecystectomy in a tertiary care Hospital.

OBJECTIVES:

Primary:

1. To document postoperative pain and analgesic need
2. To analyse total duration of hospital stay and days away from work
3. To document postoperative healing time

Secondary:

1. To assess incident of wound related complications
2. To study the difference in operative time required in these two techniques

Study design: The study will be conducted after obtaining permission from the Institutional Ethics Committee (IEC).  A prospective, observational, comparative, study to compare the surgical and cosmetic outcomes of two port Laparoscopic Cholecystectomy with Standard four port Laparoscopic cholecystectomy on 60 patients with 30 patients randomised into each group. FOR A PERIOD OF: 18 months

Group I: Patients with odd serial numbers undergoing Four Port Cholecystectomy

Group II: Patients with even serial numbers undergoing Two port Cholecystectomy.

RESEARCH METHODOLOGY AND DATA COLLECTION

Inclusion Criteria:

1. Patient who gives written informed consents
2. Patient with age greater than 18 years
3. Symptomatic Patients due to cholelithiasis without cholecystitis, cholelithiasis with

cholecystitis, acute on chronic cholecystitis

4. Incidental finding of cholelithiasis on radiological imaging.

Exclusion Criteria:

1. Patients with past history of abdominal surgeries involving midline vertical incisions,

intra-abdominal malignancies, pancreatic surgeries, etc.

2. Cases in which delayed recovery was expected i.e., septicaemic or hypovolaemic shock, profuse intraoperative or postoperative bleeding (>1 litre) and immunocompromised patients.
3. Severely cachectic patients requiring intensive care in postoperative period; severe

systemic organ dysfunction (chronic liver, renal or heart diseases, diabetes mellitus)

4. Pregnant females
5. Patients who do not give consent for the procedure or to participate in the study
6. Patients with less than 18 years of age

PROCEDURE

The patients fulfilling the selection criteria will be informed about the nature and objective of the study and a written informed consent will be taken.

The preoperative data will be collected in a case record form. All the patients to be subjected to detailed history and clinical examination followed by relevant investigations which includeUSG, CT scan, complete blood profile, renal function tests liver function tests, blood sugars, serological tests. Data will be entered in proforma. Patient’s data will be collected in a case record sheet.

Intraoperative procedures will be observed:

• Prophylactic antibiotic therapy with duration of course
• Preoperative part preparation, cleaning, painting and draping.
• Procedure performed
• Port Site closure
• Number of Patients with Two Port Laparoscopic cholecystectomy Converted to standard
• four port Laparoscopic cholecystectomy or Open cholecystectomy

 Postoperative procedures will be noted:

1. Days of check dressing
2. Need of postoperative analgesia
3. Duration of postoperative hospital stay

 Postoperative complications will be recorded:

1. Need of analgesics and subjective pain score
2. Superficial wound dehiscence and culture sensitivity findings with respect to
   1. surgical site infection
3. Examination of Suture line and associated complications

Symptoms: Fever and tachycardia

Local Examination: Soakage, induration, erythema and discharge

Lab reports: CBC and wound C/S.

 Postoperative Follow-up:

1. POD 2 check dress and suture removal after 14 days
2. 1 month after discharge- Clinical Examination and USG abdomen

STATISTICAL ANALYSIS:

Categorical variables were described in terms of frequency (percentages) and continuous variables as the median (range) or mean (± standard deviation SD). Univariate analyses were conducted using a Student’s t-test or a Mann-Whitney test for continuous variables as appropriate, and a Chi square test or Fischer’s exact test for categorical variables as appropriate. All tests were two-tailed, and p value ≤ .05, differences were deemed statistically significant. Data were analysed using the IBM-SPSS® statistics application, version 25. (56)

The following is a comprehensive analysis of the study comparing 2-port and 4-port laparoscopic cholecystectomy, based on the provided data. The results are organized into baseline characteristics, intra-operative features, and post-operative outcomes, with detailed tables and descriptions to ensure clarity and completeness.

1. Baseline Characteristics

The study enrolled 80 patients, randomly divided into two groups of 40 each: one undergoing 2-port laparoscopic cholecystectomy (LC) and the other standard 4-port LC. The baseline characteristics were assessed to ensure comparability between groups, and the results indicate no significant differences, suggesting a balanced study design.

Table 1: Baseline Characteristics

Description:

• Age and BMI: The mean age and BMI were similar, with no significant differences (p=0.089 for age, p=0.54 for BMI), indicating comparable physical profiles.
• Gender Distribution: The 2-port group had slightly more males (24 vs. 18), but the p-value (0.263) suggests no significant difference.
• Comorbidities: Patients could have multiple comorbidities, with diabetes, hypertension, and none reported. The distribution was comparable (p=0.627).
• ASA Grade: The ASA grades (1 and 2) showed no significant difference (p=0.46), though there is a noted discrepancy in totals for the 2-port group (10 + 31 = 41 > 40), which may indicate a typographical error in the original data. However, the p-value suggests comparability.
• Ultrasound Features: The distribution of acute cholecystitis, cholelithiasis, and chronic cholecystitis was similar, though a p-value was not provided, it aligns with the overall comparability of groups.

This section confirms that the randomization was effective, with both groups starting with similar baseline characteristics, which is crucial for valid comparisons in surgical outcomes.

1. Intra-operative Features

The intra-operative phase assessed various surgical parameters, with a notable finding being the shorter operative time for the 2-port group. Other intra-operative events showed no significant differences, indicating similar procedural safety.

Table 2: Intra-operative Outcomes

Description:

• Operative Time: The 2-port group had a significantly shorter mean operative time (72.2 minutes vs. 77.5 minutes, p=0.04), which is an unexpected benefit in terms of surgical efficiency, potentially reducing anesthesia time and associated risks.
• Additional Procedures: Additional trocar placement was needed in 2 patients in the 2-port group (5%), with no such need in the 4-port group (p=0.5). Additional suture placement was minimal and similar (2 patients each, p=1.0).
• Conversions: Two patients in the 2-port group required conversion to 4-port (5%), and two in each group needed conversion to open surgery (5%, p=1.0), indicating low and comparable conversion rates.
• Complications: Iatrogenic gallbladder (GB) perforation occurred in 5 patients in the 2-port group and 3 in the 4-port group (p=0.71), with no significant difference. Requirement of drains and bleeding from the liver bed were also similar (p=0.74 and p=1.0, respectively).
• Safety Profile: No major bile duct injuries or other visceral injuries were reported in either group, highlighting the safety of both approaches.

This section underscores the efficiency of the 2-port method in terms of operative time, with comparable safety profiles for intra-operative complications.

1. Post-operative Outcomes

Post-operative outcomes revealed significant advantages for the 2-port LC group, particularly in pain management, hospital stay, scar cosmesis, and recovery milestones. These findings suggest improved patient experience and potentially reduced healthcare costs.

Table 3: Post-operative Outcomes

Description:

• Analgesic Use: The 2-port group required significantly fewer analgesic doses (1.6 vs. 2.25, p=0.001), indicating better pain management post-operatively.
• Length of Stay: Hospital stay was significantly shorter in the 2-port group (3.90 days vs. 4.88 days, p=0.001), which could reduce healthcare costs and improve patient satisfaction.
• Scar Cosmesis: Assessed using the Patient and Observer Scar Assessment Scale (POSAS), both patient scores (15.83 vs. 19.85, p=0.001) and observer scores (17.78 vs. 23.45, p=0.002) were significantly better for the 2-port group, suggesting improved aesthetic outcomes.
• Pain Scores: Visual Analogue Scale (VAS) pain scores were consistently lower in the 2-port group at all measured intervals (2 hours, 4 hours, 12 hours, 24 hours, and 48 hours), with p-values ranging from 0.03 to 0.003, indicating reduced post-operative pain.
• Recovery Milestone: Time to resume oral feeds was significantly earlier in the 2-port group (6.85 hours vs. 8.95 hours, p=0.046), facilitating faster recovery.

These findings highlight the potential benefits of the 2-port approach in enhancing post-operative recovery, which could be particularly important for patient quality of life and healthcare resource utilization.

Ensuring comparability between groups is crucial for valid comparisons. Our study reported mean ages of 36.63 ± 10.98 years for four-port and 40.9 ± 11.2 years for two-port (p = 0.089), with gender distributions of 45% male and 55% female versus 60% male and 40% female (p = 0.263). BMI was similar (23.50 ± 1.84 vs. 23.15 ± 3.15, p = 0.54), as were ASA grades (p = 0.46). Other studies, such as Mohil et al., also showed comparable demographics (e.g., mean age 40.79 ± 12.67 vs. 37.04 ± 11.6 years, p = 0.12), ensuring baseline matching. However, Brajesh B Gupta et al⁸. noted a significant BMI difference (20.43 ± 1.59 vs. 22.00 ± 2.71 kg/m², p = 0.0214), suggesting potential selection bias, which our study did not replicate.

Table 4

This table highlights the consistency in baseline matching across studies, with our study providing detailed metrics like BMI and ASA grades, enhancing robustness.

Operative time is a key efficiency metric. Our study found a significant reduction for two-port LC (72.2 ± 10.6 minutes vs. 77.5 ± 12.32 minutes, p = 0.04), aligning with Poon et al⁹. (54.6 ± 24.7 vs. 66.0 ± 32.6 minutes, p = 0.04). However, Prem Chand et al¹⁰. reported a shorter time for four-port (44.76 ± 10.14 vs. 52.80 ± 14.43 minutes, p = 0.0017), and Mohil et al¹¹. found no difference (49.90 ± 21.37 vs. 51.31 ± 19.56 minutes, p = 0.727). These variations may stem from differences in surgical technique, such as the use of alligator graspers in Prem Chand et al¹⁰., or case complexity, with our study including 22.5% acute cholecystitis cases in the two-port group, potentially lengthening times compared to elective-focused studies.

Safety during surgery is paramount. Our study reported bleeding from the liver bed in 7.5% (two-port) vs. 10% (four-port, p = 1), gallbladder perforation in 12.5% vs. 7.5% (p = 0.71), and low conversion rates (5% to open in both, p = 1; 5% two-port to four-port, p = 0.5). No major bile duct injuries occurred. These findings align with Prem Chand et al¹⁰., who noted similar rates of adhesions (2% vs. 12%) and bleeding (4% both), and Mohil et al¹¹., with comparable bleeding (5.45% vs. 4.16%) and conversions (0.18% to open for two-port, 4.16% for four-port). Brajesh B Gupta et al⁸. reported higher bile spillage in four-port (47.8% vs. 8.7%, p = 0.0025), possibly due to technique differences. Overall, both techniques appear safe, with low complication rates.

Postoperative pain significantly impacts recovery. Our study found lower Visual Analogue Scale (VAS) scores for two-port LC at 2, 4, 12, 24, and 48 hours (e.g., 4.78 vs. 6.45 at 2 hours, p = 0.03; 2.70 vs. 4.45 at 24 hours, p = 0.016), with reduced analgesic doses (1.6 vs. 2.25, p = 0.001). This is consistent with Prem Chand et al. (e.g., 4.66 ± 0.98 vs. 5.44 ± 1.26 at 6 hours, p = 0.0008) and Mohil et al¹¹. (e.g., 6.56 ± 1.44 vs. 7.28 ± 1.04 at 2 hours, p = 0.006). The reduction is likely due to fewer incisions, minimizing abdominal wall trauma, a finding echoed across studies.

Cosmetic outcomes are patient-centered and crucial for satisfaction. Our study, using POSAS, reported better scores for two-port LC (patient score: 15.83 vs. 19.85, p = 0.001; observer score: 17.78 vs. 23.45, p = 0.002). Prem Chand et al. found higher cosmesis scores for two-port (7.11 ± 1.36 vs. 5.6 ± 1.30), and Mohil et al¹¹. reported 7.55 ± 1.28 vs. 5.90 ± 0.83 (p = 0.001). These results highlight the aesthetic advantage of fewer scars, enhancing patient satisfaction.

Recovery metrics vary. Our study found a shorter hospital stay for two-port LC (3.90 vs. 4.88 days, p = 0.001) and earlier oral feed resumption (6.85 vs. 8.95 hours, p = 0.046). However, Prem Chand et al¹⁰. reported no significant difference (2.25 ± 0.66 vs. 2.10 ± 0.53 days), and Mohil et al¹¹. Found similar stays (25.52 ± 8.42 vs. 24.91 ± 11.77 hours,

p = 0.76). Mohil et al¹¹. Noted faster return to daily activities for two-port (4.25 vs. 5.17 days, p = 0.001), a metric not detailed in our study but implied by shorter stays. These differences may reflect discharge protocols or patient complexity, with our broader inclusion (e.g., acute cases) potentially influencing longer stays.

Postoperative complications were minimal and comparable. Our study showed no significant differences in gallbladder perforation (12.5% vs. 7.5%, p = 0.71) or drain use (10% vs. 15%, p = 0.74), with no major visceral injuries. Mohil et al¹¹. reported a single bile duct injury in two-port (1.81%), rare and not technique-specific. Prem Chand et al. and Brajesh B Gupta et al. also found low rates, reinforcing safety for both techniques.

The evidence leans toward two-port LC as a safe, effective alternative to four-port LC, with consistent benefits in postoperative pain and cosmesis. Our study extends these to shorter hospital stays and operative times in some contexts, potentially due to refined techniques and broader patient inclusion. Variations in operative time and recovery highlight the influence of surgeon experience, case complexity, and protocols. Future research should standardize metrics and explore long-term outcomes to optimize two-port LC adoption, particularly in elective settings where patient-centered benefits are pronounced.

Table 5: Summary of Key Findings across Studies

This table summarizes key metrics, highlighting consistencies (e.g., pain, safety) and variations (e.g., operative time, hospital stay), aiding in clinical decision-making.

Our study has shown that the two Port Technique of Laparoscopic cholecystectomy can be performed as day care procedure in cases of acute cholecystitis, cholelithiasis and chronic cholecystitis. And this technique can be learned and mastered after proper training from the specialists without causing any injury to Bile duct or viscera. Two Port Laparoscopic Cholecystectomy has better surgical outcome in terms of less postoperative pain, less requirement of analgesia, less intraoperative time and better cosmesis

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