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M Patel et al
Median cosmetic scores were higher (i.e. worse score) at CoNCLuSIoN
the epigastric port, closely followed by the umbilical port- Patient questionnaires and feedback are central to assessing
with ‘color’ as the feature scored as most unlike normal and improving the quality of the services we provide. Intro-
skin at both sites. Anecdotal evidence (also mentioned in ducing SILC is unlikely to resolve the few issues which
a number of studies) would suggest the site of gallbladder have been highlighted with the standard technique. Overall
retrieval is more likely to be complicated by postoperative satisfaction with the conventional technique is high and this
wound infection and/or pain. The patients, in this study, has been confirmed in a number of studies. Published data
underwent retrieval of the excised gallbladder via the
epigastric port and this may account for the proportion of quantifying the cosmetic benefits of SILC over SLC is sparse
wound infections reported at this site and consequential poor and there is a lack of data from randomized studies valida-
cosmetic outcome. The main impetus behind the develop- ting any benefit. Robust evidence is required to demonstrate
ment of the SILC is a perceived benefit of superior cosmetic that SILC provides a cost-effective superior cosmetic/overall
outcome. There are six studies investigating cosmesis after better outcome than the SLC. Ultimately, we have to raise
SILC, with three reporting a significantly improved cosmesis the question: ‘why fix it if it is not broken?’
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with this technique. Interestingly, Bignell et al assessed
cosmetic outcome in women 4 years after SLC and con- ReFeReNCeS
cluded patients perceive cosmetic results after the procedure 1. Available at: http://www.nhs.uk/pages/homepage.aspx. Date last
as excellent, with further anecdotal evidence suggesting the accessed on 13/10/2012.
9
umbilical port as the site of problems for some patients. We 2. Navarra G, Pozza E, Occhionorelli S, Carcoforo P, Donini I. One-
wound laparoscopic cholecystectomy. Br J Surg 1997;84(5):695.
have confirmed the site of gallbladder retrieval will continue 3. Marks J, Tacchino R, Roberts K, et al. Prospective randomized
to cause problems with wound quality; importantly, the controlled trial of traditional laparoscopic cholecystectomy
results demonstrated the umbilical port site can be proble- versus single-incision laparoscopic cholecystectomy: report of
matic resulting in increased pain/suboptimal cosmetic result preliminary data. Am J Surg 2011;201(3):369-372.
irrespective of this technicality. 4. Prasad A, Mukherjee KA, Kaul S, Kaur M. Postoperative
pain after cholecystectomy: conventional laparoscopy versus
Whilst the aim of this study is not to compare the SLC single-incision laparoscopic surgery. J Minim Access Surg
with the SILC, it is our aim to measure the quality of the 2011;7(1):24-27.
services we provide and also to assess for the potential to 5. Leung D, Yetasook AK, Carbray J, Butt Z, Hoeger Y, Denham W,
provide a better surgical experience. The implementation Barrera E, Ujiki MB. Single-incision surgery has higher cost
of the Health and Social Care Act 2012 places the patient with equivalent pain and quality-of-life scores compared with
multiple-incision laparoscopic cholecystectomy: a prospec-
at the center of a new system. Patient experience, question- tive randomized blinded comparison. J Am Coll Surg 2012
naires/feedback and quality improvement will be central Nov;215(5):702-708.
to hospitals securing services. We are aware of the influ- 6. Hall TC, Dennison AR, Bilku DK, Metcalfe MS, Garcea G.
ence patient factors, such as recall accuracy may have on Single-incision laparoscopic cholecystectomy: a systematic
review. Arch Surg 2012 Jul 1;147(7):657-666.
retrospective pain ratings, however, studies have shown 7. Garg P, Thakur JD, Garg M, Menon GR. Single-incision lapa-
retrospective reports of pain intensity are consistent with roscopic cholecystectomy vs conventional laparoscopic chole-
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those made while the pain was experienced. Although we cystectomy: a meta-analysis of randomized controlled trials.
have not directly compared the SLC with the SILC, we have J Gastrointest Surg 2012 Aug;16(8):1618-1628.
been unable to generate evidence from our experience with 8. Monkhouse SJ, Court EL, Beard LA, Bunni J, Burgess P. A
the SLC that would support the use of a single umbilical retros pective wound review of standard four-port laparoscopic
cholecystectomy: is there need for single-port laparoscopic
incision to replace the SLC; the problems which do exist surgery? Surg Endosc 2012 Jan;26(1):255-260.
have been demonstrated to be acceptable to patients across 9. Bignell M, Hindmarsh A, Nageswaran H, Mothe B, Jenkinson A,
a number of studies and are those which are unlikely to be Mahon D, Rhodes M. Assessment of cosmetic outcome after
resolved by a single incision operation. It is possible, given laparoscopic cholecystectomy among women 4 years after
our data, that SILC may offer a marginal benefit in cosmesis laparoscopic cholecystectomy: is there a problem? Surg Endosc
2011 Aug;25(8):2574-2577.
by avoiding an epigastric incision. However, it remains to 10. Rohini T, Niven CA, Brodie EE. How well do patients recall
be determined if the additional expense incurred by SILC past experience of pain? Nursing Times 2007 Nov;103(42):
would make this cost-effective. 34-35.

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