Tuesday, February 18, 2014

Single-incision vs. standard 4-port laparoscopic cholecystectomy: Part 1 of 2

The saying used to be, "You can get any paper published if you have enough stamps." Now with electronic submission, you don't even need the stamps.

A retrospective study comparing single-incision laparoscopic cholecystectomy (SILC) to standard 4-port laparoscopic cholecystectomy (LC) concluded that "SILC showed no disadvantage concerning risk profiles, operative times or hospital stay."

According to the abstract, 81.7% of the 115 SILC patients had elective surgery vs. 55.5% of the 344 in the LC group. The SILC cohort experienced significantly shorter operative times (70 ± 31 vs. LC: 80 ± 27 minutes) and hospital lengths of stay (3.02 ± 1.4 vs. LC: 4.6 ± 2.8 days), p < 0.001 for both. LC was converted to open surgery in 21 cases vs. none of the SILCs, p= 0.003. Rates of bile leak and incisional hernia did not differ.

Do you see any problems with this study? I do.

The groups were not really comparable because the LC group underwent more emergency operations. That difference is significant with a p value of 0.007—conveniently omitted from the abstract. The preponderance of elective cases likely accounts for the SILC group's shorter operative duration, lower rate of conversion to open, and shorter length of stay. The SILC patients were also a mean of 10 years younger.

The average operative time for the LC patients, 80 minutes, is much longer than the 40 to 45 minutes reported in most other recent series such as this one. In statistical circles, measuring one's pet theory against a false comparator is known as setting up a "straw man." I've written about this before.

This study was done in Germany, where the hospital lengths of stay for both types of surgery are far longer than those seen in the United States where about 90% of patients go home within 24 hours of laparoscopic cholecystectomy.

The authors concluded that "SILC can be regarded as a natural evolution in the era of minimally invasive surgery."

On the other hand "No disadvantage" is another way of saying, "No advantage."

This paper didn't convince me about the value of SILC. How about you?

Part 2 of this 2-part series on SILC appeared on Thursday, 2/20.


artiger said...

Not convinced, but that doesn't matter. This is like a smaller version of the robot issue; it's all about gaining market share. I can see ads of bikini-clad models with their invisible SILC incisions, held up next to pictures of morbidly obese (OK, maybe just overweight) patients with 4 huge scars that still have skin clips in place. Which would that make you choose?

Hmm, now that I think about it, I can see a counter-advertising campaign...A super obese patient after SILC with a dehisced, draining umbilical wound compared with a model who had her 4 incisions closed with glue and treated with Mederma for 3 months. I'll get to work on that.

George Gasman said...

(grumpy old anesthesiologist here)

Mentioned the arrival of a robot in our (small) facility to the Chairman of Surgery at a local teaching hospital at a social gathering.

"Now there's a technology in search of a need," he said.

Talk about drawing your curves and then plotting your points! This study is a perfect example. Can't wait for the followup post.

This blogpost forwarded to my good friend, a curmudgeonly surgeon.

Skeptical Scalpel said...

Artiger, god idea for a study. I can't wait to see the results.

George, I could not agree more.

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