Original article / research Year :2022 Month : July-August Volume : 11 Issue : 3 Page : SO09 - SO13 Full Version Three-port Versus Four-port Laparoscopic Cholecystectomy- An Interventional Prospective Study in Public Sector Hospitals T Yuvaraj, KS Manikanta, G Monisha, Mir Md Noorul Hassan 1. Junior Resident, Department of General Surgery, Bangalore Medical College and Research Institute, Bangalore, Karnataka, India. 2. Assisstant Professor, Department of General Surgery, Bangalore Medical College and Research Institute, Bangalore, Karnataka, India. 3. Junior Resident, Department of General Surgery, Bangalore Medical College and Research Institute, Bangalore, Karnataka, India. 4. Professor, Department of General Surgery, Bangalore Medical College and Research Institute, Bangalore, Karnataka, India.   Correspondence Address : Dr. KS Manikanta, Assistant Professor, Department of General Surgery, Bangalore Medical College and Research Institute Fort, K.R. Road Bangalore-560002, Karnataka, India. E-mail: dr.manisurg@gmail.com   ABSTRACT : Introduction: Cholelithiasis is a common ailment and affects about 10% of general population. Currently, the vast majority of operations for cholelithiasis are performed using laparoscopic techniques. Aim: To compare the three-port laparoscopic cholecystectomy with conventional four-port laparoscopic cholecystectomy. Materials and Methods: A prospective interventional study was conducted on 180 cases admitted to the hospitals attached to BMCRI, Bengaluru, from November 2018 to November 2020. The clinical profile of each patient was noted. The cases were confirmed by ultrasonography and they were randomised into two groups. One group underwent three-port laparoscopic cholecystectomy and the other group underwent four-port laparoscopic cholecystectomy. Intraoperative complications, conversion rates, postoperative pain, postoperative complications and duration of stay in the hospital were compared. Statistical data was analysed using Statistical Package for Social Sciences (SPSS) version 20.0 and data was compared using Chi-square test. Results: Most of the participants were from 31-40 years (45.6%, 44.4%) in both the groups, more common in females. The mean duration of surgery in three-port and four-port group was 30.43±15.964 and 36.81±15.592 minutes, respectively. Out of 90 (100%), 56 (62.2%) in three-port group had Visual Analogue Scale (VAS) score 2 and 66 (73.3%) in four-port group had VAS score 3 (?2=71.34; p=0.001). Conversion rates to open cholecystectomy were almost similar in both the groups. Hospital stay was also similar in both groups. Conclusion: A three-port laparoscopic cholecystectomy had lesser operating time and lesser analgesics requirement with similar intra and postoperative complication when compared to four-port laparoscopic cholecystectomy. Keywords : Cholelithiasis, Chronic calculous cholecystitis, Gall bladder DOI and Others : DOI: 10.7860/IJARS/2022/53473.2804 Date of Submission: Nov 28, 2021 Date of Peer Review: Jan 08, 2022 Date of Acceptance: Jan 28, 2022 Date of Publishing: Jul 01, 2022 AUTHOR DECLARATION: • Financial or Other Competing Interests: None • Was Ethics Committee Approval obtained for this study? Yes • Was informed consent obtained from the subjects involved in the study? Yes • For any images presented appropriate consent has been obtained from the subjects. NA PLAGIARISM CHECKING METH   INTRODUCTION Cholelithiasis is the most common biliary pathology, accounts for about 10% of world population. Most of the cholelithiasis patients are asymptomatic. The prevalence of gallstone varies widely in different parts of India. Prevalence in North India is two to four folds when compared to those in South India [1,2]. Changing pattern of the disease is due to westernisation and the availability of ultrasonography in both rural and urban areas. Around 3% of the asymptomatic patients will require cholecystectomy per year. Incidence of gallstone disease increases from 21 years and reaches a peak in 5th and 6th decade of life. Women are commonly affected than men. For gall stone disease that is symptomatic, laparoscopic cholecystectomy is a safe method of treatment. Laparoscopic cholecystectomy is the gold standard treatment for gallstone disease (2). Surgeons all over the world have refined the techniques in laparoscopic cholecystectomy by reducing the size and number of ports. One of the recent concept is Single Port Laparoscopic Surgery (SILS) (3). The concept of reducing the number of ports though has many advantages in terms of patient outcome such as improved wound healing and reduced morbidity, such techniques also have disadvantages such as lack of adequate exposure and overcrowding of instruments (4). A study on 132 patients showed that three-port laparoscopic cholecystectomy method did not require conversion to four-port technique in any of the cases, whereas a study on 710 patients reported that 55 cases required an fourth port intraoperatively [5,6]. The role of fourth port has been debatable and it has been mentioned that laparoscopic cholecystectomy can be performed safely with three-ports (7). The fourth port which is inserted midway between costal margin and the anterior superior iliac spine over the anterior axillary line can be inserted if the need arises [8,9]. Majority of public sector hospitals avoid three-port laparoscopic cholecystectomy, in spite of various studies showing an advantage of three-port technique over traditional four-port, this may be because of safety concern arising due to lesser number of ports. Thus, this study was conducted to compare the outcomes of three-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy in tertiary care public health hospital.     Material and Methods A prospective interventional study was conducted on inpatient basis at the General Surgery department in the hospitals attached to Bangalore Medical College and Research Institute, Bengaluru (Victoria hospital and Bowring and Lady Curzon hospital). Study period was from November 2018 to November 2020. Institutional ethical committee approval was taken (BMC/PG/124/2018-19). Sample size selected was 180 based on convenience sampling. The cases were confirmed by ultrasonography and they were randomised into two groups. One group (90) underwent three-port laparoscopic cholecystectomy and the other group (90) underwent four-port laparoscopic cholecystectomy. Inclusion criteria: Patients aged more than 18 years, diagnosed with chronic calculus cholecystitis by Ultrasonography (USG) and willing to give informed consent were included in the study. Exclusion criteria: Exclusion criteria were patients with acute cholecystitis/carcinoma gall bladder/common bile duct stones/empyema gall bladder. Study Procedure The method for the study included patients presenting with right upper pain abdomen, vomiting, fever, dyspepsia or jaundice. Patients with the above symptoms were studied clinically and investigated in detail as per the standard hospital protocol. Ultrasound of the abdomen was done for all patients. Routine haematological and biochemical investigations were done. Endoscopic Retrograde Cholangiopancreatography (ERCP) was done when indicated. All patients were randomised into two groups (three-port vs four-port) using simple randomisation application. All patients were given symptomatic treatment and Vitamin K for three days pre-operatively. Medically, fit patients were subjected to laparoscopic cholecystectomy. Intraoperative findings such as adhesion (based on visualisation of calot’s triangle, cystic duct, cystic artery, gall bladder dissection from liver bed it was classified into no, moderate and dense adhesion), time taken to complete the surgery, complications and conversion rates were noted. Variables like age, gender, symptoms, ultrasound findings (thickened Gall Bladder (GB) wall and GB distension), intraoperative findings (adhesions, bile spillage, drain placement, duration of surgery and open conversion) and postoperative findings (pain severity, pain duration and surgical site infection) were compared between three-port and four-port group. Postoperatively patients were followed-up for pain {Severity of pain was assessed using 10 cm long horizontal VAS, before administration of analgesic and assessed every 12th hourly to adjust the dosage of analgesia}, duration of hospital stays, and postoperative complications were noted (10). All cases were followed up for recurrent symptoms. B#BSTATISTICAL ANALYSISB?B Statistical analysis was done using SPSS version 20.0 using Chi-square test. The value of <0.05 was considered as statistically significant.     Results A prospective interventional study was conducted on inpatient basis at the General Surgery department in the hospitals attached to Bangalore Medical College and Research Institute, Bengaluru (Victoria hospital and Bowring and Lady Curzon hospital). Study period was from November 2018 to November 2020. Institutional ethical committee approval was taken (BMC/PG/124/2018-19). Sample size selected was 180 based on convenience sampling. The cases were confirmed by ultrasonography and they were randomised into two groups. One group (90) underwent three-port laparoscopic cholecystectomy and the other group (90) underwent four-port laparoscopic cholecystectomy. Inclusion criteria: Patients aged more than 18 years, diagnosed with chronic calculus cholecystitis by Ultrasonography (USG) and willing to give informed consent were included in the study. Exclusion criteria: Exclusion criteria were patients with acute cholecystitis/carcinoma gall bladder/common bile duct stones/empyema gall bladder. Study Procedure The method for the study included patients presenting with right upper pain abdomen, vomiting, fever, dyspepsia or jaundice. Patients with the above symptoms were studied clinically and investigated in detail as per the standard hospital protocol. Ultrasound of the abdomen was done for all patients. Routine haematological and biochemical investigations were done. Endoscopic Retrograde Cholangiopancreatography (ERCP) was done when indicated. All patients were randomised into two groups (three-port vs four-port) using simple randomisation application. All patients were given symptomatic treatment and Vitamin K for three days pre-operatively. Medically, fit patients were subjected to laparoscopic cholecystectomy. Intraoperative findings such as adhesion (based on visualisation of calot’s triangle, cystic duct, cystic artery, gall bladder dissection from liver bed it was classified into no, moderate and dense adhesion), time taken to complete the surgery, complications and conversion rates were noted. Variables like age, gender, symptoms, ultrasound findings (thickened Gall Bladder (GB) wall and GB distension), intraoperative findings (adhesions, bile spillage, drain placement, duration of surgery and open conversion) and postoperative findings (pain severity, pain duration and surgical site infection) were compared between three-port and four-port group. Postoperatively patients were followed-up for pain {Severity of pain was assessed using 10 cm long horizontal VAS, before administration of analgesic and assessed every 12th hourly to adjust the dosage of analgesia}, duration of hospital stays, and postoperative complications were noted (10). All cases were followed up for recurrent symptoms. B#BSTATISTICAL ANALYSISB?B Statistical analysis was done using SPSS version 20.0 using Chi-square test. The value of <0.05 was considered as statistically significant.     Discussion In the present study study, age distribution, gender distribution, symptomatology distribution, co-morbidities distribution and ultrasonography distribution between three-port and four-port group were statistically similar. Intraoperative findings like adhesion, gall bladder distension, bile spillage and conversion rate among the two groups were similar without any statistically significant differences. Intraoperative adhesions and bile spillage were the predominant reasons for conversion and the results were similar to Kumar P and Rana AKS, (9). A three-port laparoscopic cholecystectomy did not alter the rate of conversion as it was not statistically significant and it was in consistent with Singhal R et al., (11). Majority of the complications seen in three-port and four-port were dealt without any form of conversion. No major complications like vascular or bile duct injuries were seen in both the groups signifying that three-port laparoscopic cholecystectomy does not alter the rates of complications, it’s in agreement with Al-Azawi D et al., and Reshie TA et al., [8,12]. In the present study, three-port laparoscopic cholecystectomy took less time to finish the procedure than four-port laparoscopic cholecystectomy, probably this time difference may be attributed to the additional port insertion in four-port and it was in consistence with Harsha H et al., (44 mins for three-port and 47.6 minutes for four-port laparoscopic cholecystectomy) (13). Out of 90(100%) subjects in each group, 56 (62.2%) in three-port group had VAS score two and 66 (73.3%) in four-port group had VAS score three in consistence with Reshie TA et al., and Kumar M et al., [12,14]. Out of 90 (100%) subjects in each group, 43 (47.8%) in three-port group had three painful days and 55 (61.1%) in four-port group had four painful days which was similar to Reshie TA et al., and Kumar M et al., [12,14]. Duration of analgesia required is less in three-port group when compared with four-port group with statistically significant differences. Three-port laparoscopic cholecystectomy did not change the duration of hospital stay and the rates of postoperative complications in contrast with Kumar P and Rana AKS (9). Four studies show decrease operating time in three-port laparoscopic cholecystectomy when compared to four-port laparoscopic cholecystectomy which is consistent with the present study (Table/Fig 11). All 7 studies, show decrease postoperative pain in three-port over four-port laparoscopic cholecystectomy [8,9,11-15]. Thus, findings of previous studies are consistent with those of the present study. Based on the above studies, it may be recommended for surgeon to begin the procedure with the three-ports and the extra port can be added if needed. The surgeon performing three-port laparoscopic cholecystectomy should not hesitate to convert if the need arises and it should not be considered as failure of surgery. Patient’s safety is of utmost importance while performing either of the procedures. Limitation(s) The yielding results in our study may be due to the expertise of the surgeons in both three and four-port techniques, while this result may not be obtained with surgeons who are only trained in four-port techniques. Probably, this maybe the cause of variable operative duration in previous studies when compared to our study. This limitation can be overcome with training.     Conclusion Based on the present study, it can be concluded that three-port laparoscopic cholecystectomy, was as safe as four-port laparoscopic cholecystectomy. 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