What is the main difference between single incision (SI) and multiple incision (MI) laparoscopic cholecystectomy (lap cholecystectomy)?

Single Incision vs Multiple Incision Laparoscopic Cholecystectomy

Conventional multiport laparoscopic cholecystectomy should be preferred over single-incision laparoscopic surgery (SILS) due to a significantly higher risk of incisional hernia with the single-incision technique, despite similar overall complication rates. 1

Key Differences Between Techniques

Incisional Hernia Risk

• Single-incision laparoscopic cholecystectomy carries a nearly 5-fold increased risk of incisional hernia compared to conventional multiport technique (OR = 4.94,95% CI 1.26-19.4), though the overall incidence remains low at approximately 5% 2
• The World Society of Emergency Surgery explicitly recommends conventional laparoscopic procedures over SILS specifically because of this elevated hernia risk 1
• When SILS is performed, meticulous fascial closure is mandatory to mitigate this increased hernia risk 1

Operative Time

• Single-incision technique requires longer operative time, with a mean difference of approximately 12-15 minutes compared to multiport technique 3, 2, 4
• This time difference decreases with surgeon experience—in larger trials with experienced surgeons, the difference narrows to approximately 6 minutes and becomes statistically insignificant 2
• One study reported SILC operative time of 111 minutes versus 80 minutes for multiport technique 5

Procedure Failure and Technical Considerations

• SILC has a higher rate of procedure failure (OR = 13.9,95% CI 4.34-44.7), with a pooled incidence of 4.39% 2
• These "failures" almost exclusively involve adding an additional trocar to complete the procedure safely, rather than conversion to open surgery 2
• The single-incision approach presents greater technical difficulty due to instrument crowding and limited triangulation 3, 5

Clinical Outcomes

Pain and Recovery:

• No significant difference in postoperative pain scores between SILC and multiport LC 3, 5, 2, 4
• Hospital length of stay shows mixed results: some studies report shorter stays with SILC (2.5 vs 3.1 days), while others show no difference 5, 4
• Same-day discharge rates may be slightly higher with SILC (85% vs 70%) 6

Safety Profile:

• Overall complication rates are similar between techniques, with SILC showing a pooled complication incidence of 5.35% 2
• Intraoperative blood loss is statistically greater with SILC but clinically irrelevant (difference of 1.29 mL) 2
• No difference in bile duct injury rates or other major complications 2

Cosmetic Outcomes

• The cosmetic benefit of SILC is modest and depends heavily on patient blinding 2
• In non-blinded studies where patients knew their technique, cosmetic satisfaction favored SILC significantly 2
• However, in blinded studies where patients were unaware of their technique, the cosmetic difference was small and statistically insignificant 2
• This suggests a significant placebo effect in perceived cosmetic benefit 2

Cost Considerations

• No significant difference in hospital charges or overall costs between SILC and conventional multiport LC when performed by experienced surgeons 6, 4

Critical Clinical Pitfalls

Avoid these common errors:

• Do not pursue SILC in patients with acute cholecystitis, severe inflammation, or difficult anatomy—the technical challenges are magnified 3, 5
• Never persist with a difficult SILC dissection when anatomy is unclear; have a low threshold for adding additional ports 3
• Do not underestimate the learning curve—early SILC cases require significantly longer operative times 5, 6
• Ensure meticulous fascial closure of the umbilical incision if SILC is performed, as this is the primary site of hernia formation 1

Evidence Quality and Guideline Strength

The 2023 World Society of Emergency Surgery guidelines provide the strongest recommendation against routine SILS use (Strong recommendation, Moderate certainty of evidence) 1. This is supported by a comprehensive 2014 meta-analysis of 30 randomized trials involving over 2,400 patients 2. The guideline recommendation is based on the clinically significant increased hernia risk that outweighs the modest cosmetic benefit, particularly given that cosmetic satisfaction is largely influenced by patient awareness rather than objective appearance 1, 2.