Surgical Science, 2013, 4, 530-534
Published Online December 2013 (
Open Access SS
Comparison of Double-Incision Laparoscopic
Cholecystectomy and Needlescopic Cholecystectomy
Kenju Ko*, Shigetoshi Yamada, Ken Hayashi,
Akira Tsunoda, Hiroshi Kusanagi, Nobuyasu Kano
Department of Surgery, Kameda Medical Center Kamogawa, Chiba, Japan
Email: *
Received November 5, 2013; revised November 25, 2013; accepted December 2, 2013
Copyright © 2013 Kenju Ko et al. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In accordance of
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Purpose: Recently, reduced port surgery is becoming popular for laparoscopic surgery. “Reduced” means reducing the
size or number of ports, but it is controversial as to which procedure is better. We evaluated double-incision laparo-
scopic cholecystectomy (DILC) and needlescopic cholecystectomy (NC) as reducing number or size of ports, respec-
tively. Method: Patient records for 51 patients undergoing DILC and 22 patients undergoing NC were retrospectively
evaluated. The p atien t and operatio n r elated var iab les of DILC and NC were co mpared by ag e, gend er , body mass index
(BMI), operative time, blood loss, length of postoperative hospital stay, numerical rating scale (NRS) pain score, and
frequency to administer NSAIDs postoperatively for three days. Results: The operative times of both groups were simi-
lar (DILC 106 ± 31 min, NC 103 ± 35 min). Blood loss did not show any difference and each of them was small in
amount (DILC 14 ± 29 ml, NC 22 ± 31 ml). Length of postoperative hospital stay of DILC (3.2 ± 0.4 days) was signifi-
cantly shorter than that of NC (3.5 ± 0.7 days). Regarding postoperative pain, frequency to administer NSAIDs and pain
score for three days postoperatively showed no significant difference. Conclusion: It is thought that DILC and NC have
the same operative difficulty. As far as early postoperative pain was concerned, both procedures did not have any difference.
Keywords: Double Incision Laparoscopic Cholecystectomy; Single Incision Laparoscopic Cholecystectomy;
Thin Forceps; Needlescopic Cholecystectomy
1. Introduction
Recently, laparoscopic cholecystectomy (LC) by single
por t has come to be performed for cosmetic impro v e me n t.
Single-incision LC has been proved to be superior in
cosmetics, body image, and quality of life [1]. Mean-
while, single-incision LC has a disadvantage as a surgical
procedure in comparison with conventional LC. Some
devices, including additional ports, are often used to keep
safety. Additional devices or ports indicate a surgeon’s
carefulness, and not a failure to perform an elegant pro-
cedure [2,3]. We perform DILC, which has an additional
3.5 mm port with single-incision LC, for more safety.
On the oth er hand, thin fo rceps are often use d for cos-
metics without losing operability of conventional LC. We
also have performed NC because operative safety of LC
with thinner forceps than conventional LC is reported [4].
In our hospital, both DILC and NC are performed for
better cosmetics after all. It is thought that DILC is more
cosmetic but more difficult than NC. But it is not obv ious
that which procedure is superior because there are no re-
ports comparing with postoperative pain, operability, and
the others.
Therefore, we retrospectively analyzed and compared
clinical outcomes of DILC and NC.
2. Patients and Methods
2.1. Patients
In this retrospective study, data of 73 patients who had
undergone DILC or NC were analyzed. All patients were
treated between June 2010 and October 2012 at Kameda
Medical Center. The cases given a diagnosis as being
severe or moderate acute cholecystitis by the Tokyo
guidelines [5] or performed with some kind of preopera-
*Corresponding a uthor.
K. KO ET AL. 531
tive drainage were excluded. DILC and NC group in-
clude 51 case and 22 cases, respectively. Both group pa-
tients were completely informed ab out the technique and
had the opportunity to choose the conventional LC pro-
2.2. Methods
All procedures were performed by some experienced
surgeons who have been trained for more than three
years. Decision for the procedure either DILC or NC
depended on surgeon’s preference and experience.
In case of DILC, the operation was started by placing a
22 mm longitudin al incision through the u mbilicus. After
cutting fascia and peritoneum, multi-channel port
pan) was constructed. Additionally, a 3.5-mm port was
constructed at right hypochondrium (Figure 1).
In case of NC, the operation was started by placing a
smaller longitudinal incision than DILC through the um-
bilicus. A 12-mm umbilical port, a 5-mm subxyphoid
port, and two 3.5-mm hypochondriac ports were con-
structed (Figure 1).
In both procedures, epidural anesthesia was not given
and total 20 ml of 0.75% ropivacaine was injected into
each wound during the operation for relieving postopera-
tive pain. Postoperative pain was managed only with
non-steroidal anti-inflammatory drugs (NSAIDs) via the
oral or intravenous route if patient complained of pain.
The patient- and operation-related variables of DILC
and NC were retrospectively compared by age, gender,
body mass index (BMI), operative time, blood loss, length
of postoperative hospital stay, numerical rating scale
(NRS) pain score, and frequency to administer NSAIDs
postope ra t ively fo r 3 da ys.
Figure 1. DILC has a 22-mm umbilical multi-channel port
and 3.5-mm additional port at right hopochondrium. NC
has a 12-mm at umbilicus, a 5-mm at subxyphoid, and two
3.5-mm ports at hypochondrium.
2.3. Statistical Analysis
Results are expressed as means ± standard error of mean.
The statistical difference was determined by Student’s t
test or the Cochran-Cox test. Dichotomous variables of
independence were evaluated by the x2 test. The results
were considered significant when the P value were P <
3. Results
The DILC included 16 (31%) male and 35 (6 9%) female
with a median age of 55.9 ± 2.0 years, whereas 8 (36%)
male and 14 (64%) female were in the NC with a median
age of 57.7 ± 2.9 years. Comparison of each group never
showed a significant difference in gender and age. The
median BMI in the DILC was 23.9 ± 0.43 and in the NC
was 23.9 ± 0.70. Each preoperative severity of inflam-
mation (none/grade I) was 41/10 for DILC and 14/8 for
NC according to Tokyo guideline criteria for acute cho-
lecystitis (Table 1).
The operative times of each group (106 ± 4.4 min for
DILC vs. 103 ±7.5 min for NC) were similar. Blood loss
did not show any difference and each of them was small
in amount (14 ± 4.1 ml for DILC vs. 22 ± 6.6 ml for NC).
Length of postoperative hospital stay of DILC was sig-
nificantly shorter than NC (Table 2).
Regarding postoperative pain, frequency to administer
NSAIDs for postoperative three days showed no signifi-
cant difference as 2.0 ± 0.25 fo r DILC and 2.1 ± 0.47 for
NC. The pain score each day postoperatively for three
days did not have any difference although both of them
decrease as time passed (Figure 2).
One patient in DILC suffered wound infection of um-
bilicus and took treatment cons ervatively.
4. Discussion
Single-incision LC had been described even a decade ago
[6] and became popular with the recent development of
surgical technologies. Single-incision LC has less inci-
sion and higher cosmetic efficiency in comparison with
conventional LC. The high cosmetic value made sin-
gle-incision LC become more popular. On the other hand,
single-incision LC has the disadvantage of operative dif-
ficulty because of conflict between forceps. The proce-
dure becomes difficult to perform safely except for ex-
perienced surgeons.
It is still controversial regarding the advantages and
disadvantages although many reports compare between
single-incision and conventional LC [7 -11]. For now, the
significant difference has not statistically shown which
procedure is superior.
Convention al LC basically needs four ports in total in-
cluding three for manipulation and one for laparoscope.
Single-incision LC, however, has just two channels for
Open Access SS
Open Access SS
Table 1. Characteristics of the patients.
DILC (n = 51) NC (n = 22) P
Sex (male/fem ale) 16/35 8/14 0.68
Age (years) 55.9 ± 2.0 57.7 ± 2.9 0.31
BMI (kg/m2) 23.9 ± 0.43 23.9 ± 0.70 0.48
Tokyo guideline criteria for acute cholecystitis (none/grade I) 41/10 14/8 v
DILC: doubl e-incision laparo s copic c h ol ecystec t o my; NC: needlescopic cholecy s t ectomy.
Table 2. Comparison of the perioperative data.
DILC (n = 51) NC (n = 22) P
Operative time (min) 106 ± 4.4 103 ± 7.5 0.362
Blood loss (ml) 14 ± 4.1 22 ± 6.6 0.134
Length of postoperative hospital stay (days) 3.2 ± 0.06 3.5 ± 0.14 0.021
Frequency to administer NSAIDs for postoperative three days 2.0 ± 0 .25 2.1 ± 0.47 0.426
Pain score
Postoperative day 1 3.8 ± 0.30 3.3 ± 0.38 0.168
Postoperative day 2 2.8 ± 0.23 3.0 ± 0.30 0.251
Postoperative day 3 1.3 ± 0.25 1.7 ± 0.33 0.214
Complication (cases) 1 (wound infection) none
DILC: doubl e-incision laparo s copic c h ol ecystec t o my; NC: needlescopic cholecy s t ectomy; NSAIDs: non-steroidal anti-inflammatory drugs.
ventional LC [13-16]. A certain report described that
operation time became longer by thin forceps and the
other did not clarify the merit of thin forceps. However,
two systematic reviews concluded that LC with thin for-
ceps can be superior in pain and cosmetics compared
with conventional LC [17,18].
Briefly, even if the size of the port is reduced for cos-
metic purposes, the operability is secured by the same
number of usable forceps as conventional LC. We also
have performed LC changing the port 10 mm to 5 mm
and 5 mm to 3.5 mm as NC based on this concept. The
use of 3.5 mm forceps is an appropriate decision because
Tagaya concluded that the most important factor for re-
ducing operative time and achieving a low conversion
rate is the use of at least a 3 - 5 mm port for NC [19].
Figure 2. Relation of the pain score and postoperative days.
Both of pain score didn’t show any significant difference
although they decreased as time passed.
manipulation because the umbilical port has only three
channels in total. It is a natural consequence that single-
incision LC, operating through one port, became more
difficult because of a smaller number of forceps than
conventional LC. Some kind of supporting device such
as additional forceps or endoscopic retractors is some-
times used for this problem and we chose a thin 3.5 mm
forceps for assistance. It is reasonable to add a forceps
because single port LC has just only two usable forceps
for handling. It is reported that an additional forceps re-
duces difficulty of single-incision LC [12]. Furthermore,
we placed importance on cosmetics by using thinner 3.5
mm forceps than 5 mm for conventional LC.
There are not any reports that compared these different
operations (DILC and NC) in consideration for operabil-
ity and cosmetics. Our study never showed any differ-
ence by age, gender, BMI, and degree of preoperative
inflammation. The op erativ e ti me an d bloo d lo ss as index
of the operative difficulty did not show any difference.
This result showed that the operative difficulty of DILC
and NC was almost same. It has been reported [17] that
NC has longer operative time than conventional LC
while there is not the comparison the operative time be-
tween DILC and conventional LC. It is known that the
operative time of single incision LC is longer than con-
ventional LC [7]. But it is doubtful whether additional
forceps for single incision LC can shorten operative time
On the other hand, some trials downsizing ports are
reported without reducing the number of ports for con-
K. KO ET AL. 533
the same as conventional LC. Perhaps DILC is expected
having longer operation time in comparison with con-
ventional LC. Therefore, it is natural that DILC and NC
needed almost same operative time as a result of our
However, the surgeon’s experience had an effect on
the decision of operative procedure in our study, and it
might have caused no difference of operative time. The
amount of blood loss was a minimal and no differences
were seen in either procedure. It was supposed that DILC
and NC have almost same operative difficulty although
the surgeon’s experience differed between these proce-
Length of hospital stay of DILC group was signifi-
cantly shorter than NC, but th e cause is not clear because
NC had no complications which extended hospital stay.
For the case which is expected to be difficult, NC might
have been chosen because decision of the procedure de-
pended on surgeon’s preference and experience.
Regarding postoperative pain, single incision LC was
expected to be less painful because of a smaller number
of wounds than conventional LC at first. Recently, some
reports have shown that single incision LC is more pain-
ful than conventional LC [8,9]. However, there is no re-
port found including a comparative review about postop-
erative pain of DILC and NC like in our report. Our
study compared frequency of administrating NSAIDs
and pain scale for the evaluation of the pain and, as a
result, it did not show any significant difference.
There is a report that postoperative analgesia require-
ments for the LC with needlescopic instruments, which
has smaller ports, were 70% lower than for the conven-
tional LC [20]. It is expected that a slightly bigger wound
to construct multichannel port for DILC caused strong
pain, but our study showed a different result. The effect
of number or size of ports on postoperative pain remains
an open que st ion.
Regarding complications, no major complications oc-
curred and both procedures seemed to be almost safe.
5. Conclusion
It is thought that DILC and NC have the same operative
difficulties on account of no difference with operative
time and blood loss. Moreover, both procedures can be
performed safely without any serious complication. Re-
garding early postoperative pain, both procedures did not
show any difference.
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