Minimally invasive surgery for gallbladder disease has become increasingly popular in pediatric patients, with advantages of less pain, shorter hospital stays, smaller scars, and quicker return to normal activities .
Conventional LC is performed with four trocars. Many surgeons have tried to reduce the number and size of the trocars used in LC in order to reduce the postoperative pain and achieve a more cosmetically satisfactory result .
Although several authors have documented the efficacy of single-incision laparoscopic cholecystectomy, there are conflicting concerns regarding increased risks of pain and port-site hernia formation with a larger umbilical incision, bile duct injury, prolonged operative time, and the need for special ports and instruments . Visualization of the critical view is challenging with single-port laparoscopic cholecystectomy as all instruments are in line with the camera and there is reduced the ability to triangulate ports .
In this study, we describe a 2I-LC marionette technique that uses three ports and allows for optimal triangulation with two handheld graspers and suture taken on the gallbladder for traction and counter traction to demonstrate the critical view, while minimizing residual scarring and maintaining cosmesis, for multiple types of benign gallbladder disease in children without prolonging operative time or increasing risks of complications and can be converted easily to a traditional 4P-LC if necessary.
In this study, we found that the lower cost was seen with marionette technique basically originated from the lower number of the trocar and less opening of instruments especially if single used ones.
Our study showed that marionette group took a non-significantly longer operative time (5.5 min more) than the standard technique and early return to work (5.69 vs 5.88 days, respectively), which is much lower than other studies. In Leow et al. study, the mean operative time was 44 ± 18 min , which was in accordance with times reported in other studies of two-port LCs [10,11,12]. Poon et al. in his two consecutive studies showed an average operative time of 53 min in 2002 and 54.6 ± 24.7 min in 2002 and 2003 [10, 13]. In Justo-Janeiro et al. study, patients were randomized into 3 groups: LC 1-port using SILC, 2-port LC, and 3-port LC using the standard ports. They found that only the mean operative time was statistically significant, as the 1PLC technique showed a longer duration of the surgery (p = 0.007) . In a study conducted by Sabuncuoglu et al., the patients were divided into 3 groups: triple-incision laparoscopic cholecystectomy (TILC), double-incision laparoscopic cholecystectomy (DILC), and single-incision laparoscopic cholecystectomy (SILC). The operation time of the three SILC cases was longer (100 ± 17.32 min and range, 90–120 min) which they thought to be due to the process of gaining experience with SILC, the use of conventional instruments rather than articulated ones and patient-related. In subsequent SILC cases, the operating time was shorter (73.75 ± 8.29 min and range 55–85 min). All the double-incision cholecystectomies were completed in a similar time to those with the 3-port method (45.85 ± 15.59 min and range 32–125 min) .
A prospective randomized blinded study by Leung et al. found SILC to take 27 min longer than multiple incisions LC, on average, when surgeon “proficiency was demonstrated by five single-site procedures completed solo” . The difference between our results and theirs’ contributed to two incisions in marionette which allowed an easier surgery and better triangulation.
The length of hospital stay in this study was short (1 day). In other studies of two-port LCs, the average postoperative stay was 1–2 days [11, 13, 17].
Most of the published studies on SILC use acute cholecystitis as an exclusion criterion while enrolling patients . Antoniou et al. has shown that acute cholecystitis is a predictor of the failure of SILC with a success rate of 59% (vs 93% success rate for indications other than acute cholecystitis) . In our study, only one patient with acute cholecystitis 1 (6.25%) out of 16 cases aged 8 years in the marionette group failed to be completed and converted to the conventional LC due to difficult surgical procedure caused by severe intraperitoneal adhesion. Although our marionette group had one patient with acute cholecystitis, as it is very rare in our studied group of pediatrics, more cases are required to compare the conversion rate of acute cholecystitis patients with previously published rates of conversion and overall conversion rate for marionette technique.
In Leow et al. study, the total conversion rate from two-incision three port LC was 17% and consisted of four cases (7%) of them converted to three-incision four-port LC and six cases (10%) to open cholecystectomy .
An advantage of the marionette over other techniques of conventional LC was the size of the fascial defects created: three 5-mm defects. The conventional LC ports require four defects of 20 mm; small defect and less incision (2 skin incision) in our Marionette group are associated with lower VAS among marionette group and subsequent better patient’s satisfaction.
According to Justo-Janeiro et al.’s results, pain scores in recovery time showed less pain in the 1PLC, except at 4 and 24 h, and there were no differences. At 5 and 8 days, patients from the 1PLC reported more pain than the 2PLC or 3PLC groups . But Leung et al. has noted no difference between the traditional LC and single-site LC in the pain severity assessed by visual analog scale scores and analgesic use .
We believe that the improved cosmesis should not be a primary outcome because it is only a natural consequence of decreased port number and does not associate with increasing the risk of intraoperative or postoperative complications. From the aesthetic point of view, the marionette technique is superior to the conventional one, since this involves only two scars (umbilical and epigastric, Fig. 5) with the advantage of avoiding additional two incisions . In some study, cosmesis considered the main outcome; however, there was evidence to support that, the inherent risks of this surgery are increased potentially by the technical difficulty associated with the 1-port technique .
In terms of the immediate postoperative complications, no patients in this study developed any complication either early or late as bleeding at the wound edge or a hernia from the supraumbilical wounds. No patient required re-hospitalization because of postoperative complications in Sabuncuoglu et al. study . Similarly, Poon et al. reported a 0% complication rate in their study , whereas in Lee at al.’s study, 6% of patients had complications and included the intra-abdominal collection, umbilical port site infection, acute urinary retention, and postoperative deranged liver function test due to choledocholithiasis . Bokobza et al. reported in their study of single umbilical incision LC (SUILC) two cases of wound abscess and one case of hemoperitoneum .
This study has several limitations. The sample size of the study was small. Also, the limitations of this technique may involve possible bile spillage during placement of suture. This is important if gallbladder carcinoma is incidentally discovered in cholecystectomy for benign disease, an incidence of approximately 0.5% in adults . Fortunately, gallbladder carcinoma is very rare in pediatrics.