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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 4  |  Page : 521-526

Comparison of single-incision and conventional laparoscopic cholecystectomy in terms of quality of life, body image, and cosmesis


1 Department of General Surgery, Gulhane Training and Research Hospital, Ankara, Turkey
2 Department of Surgery, Diskapi Yildirim Beyazit University, Training and Research Hospital, Ankara, Turkey
3 Department of Medical Biostatistics, Yildirim Beyazit University, Ankara, Turkey

Date of Acceptance10-Aug-2018
Date of Web Publication11-Apr-2019

Correspondence Address:
Dr. M Saydam
Department of Surgery, Diskapi Yildirim Beyazit University, Training and Research Hospital, Diskapi, Ankara - 06110
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_218_18

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   Abstract 


Background: Clinical studies indicate that single-incision laparoscopic cholecystectomy (SILC) has many advantages over conventional laparoscopic cholecystectomy (CLC), such as improved cosmesis, reduced postoperative pain, and shorter hospital stay. The aim of this study was to compare quality of life, body image, and cosmesis between single-incision laparoscopic and conventional laparoscopic approaches in patients undergoing cholecystectomies. Subjects and Methods: This retrospective study between SILC and CLC and was conducted among 58 patients undergoing SILC and CLC from January 2011 to March 2013 in Turkey. After the surgery, the EuroQol-5 Dimension Questionnaire (EQ-5D™), and body image questionnaire (BIQ) were administered to the patients. Results: Differences between the early and late postoperative scores in the EQ-5D were statistically significant (P < 0.001). Differences between most BIQ areas favored SILC, especially regarding cosmesis (P = 0.016); SILC patients had higher satisfaction with their scar's appearance. Conclusion: SILC is a promising alternative to traditional laparoscopic cholecystectomy in terms of quality of life, body image, and cosmesis in selected patients.

Keywords: Cholecystectomy, comparison, cosmesis, quality of life, single incision


How to cite this article:
Sinan H, Saydam M, Demir P, Ozer M T, Demirbas S. Comparison of single-incision and conventional laparoscopic cholecystectomy in terms of quality of life, body image, and cosmesis. Niger J Clin Pract 2019;22:521-6

How to cite this URL:
Sinan H, Saydam M, Demir P, Ozer M T, Demirbas S. Comparison of single-incision and conventional laparoscopic cholecystectomy in terms of quality of life, body image, and cosmesis. Niger J Clin Pract [serial online] 2019 [cited 2019 Apr 22];22:521-6. Available from: http://www.njcponline.com/text.asp?2019/22/4/521/255918




   Introduction Top


Laparoscopic surgery has been performed routinely worldwide for surgical diseases of the gallbladder for about three decades. Conventional laparoscopic cholecystectomy (CLC) has been one of the minimally invasive techniques and has become the gold standard surgical procedure for gallbladder removal since 1985.[1] Single-incision laparoscopic surgery is another minimally invasive technique that was first used in 1998.[2] Various clinical studies have indicated that single-incision laparoscopic cholecystectomy (SILC) has many advantages over CLC. These include improved cosmesis, reduced postoperative pain, and shorter hospital stay.


   Subjects and Methods Top


Study design

This retrospective clinical study was conducted in 2013 with the patients undergoing SILC and CLC between January 2011 and March 2013 in Gulhane Military Medical Academy, Turkey. The study protocol was approved by the local Ethics Council (number 1648. 4-70), and registered on ClinicalTrials.gov (ID number NCT02417857). Detailed files of the patients who had undergone surgery by these two techniques were obtained from hospital archives through the patients' communication numbers, and the patients were contacted. The patients were invited to the hospital to participate in a survey. Fifty-eight patients who had undergone surgery[3] were divided into two groups: 28 patients who underwent SILC (designated as Group 1) and 30 patients who underwent CLC (designated as Group 2). All study participants received detailed information about the study and confirmed their willingness to participate via a written consent form.

Obtaining ınformation from the questionnaires

Questionnaires were used to compare postoperative quality of life, body image, and cosmesis between the subjects who underwent SILC and those who underwent CLC. All of the questionnaires were administered on the 10th postoperative day (early period) and at 12 months after surgery (late period). The information was gathered from inpatients directly or via telephone. Quality of life was the primary endpoint of this study and was evaluated by the EuroQol-5 Dimension Questionnaire (EQ-5D™) consisting of six questions. The first five questions cover the EQ descriptive system (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression). The purpose of the sixth question is to obtain the EQ self-determination of the person's health status. In this part, the individual gives a value between 0 (worst) and 100 (maximum well-being) by marking it on a visual analog scale to evaluate the patient's current health status.

The secondary endpoint of the present study concerned cosmesis and was evaluated by the body image questionnaire (BIQ).[2],[4] The BIQ consists of questions that investigate the attitude of patients toward their bodily appearance [body image scale (BIS), questions 1 to 5], their degree of satisfaction with the appearance of the scar [cosmesis scale (CS) questions 6–8], and their self-confidence (questions 9–10). In this questionnaire, a higher score indicates greater patient satisfaction.

Power and sample size

Power and sample size were calculated by G*Power (G*Power, Ver. 3.0.10, Universität Kiel, Kiel, Germany; http://www.psycho.uni-dusseldorf.de/aap/projects/gpower/). To obtain 95% power from this study, with f = 0.25 effect width, and α = 0.05 type I error and β = 0.05 type II error ratios, it was calculated that at least 27 patients must be assigned to each group for every single repeat for obtaining twice-repeated questionnaire scores. Because of the follow-up time, and for preventing possible onward data loss, three substitute patients were added to each group. Two patients in Group 1 did not want to continue their participation in the study, so the study was completed with 58 patients: 28 patients in Group 1 (SILC) and 30 patients in Group 2 (CLC).

Statistical analysis

Conformity to the normal distribution for the age variables was assessed by the Shapiro–Wilks test. Number (n) and percentage age values were given in order to indicate the responses and gender distribution of individuals. Gender distribution differences in the groups were examined using Pearson's Chi-squared test. The independent samples' t-test was used in the assessment of similarity of the individuals' ages in the groups. Any differences in the EQ-5D index and percentage (6th question), and the BIQ results between the two periods in the SILC and CLC groups were calculated by nonparametric analysis of longitudinal data in factorial experiments—nonparametric tests for the “F1_LD_F1 design.” The relative treatment effect (RTE) for binary comparison of the factors which had identified significant differences was evaluated. All statistical analyses and calculations were performed by IBM SPSS Statistics for Windows, version 21.0. (released 2012; IBM Corporation, Armonk, NY, USA) and MS-Excel 2007 (Microsoft Corporation, Redmond, WA, USA). A value of P < 0.05 was accepted as statistically significant.


   Results Top


The mean age in both groups was 46.2 ± 14.3 (20.0-79.0) years. The gender distribution of individuals in the groups (χ2 = 1.105; P = 0.293) and the mean age were statistically similar (t = 1.176; P = 0.245). Female patients constituted 57.1% of the patients who underwent SILC (n = 16) and 43.3% of the patients who underwent CLC (n = 13).

Differences in the overall responses of the EQ-5D percentage and values of the EQ-5D index between groups were not found to be statistically significant [Table 1]. The overall time difference between groups was measured by underestimating the time value and is shown in the “Group” column. Conversely, the calculations of the differences between the early and the late period were measured by underestimating the groups and are shown in the “Period” column. In this study, the early and late period values were found to be statistically significant [Table 1]. The statistical differences in the changes of the time-dependent groups were analyzed in the “Group and Period” column [Table 1]. Time-dependent changes in the groups were not statistically significant in this study [Table 1]. The EQ-5D index values obtained from both the SILC and CLC groups in the late period were significantly higher [Table 2]; [Figure 1]. The EQ-5D percentage distribution in the late period was significantly higher than in the early period [Table 2]. The changes were similar in both groups [Figure 1].
Table 1: The comparison of the EQ-5D index and EQ-5D question 6 in terms of groups and periods*

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Table 2: RTE of EQ-5D index and percentages for groups and periods

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Figure 1: Periodic changes of RTE for EQ-5D index and percentage

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The interaction of the responses to BIQ question 1 was statistically significant [Table 3]. In general, considering the time-dependent and non-time-dependent changes in the groups, there was a statistically significant difference in favor of the overall late period. This rate was significantly higher in Group 1 than in Group 2 [Figure 2].
Table 3: Comparison of the body index questionnaire (BIQ) variables in terms of groups and periods*

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Figure 2: Periodic changes of RTE for BIQ questions 1-2-3-4 F

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The interactions of the responses to BIQ questions 2, 3, and 5 were not statistically significant. Likewise, there were no statistically significant differences between groups in the time periods [Table 3], [Figure 2] and [Figure 3].
Figure 3: Periodic changes of RTE for BIQ questions 5-6-7-8

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The interaction of the “Group and Period” from the responses of the BIQ 6th and 7th questions was determined to be statistically significant [Table 3]. Although there was an increase in both groups in favor of the late period for the responses to BIQ question 6, the increase in Group 1 was statistically significant, but the increase in Group 2 was not statistically significant [Figure 3]. There was an increase in both groups in favor of the late period for the responses to BIQ question 7; this increase was statistically significant for Group 1, whereas there was no statistically significant change for Group 2 [Figure 3].

The “Group and Period” interaction for the responses to BIQ questions 8 and 10 was determined to be statistically significant [Table 3]. There was an increase in both groups in favor of the late period for the responses to BIQ question 8; this increase was statistically significant for Group 1, whereas there was no statistically significant change for Group 2 [Figure 3]. There was an increase in both groups in favor of the late period for the responses to BIQ question 10; this increase was statistically significant for Group 1, whereas there was no statistically significant change for Group 2 [Figure 4].
Figure 4: Periodic changes of RTE for BIQ questions 9-10

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   Discussion Top


Surgeons are always seeking new techniques to provide greater benefits for both the patients and the providers. Of course, any improved techniques must primarily allow safety and uneventful recovery. Improved techniques also must yield less pain, reduced scarring, shorter operative time, and shorter hospital length of stay.[3] A constant desire for innovative surgical techniques has motivated researchers to develop new techniques for more minimally invasive surgery. As an outcome of this research, single-incision laparoscopic cholecystectomy was described.[5]

According to some researchers, SILC offers several advantages, such as reduced postoperative pain, reduced trauma to the abdominal wall, and virtually no scar.[6] In addition, single-incision surgery has the additional advantage of fewer ports. The fundamental reason for reducing the number of incisions is lowered risks from incisions, including morbidity from bleeding, the possibility of incisional hernia, and potential organ damage.[7]

The primary endpoint in this study was quality-of-life measures, which is an important parameter for comparing two surgical techniques.[8] According to the literature, which includes comparisons of SILC and CLC in terms of quality of life, higher results on the emotional scale favor the use of SILC.[9],[10],[11],[12],[13],[14] The current study did not establish SILC as statistically superior to CLC in terms of quality of life. However, patient satisfaction is a comprehensive topic with many components, some of which include what a patient expects from the surgery, and the outcome that might have resulted if the other technique had been used for the patient. Standardized methods of measuring patient satisfaction should be used in a randomized clinical trial with large sample size to compare satisfaction between patients undergoing SILC or CLC.[8]

The secondary endpoint in this study was cosmesis. In fact, the reason for the existence of single-incision surgery is improvement of cosmetic outcome. “Body image” is described as a person's perception of satisfaction with, and behavior toward, his or her body in general, and toward specific areas of the body.[2],[4] In this study, patient satisfaction was in favor of SILC regarding cosmesis and, in particular, self-confidence, especially in the late period. Therefore, it may be interpreted that the patients in the present study had more postoperative satisfaction regarding self-image after the SILC operation than after the CLC operation. Eight meta-analyses also showed that SILC produced a better cosmetic score than CLC.[6] On the contrary, some studies have suggested that SILC has only a small cosmetic benefit compared with CLC.[15] SILC provides a good satisfactory result for the umbilicus, because the umbilicus is centrally located in the abdomen. Closure of the incision heals without obvious scarring due to the hidden incision in the umbilicus; the “hidden” SILC umbilical incision is not noticeable like the CLC umbilical incision.

The other satisfactory result in this study was that the self-confidence section of the BIQ was in favor of SILC group. This result was most probably due to the scar size. In our opinion, when the patients see their “scarless skin,” they feel more whole. This is not at all to denigrate CLC, but there is undeniably more satisfaction with SILC in terms of cosmesis and patient self-confidence. On the other hand, when it comes to aspects of SILC other than cosmesis, more time may be needed for wide acceptance of SILC, as well as more studies with large numbers of patients to prove the other aspects to be comparable with CLC.

The present study focused on the areas of quality of life and cosmesis in the performance of SILC. In evaluating aspects of SILC other than cosmesis, such as cost-effectiveness, operating time, and learning curve, a longer study period and a larger number of patients are needed to lead to the wide acceptance of SILC and to prove that the results of SILC are comparable to those of CLC.


   Conclusion Top


In conclusion, this study results showed that patients who underwent SILC had better satisfaction with the appearance of their scar; this seems to be the major advantage of SILC as found in the current study. SILC is a promising alternative to CLC in selected patients. Further prospective studies in large patient populations are needed to more fully assess the advantages of SILC over CLC.

Acknowledgements

Thanks to Marilyn Carlson for her editorial assistance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Litynski GS. Highlights in the History of Laparoscopy. Frankfurt, Germany: Barbara Bernert Verlag; 1996. p. 165-8.  Back to cited text no. 1
    
2.
Dunker MS, Bemelman WA, Slors JF, Van DP, Gouma DJ. Functional outcome, quality of life, body image, and cosmesis in patients after laparoscopic-assisted and conventional restorative proctocolectomy: A comparative study. Dis Colon Rectum 2001;44:1800-7.  Back to cited text no. 2
    
3.
Sinan H, Demirbas S, Ozer MT, Akyol M. Single-incision laparoscopic cholecystectomy versus laparoscopic cholecystectomy: A prospective randomized study. Surg Laparosc Endosc Percutan Tech 2012;22:12-6.  Back to cited text no. 3
    
4.
Sucullu I, Filiz AI, Canda AE, Yucel E, Kurt Y, Yildiz M. Body image and cosmesis after laparoscopic or open appendectomy. Surg Laparosc Endosc Percutan Tech 2009;19:401-4.  Back to cited text no. 4
    
5.
Navarra G, Pozza E, Occhionorelli S, Carcoforo P, Donini I. One-wound laparoscopic cholecystectomy. Br J Surg 1997;84:695.  Back to cited text no. 5
    
6.
Geng L, Sun C, Bai J. Single incision versus conventional laparoscopic cholecystectomy outcomes: A meta-analysis of randomized controlled trials. PloS One 2013;8:e76530.  Back to cited text no. 6
    
7.
Hirano Y, Watanabe T, Uchida T, Yoshida S, Tawaraya K, Kato H, et al. Single-incision laparoscopic cholecystectomy: Single institution experience and literature review. World J Gastroenterol 2010;16:270-4.  Back to cited text no. 7
    
8.
Khorgami Z, Shoar S, Shoar N, Shakoor D, Mahdavian S, Nasiri S, et al. Single ıncision laparoscopic surgery: Review of pros and cons. Acad J Surg 2014;1:25-32.  Back to cited text no. 8
    
9.
Markar SR, Karthikesalingam A, Thrumurthy S, Muirhead L, Kinross J, Paraskeva P. Single-incision laparoscopic surgery (SILS) vs. conventional multiport cholecystectomy: Systematic review and meta-analysis. Surg Endosc 2012;26:1205-13.  Back to cited text no. 9
    
10.
Sajid MS, Ladwa N, Kalra L, Hutson KK, Singh KK, Sayegh M. Single-incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy: Meta-analysis and systematic review of randomized controlled trials. World J Surg 2012;36:2644-53.  Back to cited text no. 10
    
11.
Ahmed K, Wang TT, Patel VM, Nagpal K, Clark J, Ali M, et al. The role of single-incision laparoscopic surgery in abdominal and pelvic surgery: A systematic review. Surg Endosc 2011;25:378-96.  Back to cited text no. 11
    
12.
Song T, Liao B, Liu J, Yin Y, Luo Q, Cheng N. Single-incision versus conventional laparoscopic cholecystectomy: A systematic review of available data. Surg Laparosc Endosc Percutan Tech 2012;22:e190-6.  Back to cited text no. 12
    
13.
Hall TC, Dennison AR, Bilku DK, Metcalfe MS, Garcea G. Single-incision laparoscopic cholecystectomy: A systematic review. Arch Surg 2012;147:657-66.  Back to cited text no. 13
    
14.
Ellatif ME, Askar WA, Abbas AE, Noaman N, Negm A, El-Morsy G, et al. Quality-of-life measures after single-access versus conventional laparoscopic cholecystectomy: A prospective randomized study. Surg Endosc 2013;27:1896-1906.  Back to cited text no. 14
    
15.
Hey J, Roberts KJ, Morris-Stiff GJ, Toogood GJ. Patient views through the keyhole: New perspectives on single-incision vs. multiport laparoscopic cholecystectomy. HPB (Oxford) 2012;14:242-6.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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