The Science Behind Mini-Laparoscopic Cholecystectomy.

BACKGROUND: Mini-laparoscopy (Mini) was pioneered more than 20 years ago. Newer generation mini instruments have recently become available with improved effector tips, a choice of shaft diameters and lengths, better shaft insulation and electrosurgery capability, improved shaft strength and rotation, more ergonomic handles, low-friction trocar options, and improved instrument durability. Whether the use of mini instruments, particularly newer generation instruments, offers advantages for laparoscopic cholecystectomy is the subject of this review.

MATERIALS AND METHODS: The literature was searched for level I data comparing mini-laparoscopic cholecystectomy (Mini LC) to standard laparoscopic cholecystectomy (Std LC). Three systematic reviews and 19 randomized clinical trials were identified and these were studied to evaluate the science behind Mini LC.

RESULTS: Mini LC requires conversion to Std LC in 12.3% of patients. Mini LC and Std LC require conversion to open cholecystectomy at the same rate (2-3%). As compared to Std LC, Mini LC: (1) takes 3.4-4.9 minutes longer to perform; (2) has the same rate of intraoperative and postoperative complications; (3) may result in slightly less pain in the first 24 hours after surgery; (4) has the same duration of hospital stay, pain scores 1-28 days after surgery, time to return to activity, time to return to work, and postoperative quality of life 10 days after surgery; (5) provides a better early cosmetic result (as graded by patients and by blinded observers); and (6) provides no apparent difference in late cosmesis (as evaluated 6-12 months postop). There are minimal level I data published on the effects of newer mini instruments for laparoscopic cholecystectomy.

CONCLUSION: When applied to elective laparoscopic cholecystectomy, the use of mini-laparoscopic instruments results in a slightly longer operative procedure (3-5 minutes), slightly less immediate postoperative pain (in the first 24 hours), and a better early cosmetic result, with no other apparent significant differences. Additional data are needed from large, well-conducted studies of Mini LC to resolve several unanswered questions, including the role of newer mini instruments.