Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials

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Single-incision laparoscopic cholecystectomy (SILC) has gained attention due to its benefits in improving patient cosmetic results and pain reduction. We aim to assess the latest evidence on the feasibility, safety and surgical outcomes of SILC and CMLC. Methods We conducted searches for randomized controlled trials (RCTs) in PubMed, PubMed Central (PMC), and Europe PMC between December 2011 and 2021. The latest search was conducted in January 2022. We analyzed several outcomes, including perioperative complications, estimated blood loss, operation time, conversion to open surgery, hospital stay, pain score, cosmesis, and days of return to work. Cochrane Risk of Bias (RoB) 2.0 tool was used to evaluate quality of studies. Mantel-Haenszel’s formula and Inverse Variance method were conducted to synthesize results. This study was accomplished in accordance with the PRISMA guidelines. Results A total of 37 studies were eligible, with a total of 2,129 and 2,392 patients who underwent SILC and CMLC. Our study demonstrated a superiority of SILC for the visual analog score (VAS) at six hours post-operation [mean difference (MD) -0.58 (95% CI -1.11, -0.05), p=0.03], cosmesis one-month post-operation [standard MD 2.12 (95% CI 1.10, 3.13), p<0.0001], and cosmesis six months post-operation [standard MD 0.53 (95% CI 0.06, 0.99), p<0.0001]. Meanwhile, SILC showed a longer operation time [MD 10.45 (95% CI 6.74, 14.17), p<0.00001]. In terms of VAS at four time points (4, 8, 12, and 24 hours), perioperative complications, estimated blood loss, conversion to open surgery, hospital stay and days to return to work, SILC did not differ from CMLC. Conclusions SILC is a safe, feasible and favorable procedure in terms of pain reduction and cosmetic results. The option between both procedures is based on surgeon preferences. Registration: PROSPERO (CRD42022306532; 23 February 2022). 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F1000Research 2024, 11 :754 ( https://doi.org/10.12688/f1000research.122102.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Systematic Review Revised Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials [version 2; peer review: 1 approved, 2 approved with reservations] Reno Rudiman https://orcid.org/0000-0001-6826-6313 1 , Ricarhdo Valentino Hanafi 2 , Alma Wijaya 1 Reno Rudiman https://orcid.org/0000-0001-6826-6313 1 , Ricarhdo Valentino Hanafi 2 , Alma Wijaya 1 PUBLISHED 18 Nov 2024 Author details Author details 1 Division of Digestive Surgery, Department of General Surgery, School of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, 40161, Indonesia 2 Faculty of Medicine, Pelita Harapan University, Tangerang, 15810, Indonesia Reno Rudiman Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Ricarhdo Valentino Hanafi Roles: Data Curation, Formal Analysis, Methodology, Project Administration, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Alma Wijaya Roles: Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background Conventional multi-port laparoscopic cholecystectomy (CMLC) has become the current ‘gold standard’ technique in gallbladder disease. Single-incision laparoscopic cholecystectomy (SILC) has gained attention due to its benefits in improving patient cosmetic results and pain reduction. We aim to assess the latest evidence on the feasibility, safety and surgical outcomes of SILC and CMLC. Methods We conducted searches for randomized controlled trials (RCTs) in PubMed, PubMed Central (PMC), and Europe PMC between December 2011 and 2021. The latest search was conducted in January 2022. We analyzed several outcomes, including perioperative complications, estimated blood loss, operation time, conversion to open surgery, hospital stay, pain score, cosmesis, and days of return to work. Cochrane Risk of Bias (RoB) 2.0 tool was used to evaluate quality of studies. Mantel-Haenszel’s formula and Inverse Variance method were conducted to synthesize results. This study was accomplished in accordance with the PRISMA guidelines. Results A total of 37 studies were eligible, with a total of 2,129 and 2,392 patients who underwent SILC and CMLC. Our study demonstrated a superiority of SILC for the visual analog score (VAS) at six hours post-operation [mean difference (MD) -0.58 (95% CI -1.11, -0.05), p=0.03], cosmesis one-month post-operation [standard MD 2.12 (95% CI 1.10, 3.13), p<0.0001], and cosmesis six months post-operation [standard MD 0.53 (95% CI 0.06, 0.99), p<0.0001]. Meanwhile, SILC showed a longer operation time [MD 10.45 (95% CI 6.74, 14.17), p<0.00001]. In terms of VAS at four time points (4, 8, 12, and 24 hours), perioperative complications, estimated blood loss, conversion to open surgery, hospital stay and days to return to work, SILC did not differ from CMLC. Conclusions SILC is a safe, feasible and favorable procedure in terms of pain reduction and cosmetic results. The option between both procedures is based on surgeon preferences. Registration: PROSPERO (CRD42022306532; 23 February 2022). READ ALL READ LESS Keywords Cholecystectomy, laparoscopic surgery, meta-analysis, minimal invasive surgery, systematic review Corresponding Author(s) Reno Rudiman ( [email protected] ) Close Corresponding author: Reno Rudiman Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2024 Rudiman R et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Rudiman R, Hanafi RV and Wijaya A. Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 11 :754 ( https://doi.org/10.12688/f1000research.122102.2 ) First published: 06 Jul 2022, 11 :754 ( https://doi.org/10.12688/f1000research.122102.1 ) Latest published: 18 Nov 2024, 11 :754 ( https://doi.org/10.12688/f1000research.122102.2 ) Revised Amendments from Version 1 We revise the discussion section to be more academic in nature and expand the conclusion section. We revise the discussion section to be more academic in nature and expand the conclusion section. See the authors' detailed response to the review by Yunushan Furkan Aydoğdu READ REVIEWER RESPONSES Introduction For decades, conventional multi-port laparoscopic cholecystectomy (CMLC) has been a favored procedure in gall bladder diseases. 1 This technique differs from any laparoscopic surgery, which requires advanced technology and skill. The gains in CMLC aggregate the learning curve and surgical aftermaths. 2 Many adjustments and modifications are made in CMLC; fundamentally, CMLC consists of four ports. The adaptations may be a reduced port size, such as 10 mm to 5 mm or 5 mm to 2/3 mm, or reduced port numbers. These changes intend to amend patient outcomes in any aspect. 3 The curiosity about single-incision laparoscopic cholecystectomy (SILC) has increased in the past years. A single incision implies when many ports are inserted at a single site (umbilicus). Many studies have demonstrated technical difficulty and increasing complications. 4 , 5 A recent study indicated a feasible and valuable technique with superior cosmetic outcomes, pain reduction, and nil complications. 6 We speculate that knowledge about SILC will improve in the following years. Pros and cons remain disputable in many systematic reviews. 7 – 12 We would like to update the recent randomized controlled trials (RCTs) regarding these techniques because there has not been a newer systematic review to analyze the latest amendment. The latest meta-analysis by Lyu et al ., 12 determined that a limitation of their study was that only three and four ports of instruments, plus non-RCT were included; thus, our study addresses the limitations of the latest research and expects different outcomes. Our hypothesis is that SILC is superior to CMLC in all aspects. Consequently, this study aimed to assess and evaluate the latest evidence on the feasibility, safety, and surgical outcomes of SILC and CMLC. Methods Eligibility criteria We conducted a systematic review and meta-analysis study from clinical trial studies. We registered this systematic review in PROSPERO ( CRD42022306532 ) on 23 February 2022. Articles were included in this systematic review and meta-analysis if they fulfilled the Population, Intervention, Comparison, Outcomes and Study (PICOS) framework as follows: • P - Population: Adults aged >18 years old with body mass index (BMI) <35 kg/m 2 with uncomplicated gall bladder disease who were eligible to undergo either SILC or CMLC with the American Society of Anesthesiology (ASA) Score I-III. 13 • I - Intervention: Patients who underwent SILC to treat their gall bladder diseases. • C - Comparator: Patients who underwent CMLC as surgical treatment for gall bladder diseases. • O - Outcomes: Bile duct injury (BDI), bile leakage, gallbladder perforation, wound infection, incisional hernia, total intraoperative complications, total post-operative complications, conversion to open cholecystectomy, operating time, estimated blood loss volume, length of hospital stay, cosmesis (satisfactory quantitative scores) at one month and six months post-operation, days to return to work, and post-operative pain score assessed by a visual analog score (VAS) at five-time points (4, 6, 8, 12, and 24 hours post-procedure). • S - Study design: Randomized clinical trials All studies besides original articles (correspondence, letter to editor, or review articles), observational studies (cohort or case-control designs), case series, case report studies, studies reported in a language other than English, research focusing on pregnant women and populations below the age of 18 years were excluded. Search strategy and study selection We conducted systematic literature searches in three databases: PubMed (RRID:SCR_004846), PubMed Central (PMC) (RRID:SCR_004166), and Europe PubMed Central (EuroPMC) (RRID:SCR_005901) from December 2011 until December 2021. The latest search was conducted in January 2022. To filter the intended studies, combined keywords were used, but were not limited to, the following: “single-incision”, “single-port”, “single access”, “conventional”, “standard”, “multi-port”, “laparoscopic cholecystectomy”. Two researchers (RR and RVH) independently screened the titles and abstracts to find the eligible articles. Additional evaluation of references from eligible studies was also conducted to search for more potential articles. Full-text articles were then assessed independently according to the inclusion and exclusion criteria. This study is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines 63 and the PRISMA diagram shows the strategy we employed during our study ( Figure 1 ). Figure 1. PRISMA flowchart. RISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; EuroPMC, Europe PubMed Central; RCT, randomised controlled trial. Data extraction and quality assessment Two researchers (RR and RVH) independently conducted the data extraction process. An extraction form was developed to list information about the study, such as the study’s general information (title, authors, year of publication, study design), population characteristics, and outcomes measured. The data were then extracted through Covidence (RRID:SCR_016484). Conflicts in data abstraction were resolved by consensus and referring to the original article. Two authors (RR and RVH) assessed the quality of each study involved in this review independently. The Cochrane Risk of Bias (RoB) 2.0 tool was used to evaluate the quality of clinical trial studies. This tool is comprised of five domains, including (1) bias arising from the randomization process; (2) bias due to deviations from intended interventions; (3) bias due to missing outcome data; (4) bias in measurement of the outcome; and (5) bias in the selection of the reported results. The final judgments of each domain were categorized as low risk, some concerns, or high risk. The summarized five domains of RoB were concluded by RR and RVH, whereas a discussion with AW resolved any discrepancies in the judgments to reach the final consensus. Statistical analysis Meta-analysis was done using Review Manager 5.4 (Cochrane Collaboration) and Comprehensive Meta-Analysis version 3 software . The Mantel-Haenszel formula was used to obtain the risk ratio (RR) and 95% confidence interval (CI). At the same time, the Inverse Variance method was used to obtain the mean difference (MD), standardized mean difference (SMD), and standard deviation (SD). We used the random-effects model for all outcomes of interest in this study, regardless of heterogeneity. This meta-analysis assessed heterogeneity between studies by I-squared (I 2 ; inconsistency). The I 2 statistic with a value of 50% is considered a high degree of heterogeneity. Funnel plot analysis was utilized to assess the qualitative risk of publication bias, while Egger’s regression method was used to evaluate the quantitative risk of publication bias. Results Study selection and study characteristics The initial search generated 222 records, in which 37 RCTs were included for qualitative synthesis (systematic review) following the screening, removing duplication, and excluding of several studies ( Figure 1 ). 14 – 50 These final included RCTs yielded 2,129 and 2,392 patients who underwent SILC and CMLC. All patients had uncomplicated gall bladder diseases with ASA grade I-III and were eligible to undergo both techniques. The types of surgical ports ranged from conventional instruments to specific models. Three studies were double-blind RCTs, one was a single-blind RCT, and the remaining RCTs did not elaborate on the blinding method. A total of 10 studies were excluded due to including BMI >35 kg/m 2 , age <18 years old, and retrospective study. 51 – 60 The full details of data characteristics are available in Table 1 . Table 1. Data characteristics. Authors Year Type of port(s) Sample size, n Age, years, mean (SD) Male sex, n (%) BMI, kg/m 2 , mean (SD) ASA grade, mean (SD) SILC CMLC SILC CMLC Arezzo et al. 14 2017 Singe-port device 10 mm port and two 2 mm port 263 278 48.3 (15.8) NR 26.9 (4.1) NR Bingener et al. 15 2016 TriPort™ (Olympus) Two 10 mm and two 5 mm port 55 55 48.4 (16.2) 21 (19.1%) 31.7 (6.1) 1.95 (0.5) Borle et al. 16 2014 Conventional instruments Two 11 mm and two 5 mm port 30 30 41.25 (13.09) 17 (28.3%) 23.2 (1.7) NR Brown et al. 17 2013 SILS ® port (Covidien) One 11 mm and three 5 mm port 40 39 45 (13.9) 18 (22.8%) 29.8 (6.0) NR Bucher et al. 18 2011 TriPort™ (Olympus) Two 10 mm and two 5 mm port 75 75 46.12 (10.03) NR 35.3 (2.5) 2 (0.3) Cao et al. 19 2011 Conventional instruments Two 10 mm and one 5 mm port 57 51 61.0 (4.9) 45 (41.7%) 28.3 (4.7) 1.85 (0.6) Chang et al. 20 2015 SILS ® port (Covidien) 10 mm port (Genicon) 50 50 50.3 (12.9) 39 (39%) 25.5 (5.5) 1.65 (0.5) Deveci et al. 21 2013 SILS ® port (Covidien) Two 10 mm and one 5 mm port 50 50 41.4 (12.1) 12 (12%) 28 (5.02) 1.75 (0.5) Ellatif et al. 22 2013 Conventional instruments Two 10 mm and two 5 mm port 125 125 47.3 (10.9) 67 (26.8%) 28.2 (5.7) 1.55 (0.3) Goel et al. 23 2016 Conventional instruments NR 30 30 38.5 (7.8) 11 (18.3%) NR NR Guo et al. 24 2015 Conventional instruments Two 10 mm and one or two 5 mm port 138 414 43.9 (12.1) 137 (24.8%) 24.9 (2.7) NR Hajong et al. 25 2016 Conventional instruments Two 10 mm and two 5 mm port 32 32 NR 12.50% NR NR He et al. 26 2015 Conventional instruments One 10 mm and two 5 mm port 100 100 40.6 (13.3) 99 (49.5%) 26.1 (7.1) 1.6 (0.5) Ito et al. 27 2019 Single device (EZ ACCESS) One 12 mm and three 5 mm port 58 53 57.4 (12.5) 47 (42.3%) 24.5 (3.7) NR Jorgensen et al. 28 2014 SILS ® port (Covidien) One 12 mm and two 5 mm port 60 60 45.1 (5.4) NR 25.7 (1.6) 1.35 (0.5) Justo-Janeiro et al. 29 2014 SILS ® port (Covidien) Two 10 mm and one 5 mm port 17 17 43.4 (16.4) 5 (14.7%) 27.8 (3.9) 1.5 (0.25) Khorgami et al. 30 2014 Conventional instruments One 10 mm and three 5 mm port 30 30 42.6 (11.8) 17 (28.3%) 27.3 (4.1) NR Klein et al. 31 2020 TriPort™ or TriPort+™ (Olympus) Two 10 mm and one 5 mm port 98 95 47.2 (15.4) 64 (33.1%) 28.6 (6.1) 1.6 (0.3) Koirala et al. 32 2019 Conventional instruments Two 10 mm and two 5 mm port 100 100 41 (14.2) 41 (20.5%) NR NR Lai et al. 33 2011 SILS ® port (Covidien) One 10 mm and three 5 mm port 24 27 53.1 (12.6) 19 (37.3%) 24.7 (2.9) 1.5 (0.5) Leung et al. 34 2012 NR NR 36 43 47.5 (19.2) 25.70% 28.5 (6.4) NR Lirici et al. 35 2011 TriPort™ (Olympus) Two 12 mm and two 5 mm port 20 20 46.2 (13.2) 12 (30%) 24.8 (2.9) 1.9 (0.5) Luna et al. 36 2013 SITRACC device Two 10 mm and two 5 mm ports 20 20 NR NR NR NR Lurje et al. 37 2015 SILS ® port (Covidien) NR 48 48 46.0 (14.0) 62 (64.6%) 25.0 (4.0) 1.5 (0.3) Noguera et al. 38 2013 SILS ® port (Covidien) One 1 mm and two 5 mm port 20 20 54.5 (7.1) 7 (17.5%) 29.0 (3.1) 1.6 (0.5) Partelli et al. 39 2016 Single Site Laparoscopic Access System Two 10 mm and two 5 mm port 30 29 44.8 (12.9) 22 (37.2%) 24.2 (3.4) NR Qu et al. 40 2019 Single port Two 10 mm and two 5 mm port 49 42 46.4 (9.8) 41 (45.1%) 23.3 (2.7) NR Rizwi et al. 41 2014 NR NR 100 100 41.7 (8.3) 84 (42%) NR NR Saad et al. 42 2013 SILS ® port (Covidien) Two 10 mm and two 5 mm port 35 35 47.0 (15.6) 54 (77.1%) 25.4 (2.8) 1.6 (0.5) Sasaki et al. 43 2012 SILS ® port (Covidien) One 12 mm and three 5 mm port 27 27 57.4 (13.2) 28 (51.8%) 24.7 (3.2) NR Solomon et al. 44 2012 SILS ® port (Covidien) One 11 mm and three 5 mm port 22 11 37.4 (3.8) NR 31.7 (1.7) NR Subirana et al. 45 2021 TriPort+™ (Olympus) Two 10 mm and two 5 mm port 37 36 38.1 (10.3) 9 (12.3%) 26.3 (3.8) 1.35 (0.3) Sulu et al. 46 2015 SILS ® port (Covidien) Two 5 mm and two 2 mm port 30 30 46.3 (9.7) 21 (35%) 29.4 (5.0) 1.6 (0.5) Ye et al. 47 2015 Single 5mm port NR 100 100 NR NR NR NR Yilmaz et al. 48 2013 SILS ® port (Covidien) NR 43 40 49.7 (10.7) 61 (73.4%) 23.8 (3.6) 2.0 (0.5) Zhao et al. 49 2016 Single Site Laparoscopic Access System NR 50 50 48.1 (8.9) 32 (32%) 24.9 (3.8) NR Zheng et al. 50 2012 A single Tri-port (Advanced Surgical Concept) Two 10 mm and one 5 mm port 30 30 45.2 (12.9) 29 (48.3%) 25.3 (3.8) NR Risk of bias in studies The Cochrane RoB 2.0 tool was applied to determine the quality of RCTs. A total of 33 studies were categorized as low risk of bias studies. Two studies were determined to have some concerns because the long-term follow-up results could not be fully concluded. The other two studies were evaluated for having a high risk of bias due to having a higher percentage of loss to follow-up and a high risk of false-positive results. The evaluation of RoB is summarized in Figure 2 . Figure 2. The overall judgment of included studies. Outcome effects Bile duct injury A total of 17 studies (n=2,114) reported the BDI outcome. Our pooled analysis showed that the SILC procedure did not differ from the CMLC procedure in terms of risk for BDI [RR 0.83 (95% CI 0.17–4.04), p=0.82, I 2 =0%, random-effect modeling] ( Figure 3A ). Figure 3. Forrest plots of SILC vs. CMLC. (A) Bile duct injury. (B) Bile leakage. (C) Gall bladder perforation. (D) Wound infection. SILC, single-incision laparoscopic cholecystectomy; CMLC, conventional multi-port laparoscopic cholecystectomy. Bile leakage A total of 16 studies (n=2,363) reported on the bile leakage outcome. Our pooled analysis showed that the SILC procedure did not differ from the CMLC procedure in terms of risk for bile leakage incidence [RR 1.31 (95% CI 0.72–2.39), p=0.38, I 2 =0%, random-effect modelling] ( Figure 3B ). Gallbladder perforation Nine studies (n=1,874) reported on the gallbladder perforation outcome. Our pooled analysis showed that the SILC procedure did not differ from the CMLC procedure in terms of gallbladder perforation incidence [RR 0.94 (95% CI 0.71–1.26), p=0.68, I 2 =0%, random-effect modelling] ( Figure 3C ). Wound infection A total of 24 studies (n=2,926) reported on the wound infection outcome. Our pooled analysis showed that the SILC procedure did not change the risk of wound infection incidence when compared with the CMLC procedure [RR 1.20 (95% CI 0.72–2.03), p=0.48, I 2 =0%, random-effect modelling] ( Figure 3D ). Incisional hernia A total of 28 studies (n=3,788) reported on the incisional hernia outcome. Our pooled analysis showed that the SILC procedure did not change the risk of incisional hernia incidence when compared with the CMLC procedure [RR 1.43 (95% CI 0.75–2.74), p=0.28, I 2 =0%, random-effect modelling] ( Figure 4A ). Figure 4. Forrest plots of SILC vs. CMLC. (A) Incisional hernia. (B) Total intra-operative complications. (C) Total post-operative complications. SILC, single-incision laparoscopic cholecystectomy; CMLC, conventional multi-port laparoscopic cholecystectomy. Total intra-operative complications A total of 26 studies (n=3,717) reported on the total intra-operative outcome. Our pooled analysis showed that the SILC procedure did not differ from the CMLC procedure in terms of the incidence of total intra-operative complications [RR 1.22 (95% CI 0.93–1.59), p=0.15, I 2 =0%, random-effect modelling] ( Figure 4B ). Total post-operative complications A total of 30 studies (n=3,882) reported on the total post-operative outcome. Our pooled analysis showed that the SILC procedure did not differ from the CMLC procedure in terms of the incidence of total post-operative complications [RR 1.04 (95% CI 0.93–1.59), p=0.15, I 2 =0%, random-effect modelling] ( Figure 4C ). Estimated blood loss A total of 12 studies (n=1,416) reported on the estimated blood loss outcome. Our pooled analysis showed that the SILC procedure did not differ from the CMLC procedure in terms of estimated blood loss volume [MD 1.29 (95% CI -0.85, 3.43), p=0.24, I 2 =86%, random-effect modelling] ( Figure 5A ). Figure 5. Forrest plots of SILC vs. CMLC. (A) Estimated blood loss. (B) Operation time. (C) Conversion to open surgery. (D) Hospital stay. SILC, single-incision laparoscopic cholecystectomy; CMLC, conventional multi-port laparoscopic cholecystectomy. Operation time A total of 34 studies (n=3,972) reported on the operation time outcome. Our pooled analysis showed that the SILC procedure significantly increased the length of operation time when compared with the CMLC procedure [MD 10.45 (95% CI 6.74, 14.17), p<0.00001, I 2 =97%, random-effect modelling] ( Figure 5B ). Conversion to open cholecystectomy A total of 27 studies (n=3,701) reported on the conversion to open cholecystectomy outcome. Our pooled analysis showed that the SILC procedure did not differ from the CMLC procedure in terms of conversion to open cholecystectomy rate [RR 1.07 (95% CI 0.53–2.19), p=0.84, I 2 =0%, random-effect modelling] ( Figure 5C ). Length of hospital stay A total of 26 studies (n=3,868) reported on the length of hospital stay outcome. Our pooled analysis showed that the SILC procedure did not differ from the CMLC procedure in terms of length of hospital stay [MD -0.11 (95% CI -0.26, 0.05), p=0.18, I 2 =90%, random-effect modelling] ( Figure 5D ). VAS at four hours post-operation Five studies (n=537) reported on VAS at the four-hour post-operative observation. Our pooled analysis showed that the SILC procedure did not offer benefits in VAS at four hours post-operation when compared with the CMLC procedure [MD -0.70 (95% CI -1.89, 0.49), p=0.25, I 2 =95%, random-effect modelling] ( Figure 6A ). Figure 6. Forrest plots of SILC vs. CMLC. VAS at (A) 4, (B) 6, (C) 8, (D) 12 and 24 hours post-operation. Cosmesis at (F) one month and (G) six months post-operation. (H) Days to return to work. SILC, single-incision laparoscopic cholecystectomy; CMLC, conventional multi-port laparoscopic cholecystectomy; VAS, visual analog score. VAS at six hours post-operation Nine studies (n=1,204) reported on VAS at the six-hour post-operative observation. Our pooled analysis showed that the SILC procedure offered benefits in reducing the VAS at six hours post-operation when compared with the CMLC procedure [MD -0.58 (95% CI -1.11, -0.05), p=0.03, I 2 =93%, random-effect modelling] ( Figure 6B ). VAS at eight hours post-operation Five studies (n=573) reported on VAS at the eight-hour post-operative observation. Our pooled analysis showed that the SILC procedure did not offer benefits in VAS at eight hours post-operation when compared with the CMLC procedure [MD -0.50 (95% CI -1.17, 0.17), p=0.15, I 2 =95%, random-effect modelling] ( Figure 6C ). VAS at 12 hours post-operation Four studies (n=459) reported on VAS at the 12-hour post-operative observation. Our pooled analysis showed that the SILC procedure did not offer benefits in VAS at 12 hours post-operation when compared with the CMLC procedure [MD -0.86 (95% CI -2.02, 0.30), p=0.15, I 2 =95%, random-effect modelling] ( Figure 6D ). VAS at 24 hours post-operation A total of 29 studies (n=4,096) reported on VAS at the 24-hour post-operative observation. Our pooled analysis showed that the SILC procedure did not offer benefits in VAS at 24 hours post-operation when compared with the CMLC procedure [MD -0.14 (95% CI -0.42, 0.14), p=0.32, I 2 =94%, random-effect modelling] ( Figure 6E ). Cosmesis at one month Five studies (n=1,196) reported on the outcome of cosmesis one-month post-operation. Our pooled analysis showed that the SILC procedure offered benefits in increasing the cosmesis score one-month post-operation when compared with the CMLC procedure [SMD 2.12 (95% CI 1.10, 3.13), p<0.0001, I 2 =98%, random-effect modelling] ( Figure 6F ). Cosmesis at six months Three studies (n=446) reported on the outcome of cosmesis six months post-operation. Our pooled analysis showed that the SILC procedure offered benefits in increasing the cosmesis score at six months post-operation compared with the CMLC procedure [SMD 0.53 (95% CI 0.06, 0.99), p=0.03, I 2 =81%, random-effect modelling] ( Figure 6G ). Days to return to work Eight studies (n=771) reported on the days to return to work outcomes. Our pooled analysis showed that the SILC procedure did not differ from the CMLC procedure in terms of the number of days it took to return to work [MD 0.00 (95% CI -1.42, 1.43), p=1.00, I 2 =96%, random-effect modelling] ( Figure 6H ). Meta-regression Meta-regression was performed to identify risk factors that influence the relationship between SILC procedure and statistically significant outcomes, consisting of the operation time, VAS at six hours post-operation, cosmesis score at one-month post-operation, and cosmesis score at six months post-operation. The results of the meta-regression analyses can be found as Extended data. 63 Our meta-regression revealed that variability in those outcomes in patients who underwent the SILC procedure compared with the CMLC procedure was explained by known patient factors associated with predictors of abdominal surgery outcomes. From our meta-regression analysis, it was revealed that the length of operation time in patients who underwent the SILC procedure compared with the CMLC procedure was not significantly influenced by age (p=0.1133), sex (p=0.1936), BMI (p=0.4407), and ASA score (p=0.0557). In terms of VAS at six hours post-operation, a statistically significant association was present for BMI (beta coefficient: -0.1120; 95% CI: -0.2161, -0.0079; p=0.0350). However, other factors such as age (p=0.7800), sex (p=0.8660), and ASA score (p=0.0976) did not significantly affect the relationship between the SILC procedure compared with the CMLC procedure on the VAS at six hours post-operation. Meanwhile, in terms of cosmesis at one-month post-operation, a statistically significant association was also present for BMI (beta coefficient: -1.2241; 95% CI: -1.7181, -0.7302; p < 0.0001). Our meta-regression also revealed that cosmesis at one-month post-operation was not significantly influenced by age (p=0.2866), and sex (p=0.9090). Lastly, for cosmesis at six months post-operation, the meta-regression analysis could not be performed as there were too many included studies in the analysis. Publication bias We used Funnel plot analysis for the assessment of publication bias in each outcome of interest. This analysis showed a relatively symmetrical inverted plot for all outcomes of interest in this study, indicating no publication bias. 63 Furthermore, the Egger regression test results were also not statistically significant for all outcomes of interest, confirming the results from funnel plot analysis in which no sign of publication bias was found ( Table 2 ). Table 2. Summary of publication bias analysis. Outcomes Funnel-plot Egger’s test Bile duct injury Symmetrical p=0.93632 Bile leakage Symmetrical p=0.42522 Gallbladder perforation Symmetrical p=0.28977 Wound infection Symmetrical p=0.62726 Incisional hernia Symmetrical p=0.27176 Total intra-operative complications Symmetrical p=0.71848 Total post-operative complications Symmetrical p=0.14619 Estimated blood loss Symmetrical p=0.57188 Operation time Symmetrical p=0.82622 Conversion to open cholecystectomy Symmetrical p=0.54945 Length of hospital stay Symmetrical p=0.38360 VAS at four hours post-operation Symmetrical p=0.83937 VAS at six hours post-operation Symmetrical p=0.59750 VAS at six hours post-operation Symmetrical p=0.28533 VAS at 12 hours post-operation Symmetrical p=0.18789 VAS at 24 hours post-operation Symmetrical p=0.47530 Cosmesis at one-month post-operation Symmetrical p=0.08651 Cosmesis at six months post-operation Symmetrical p=0.95798 Days to return to work Symmetrical p=0.95410 Discussion The current ‘gold standard’ for cholecystectomy is laparoscopic cholecystectomy. This established technique has replaced the open method for routine cholecystectomy since the 1990s. Numerous studies have shown that traditional laparoscopic surgery (utilising three or four ports) is viable, secure, and advantageous for cholecystectomy. 61 Technological advancements in surgery are progressing rapidly; hence, the single incision technique was established in 1997 to enhance post-operative pain management and cosmetic outcomes. Currently, SILC and CMLC are the available techniques for cholecystectomy, each with distinct considerations. Numerous RCTs have highlighted the advantages and disadvantages of both methods, however the conclusions remain disputed. The current ‘gold standard’ for cholecystectomy is laparoscopic cholecystectomy. This established technique has replaced the open method for routine cholecystectomy since the 1990s. Numerous studies have shown that traditional laparoscopic surgery (utilising three or four ports) is viable, secure, and advantageous for cholecystectomy. Sixty-one Technological advancements in surgery are progressing rapidly; hence, the single incision technique was established in 1997 to enhance post-operative pain management and cosmetic outcomes. Currently, SILC and CMLC are the available techniques for cholecystectomy, each with distinct considerations. Numerous RCTs have highlighted the advantages and disadvantages of both methods, however the conclusions remain disputed. 1 A recent systematic evaluation by Lyu et al. 12 indicated that SILC did not provide benefits over CMLC. The comprehensive findings of our study indicated that SILC enhanced post-operative pain management and aesthetic outcomes without an increased occurrence of perioperative problems, blood loss, conversion to open cholecystectomy, prolonged hospital stays, or delayed return to work in comparison to CMLC. Conversely, extended operational duration remains a significant concern for SILC. Perioperative complications are a prevalent concern and continue to be contentious in every investigation. Evers et al. 7 (2017) demonstrated that SILC was inferior than CMLC [RR 3.00 (95% CI 1.05–8.58)]. A further systematic review by Hall et al. 11 further corroborated the inferiority of SILC in terms of overall problems. Our investigation indicated that biliary duct injuries, bile leakage, gallbladder perforation, wound infection, and incisional hernia exhibited no significant differences between SILC and CMLC. These assertions align with prior systematic reviews. 9 , 13 , 62 We hypothesise that the improved understanding and development of single incision ports have reduced the likelihood of problems. Consequently, SILC is seen as equally viable as CMLC. The remaining challenge for SILC is operational duration. Our research revealed an extended duration in SILC with a statistically significant p-value. None of the other systematic reviews demonstrated a shorter duration for SILC compared to CMLC. 7 , 9 , 11 , 13 Numerous factors can impede the operational duration of SILC, including the specific approach employed, the type of instruments utilised, the viewpoint of the camera angle, and the intersection of instruments. These challenges can be surmounted by surgical expertise and the advancement of sophisticated equipment. Consequently, the duration of the operation may be identical in both methodologies. Post-operative pain was assessed using the Visual Analogue Scale (VAS) at four intervals: 4, 6, 8, 12, and 24 hours. Our study demonstrated a notable reduction in pain at the six-hour postoperative mark; however, the Visual Analogue Scale scores at 4, 8, 12, and 24 hours did not exhibit differences between the two groups. The tests conducted by Hall et al. 11 and Arezzo et al. 9 indicated that the VAS did not exhibit significant differences. Simultaneously, Lirici et al. 62 demonstrated an enhancement in VAS following the first day; nevertheless, the pain scores on day one exhibited no changes between SILC and CMLC. Conversely, Evers et al. 7 demonstrated an improved VAS outcome in the SILC group at 24 hours. Lyu et al. 12 observed contrasting results, indicating that SILC was less effective in reducing post-operative pain at 6, 8, 12, and 24 hours. The variability of VAS was affected by numerous factors, including the type of anaesthetic agents, incision length, and psychological influences. Consequently, our analysis indicated a significant level of heterogeneity. The aesthetic superiority of SILC was definitely evident. Our study indicated superior cosmetic results at both one month and six months post-operation. Numerous studies have corroborated our findings. 7 , 9 , 11 , 62 The benefit of a solitary incision at the umbilicus results in a continuous scar, enhancing patient satisfaction. The definition of cosmesis differed across studies, resulting in significant variation. Our study revealed no differences between SILC and CMLC regarding blood loss, conversion to open surgery, length of hospital stay, and time to return to work. Supporting research also indicated comparable results, demonstrating that SILC did not improve the outcomes in those areas. 7 , 9 , 11 , 62 This study is limited by the inclusion of only English-language papers, significant variability across all features, numerous randomised controlled trials with a high risk of bias, and varied definitions of all evaluated outcomes. We recommend equal weighting for pain and cosmesis scores to reduce heterogeneity, together with a more exact description of perioperative problems and operational duration to standardise outcome measurement. Therefore, extensive, double-blind, well planned randomised controlled trials are advised. Conclusions Technical evolution has made SILC and CMLC known alternatives. However, in a recent systematic review, it was established that SILC did not offer advantages over CMLC and also that the operational time of SILC still remains a serious issue. The VAS measured the post-operative pain and cosmetic results, which indicated the superiority of SILC. Thus, SILC may be an option for cholecystectomy depending on the surgeon’s experience. Data availability Underlying data All data underlying the results are available as part of the article and no additional source data are required. Extended data Zenodo: Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials. https://doi.org/10.5281/zenodo.6416832 . 63 This project contains the following extended data: - ROB2_IRPG_beta_v9_Sysrev.xlsm (dataset) - Supplementary Figure 1.pdf - Supplementary Figure 2.pdf - Supplementary Figure 3.pdf - Supplementary Figure 4.pdf - Supplementary Table 1.docx - Search Strategy.docx Reporting guidelines Zenodo: PRISMA checklist for ‘Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials.’ https://doi.org/10.5281/zenodo.6416832 . 63 Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). References 1. 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Publisher Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 06 Jul 2022 ADD YOUR COMMENT Comment Author details Author details 1 Division of Digestive Surgery, Department of General Surgery, School of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, 40161, Indonesia 2 Faculty of Medicine, Pelita Harapan University, Tangerang, 15810, Indonesia Reno Rudiman Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Ricarhdo Valentino Hanafi Roles: Data Curation, Formal Analysis, Methodology, Project Administration, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Alma Wijaya Roles: Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 18 Nov 2024, 11:754 https://doi.org/10.12688/f1000research.122102.2 version 1 Published: 06 Jul 2022, 11:754 https://doi.org/10.12688/f1000research.122102.1 Copyright © 2024 Rudiman R et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Rudiman R, Hanafi RV and Wijaya A. Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 11 :754 ( https://doi.org/10.12688/f1000research.122102.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 18 Nov 2024 Revised Views 0 Cite How to cite this report: Korayem I. Reviewer Report For: Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 11 :754 ( https://doi.org/10.5256/f1000research.174548.r345779 ) The direct URL for this report is: https://f1000research.com/articles/11-754/v2#referee-response-345779 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 18 Dec 2024 Islam Korayem , Alexandria University, Alexandria, Alexandria Governorate, Egypt Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.174548.r345779 Thank you for giving me the chance to review this manuscript. Comparing different approached of laparoscopic cholecystectomy remains to be a hot topic with abundant contributions and debates. Overall, the manuscript is well written in a proper ... Continue reading READ ALL Thank you for giving me the chance to review this manuscript. Comparing different approached of laparoscopic cholecystectomy remains to be a hot topic with abundant contributions and debates. Overall, the manuscript is well written in a proper manner both scientifically and linguistically. There are, however, some points that require further attention and revision by the authors to improve the current version of the manuscript. - Conventional LC always refers to the standard 4-port LC performed with two 10/12 mm ports and two 5mm ports. Any modification of this pattern as reduced port size or number should not be considered conventional. Since the manuscript included studies comparing SILC to 4-port, 3-port, 2-port, or reduced-port size (3mm and 1mm), thus placing those as conventional is not accurate. Accordingly, I recommend the authors to omit the word "conventional" from the manuscript title as well as the group designation that is compared to SILC group. Using the term "Multiport LC (MPLC)" will be more descriptive as it will encompass all forms of multiport LC using any numbers and sizes of ports (including the conventional/standard LC). - Always add "respectively" to the end of the statement whenever you mention the 2 groups and their numbers following them to ensure the orderly fashion of the displayed numbers related to each the groups. This should be followed in the Abstract and the Results sections to look as such: (2129 and 2392 patients were included in the SILC and MPLC groups, respectively ). - The heterogeneity of the MPLC group as illustrated in Table 1 should be addressed as a potential form of bias since such standard group is not the same across the included studies. - The PRISMA flowchart needs to be modified as follows: 1- The first 2 boxes need to be merged into 1 box, where the total number of studies identified upon online search is 222 which is broken down to 120 from PubMed, 61 from PMC, and 41 from EuroPMC. The horizontal arrow going toward the excluded box should come out from the vertical downward arrow and Not from the box. 2- The next box should be the remaining studies to be screened after exclusion which will be 62 studies. The arrow going downward from it should divide to a horizontal arrow which illustrates the exclusion of 15 duplicate studies. 3- The next box should be the remainder after exclusion of duplicates in the above step, which will be 47 studies. The arrow going vertically downwards from this third box will have another horizontal arrow going to the excluded 10 studies based on exclusion criteria defined. 4- A final box of 37 studies included in the analysis should be the end of this chart - In the Methodology, defining pain assessment using VAS should also include the type of the analgesic used, the dosing, and the frequency of administration across all the studies to ensure a transparent comparison of both groups. - In the discussion section, the first paragraph is repeated twice (lines 1-7, and lines 7-14). Delete the any group of the repeated lines. - The beginning of the paragraph should be modified as follows: ( The gold standard treatment for gallstone disease is laparoscopic cholecystectomy). - The conclusion needs to better highlight the results arising from this study. Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes Are sufficient details of the methods and analysis provided to allow replication by others? Yes Is the statistical analysis and its interpretation appropriate? Yes Are the conclusions drawn adequately supported by the results presented in the review? Partly If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.) Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: Hepatobiliary and Pancreatic Surgery, Laparoscopic Abdominal Surgery, Liver resection, Liver Transplantation, Hernia Surgery, Colorectal Surgery, Gastrointestinal Surgery, Abdominoplasty Surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Korayem I. Reviewer Report For: Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 11 :754 ( https://doi.org/10.5256/f1000research.174548.r345779 ) The direct URL for this report is: https://f1000research.com/articles/11-754/v2#referee-response-345779 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Aydoğdu YF. Reviewer Report For: Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 11 :754 ( https://doi.org/10.5256/f1000research.174548.r341301 ) The direct URL for this report is: https://f1000research.com/articles/11-754/v2#referee-response-341301 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 21 Nov 2024 Yunushan Furkan Aydoğdu , Department of General Surgery, Bandırma Training and Research Hospital, Balıkesir, Turkey Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.174548.r341301 Dear Author In general, the requested revisions were made, but the article suggestions in the first revision was ... Continue reading READ ALL Dear Author In general, the requested revisions were made, but the article suggestions in the first revision was not added. Adding it will increase the development and acceptability of the article. It is also thought to increase its readability. Competing Interests: No competing interests were disclosed. Reviewer Expertise: General Surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Aydoğdu YF. Reviewer Report For: Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 11 :754 ( https://doi.org/10.5256/f1000research.174548.r341301 ) The direct URL for this report is: https://f1000research.com/articles/11-754/v2#referee-response-341301 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 06 Jul 2022 Views 0 Cite How to cite this report: Aydoğdu YF. Reviewer Report For: Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 11 :754 ( https://doi.org/10.5256/f1000research.134047.r335341 ) The direct URL for this report is: https://f1000research.com/articles/11-754/v1#referee-response-335341 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 06 Nov 2024 Yunushan Furkan Aydoğdu , Department of General Surgery, Bandırma Training and Research Hospital, Balıkesir, Turkey Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.134047.r335341 General Evaluation Subject and Objective: The study focused on the comparison of SILC and CMLC techniques. The purpose of the research is clearly defined and targets existing gaps in the literature. This draws the reader's attention. ... Continue reading READ ALL General Evaluation Subject and Objective: The study focused on the comparison of SILC and CMLC techniques. The purpose of the research is clearly defined and targets existing gaps in the literature. This draws the reader's attention. Methods: The methods section clearly describes the systematic review and meta-analysis processes. A specific framework is established with PICOS criteria. The search strategy and study selection process are described in detail. Results: The results section presented the analyzed data in a systematic way. Statistical data are well summarized, but could be strengthened with more visual support (graphs or tables). Discussion: The discussion section provides a good overview of the relevance of the findings to the existing literature. The advantages and disadvantages of SILC are clearly discussed. However, some sentences may need to be simplified to improve fluency. Recommendations Expansion of Limitations: The limitations section could be enriched by adding more detail. For example, more emphasis could be placed on the potential impacts of the language limitation in the study. Summarizing the Results: At the end of the study, it may be useful to provide a brief summary of the main findings and recommendations for future research. This makes it easier for readers to remember the main points. References and Citations: The use of references in more contexts throughout the study may increase the credibility of the text. (As a suggestion regarding the study I am reviewing, I would like to state that the article by Aydoğdu et al. (2024) titled “Minimally invasive approach in a rare emergency surgery, gallbladder perforation” should also be included in the evaluation. This study highlights the efficacy of minimally invasive approaches for a rare surgical emergency such as gallbladder perforation. ) Conclusion Overall, the paper is well structured and provides important insights on the topic. Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes Are sufficient details of the methods and analysis provided to allow replication by others? Yes Is the statistical analysis and its interpretation appropriate? Yes Are the conclusions drawn adequately supported by the results presented in the review? Partly If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.) Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: General Surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Aydoğdu YF. Reviewer Report For: Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 11 :754 ( https://doi.org/10.5256/f1000research.134047.r335341 ) The direct URL for this report is: https://f1000research.com/articles/11-754/v1#referee-response-335341 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 08 Nov 2024 Reno Rudiman , Division of Digestive Surgery, Department of General Surgery, School of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, 40161, Indonesia 08 Nov 2024 Author Response Dear Dr. Yunushan Furkan Aydoğdu, Thank you for your insightful recommendations on our manuscript. Therefore, we will proceed to revise based on the details you have provided. Best regards ... Continue reading Dear Dr. Yunushan Furkan Aydoğdu, Thank you for your insightful recommendations on our manuscript. Therefore, we will proceed to revise based on the details you have provided. Best regards Rudiman Dear Dr. Yunushan Furkan Aydoğdu, Thank you for your insightful recommendations on our manuscript. Therefore, we will proceed to revise based on the details you have provided. Best regards Rudiman Competing Interests: We declare there is no competing interest in any circumstances. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 08 Nov 2024 Reno Rudiman , Division of Digestive Surgery, Department of General Surgery, School of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, 40161, Indonesia 08 Nov 2024 Author Response Dear Dr. Yunushan Furkan Aydoğdu, Thank you for your insightful recommendations on our manuscript. Therefore, we will proceed to revise based on the details you have provided. Best regards ... Continue reading Dear Dr. Yunushan Furkan Aydoğdu, Thank you for your insightful recommendations on our manuscript. Therefore, we will proceed to revise based on the details you have provided. Best regards Rudiman Dear Dr. Yunushan Furkan Aydoğdu, Thank you for your insightful recommendations on our manuscript. Therefore, we will proceed to revise based on the details you have provided. Best regards Rudiman Competing Interests: We declare there is no competing interest in any circumstances. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Budipramana VS and Pramana Witarto A. Reviewer Report For: Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 11 :754 ( https://doi.org/10.5256/f1000research.134047.r155047 ) The direct URL for this report is: https://f1000research.com/articles/11-754/v1#referee-response-155047 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 07 Feb 2024 Vicky Sumarki Budipramana , Department of Surgery, Premier Surabaya Hospital, Surabaya, Indonesia; Airlangga University, Surabaya, East Java, Indonesia Andro Pramana Witarto , Airlangga University, Surabaya, East Java, Indonesia Approved VIEWS 0 https://doi.org/10.5256/f1000research.134047.r155047 In Fig. 1 regarding PRISMA flowchart, section “Reports excluded: Exclusion criteria (n = 10)” were not clearly detailed into some points and the number of the excluded studies in each of the exclusion criteria. It will be ... Continue reading READ ALL In Fig. 1 regarding PRISMA flowchart, section “Reports excluded: Exclusion criteria (n = 10)” were not clearly detailed into some points and the number of the excluded studies in each of the exclusion criteria. It will be better to input the detailed information to avoid misunderstandings among readers regarding the exclusion criteria. In I 2 statistic’s cut-off values, the authors stated three categories: 50%. “26-50%” should have been “25-50%”, shouldn't it? Please correct the written cut-off to prevent misinterpretation if the I 2 = 25%. The figure legends of Fig. 3 to Fig. 6 should have been clearly stated regarding the classification of the outcomes. Why were the figures separated into Fig. 3 to Fig. 6? Since the outcomes should have been only classified into three (feasibility, safety, and surgical outcome). This should also have gone to the “Outcome effect” section in the results. Please clasify the outcomes in the results section based on the primary goal of this study in order for the readers to understand the outcomes easily. Please explain the novelty of this study as compared with reference No. 12 since it also carries the similar title to the current study. In the discussion section, in paragraph 6, the authors are encouraged to add an explanation regarding the fact that cosmesis is influenced by BMI based on the meta-regression analysis. This is an interesting finding that should have been revealed in the discussion section. Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes Are sufficient details of the methods and analysis provided to allow replication by others? Yes Is the statistical analysis and its interpretation appropriate? Yes Are the conclusions drawn adequately supported by the results presented in the review? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Gastroentestinal surgery We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Budipramana VS and Pramana Witarto A. Reviewer Report For: Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 11 :754 ( https://doi.org/10.5256/f1000research.134047.r155047 ) The direct URL for this report is: https://f1000research.com/articles/11-754/v1#referee-response-155047 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 06 Jul 2022 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 3 Version 2 (revision) 18 Nov 24 read read Version 1 06 Jul 22 read read Vicky Sumarki Budipramana , Premier Surabaya Hospital, Surabaya, Indonesia; Airlangga University, Surabaya, Indonesia Andro Pramana Witarto , Airlangga University, Surabaya, Indonesia Yunushan Furkan Aydoğdu , Bandırma Training and Research Hospital, Balıkesir, Turkey Islam Korayem , Alexandria University, Alexandria, Egypt Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Korayem I. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 18 Dec 2024 | for Version 2 Islam Korayem , Alexandria University, Alexandria, Alexandria Governorate, Egypt 0 Views copyright © 2024 Korayem I. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for giving me the chance to review this manuscript. Comparing different approached of laparoscopic cholecystectomy remains to be a hot topic with abundant contributions and debates. Overall, the manuscript is well written in a proper manner both scientifically and linguistically. There are, however, some points that require further attention and revision by the authors to improve the current version of the manuscript. - Conventional LC always refers to the standard 4-port LC performed with two 10/12 mm ports and two 5mm ports. Any modification of this pattern as reduced port size or number should not be considered conventional. Since the manuscript included studies comparing SILC to 4-port, 3-port, 2-port, or reduced-port size (3mm and 1mm), thus placing those as conventional is not accurate. Accordingly, I recommend the authors to omit the word "conventional" from the manuscript title as well as the group designation that is compared to SILC group. Using the term "Multiport LC (MPLC)" will be more descriptive as it will encompass all forms of multiport LC using any numbers and sizes of ports (including the conventional/standard LC). - Always add "respectively" to the end of the statement whenever you mention the 2 groups and their numbers following them to ensure the orderly fashion of the displayed numbers related to each the groups. This should be followed in the Abstract and the Results sections to look as such: (2129 and 2392 patients were included in the SILC and MPLC groups, respectively ). - The heterogeneity of the MPLC group as illustrated in Table 1 should be addressed as a potential form of bias since such standard group is not the same across the included studies. - The PRISMA flowchart needs to be modified as follows: 1- The first 2 boxes need to be merged into 1 box, where the total number of studies identified upon online search is 222 which is broken down to 120 from PubMed, 61 from PMC, and 41 from EuroPMC. The horizontal arrow going toward the excluded box should come out from the vertical downward arrow and Not from the box. 2- The next box should be the remaining studies to be screened after exclusion which will be 62 studies. The arrow going downward from it should divide to a horizontal arrow which illustrates the exclusion of 15 duplicate studies. 3- The next box should be the remainder after exclusion of duplicates in the above step, which will be 47 studies. The arrow going vertically downwards from this third box will have another horizontal arrow going to the excluded 10 studies based on exclusion criteria defined. 4- A final box of 37 studies included in the analysis should be the end of this chart - In the Methodology, defining pain assessment using VAS should also include the type of the analgesic used, the dosing, and the frequency of administration across all the studies to ensure a transparent comparison of both groups. - In the discussion section, the first paragraph is repeated twice (lines 1-7, and lines 7-14). Delete the any group of the repeated lines. - The beginning of the paragraph should be modified as follows: ( The gold standard treatment for gallstone disease is laparoscopic cholecystectomy). - The conclusion needs to better highlight the results arising from this study. Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes Are sufficient details of the methods and analysis provided to allow replication by others? Yes Is the statistical analysis and its interpretation appropriate? Yes Are the conclusions drawn adequately supported by the results presented in the review? Partly If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.) Not applicable Competing Interests No competing interests were disclosed. Reviewer Expertise Hepatobiliary and Pancreatic Surgery, Laparoscopic Abdominal Surgery, Liver resection, Liver Transplantation, Hernia Surgery, Colorectal Surgery, Gastrointestinal Surgery, Abdominoplasty Surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Korayem I. Peer Review Report For: Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 11 :754 ( https://doi.org/10.5256/f1000research.174548.r345779) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/11-754/v2#referee-response-345779 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Aydoğdu Y. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 21 Nov 2024 | for Version 2 Yunushan Furkan Aydoğdu , Department of General Surgery, Bandırma Training and Research Hospital, Balıkesir, Turkey 0 Views copyright © 2024 Aydoğdu Y. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Dear Author In general, the requested revisions were made, but the article suggestions in the first revision was not added. Adding it will increase the development and acceptability of the article. It is also thought to increase its readability. Competing Interests No competing interests were disclosed. Reviewer Expertise General Surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Aydoğdu YF. Peer Review Report For: Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 11 :754 ( https://doi.org/10.5256/f1000research.174548.r341301) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/11-754/v2#referee-response-341301 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Aydoğdu Y. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 06 Nov 2024 | for Version 1 Yunushan Furkan Aydoğdu , Department of General Surgery, Bandırma Training and Research Hospital, Balıkesir, Turkey 0 Views copyright © 2024 Aydoğdu Y. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions General Evaluation Subject and Objective: The study focused on the comparison of SILC and CMLC techniques. The purpose of the research is clearly defined and targets existing gaps in the literature. This draws the reader's attention. Methods: The methods section clearly describes the systematic review and meta-analysis processes. A specific framework is established with PICOS criteria. The search strategy and study selection process are described in detail. Results: The results section presented the analyzed data in a systematic way. Statistical data are well summarized, but could be strengthened with more visual support (graphs or tables). Discussion: The discussion section provides a good overview of the relevance of the findings to the existing literature. The advantages and disadvantages of SILC are clearly discussed. However, some sentences may need to be simplified to improve fluency. Recommendations Expansion of Limitations: The limitations section could be enriched by adding more detail. For example, more emphasis could be placed on the potential impacts of the language limitation in the study. Summarizing the Results: At the end of the study, it may be useful to provide a brief summary of the main findings and recommendations for future research. This makes it easier for readers to remember the main points. References and Citations: The use of references in more contexts throughout the study may increase the credibility of the text. (As a suggestion regarding the study I am reviewing, I would like to state that the article by Aydoğdu et al. (2024) titled “Minimally invasive approach in a rare emergency surgery, gallbladder perforation” should also be included in the evaluation. This study highlights the efficacy of minimally invasive approaches for a rare surgical emergency such as gallbladder perforation. ) Conclusion Overall, the paper is well structured and provides important insights on the topic. Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes Are sufficient details of the methods and analysis provided to allow replication by others? Yes Is the statistical analysis and its interpretation appropriate? Yes Are the conclusions drawn adequately supported by the results presented in the review? Partly If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.) Not applicable Competing Interests No competing interests were disclosed. Reviewer Expertise General Surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 08 Nov 2024 Reno Rudiman, Division of Digestive Surgery, Department of General Surgery, School of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, 40161, Indonesia Dear Dr. Yunushan Furkan Aydoğdu, Thank you for your insightful recommendations on our manuscript. Therefore, we will proceed to revise based on the details you have provided. Best regards Rudiman View more View less Competing Interests We declare there is no competing interest in any circumstances. reply Respond Report a concern Aydoğdu YF. Peer Review Report For: Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 11 :754 ( https://doi.org/10.5256/f1000research.134047.r335341) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/11-754/v1#referee-response-335341 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Budipramana V et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 07 Feb 2024 | for Version 1 Vicky Sumarki Budipramana , Department of Surgery, Premier Surabaya Hospital, Surabaya, Indonesia; Airlangga University, Surabaya, East Java, Indonesia Andro Pramana Witarto , Airlangga University, Surabaya, East Java, Indonesia 0 Views copyright © 2024 Budipramana V et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions In Fig. 1 regarding PRISMA flowchart, section “Reports excluded: Exclusion criteria (n = 10)” were not clearly detailed into some points and the number of the excluded studies in each of the exclusion criteria. It will be better to input the detailed information to avoid misunderstandings among readers regarding the exclusion criteria. In I 2 statistic’s cut-off values, the authors stated three categories: 50%. “26-50%” should have been “25-50%”, shouldn't it? Please correct the written cut-off to prevent misinterpretation if the I 2 = 25%. The figure legends of Fig. 3 to Fig. 6 should have been clearly stated regarding the classification of the outcomes. Why were the figures separated into Fig. 3 to Fig. 6? Since the outcomes should have been only classified into three (feasibility, safety, and surgical outcome). This should also have gone to the “Outcome effect” section in the results. Please clasify the outcomes in the results section based on the primary goal of this study in order for the readers to understand the outcomes easily. Please explain the novelty of this study as compared with reference No. 12 since it also carries the similar title to the current study. In the discussion section, in paragraph 6, the authors are encouraged to add an explanation regarding the fact that cosmesis is influenced by BMI based on the meta-regression analysis. This is an interesting finding that should have been revealed in the discussion section. Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes Are sufficient details of the methods and analysis provided to allow replication by others? Yes Is the statistical analysis and its interpretation appropriate? Yes Are the conclusions drawn adequately supported by the results presented in the review? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Gastroentestinal surgery We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Budipramana VS and Pramana Witarto A. Peer Review Report For: Single-incision laparoscopic cholecystectomy versus conventional multi-port laparoscopic cholecystectomy: A systematic review, meta-analysis, and meta-regression of randomized controlled trials [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 11 :754 ( https://doi.org/10.5256/f1000research.134047.r155047) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/11-754/v1#referee-response-155047 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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