Three-port versus four-port technique for laparoscopic cholecystectomy: systematic review and meta-analysis

The four-port laparoscopic technique is the standard approach for cholecystectomy. A three-port technique has been described, but there is no consensus over the outcomes and efficacy of this approach. The aim was to perform a systematic review and meta-analysis to compare the three- and four-port techniques in laparoscopic cholecystectomy for benign diseases of the gallbladder.

The review was conducted according to a predefined protocol registered on PROSPERO. Two authors independently conducted an electronic database search of CENTRAL, MEDLINE, Embase, CINAHL, WHO International Clinical Trials Registry, and ClinicalTrials.gov. Outcomes are reported as risk ratios (RR), mean difference (m.d.), or standardized mean difference (s.m.d.) with 95 per cent confidence intervals.

Eighteen trials were included with 2085 patients. Length of hospital stay and postoperative analgesia requirement favoured the three-port group (m.d. -0.29, 95 per cent c.i. -0.43 to -0.16 (P < 0.001); and s.m.d. -0.68, 95 per cent c.i. -1.03 to -0.33 (P < 0.001), respectively). There were no differences in length of procedure or success rate between the two groups (m.d. 0.90, 95 per cent c.i. -3.78 to 5.58 (P = 0.71) and RR 0.99, 95 per cent c.i. 0.97 to 1.01 (P = 0.17), respectively). There were no differences in adverse events. The overall quality of evidence was low.

The three-port technique for laparoscopic cholecystectomy is an option for appropriately trained surgeons who perform it regularly. However, the decision to use three ports should not be at the expense of safe dissection of Calot's triangle.