Review

of literature of 3 port versus standard 4 port

cholecystectomy

Objective:
To review the different studies done on the comparison of 3 port and 4 port
cholecystectomy and compare are the outcomes of both these techniques.

Introduction
The first laparoscopic cholecystectomy was done by Philip Mouret in 1987 and
later established by Dubois and Perissat in 1990. Since then it has gained wide
acceptance and has become a gold standard for cholecystectomy in the
present days.(1) Standard laparoscopy is done using 4 ports. One of them is for
camera, the other two are for dissection of Calot’s triangle and the 4th lateral
port is to grasp the gallbladder fundus and give it a traction upwards so that
the Calot’s triangle is exposed better.(2)
With the passage of time, many refinements have been done for this surgery
and many newer techniques have been developed like single incision
laparoscopic cholecystectomy(SILS) – with or without the Gelport, 3 port
cholecystectomy, etc. Reduction in the size and number of ports has been
proposed as a method of reduced pain and duration of hospital stay which is
the whole purpose of doing a laparoscopic versus open surgery.(1)








Methods:

The sites of port placement of both these techniques are as shown above.(3),
(4) The only difference is the omission of 5mm right anterior axillary line port
in 3 port cholecystectomy.



Review of Literature:
One of the studies by Kumar et al recruited 75 patients aged 18 to 75 who
were indicated for elective laparoscopic cholecystectomy. Exclusion criteria
included patients with acute cholecystitis with empyema gallbladder and
patients who were not fit for surgery. The patients were randomized to receive
either 3 port or 4 port cholecystectomy.(2)
Results of this study showed that there was significantly reduced operative
time for 3 port cholecystectomy as compared for standard 4 port (47.3
minutes vs 60.8 minutes). There were no other statistically significant
outcomes in terms of analgesic requirement, post-op stay, days to return to
normal activity, success rate, VAS score or satisfaction score. (2)

Another study by Dhafir et al compared the data that they obtained from their
495 patients, out of which 283 were posted for 3 port cholecystectomy while
212 patients underwent standard 4 port technique. They evaluated their data
using the similar variables as Kumar et al and found that there was no
statistically significant difference in the operative time of both these
techniques but the post-operative pain management which was measured in
terms of requirement of Pethidine was significant. The values were 167mg for
3 port cholecystectomy vs 210mg for 4 port technique. Overall, they found that
use of three ports in LC did not affect the procedure's safety, conversion rate,
and operating time when used in AC and CC. The introduction of the three-port
technique, which is still in routine practice in their institute, meant patients,
needed fewer painkillers and shorter hospital stays; other advantages include
fewer scars and more cost savings.(5)

Another study by Peeyush et al which involved 90 patients of which 45
underwent 3 port LC also found that there was statistically significant
difference in VAS scores for pain at 6 and 24 hours (5.71 vs 6.60). Cosmetic
outcomes as perceived by the patients was also better in the 3 port group.(1)

Conclusion
By reviewing the above studies, we can say that the post-operative pain,
analgesia requirement and thus hospital stay is definitely better in the patients
who undergo 3 port cholecystectomy as compared to the standard 4 port. The
only thing to be kept in mind is that the 3 port cholecystectomy was done by
experienced surgeons and that is why there were no reports of biliary or bowel
injuries, irrespective of the methods used. So in conclusion, we can say that
the 3 port cholecystectomy should be done in patients by experienced expert
laparoscopic surgeons, provided it can be completed safely.













Bibliography:
1. Kumar P, Rana AKS. Three-port versus four-port laparoscopic
cholecystectomy: a comparative study at a tertiary care centre in North
India. Int Surg J. 2018 Jan 25;5(2):426–32.

2. Kumar M, Agrawal CS, Gupta RK. Three-Port Versus Standard Four-Port

Laparoscopic Cholecystectomy: a Randomized Controlled Clinical Trial in a
Community-Based Teaching Hospital in Eastern Nepal. JSLS.
2007;11(3):358–62.

3. TVASurg Difficult Choles Module - Port Placement [Internet]. [cited 2018

Aug 30]. Available from:
http://pie.med.utoronto.ca/tvasurg/tvasurg_content/assets/masterFolders
/PB_difficultCholecystectomyModule/module/content/overview_orSetup/i
ndex.html

4. PAFMJ [Internet]. [cited 2018 Aug 30]. Available from:

http://www.pafmj.org/showdetails.php?id=716&t=o

5. Al-Azawi D, Houssein N, Rayis AB, McMahon D, Hehir DJ. Three-port versus

four-port laparoscopic cholecystectomy in acute and chronic cholecystitis.
BMC Surg. 2007 Jun 13;7(1):8.