title: Single-incision laparoscopic cholecystectomy: a systematic review.
abstract: BACKGROUND
  Laparoscopic techniques induced a tremendous revolution in surgery of the biliary tract, mainly due to improved results compared with the open approach and secondary because of their cosmetic advantage. A trend toward even more minimally invasive approaches has led to techniques of single-incision and natural orifice laparoscopic surgery. Because the evaluation of single-incision laparoscopic cholecystectomy (SILC) is rather fragmentary by single-institution small patient series, this article intends to examine the success and the risks of the technique, and attempts to determine its potential limitations.
  
  
  METHODS
  A systematic review of the literature was performed to identify relevant articles. Studies enrolling at least ten patients who underwent SILC and reporting on analytical complication data were considered for inclusion.
  
  
  RESULTS
  The literature search identified 29 studies, which included a total of 1,166 patients. Success and complication rates were 90.7% and 6.1%, respectively. Mean adjusted operative time was 70.2 min and mean adjusted hospital stay was 1.4 days. Analysis of outcome exhibited higher complication rates for studies with a mean patient age older than 45 years (p=0.04), and higher operative time for studies with a mean body mass index>30 kg/m2 (83.4 vs. 74.5 min) and female percentage lower than 70% (78.7 vs. 68.5 min). Acute cholecystitis as inclusion criterion was a factor for technical failure (success rate 59.9 vs. 93.0%, p=0.005) and resulted in an increase of operative time (78.1 vs. 70.6 min). Suture suspension of the gallbladder yielded significantly lower complication rates compared with instrument usage (3.3 vs. 13.3%, p<0.0001).
  
  
  CONCLUSIONS
  The clinical application of SILC exhibited satisfactory results. Cases of acute cholecystitis and older patients should be approached with caution, whereas improvement of the instrumentation is necessary.
authors.affiliation: Department of General and Visceral Surgery, Center for Minimally Invasive Surgery, Hospital Maria v. d. Aposteln Neuwerk, Mönchengladbach, Germany. stavros.antoniou@hotmail.com
authors.forename: Stavros A
authors.initials: SA
authors.lastname: Antoniou
authors.forename: Rudolph
authors.initials: R
authors.lastname: Pointner
authors.forename: Frank A
authors.initials: FA
authors.lastname: Granderath
mesh_terms: D000328:Adult; D000367:Age Factors; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D020706:Laparoscopes; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000295:instrumentation / Q000379:methods; D057605:Natural Orifice Endoscopic Surgery / Q000295:instrumentation / Q000379:methods*; D010149:Postoperative Pain / Q000453:epidemiology / Q000503:physiopathology; D011183:Postoperative Complications / Q000453:epidemiology / Q000503:physiopathology; D018570:Risk Assessment; D012737:Sex Factors; D016896:Treatment Outcome; D014472:Umbilicus