This study was done to compare postoperative pain after cholecystectomy done by single incision laparoscopic surgery (SILS) versus conventional four port laparoscopy.

1. Post Operative Pain after Cholecystectomy: Conventional
Laparoscopy Versus Single Incision Laparoscopic Surgery (SILS)

2. Original Article
POST OPERATIVE PAIN AFTER CHOLECYSTECTOMY: CONVENTIONAL LAPAROSCOPY
VERSUS SINGLE INCISION LAPAROSCOPIC SURGERY (SILS)
A Prasad, KA Mukherjee, S Kaul and M Kaur
Department of Minimal Access Surgery, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India.
Correspondence to: Dr Arun Prasad, Department of Minimal Access Surgery, Indraprastha Apollo Hospitals,
Sarita Vihar, New Delhi 110 076, India.
e-mail: surgerytimes@gmail.com
Background: This study was done to compare postoperative pain after cholecystectomy done by single
incision laparoscopic surgery (SILS) versus conventional four port laparoscopy. Methods: 100 patients
undergoing cholecystectomy for symptomatic gall stones who were willing to be part of this comparison were
included in the study. Patients were randomized into two groups of 50 each. Only conventional instruments
were used in both groups to keep the cost of surgery same. No special ports, roticulating instruments or flexible
telescopes were used. Pain score was checked after 6 hours of surgery using a visual analogue score.
Results: We observed that there was no statistically significant difference in overall post operative pain. But on
further analysis, we found significant difference in post operative pain score in latter half of our series of SILS
when compared to conventional laparoscopic cholecystectomy and also the first half of the SILS group. There
was also significant difference between operative times in earlier and latter half of SILS. Conclusion: Single
incision laparoscopic surgery is a feasible and a promising method for cholecystectomy. It is possible to do this
procedure with out using special equipment. Although there was no significant difference in overall
postoperative pain, there is a possibility that after the initial learning curve, when the operative time reduces,
the postoperative pain may also decrease. More studies are needed.
Keywords: Laparoscopy, Cholecystectomy, Single Incision Laparoscopic Surgery (SILS).
INTRODUCTION
Laparoscopic cholecystectomy has replaced open
cholecystectomy as the gold standard surgical procedure
for majority of patients of gall stone disease [1].
Conventional laparoscopic Cholecystectomy is being
performed using 4 ports. There was a continuous effort to
minimize the number of ports, and finally single incision
laparoscopic surgery (SILS) came into practice [2].
Single incision laparoscopic surgery is a rapidly
evolving method that is complementing traditional
laparoscopy in selected fields and patients [3,4]. It has also
been suggested as a bridge between traditional
laparoscopy and natural orifice transluminal endoscopic
surgery [5].
Single incision laparoscopic surgery utilizes three ports
through the single skin incision at umbilicus [6]. It is being
considered as no scar surgery, because the incision is
placed within the umbilical scar that is not visible [7,8].
SILS has also decreased post operative pain in some
studies [9]. Many special instruments [6] and ports [10,11]
are available now for SILS. Technical modifications like
Apollo Medicine, Vol. 7, No. 2, June 2010
124
puppeteering of the gall bladder with a suture have been
done [12]. We however performed SILS cholecystectomy
using only conventional laparoscopic instruments. The
study compared SILS and conventional laparoscopic
cholecystectomy for post operative pain.
METHODS
Study was done at Indraprastha Apollo Hospital, New
Delhi, India from 1st October 2009 to 31st March 2010.
100 patients undergoing cholecystectomy for
symptomatic gall stones who were willing to be part of
this comparison were included in the study. Patients were
randomized into two groups of 50 each.
Inclusion criteria
Patient with symptomatic cholelithiasis and fit for
general anesthesia
Exclusion criteria
Patient unwilling to participate in the study
Acute cholecystitis
Abnormal liver function tests

3. Original Article
Contracted gall bladder on ultrasound
Thickened gall bladder wall on ultrasound
Suspicion of gall bladder carcinoma
While the above exclusion criteria are not always
contraindications for laparoscopic cholecystectomy, they
were excluded from the study as the focus was on post
operative pain and not feasibility in difficult operative
situations which could be the topic of a future study once
the benefits are established.
The name of the procedure was kept in a sealed
envelope that was opened after the patient was
anaesthetized. Only conventional instruments were used
in both groups to keep the cost of surgery same. No special
ports, roticulating instruments or flexible telescopes were
used.
A standard 4 port cholecystectomy was done for the
conventional group.
For the SILS group, a 2 cm transverse incision was
made at the level of umbilicus. Upper skin flap was raised
for a distance of 1 cm. After initial insufflation with Veress
needle, a 10 mm cannula was inserted at the incision line
and the two 5 mm cannulas half cm inferiorly and laterally
on both sides through the same incision (Fig.1). A grasper
introduced through the right lateral cannula did fundus
traction. The left lateral cannula was used for introduction
of the dissector to define Calot’s triangle (Fig.2). The
instrument cannulas and telescope cannula were crossed
by a chop stick method (Fig.3) to avoid sword fighting and
clashing of instruments in the abdomen. We started the
procedure with 10 mm laparoscope and later shifted to a 5
mm scope from the left lateral cannula to insert the 10 mm
clip applicator from the central cannula for clipping of the
cystic duct and artery. After dissection from the liver bed
and hemostasis, the gall bladder was delivered from the
central port site. Fascial defects were closed meticulously
and skin apposed.
Pain score was checked 6 hours after surgery using a
visual analogue score. Post operative analgesia was the
same for all patients in the form of injection Diclofenac
Sodium 75 mg given every12 hours.
Statistical analysis
A member of the team who did not know about
procedure performed on the patient did the statistical
analysis.
RESULTS
100 consecutive patients undergoing cholecystectomy
were taken for study and they were divided into two
groups having 50 patients in each group.
Group A – Conventional laparoscopy
Group B – Single incision laparoscopic surgery (SILS)
Patients were in between 19 to 57 years old. We had 21
male and 29 female patients in group A (conventional) and
Fig.1
125
Apollo Medicine, Vol. 7, No. 2, June 2010

4. Original Article
SILS group. In the first 25 patients of SILS, the mean pain
score was 1.9 which was not only higher than the mean
pain score of SILS group but also higher than
conventional group. Post operative pain was less in the
latter 25 patients of SILS group with a mean score of
1.6 (p value <0.05) in comparison to both conventional as
well as first half of SILS group.
Another finding in our study is change in operative
time in SILS group. Mean operative time in conventional
laparoscopy group was 28.08±1.35 while in SILS group it
was 66.76±5.78 minutes. Operative time (OT) in SILS
group varied grossly between earlier cases and latter
cases. In first 25 cases mean OT was 79.2 but in later half
it come down to 54.32 which is a significant decrease
(p value <0.001) (Table 1).
There were no conversions from SILS to conventional
laparoscopic cholecystectomy or conversion to open
surgery.
DISCUSSION
Fig.2
SILS is not a new concept, and was described as early
group B (SILS) comprised of 26 male and 24 female
patients. The average BMI was 27.3 and 27.7 respectively.
The two groups were statistically matched (Table 1).
We tabulated the pain score in both groups (Table 2).
The mean pain score was more in the conventional
laparoscopy group (1.78) compared to the SILS group
(1.7) but that difference was not statistically significant.
We observed that pain score was not evenly distributed in
Fig.3
Apollo Medicine, Vol. 7, No. 2, June 2010
126
Table 1. Age, sex and BMI distribution
Age
Male
Female BMI
Group A (conventional
Laparoscopic
cholecystectomy)
37.5
21
29
27.3
Group B (SILC)
38.1
26
24
27.7

5. Original Article
Table 2. Mean post operative pain score in different groups of patient
Number of
patients
Mean
pain score
P value
( t test )
Statistically
significant
Group A (Conventional)
50
2.78
0.16
No
Group B (SILS)
50
2.64
First Half (SILS)
25
2.84
0.02
Yes
Second Half (SILS)
25
2.48
Group A (Conventional)
50
2.78
0.04
Yes
Second Half (SILS)
25
2.48
Table 3. Mean operative time in different groups of patient
Group A
(Conventional
Lap Chole)
Group B
SILS
(Total)
Early
Half
Later
Half
Number of patient
50
50
25
25
Mean operative time
28.08 ± 1.35
66.76 ± 5.78
79.2
54.32
as 1992 by Pelosi, et al [2] who performed a singlepuncture laparoscopic appendectomy. First experiences
with SILS cholecystectomy were reported by Navarra,
et al in 1997 [3] and with a different approach by Piskun
and Rajpal in 1999 [4].
In recent years, SILS has been focused upon as a
bridge between Natural orifice transluminal endoscopic
surgery (NOTES) and traditional laparoscopic surgery [5].
NOTES is a technically challenging procedure and current
instruments need to be further improved [13]. SILS, on the
other hand, enables the application of a wide range of
already existing instruments. The main point for reducing
the number of incisions has not only been the cosmetic
advantage but also lowered incision risks, morbidity of
bleeding, incisional hernia, and organ damage. But
benefits regarding post operative pain in SILS has not
been confirmed. There were some studies that indicate
reduction in post operative pain [9] but those are small and
not sufficient to come to a conclusion.
Most of the available special ports and flexible
instruments are costly and disposable thereby increasing
the cost of the procedure significantly. In our series we
used only traditional laparoscopic instrument and
traditional ports. We did not use any specialized port,
rather we adopted different indigenous methods to prevent
air leak such as applying adhesive dressings, gauze soaked
with ointment etc around the cannulas.
The real challenge of SILS is to avoid conflict between
the operative instruments and the camera, to maintain the
pneumoperitoneum and reduce operative stress. As a
result of the limited space with using only a single
incision, it is difficult for both the surgeon and the
assistant to work in the area [14]. We have developed a
chop stick method to minimize instrument and telescope
clash during the procedure.
In our study we had 100 patients who were randomly
divided into two groups of 50 patients. Mean post
operative pain was less in SILS group but this was not
statistically significant. Operative time was higher in SILS
group which is comparable to the recently published series
[8,15]. In our early half of SILS series, the operative time
was more than latter half. We found that there was
significant difference in post operative pain between
earlier half and latter half of our SILS series. Post
operative pain is also significantly low if we compare
latter half of SILS group with traditional laparoscopic
series. So from these available data it is evident that post
operative pain may have some relation with operative
time. But it is also true that post operative pain was more in
patients of conventional laparoscopy group in compare to
later half of SILS although operative time is more in
second group. So to establish a mathematical relation
between these two variable (operative time and post
operative pain) a larger study is required. It is likely that
with increasing experience operative time as well as post
operative pain may decrease.
127
Apollo Medicine, Vol. 7, No. 2, June 2010

6. Original Article
Single-incision laparoscopic surgery for gall bladder
removal is a feasible and promising method for the treatment of symptomatic cholelithiasis [16]. This surgery can
be performed with traditional re-usable laparoscopic
instruments [17]. With experience the operative time is
expected to become comparable with conventional
laparoscopic cholecystectomy. Our study did not show
any difference in post operative pain after SILS compared
to standard laparoscopy but we feel that expertise and
reduction of operative time may reduce post operative
pain. No special telescopes, ports or hand instruments are
needed for this procedure but may have a role in advanced
laparoscopic procedures.
8. Hong TH, You YK, Lee KH. Transumbilical single-port
laparoscopic cholecystectomy: scarless cholecystectomy. Surg Endosc 2009; 23: 1393-1397.
9. Kurpiewski W, Pesta W, Kowalczyk M, Glowacki L,
Juskiewicz W. SILS cholecystectomy – our first
experiences. Videosurgery and other miniinvasive
techniques 2009; 4 (3): 91-94.
10. Romanelli JR, Mark L, Omotosho PA. Single port
laparoscopic cholecystectomy with the TriPort system: a
case report. Surg Innov 2008; 15: 223-228.
11. Merchant AM, Cook MW, White BC, Davis SS, Sweeney
JF, Lin E. Transumbilical Gelport access technique for
performing single incision laparoscopic surgery (SILS). J
Gastrointest Surg 2009; 13: 159-162.
REFERENCES
1. Johnson, CD. ABC of the upper gastrointestinal tract
Upper abdominal pain: Gall bladder. Br Med Journal
2001; 323:1170-1173.
2. Pelosi MA, Pelosi MA. Laparoscopic appendectomy
using a single umbilical puncture (minilaparoscopy). J
Reprod Med 1992; 37: 588-594.
3. Navarra G, Pozza E, Occhionorelli S, Carcoforo P, Donini
I. One-wound laparoscopic cholecystectomy. Br J Surg
1997; 84: 695.
4. Piskun G, Rajpal S. Transumbilical laparoscopic
cholecystectomy utilizes no incisions outside the umbilicus. J Laparoendosc Adv Surg Tech. 1999; 9: 361-364.
12. Chow A, Purkayastha S, Aziz O, Paraskeva P.
Single-incision
laparoscopic
surgery
for
cholecystectomy: an evolving technique. Surg Endosc.
2010; 24:709-714.
13. Marescaux J, Dallemagne B, Perretta S, Wattiez A,
Mutter D, Coumaros D. Surgery without scars: report of
transluminal cholecystectomy in a human being. Arch
Surg 2007; 142: 823-827.
14. Ishikawa N, Arano Y, Shimizu S, et al. Single incision
laparoscopic surgery (SILS) using cross hand technique.
Minim Invasive Ther Allied Technol. 2009;18:322-324.
5. Bresadola F, Pasqualucci A, Donini A, et al. Elective
transumbilical compared with standard laparoscopic
cholecystectomy. Eur J Surg. 1999; 165(1): 29-34.
15. Kuon Lee S, You YK, Park JH, Kim HJ, Lee KK, Kim DG.
Single-port transumbilical laparoscopic cholecystectomy: a preliminary study in 37 patients with
gallbladder disease. J Laparoendosc Adv Surg Tech A
2009; 19: 495-499.
6. Tacchino R, Greco F, Matera D. Single-incision
laparoscopic cholecystectomy: surgery without a visible
scar. Surg Endosc 2009; 23: 896-899.
16. Ersin S, Firat O, Sozbilen M. Single-incision laparoscopic
cholecystectomy: is it more than a challenge? Surg
Endosc 2010; 24: 68-71.
7. Cuesta MA, Berends F, Veenhof AA. The “invisible chole
cystectomy”: A transumbilical laparoscopic operation
without a scar. Surg Endosc 2008; 22: 1211-1213.
17. Cugura JF, Jankoviæ J, Kulis T, Kirac I, Beslin MB. Single
incision laparoscopic surgery (SILS) cholecystectomy:
where are we? Acta Clin Croat 2008; 47: 245-248.
Apollo Medicine, Vol. 7, No. 2, June 2010
128

7. A o oh s i l ht:w wa o o o p a . m/
p l o p a : t / w .p l h s i lc
l
ts p /
l
ts o
T ie: t s / ie. m/o p a A o o
wt rht :t t r o H s i l p l
t
p /w t c
ts
l
Y uu e ht:w wy uu ec m/p l h s i ln i
o tb : t / w . tb . a o o o p a i a
p/
o
o
l
ts d
F c b o : t :w wfc b o . m/h A o o o p a
a e o k ht / w . e o k o T e p l H s i l
p/
a
c
l
ts
Si s ae ht:w wsd s aen t p l _ o p a
l e h r: t / w .i h r.e/ o o H s i l
d
p/
le
A l
ts
L k d : t :w wl k d . m/ mp n /p l -o p a
i e i ht / w . e i c c a y o oh s i l
n n p/
i
n no o
a l
ts
Bo : t :w wl s l e l . /
l ht / w . t a h a hi
g p/
e tk t n