Risk Factors for Difficult Three-Port Laparoscopic Cholecystectomy

Background Standard laparoscopic cholecystectomy (LC) is a four-port technique in which a camera port and three additional ports are used. The advantages of minimally invasive surgery with reduced-port surgery have been reported. However, evidence on the indications for minimally invasive surgery in patients with severe acute cholecystitis or previous upper abdominal surgery in whom laparoscopic surgery is considered challenging is limited. Therefore, this study aimed to explore the factors that complicate reduced-port LC. Methods Data from 47 consecutive patients who underwent three-port LC using two 5 mm ports and 12 mm umbilical ports for symptomatic cholecystolithiasis, chronic cholecystitis, and acute cholecystitis between November 2021 and November 2023 by a single surgeon were retrospectively collected. Noncomplete LC was defined as a change of 5 mm to 12 mm port, the addition of ports, a change to subtotal cholecystectomy, or open conversion cholecystectomy. The patients were divided into two groups according to complete or noncomplete LC, and the risk factors that might have contributed to noncomplete LC were explored. Results Among the 47 patients, the median (range) age was 74 (25-97) years, 21 were men and 26 were women, 30 (63.8%) had acute cholecystitis, and 21 (44.7%) underwent emergency LC. No conversion to open cholecystectomy was performed. Six of the 47 patients had noncomplete LC, three of whom were converted to subtotal cholecystectomy, one had the midepigastric port changed from 5 mm to 12 mm to use an automatic anastomosis device, and two were converted to subtotal cholecystectomy with a 12 mm midepigastric port. In the univariate analysis, the noncomplete LC group had significantly more cases of preoperative gallbladder drainage and a smaller body mass index than the complete group. No significant differences were found in previous epigastric surgeries or in the presence of acute cholecystitis. Postoperative outcomes showed a significantly longer operative time, more intraoperative blood loss, longer postoperative hospital stay, and higher Estimation of Physiologic Ability and Surgical Stress and surgical stress score in the noncomplete LC group than in the complete group. Conclusions Three-port LC may be difficult to perform in patients with preoperative gallbladder drainage and severe scarring of the gallbladder neck. For patients with risk factors for three-port LC, adequate manpower and early conversion to subtotal or open cholecystectomy are necessary to avoid intraoperative complications. Further studies are required to determine significant risk factors for noncomplete LC.