Is smaller necessarily better? A systematic review comparing the effects of minilaparoscopic and conventional laparoscopic cholecystectomy on patient outcomes

Background: In recent years, minilaparoscopic cholecystectomy (MLC; total size of trocar incision <25 mm) has been increasingly advocated for the removal of the gallbladder, due to potentially better surgical outcomes (e.g., better cosmetic result, reduced pain, shorter hospital stay, quicker return to activity), but an evidence-based approach has been lacking. The current systematic review was undertaken to evaluate the importance of total size of trocar incision in improving surgical outcomes in adult laparoscopic cholecystectomy (LC). Methods: The literature was systematically reviewed using MEDLINE and EmBASE. Only randomized controlled trials in English, investigating minilaparoscopic versus conventional LC (total size of trocar incision ≥25 mm) and reporting pain scores were included. Quantitative analyses (meta-analyses) were performed on postoperative pain scores and other patient outcomes from more than one study where feasible and appropriate. Qualitative analyses consisted of assessing the number of studies showing a significant difference between the techniques. Results: Thirteen trials met the inclusion criteria. There was a trend towards reduced pain with MLC compared with conventional LC, without reduction in opioid use. Patients in the MLC group had slightly reduced length of hospital stay, but there were no significant differences for return to activity. The two interventions were also similar in terms of operating times and adverse events, but MLC was associated with better cosmetic result (largely patient rated). There was a significantly greater likelihood of conversion to conventional LC or to open cholecystectomy in the MLC group than there was of conversion to open cholecystectomy in the conventional LC group [OR 4.71 (95% confidence interval 2.67-8.31), p < 0.00001]. Conclusions: The data included in this review suggest that reducing the size of trocar incision results in some limited improvements in surgical outcomes after LC. However, it carries a higher risk of conversion to conventional LC or open cholecystectomy.