الفهرس 
AcknowledgementOnly 14 pages are availabe for public view
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Abstract
Cholecystectomy has come a long way since it was first performed by Langenbuch in year 1882. The increasing acceptance of surgical treatment for gall stone disease over past 130 years is the result of increasing safety and ease with which the operation is accomplished and the satisfactory long-term relief of symptoms and interruption of the pathological processes involved Today laparoscopic cholecystectomy has become the gold standard for treating cholelithiasis, and since its advent four ports have been used for performing the procedure. But with time, many refinements have been made. These include decreasing the number of ports and port-size leading to evolution of the three port procedure, two-port procedure and even single incision laparoscopic cholecystectomy Laparoscopic cholecystectomy is conventionally performed using four laparoscopic ports. Despite the observed benefits of the standard four-port technique, there have been many efforts to make laparoscopic cholecystectomy even less invasive by reducing the size or number of ports to reduce the postoperative pain and analgesia requirement Single-incision laparoscopic cholecystectomy initially gained popularity in terms of cosmetic outcomes and pain reduction; however, it lost its popularity due to higher risks of complications in comparison with the standard technique Three-port laparoscopic cholecystectomy has been proposed as an alternative to standard four-port technique. In the three-port technique, the fourth or lateral port which is normally used to retract the fundus of gallbladder is omitted One hundred patients with cholelithiasis in the age group of 25-60, admitted, to Department of General Surgery of Assiut University Hospitals were taken up for the present study. Those patients were randomly subdivided into group I included patients who underwent 3 port LC (n= 50 patients) and group II included patients who underwent 4 port LC (n= 50 patients). Both groups in the current study had insignificant difference regarding baseline data. It was found that majority had chronic symptoms and multiple stones within the gall bladder. Also, majority in both groups was females. In consistent with the current findings, a previous study of 90 patients stated that most of the patients were females (77.8%) in the age group of 40-50 years. The overall female to male ratio was 7.2:1. Age and gender distribution was almost similar in the two groups Gall stone disease is a female preponderant disease, mostly affecting middle aged females. Few studies have linked the etiology to estrogen hormone. Most of the patients in either groups had multiple calculi with chronic symptoms The current study revealed that mean operative time was insignificantly longer among 4-port LC (46.78 ± 5.93 vs. 47.56 ± 5.70 (minute); p= 0.85). Also, both groups had insignificant differences as regard intraoperative complications in form of bile duct injury (4% vs. 4%; p= 0.69), bleeding from cystic artery (6% vs. 4%; p=0.50) and bile leakage (12% vs. 16%; p= 0.38). In line with the current study, a recent published a meta-analysis on 2111 patients from 13 studies showed no difference in operative time between the two groups [80] Also, Kumar et al. (2018) found that mean operative time in the four-port group was found to be slightly less than the three-port group. This is probably because the addition of the fourth port facilitates dissection of the Calot’s triangle as it is better exposed due to laterally retracted gall bladder In contrast, Garge et al. (2022) stated that minimum time taken to perform 3-port laparoscopic cholecystectomy was 65 minute and to perform 4-port laparoscopic cholecystectomy was 30 minutes. In 100% patients in group 4-port LC the operation was completed in less than 80 minute. 17 patients (57%) in group 3-port LC took more than 80 minute for operation. The difference in mean operative time between both the groups is statistically significant Mixed results have been found in literature in this regard. While some authors have reported similar findings, some have reported three port procedure to be shorter than four-port. They have explained this on the basis of less time required to create an additional port(6-8) . We believe that three port cholecystectomy is a relatively new technique and with increasing experience, mean procedural time is likely to reduce The difference in operative time in these studies is due to different criterion used by surgeons for operative time whereas in our study it was taken as time from skin incision to closure. Also, as the experience of the surgeons is growing in both the procedures the operative time is decreasing . In agreement with the current study, a previous study found no significant difference in the number of complications in the two groups. However, number of bleeds in the four-port group was slightly more than the three-port group. The reason could be that more patients in the four-port group were found to have adhesions in the Calot’s triangle Our study found that a total of 5 (5%) patients in the study underwent conversion to open cholecystectomy (two patients from 3-port LC and three patients form 4-port LC) with no significant differences between both groups. In accordance with the current study, analysis of 2150 patients from 12 studies showed no difference in the risk of conversion to open operation between the two groups In line with the current study, it was found that, 41 cases were completed successfully without any need for conversion in the three-port group. 3 patients were converted to four-port procedure and 1 patient was converted to open cholecystectomy. In the four-port group, 3 cases were converted to open cholecystectomy for completion. This result was not statistically significant [81]. Many authors reported similar results in their studies (10-12). Regarding postoperative pain and complications, it was found that 3-port LC had significantly lower VAS at 6 hours post-operative (5.76 ± 0.92 vs. 6.20 ± 0.99; p= 0.01) and VAS at 24-hour postoperative (2.76 ± 0.91vs. 3.66 ± 0.76; p= 0.02). Also, diclophenac ampule need was significantly lower in 3-port LC group (3.35 ± 0.90 vs. 3.80 ± 0.76 (amp); p< 0.001). Also, the current study found that two patients in each group had wound infection while port site bleeding reported in only two patients of 4-port LC. Paralytic ileus occurred in two patients of 3-port LC group and one patient of 4-port LC group. Both groups had insignificant difference regarding hospital stay (33.32 ± 9.31 vs. 35.40 ± 7.27 (hours); p= 0.25). Our study noticed that both groups had significant difference (p> 0.001) as regard patient’s satisfaction where good, average and poor satisfaction present in 47 (94%), 2 (4%) and 1 (2%) patients of 3-port LC group and present in 27 (54%), 21 (42%) and 2 (4%) patients of 4-port LC group. Return to daily activity was insignificantly earlier among 3-port LC group (6.35 ± 0.90 vs. 6.70 ± 0.56 (day); p= 0.86). Similarly, post-operative pain at 6 and 24 hours and use of analgesics were statistically less in the three-port group and so was the duration of return to work and normal activity. Mean duration of hospital stay was also slightly less in the three-port group Also, in line with the current results, Hajibandeh et al. (2021) showed that lower VAS pain score at 24 h postoperatively in the 3-port group. Also, the authors found that no difference in length of hospital stay between the two groups. Time taken to return to daily activities was shorter time to return to normal activities in the 3-port group In postoperative period, during hospital stay and during follow-up visits at 1 week, 1 month, 2 months and 3 months’ patients were asked for evaluation of their respective operations. Factors included were improvement in symptoms, return to normal activity and cosmetic results. More than 77% patients in both the groups had assessed their respective procedures good. Only 18% of the patients assessed their procedures as very good but none complained of poor outcome after their operation. The difference in patients’ experience in this regard for the two groups is not statistically significant The cosmetic effect of the surgery in both groups was evaluated one month after surgery and patient satisfaction was overall found to be better in the three-port group. In the three-port group, 32 (78%) patients were completely satisfied with the scar and cosmetic outcome, 8 (19.6%) patients were partially satisfied, whereas 1 (2.4%) patient was unsatisfied due to poor scar and cosmetic result. In the four-port group, 21 (50%) patients were completely satisfied with the cosmic outcome, 20 (47.6%) were partially satisfied and one patient was unsatisfied Thus, overall patient satisfaction regarding scar outcome was significantly better in the three-port group. The main reason for partial satisfaction was that the patients in four-port group were aware of the fact that the number of scars could have been reduced
The main limitation of the current study is that the study was conducted on a small group of patients at a single canter. Similar studies conducted on a larger study population at different centers can further be done to validate our results. But being a randomized controlled trials, this is point of strength of the current study. Cholecystectomy is the mainstay of treatment for symptomatic gall stone disease. The management of patients with gall stone disease has been revolutionized during the last several years with the introduction of Laparoscopic cholecystectomy. To assess the efficacy and safety of three-port versus four-port laparoscopic cholecystectomy 100 patients with cholelithiasis in the age group of 25-60, admitted to Department of General Surgery of Assiut University Hospitals were taken up for the present study. Those patients were randomly subdivided into group I included patients who underwent 3 port LC (n= 50 patients) and group I included patients who underwent 4 port LC (n= 50 patients). Majority of patients was females and had multiple stones within the gall bladder. The main results of the current study found that both group had insignificant differences as regard baseline data, operative time and intraoperative and post-operative complications. The results of current study suggest that omitting the lateral or forth port from the standard four-port laparoscopic cholecystectomy technique does not have negative impact on procedural outcomes. On the other hand, our results suggest that reducing the number of ports from four to three results in less postoperative pain for patients which subsequently explains the shorter length of hospital stay and shorter time to return to normal activities. Although less postoperative pain is an important finding, it is debatable whether shorter hospital stay is clinically important as nowadays most cases of elective laparoscopic cholecystectomy are done as day case procedure. In conclusion, the current study suggests that in an elective setting with uncomplicated cholelithiasis as indication for cholecystectomy, three-port laparoscopic cholecystectomy is comparable with the four-port technique in terms of procedural and morbidity outcomes and may be associated with less postoperative pain, shorter length of hospital stay and shorter time to return to normal activities. The comparative evidence in emergency setting and in cases with complicated disease remains unanswered.