Skip to main content
Download PDF

Evolution of minimally invasive cholecystectomy: a narrative review

BMC Surgery volume 24, Article number: 378 (2024) Cite this article

A Correction to this article was published on 17 December 2024

This article has been updated

Abstract

Background

Laparoscopic cholecystectomy, being a prevalent abdominal surgical procedure, has transitioned through various innovative stages aimed at reducing the procedure's invasiveness. These stages encompass Single-Incision Laparoscopic Cholecystectomy (SILC), Mini Laparoscopic Cholecystectomy (MLC), Natural Orifice Transluminal Endoscopic Surgery (NOTES), and Robotic-Assisted Laparoscopic Cholecystectomy (RALC). The purpose of this review is to trace the evolution of minimally invasive cholecystectomy techniques, assess their status, and identify emerging trends and challenges in the field.

Method

An extensive review was performed to explore the evolution and characteristics of SILC, MLC, NOTES, and RALC. The approach involved an in-depth examination of literature available on PubMed, coupled with a critical assessment of surgical outcomes, associated complications, and technical hurdles posed by these methods.

Results

SILC, despite its potential for reduced scarring, exhibits an elevated risk of bile duct damage and incisional hernia occurrences. MLC, mirroring the standard technique closely, presents minor benefits without amplifying postoperative complications, hence, positing itself as a feasible choice for routine elective cholecystectomy. NOTES, although still facing technical challenges, the hybrid transvaginal procedure is gaining clinical interest. RALC, heralded for its augmented precision and dexterity, emerges as a potential future avenue, although necessitating further exploration to ascertain its efficacy and safety.

Conclusion

The progression of laparoscopic cholecystectomy methodologies embodies the surgical society's aspiration to minimize invasiveness whilst enhancing patient outcomes. This review endeavors to offer a structured discourse on SILC, MLC, NOTES, and RALC, aspiring to aid the ongoing deliberation on the judicious selection of surgical techniques in clinical practice.

Peer Review reports

Introduction

Laparoscopic cholecystectomy (LC) has become the preferred method for gallbladder removal, offering benefits such as less postoperative pain, faster recovery, shorter hospital stays, better cosmetic outcomes and increased patient satisfaction [1,2,3].The shift towards LC was not initially driven by clinical trials but by a consensus on its benefits within the medical community. By the time randomized trials were conducted, LC's advantages were already well recognized, helping it become the gold standard for treating symptomatic cholelithiasis [4].

Currently, many different methods of minimally invasive cholecystectomy are being performed. Fig. 1 shows a brief timetable of the evolution of surgical technique for minimally invasive cholecystectomy. Conventional Laparoscopic Cholecystectomy (CLC), using four ports, has evolved to reduce invasiveness. Mini Laparoscopic Cholecystectomy (MLC) utilizes smaller incisions for the same procedure [5], while Needlescopic surgery, a subset of MLC, uses ≤ 3 mm diameter instruments [6]. Single Incision Laparoscopic Cholecystectomy (SILC) further minimizes incisions by using only one incision [7, 8]. Natural Orifice Transluminal Endoscopic Surgery (NOTES) eliminates external incisions, accessing the target organ via natural orifices [9]. Lastly, Robotic-Assisted Laparoscopic Cholecystectomy (RALC) introduces robotic technology for enhanced surgical precision and control [10], marking the latest advancement in minimally invasive gallbladder surgery. Fig. 2 shows three representative methods of minimally invasive cholecystectomy, CLC, SILC, and RALC.

Fig. 1
figure 1

Timetable for the evolution of the LC modality

Full size image
Fig. 2
figure 2

Three representative methods of minimally invasive cholecystectomy. A Conventional laparoscopic cholecystectomy, using 3 ports. B Single incision laparoscopic cholecystectomy, using a single incision through the umbilicus. C Robot assisted laparoscopic cholecystectomy. The robotic surgical system is docked to the patient’s abdomen

Full size image

This review aims to trace the evolution of minimally invasive cholecystectomy techniques, assess their status, and identify emerging trends and challenges. We focus on advancements in single-incision laparoscopic cholecystectomy (SILC), mini-laparoscopic cholecystectomy (MLC), natural orifice transluminal endoscopic surgery (NOTES), and robotic-assisted laparoscopic cholecystectomy (RALC) for treating gallbladder diseases. While many surgeons are familiar with these procedures, our target audience extends beyond experienced practitioners. We seek to serve a diverse readership, including general surgeons looking for the latest developments, surgical trainees requiring a thorough overview, researchers interested in comparative outcomes, and medical students pursuing an in-depth understanding of surgical advancements.

Methods

This narrative review aims to provide a comprehensive overview of the evolution and current status of minimally invasive cholecystectomy techniques. We employed a systematic approach to literature search and selection, while maintaining the flexibility inherent to narrative reviews to capture the breadth of developments in this rapidly evolving field.

Search strategy

We conducted a comprehensive literature search using PubMed, Embase, and Cochrane Library. The search included articles published up to August 2024. We used a combination of Medical Subject Headings (MeSH) terms and free-text keywords, including but not limited to: "laparoscopic cholecystectomy," "single-incision laparoscopic cholecystectomy," "mini-laparoscopic cholecystectomy," "natural orifice transluminal endoscopic surgery", "cholecystectomy," and "robotic-assisted cholecystectomy."

Inclusion criteria

We included articles that met the following criteria: original research articles, systematic reviews, meta-analyses, and notable case series; focus on minimally invasive cholecystectomy techniques; published in peer-reviewed journals; and full text available in English.

Exclusion criteria

We excluded articles that focused solely on open cholecystectomy techniques, were published as abstracts only, letters, or commentaries without original data, or described techniques in non-human subjects.

Article selection process

Two reviewers independently screened titles and abstracts of retrieved articles. Full texts of potentially eligible articles were then assessed for inclusion. Disagreements were resolved through discussion with a third reviewer. We did not apply strict quality assessment criteria, as our goal was to capture the full spectrum of developments in minimally invasive cholecystectomy. However, we critically appraised each included study, considering factors such as study design, sample size, and potential biases.

Data extraction and synthesis

From each included article, we extracted data on study characteristics (author, year, country, study design), patient demographics, surgical technique details, outcomes, and authors' conclusions and recommendations. Given the narrative nature of this review, we synthesized the extracted data qualitatively, organizing our findings thematically to trace the evolution of minimally invasive cholecystectomy techniques and highlight current trends and challenges.

Single-Incision Laparoscopic Cholecystectomy (SILC)

Introduction

Definition of SILC

Compared to open cholecystectomy, CLC offers benefits such as reduced pain and lower risks of wound infection or hernia due to less abdominal trauma. Building on this, SILC was developed in the late 1990s [7], introducing a technique where multiple instruments are inserted through a single navel incision, promoting it as a 'scarless surgery'.

Abbreviation of the existing literature

Table 1 summarizes the advantages and disadvantages of SILC over CLC (Additional file).

In assessing the efficacy of SILC versus CLC, findings from 9 Systematic Reviews (SRs) were analyzed [11,12,13,14,15,16,17,18,19]. The synthesis of these studies revealed that SILC offers better cosmetic outcomes than CLC but falls short in terms of operation duration, need for additional ports, incisional hernia rates, and costs. No significant differences were noted between SILC and CLC regarding conversion rates, overall complications, bile duct injury (BDI) rates, hospital stay length, and quality of life (QoL). Pain outcomes were mixed, with six SRs finding SILC either better or comparable to CLC, while one SR favored CLC for pain management.

Surgical method

Basic surgical procedures

SILC aims to reduce port usage, typically employing a single incision in the umbilical area for the camera and the surgical instruments. However, the method faces challenges such as limited retraction and triangulation due to the close arrangement of instruments, which complicates the exposure of Calot's triangle and can lead to instrument collisions during precise dissections [1].

Konyang standard method (KSM)

The Konyang Standard Method (KSM), devised at Konyang University in 2010, addresses the limitations of traditional SILC, particularly for severe cholecystitis or gallstones. KSM utilizes three trocars (5, 10, and 12 mm) and flexible instruments to improve the surgical field and minimize complications, demonstrating enhanced outcomes in surgical time, length of hospital stay (LOH), and bleeding volume [20].

Ports and instruments

Different types of ports used (SILSâ„¢ port vs Glove port)

SILC, which involves using a single port for laparoscopic cholecystectomy, includes various port types like the SILS™ port and the glove port. The SILS™ port is an elastic, hourglass-shaped device with one insufflation and three trocar openings for 5-12 mm trocars [21, 22]. Alternatively, the glove port utilizes a sterilized surgical glove with trocars inserted into the glove's fingers, offering a cost-effective option for single-incision surgery, particularly in resource-limited settings [22, 23].

Instrument designs

Research has shown that using curved instruments is more challenging than using linear instruments. This increases the difficulty due to the need for auxiliary measures and prolongs surgical time [24].

Complications

Research suggests SILC is a safe and viable option with a low complication rate [25]. The available systematic reviews indicate that SILC's overall complication and Bile Duct Injury (BDI) rates are comparable to CLC, with a noted increase in incisional hernias post-SILC [11, 13, 17,18,19].

Bile Duct Injury [BDI]

BDI is a severe complication of cholecystectomy, sometimes necessitating lifelong management. The Critical View of Safety (CVS) technique is widely adopted to minimize BDI risk during cholecystectomy by ensuring clear visibility of key anatomical structures [26]. However, the unique challenges of SILC, such as limited visibility and instrument crowding, can hinder achieving CVS [16]. To mitigate this, Magnetic Resonance Cholangio-Pancreatography (MRCP) has has been used to better delineate biliary anatomy pre-surgery [27]. An alternative method was reported, using intravenous injection of indocyanine green and direct fluorescent cholangiography [28]. However, due to the abundant adipose tissue, the effectiveness was compromised in obese patients.

Incisional hernia

Laparoscopic surgery, known for its minimal incisions and reduced hernia risk, faces a challenge with SILC due to its single larger incision potentially increasing hernia risk [15, 19]. Studies on hernia rates post-SILC versus CLC have shown mixed results. Two retrospective cohort studies observed higher hernia rates following SILC compared to CLC [29, 30], while another study reported no significant difference [31]. Additionally, a 2021 meta-analysis of 89 studies indicated a higher hernia occurrence after SILC at 6- and 12-months post-operation [32]. Suggestions to mitigate hernia risk include preferring SILC for younger, non-obese patients [33].

These varied findings on SILC complications like BDI and incisional hernia underscore the necessity for standardized SILC techniques and better complication management strategies.

QoL

Cosmetic satisfaction

According to the majority of the 9 SRs previously analyzed, SILC has significant benefits over CLC in terms of aesthetics and body image [12,13,14,15, 17, 19]. This benefit arises from the fact that SILC requires fewer incisions, making it cosmetically more appealing.

Comprehensive QoL

Furthermore, 6 of the SRs suggest that SILC either has an advantage over CLC in terms of postoperative pain [12, 13, 15] or shows no significant difference [17,18,19]. However, one study indicated that SILC might be at a disadvantage compared to CLC in terms of pain [34]. The influence of SILC on postoperative pain varies across studies, implying the need for further research in this domain. When comparing the overall QoL, there appears to be no significant difference between SILC and CLC [13].

Cost

It has been reported that SILC is significantly more expensive than CLC [17]. This higher cost is attributed to the specially designed single-port systems and instruments for SILC. This cost factor could pose a barrier to the further integration of SILC.

Additional comments

Indications for SILC

The criteria for SILC application vary, reflecting ongoing debates. A Japanese study with 232 patients outlined SILC's effective indications as preventive surgery, age under 60, and BMI under 30 kg/m2, while contraindications included a thick gallbladder wall, prior abdominal surgery, bile duct stones, and severe comorbidities [35]. Conversely, a larger involving 6,497 patients suggested that technological advancements have broadened SILC's applicability, even for patients with acute cholecystitis [36].

Surgeon factor

The surgeon's expertise and level of training are pivotal for the successful performance of SILC, which is technically more demanding and stressful than CLC. Studies have shown that SILC places greater physical and mental strain on surgeons, as evidenced by higher salivary cortisol levels and increased heart rate during SILC procedures compared to CLC [37]. This may be because single incision surgery requires an ergonomically uncomfortable position, resulting in greater muscular activity [38].

The surgical training continuum for SILC involves a progression from competency to proficiency. Competency refers to the basic ability to perform the procedure safely and effectively, typically involving completion within an acceptable timeframe and with minimal complications. Proficiency, on the other hand, goes beyond this basic level, indicating a high degree of skill, efficiency, and consistency. This progression highlights the importance of continued training and experience in mastering the technically demanding SILC procedure.

Conclusion

SILC represents a significant advancement in laparoscopic surgery, enhancing patient satisfaction through better cosmetic outcomes, positive body image perceptions, and quicker recovery times. Ongoing debates about SILC's safety and effectiveness highlight concerns over complications such as BDI and incisional hernia. Emphasizing the need for precise bile duct identification can help reduce these risks, with standardized techniques expected to improve safety. While SILC may incur higher costs compared to CLC, the evolving criteria for its application and the importance of surgeon expertise are key areas for ongoing study and development.

Mini-laparoscopic cholecystectomy(MLC)

Introduction

Definition of MLC

The introduction of MLC in the late 1990s marked a significant advancement in laparoscopic surgery, aiming to minimize incision sizes further by using ports smaller than 3 mm [5, 6, 39, 40]. Despite the insertion points for MLC being similar to those of CLC, MLC demands greater surgical skill due to the reduced size of the ports. These smaller ports lead to decreased instrument rigidity and maneuverability [41]. Nonetheless, MLC offers the benefit of being less invasive and maintains the critical aspect of triangulation, which is often compromised in SILC.

Abbreviation of the existing literature

Tables 1 and 2 summarizes the advantages of disadvantages of MLC over CLC and SILC.

Table 1 Advantages and disadvantages of MLC over other methods of cholecystectomy. A A comparison of MLC and CLC
Full size table

Comparing MLC with CLC, previous studies [42, 43] have shown MLC's superiority in reducing pain, enhancing cosmesis, lessening fatigue, shortening operating times, and decreasing the LOH. However, both techniques were similar in the postoperative recovery.

Table 2 Advantages and disadvantages of MLC over other methods of cholecystectomy. B A comparison of MLC and SILC
Full size table

In comparing MLC to SILC, analyses from two meta-analyses and one RCT [43,44,45] indicated that MLC generally surpasses SILC in reducing pain, operating time, and LOH. There were no notable differences in cosmetic satisfaction, conversion rates, and complications between MLC and SILC, although SILC had a shorter wound length advantage.

Complications

From a previous meta-analysis, no significant difference was found in the occurrence of complications between MLC and SILC [44]. However, due to the use of smaller ports in MLC, there might be a suboptimal video quality. This can increase the risk of gallbladder wall perforation and spillage of gallbladder contents [44].

Conclusion

MLC is recognized for its potential to lessen post-operative pain and offer superior cosmetic results due to smaller incisions. Despite these benefits, MLC introduces challenges such as reduced instrument stability and visual limitations. Comparative studies between MLC and CLC have generally shown no significant difference in complication rates. However, the smaller ports used in MLC may heighten the risk of complications like gallbladder wall damage and bile spillage, highlighting the need for surgical skill and experience.

Natural orifice transluminal endoscopic surgery(NOTES) cholecystectomy

Introduction

Definition of NOTES

Introduced in 2004 [46], NOTES represents a surgical technique where endoscopic and surgical instruments are introduced through natural orifices such as oral, vaginal, or rectal to remove the gallbladder. NOTES cholecystectomy is generally considered more minimally invasive than CLC.

Abbreviation of the existing literature

Table 3 summarizes the advantages and disadvantages of NOTES over CLC.

Table 3 Advantages and disadvantages of SILC over CLC
Full size table

To compare the efficacy of NOTES cholecystectomy with CLC, two meta-analyses and one RCT were referenced [47,48,49]. According to these studies, NOTES cholecystectomy mostly outperformed CLC in terms of return to normal activity, pain, QoL, and cosmetic satisfaction. However, the complication rates between the two methods showed no significant difference. In terms of conversion rate, CLC was superior to NOTES. An important limitation of this comparison between NOTES and CLC is that the different types of NOTES are all assumed to be a single surgical technique, for the purpose of comparison. The details and nuances of each technique are discussed in the following respective subsections.

Surgical method

NOTES cholecystectomy can be categorized into pure and hybrid based on the instruments used and the approach employed. A Pure NOTES cholecystectomy is conducted solely with an endoscope, while a Hybrid NOTES cholecystectomy combines both endoscopy and laparoscopy. Furthermore, NOTES can be classified based on the route of entry to the abdominal cavity, with the principal methods for cholecystectomy being trans-gastric, -vaginal, and -rectal [50].

Transgastric NOTES(TG-NOTES) chlecystectomy

Most TG-NOTES cholecystectomy procedures performed to date required at least one transabdominal port to ensure safety by exposing Calot’s triangle. Gastrotomy was carried out using an endoscopic method under direct visualization from laparoscopy, with laparoscopic suturing. Gallbladders exceeding 2 cm were typically retrieved through an abdominal port as esophageal extraction proved challenging. A unique challenge of TG-NOTES cholecystectomy is that endoscopic dissection is only feasible in a retroverted position [50, 51].

Transvaginal NOTES(TV-NOTES) cholecystectomy

The number of TV-NOTES procedures has steadily increased since its inception with 9 cases in 2007 [52, 53]. Much like TG, Hybrid procedures outnumbered Pure ones. The cystic duct ligation employed surgical clips because endoclips weren’t designed to fully occlude tubular structures [50].

Transrectal NOTES (TR-NOTES) cholecystectomy

TR-NOTES, primarily explored for lower rectal cancer treatments due to concerns over fecal contamination, has seen limited use compared to TG- and TV-NOTES. Nonetheless, its application in cholecystectomy persists. In 2016, advancements in rectoscope and trocar technology facilitated the development of a device enhancing transrectal trocar placement [54]. These innovations may pave the way for broader clinical adoption of TR-NOTES procedures in the future.

Complications

Meta-analyses and an RCT comparing NOTES cholecystectomy with CLC found no significant differences in complication rates, indicating comparable safety profiles for both techniques [47,48,49]. Similarly, no significant difference in complications was observed between NOTES and MLC [55]. Concerns about sexual function changes after TV-NOTES cholecystectomy were addressed in a 2018 case series, which reported no adverse effects on sexual function in 47 patients, with high satisfaction rates regarding cosmetic outcomes [56]. These findings support the notion that NOTES cholecystectomy is as safe as traditional methods, suggesting a shift in perception towards the technique's safety and efficacy may be warranted.

QoL

Two meta-analyses and one RCT comparing NOTES cholecystectomy with CLC, and another RCT comparing it with MLC, suggest that NOTES may be superior in various aspects such as overall quality of life, postoperative pain, recovery, and cosmetic satisfaction [48, 49, 55].

Additional comments

Obese patients

A study involving 231 patients evaluated the impact of obesity on Hybrid TV-NOTES cholecystectomy outcomes, revealing that while procedural time, ASA classification, and the use of percutaneous trocars increased with higher BMI, there were no significant differences in complications, LOH, or fatalities. [57] Comparative research between TV-NOTES and CLC in obese patients highlighted TV-NOTES's benefits, such as reduced postoperative pain and shorter LOH, without significant differences in complication rates or operation duration. These findings suggest TV-NOTES offers short-term benefits for obese patients over CLC [58].

Patients with a History of Hysterectomy

Research on the usability and effects of TV-NOTES cholecystectomy in patients with a prior hysterectomy found that the procedure was more challenging in these patients, requiring additional laparoscopic ports and longer surgical durations. However, the rates of intra- and post-operative complications did not show significant differences when compared with those who hadn't undergone a hysterectomy [59].

Conclusion

NOTES, a method using natural orifices for gallbladder surgery, has the benefits of less pain, quicker recovery, and better post-surgery life quality. NOTES cholecystectomy seemed to gain traction in its experimental phase, but interest in this procedure seems to be waning, due to concerns about potential bias in research and the necessity of its high technical demands. Another point to consider is whether NOTES's internal organ injury is preferable to abdominal wall injury from traditional methods like SILC or MLC.

Robot-Assisted Laparoscopic Cholecystectomy (RALC)

Introduction

Definition of RALC

RALC integrates robotic technology into laparoscopic cholecystectomy, enhancing surgical precision and efficiency. Since the introduction of robotic systems in the 1990s and the advent of the da Vinci Surgical System in the 2000s, RALC's popularity has significantly increased, with its usage rising from 0.02% to 3.2% of all cholecystectomies between 2008 and 2017 [60].

Abbreviation of the existing literature

A 2017 meta-analysis found no significant difference in LOH, conversion rates, or complications between RALC and CLC, although RALC generally required longer operating times [61]. Other studies, however, have indicated potential advantages of RALC, including lower conversion rates and reduced blood loss [62,63,64].

Surgical method

RALC allows surgeons to operate with robotic arms controlled from a console, providing a 3D view of the operative field. This method offers several advantages over CLC, including enhanced dexterity through robotic wrist-like joint movements, superior three-dimensional visualization, and better image. These features are particularly beneficial for complex surgical tasks, such as managing advanced gallbladder cancer [65, 66]. However, the effectiveness of RALC can vary significantly depending on the robotic system, with the da Vinci Surgical System and Senhance being notable examples approved by the FDA [67].

Single-Incision Robotic Cholecystectomy(SIRC)

SIRC represents an advanced approach in minimally invasive surgery, leveraging robotics to enhance SILC. A comprehensive meta-analysis in 2023 highlighted SIRC's superiority in reducing post-operative complications such as BDI and LOH compared to SILC, MLC, and CLC [14]. The robotic systems' capabilities to mimic full joint movements, provide a 3D view, ensure image stability, and enhance instrument mobility significantly contribute to SIRC's lower learning curve and reduced surgeon stress, addressing limitations inherent in SILC [66].

SIRC has been deemed feasible and safe for a broader range of patients, including obese individuals, those with previous hysterectomies, and pediatric patients, as evidenced by various studies [68,69,70]. The da Vinci Xi and SP systems are predominantly used for SIRC, with the SP system, introduced in 2018, being specifically designed for single-port surgeries. Recent research confirms the SP system's safety and efficacy in adolescent patients [71], with minimal clinical differences observed between the Xi and SP models [72].

Emerging robotic platforms, including the Senhance system and the not-yet FDA-approved Micro Hand S and Versius systems, are broadening SIRC's applications. The Micro Hand S, a cost-effective Chinese innovation, and the UK-developed Versius, with its small, modular design, have both shown promise in enhancing surgical performance and safety, even in complex cases like obesity [73, 74].

Additional comments

Financial aspect

The financial implications of adopting RALC present a significant challenge for hospitals, given the high costs associated with procurement and maintenance of robotic systems like the da Vinci. Initial costs for these systems can range between 0.6 to 2.5 million dollars, with annual maintenance fees of 100,000 to 170,000 dollars, leading to an additional 1,600 dollars per procedure. This increases the per-case cost to approximately 3,200 dollars when including the purchase price [75].

However, a study comparing RALC and CLC financials over two years at a single institution found no significant difference in net income between the two methods, suggesting that with strategic management, the financial gap can be narrowed [76]. The impending expiration of key patents in the robotic surgery field is expected to introduce more competition, potentially lowering costs and making RALC more accessible [75].

Despite the financial challenges, the demand for robotic surgery, driven by surgeon preference and market demand, encourages hospitals to invest in RALC. The ongoing development of policies and technologies aims to alleviate the financial burden, suggesting a future where RALC could become more widely adopted and financially viable.

Conclusion

RALC offers surgeons advanced control, manipulation, and 3D visualization. Comparative studies highlight RALC's superiority over CLC in aspects such as lower conversion rates, reduced blood loss, shorter hospital stays, and fewer complications. RALC is also noted for its easier learning curve for beginners and its applicability to specific demographics like obese patients and children. In SIRC, the robotic system's advantages help overcome the limitations seen in SILC, making SIRC preferable for single-incision procedures.

The high cost of robotic systems poses a significant barrier to RALC's widespread adoption. However, studies indicating minimal differences in overall surgical costs between RALC and CLC, along with the potential for market competition following patent expirations, suggest financial viability.

Conclusion

The evolution of surgical methods, especially in laparoscopic cholecystectomy, showcases the continuous endeavor to improve patient outcomes. However, the existing literature does not sufficiently support a comprehensive evaluation of the newly introduced minimally invasive techniques for LC. The techniques discussed, namely SILC, MLC, NOTES, and RALC, each come with their unique set of merits and challenges that require thorough exploration for beneficial clinical adoption. A summary of the advantages, limitations, and other notable aspects of each modality is provided in Table 4 (additional file).

This review reveals that none of the discussed innovative techniques have showcased clear advantages over CLC. Specifically, SILC, while aiming to minimize scarring, is linked with a heightened risk of BDI and a potential rise in incisional hernia incidences, rendering its current clinical recommendation premature. NOTES cholecystectomy seemed to gain traction in its experimental phase, but interest in this procedure seems to be waning, due to high technical demand and the need for internal organ injury. MLC, being nearly identical to the conventional technique, potentially offers minor advantages without increasing postoperative complications, thereby presenting itself as a suitable option for routine elective cholecystectomy.

Furthermore, the introduction of RALC adds a new dimension to this discussion. RALC, with its superior precision and control facilitated by robotic assistance, hints at a promising pathway forward. Nevertheless, its efficacy and safety necessitate rigorous scrutiny through well-designed clinical trials to ascertain its standing in the array of laparoscopic cholecystectomy techniques.

In summary, this review accentuates the need for a tailored approach to discern the most appropriate technique for each patient. Such deliberations are crucial not only for advancing surgical practice but also for ensuring patient safety and well-being. The ongoing effort to meticulously evaluate and refine surgical techniques is essential for transitioning towards an era of more efficacious and less invasive surgical interventions.

Declaration of AI and AI-assisted technologies in the writing process

In the preparation of this manuscript, we utilized the AI language model ChatGPT (version 4o) developed by OpenAI.

Method and questions posed

We requested assistance in phrasing complex medical concepts in clear, accessible language.

Extent of AI usage

We estimate that approximately 20% of the initial draft was generated with the assistance of ChatGPT. However, all technical content, data interpretation, and conclusions were directly input and overseen by the authors.

Final responsibility

While we utilized AI to assist in the writing process, the authors take full responsibility for the content and accuracy of this publication.

Data availability

No datasets were generated or analysed during the current study.

Change history

References

  1. Gaillard M. New minimally invasive approaches for cholecystectomy: Review of literature. World J Gastrointest Surg. 2015;7:243.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Litwin DEM, Cahan MA. Laparoscopic cholecystectomy. Surg Clin North Am. 2008;88:1295–313.

    Article  PubMed  Google Scholar 

  3. McMahon AJ, Baxter JN, Anderson JR, Ramsay G, O’Dwyer PJ, Russell IT, et al. Laparoscopic versus minilaparotomy cholecystectomy: a randomised trial. Lancet. 1994;343:135–8.

    Article  CAS  PubMed  Google Scholar 

  4. Gollan JL, Bulkley GB, Diehl AM, Elashoff JD, Federle MP, Hogan WJ, et al. Gallstones and Laparoscopic Cholecystectomy. JAMA. 1993;269:1018–24.

    Article  Google Scholar 

  5. Yuan RH, Lee WJ, Yu SC. Mini-laparoscopic cholecystectomy: a cosmetically better, almost scarless procedure. J Laparoendosc Adv Surg Tech A. 1997;7:205–11.

    Article  CAS  PubMed  Google Scholar 

  6. Ngoi SS, Goh P, Kok K, Kum CK, Cheah WK. Needlescopic or minisite cholecystectomy. Surg Endosc. 1999;13:303–5.

    Article  CAS  PubMed  Google Scholar 

  7. Navarra G. One-wound laparoscopic cholecystectomy. Br J Surg. 1997;84(5):695.

    CAS  PubMed  Google Scholar 

  8. Ahmed K, Wang TT, Patel VM, Nagpal K, Clark J, Ali M, et al. The role of single-incision laparoscopic surgery in abdominal and pelvic surgery: a systematic review. Surg Endosc. 2011;25:378–96.

    Article  PubMed  Google Scholar 

  9. Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D, Coumaros D. Surgery without scars: report of transluminal cholecystectomy in a human being. Arch Surg. 2007;142:823–6.

    Article  PubMed  Google Scholar 

  10. Gagner M, Begin E, Hurteau R, Pomp A. Robotic Interactive laparoscopic cholecystectomy. Lancet. 1994;343:596–7.

    Article  CAS  PubMed  Google Scholar 

  11. Allemann P, Demartines N, Schäfer M. Remains of the day: Biliary complications related to single-port laparoscopic cholecystectomy. World J Gastroenterol. 2014;20:843–51.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Arezzo A, Scozzari G, Famiglietti F, Passera R, Morino M. Is single-incision laparoscopic cholecystectomy safe? Results of a systematic review and meta-analysis. Surg Endosc. 2013;27:2293–304.

    Article  PubMed  Google Scholar 

  13. Evers L, Bouvy N, Branje D, Peeters A. Single-incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy: a systematic review and meta-analysis. Surg Endosc. 2017;31:3437–48.

    Article  PubMed  Google Scholar 

  14. Lin H, Zhang J, Li X, Li Y, Su S. Comparative outcomes of single-incision laparoscopic, mini-laparoscopic, four-port laparoscopic, three-port laparoscopic, and single-incision robotic cholecystectomy: a systematic review and network meta-analysis. Updat Surg. 2023;75:41–51.

    Article  Google Scholar 

  15. Haueter R, Schütz T, Raptis DA, Clavien PA, Zuber M. Meta-analysis of single-port versus conventional laparoscopic cholecystectomy comparing body image and cosmesis. Br J Surg. 2017;104:1141–59.

    Article  CAS  PubMed  Google Scholar 

  16. Joseph M, Phillips MR, Farrell TM, Rupp CC. Single incision laparoscopic cholecystectomy is associated with a higher bile duct injury rate: a review and a word of caution. Ann Surg. 2012;256:1–6.

    Article  PubMed  Google Scholar 

  17. Lirici MM, Tierno SM, Ponzano C. Single-incision laparoscopic cholecystectomy: does it work? A systematic review. Surg Endosc. 2016;30:4389–99.

    Article  PubMed  Google Scholar 

  18. Markar SR, Karthikesalingam A, Thrumurthy S, Muirhead L, Kinross J, Paraskeva P. Single-incision laparoscopic surgery (SILS) vs. conventional multiport cholecystectomy: Systematic review and meta-analysis. Surg Endosc. 2012;26(5):1205–13.

    Article  CAS  PubMed  Google Scholar 

  19. Milas M, Devedija S, Trkulja V. Single incision versus standard multiport laparoscopic cholecystectomy: Up-dated systematic review and meta-analysis of randomized trials. Surgeon. 2014;12:271–89.

    Article  PubMed  Google Scholar 

  20. Kim MK, Choi IS, Moon JI, Lee SE, Yoon DS, Kwon SU, et al. Evolution of the Konyang Standard Method for single incision laparoscopic cholecystectomy: the result from a thousand case of a single center experience. Ann Surg Treat Res. 2018;95:80–6.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Romanelli JR, Earle DB. Single-port laparoscopic surgery: an overview. Surg Endosc. 2009;23:1419–27.

    Article  PubMed  Google Scholar 

  22. Strohmeier U, Dupré G, Bockstahler B, Tichy A, Liehmann L. Comparison of a single-access glove port with a SILSTM port in a surgical simulator model using MISTELS. BMC Vet Res. 2021;17(1):285.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Tai HC, Da LC, Wu CC, Tsai YC, Yang SSD. Homemade transumbilical port: an alternative access for laparoendoscopic single-site surgery (LESS). Surg Endosc. 2010;24:705–8.

    Article  PubMed  Google Scholar 

  24. Antoniou SA, Morales-Conde S, Antoniou GA, Pointner R, Granderath FA. Single-incision laparoscopic cholecystectomy with curved versus linear instruments assessed by systematic review and network meta-analysis of randomized trials. Surg Endosc. 2016;30:819–31.

    Article  PubMed  Google Scholar 

  25. Wu S, Lv C, Tian Y, Fan Y, Yu H, Kong J, et al. Transumbilical single-incision laparoscopic cholecystectomy: long-term review from a single center. Surg Endosc. 2016;30:3375–85.

    Article  PubMed  Google Scholar 

  26. Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg. 2010;211:132–8.

    Article  PubMed  Google Scholar 

  27. Li T, Kim G, Chang S. Tips and tricks to avoid bile duct injury in SILC: an experience of 500 cases. Surg Endosc. 2016;30:4750–5.

    Article  PubMed  Google Scholar 

  28. Igami T, Nojiri M, Shinohara K, Ebata T, Yokoyama Y, Sugawara G, et al. Clinical value and pitfalls of fluorescent cholangiography during single-incision laparoscopic cholecystectomy. Surg Today. 2016;46:1443–50.

    Article  PubMed  Google Scholar 

  29. Alptekin H, Yilmaz H, Acar F, Kafali ME, Sahin M. Incisional hernia rate may increase after single-port cholecystectomy. J Laparoendosc Adv Surg Tech. 2012;22:731–7.

    Article  Google Scholar 

  30. Hoyuela C, Juvany M, Guillaumes S, Ardid J, Trias M, Bachero I, et al. Long-term incisional hernia rate after single-incision laparoscopic cholecystectomy is significantly higher than that after standard three-port laparoscopy: a cohort study. Hernia. 2019;23:1205–13.

    Article  CAS  PubMed  Google Scholar 

  31. Christoffersen MW, Brandt E, Oehlenschläger J, Rosenberg J, Helgstrand F, Jørgensen LN, et al. No difference in incidence of port-site hernia and chronic pain after single-incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy: a nationwide prospective, matched cohort study. Surg Endosc. 2015;29:3239–45.

    Article  PubMed  Google Scholar 

  32. Jensen SAMS, Fonnes S, Gram-Hanssen A, Andresen K, Rosenberg J. Low long-term incidence of incisional hernia after cholecystectomy: A systematic review with meta-analysis. Surgery (United States). 2021;169:1268–77.

    Google Scholar 

  33. Julliard O, Hauters P, Possoz J, Malvaux P, Landenne J, Gherardi D. Incisional hernia after single-incision laparoscopic cholecystectomy: incidence and predictive factors. Surg Endosc. 2016;30:4539–43.

    Article  CAS  PubMed  Google Scholar 

  34. Hall TC, Dennison AR, Bilku DK, Metcalfe MS, Garcea G. Single-incision laparoscopic cholecystectomy a systematic review. Arch Surg. 2012;147(7):657–66.

    Article  PubMed  Google Scholar 

  35. Matsui Y, Yamaki S, Hirooka S, Yamamoto T, Yanagimoto H, Satoi S, et al. Evaluation of relative criteria for single-incision laparoscopic cholecystectomy. Asian J Surg. 2018;41:216–21.

    Article  PubMed  Google Scholar 

  36. Lee W, Roh YH, Kang SH, Kim CY, Choi YR, Han HS, et al. The chronological change of indications and outcomes for single-incision laparoscopic cholecystectomy: a Korean multicenter study. Surg Endosc. 2021;35:3025–32.

    Article  PubMed  Google Scholar 

  37. Abdelrahman AM, Bingener J, Yu D, Lowndes BR, Mohamed A, McConico AL, et al. Impact of single-incision laparoscopic cholecystectomy (SILC) versus conventional laparoscopic cholecystectomy (CLC) procedures on surgeon stress and workload: a randomized controlled trial. Surg Endosc. 2016;30:1205–11.

    Article  PubMed  Google Scholar 

  38. Pérez-Duarte FJ, Lucas-Hernández M, Matos-Azevedo A, Sánchez-Margallo JA, Díaz-Güemes I, Sánchez-Margallo FM. Objective analysis of surgeons’ ergonomy during laparoendoscopic single-site surgery through the use of surface electromyography and a motion capture data glove. Surg Endosc. 2014;28:1314–20.

    Article  PubMed  Google Scholar 

  39. Kimura T, Sakuramachi S, Yoshida M, Kobayashi T, Takeuchi Y. Laparoscopic cholecystectomy using fine-caliber instruments. Surg Endosc. 1998;12:283–6.

    Article  CAS  PubMed  Google Scholar 

  40. Reardon PR, Kamelgard JI, Applebaum B, Rossman L, Brunicardi FC. Feasibility of laparoscopic cholecystectomy with miniaturized instrumentation in 50 consecutive cases. World J Surg. 1999;23:128–32.

    Article  CAS  PubMed  Google Scholar 

  41. Lee PC, Lai IR, Yu SC. Minilaparoscopic (needlescopic) cholecystectomy: A study of 1,011 cases. Surg Endosc Other Interv Tech. 2004;18:1480–4.

    Google Scholar 

  42. Alhashemi M, Almahroos M, Fiore JF, Kaneva P, Gutierrez JM, Neville A, et al. Impact of miniport laparoscopic cholecystectomy versus standard port laparoscopic cholecystectomy on recovery of physical activity: a randomized trial. Surg Endosc. 2017;31:2299–309.

    Article  PubMed  Google Scholar 

  43. Zhao JJ, Syn NL, Chong C, Tan HL, Ng JYX, Yap A, et al. Comparative outcomes of needlescopic, single-incision laparoscopic, standard laparoscopic, mini-laparotomy, and open cholecystectomy: A systematic review and network meta-analysis of 96 randomized controlled trials with 11,083 patients. Surgery (United States). 2021;170:994–1003.

    Google Scholar 

  44. Tan X, Wang G, Tang Y, Bai J, Tao K, Ye L. Minilaparoscopic versus single incision cholecystectomy for the treatment of cholecystolithiasis: a meta-analysis and systematic review. BMC Surg. 2017;17(1):91.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Umemura A, Suto T, Nakamura S, Fujiwara H, Endo F, Nitta H, et al. Dig Surg. 2018;36:53–8.

    Article  PubMed  Google Scholar 

  46. Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc. 2004;60:114–7.

    Article  PubMed  Google Scholar 

  47. Bulian DR, Knuth J, Lehmann KS, Sauerwald A, Heiss MM. Systematic analysis of the safety and benefits of transvaginal hybrid-NOTES cholecystectomy. World J Gastroenterol: WJG. 2015;21:10915.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  48. Peng C, Ling Y, Ma C, Ma X, Fan W, Niu W, et al. Safety outcomes of NOTES cholecystectomy versus laparoscopic cholecystectomy: a systematic review and meta-analysis. Surg Laparosc Endosc Percutan Tech. 2016;26:347.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Sodergren MH, Markar S, Pucher PH, Badran IA, Jiao LR, Darzi A. Safety of transvaginal hybrid NOTES cholecystectomy: a systematic review and meta-analysis. Surg Endosc. 2015;29:2077–90.

    Article  PubMed  Google Scholar 

  50. Liu L, Chiu PWY, Reddy N, Ho KY, Kitano S, Seo DW, et al. Natural orifice transluminal endoscopic surgery (NOTES) for clinical management of intra-abdominal diseases. Dig Endosc. 2013;25:565–77.

    Article  PubMed  Google Scholar 

  51. Horgan S, Thompson K, Talamini M, Ferreres A, Jacobsen G, Spaun G, et al. Clinical experience with a multifunctional, flexible surgery system for endolumenal, single-port, and NOTES procedures. Surg Endosc. 2011;25:586–92.

    Article  PubMed  Google Scholar 

  52. Zornig C, Siemssen L, Emmermann A, Alm M, Von Waldenfels HA, Felixmüller C, et al. NOTES cholecystectomy: matched-pair analysis comparing the transvaginal hybrid and conventional laparoscopic techniques in a series of 216 patients. Surg Endosc. 2011;25:1822–6.

    Article  PubMed  Google Scholar 

  53. Noguera JF, Cuadrado A, Dolz C, Olea JM, García JC. Prospective randomized clinical trial comparing laparoscopic cholecystectomy and hybrid natural orifice transluminal endoscopic surgery (NOTES) (NCT00835250). Surg Endosc. 2012;26:3435–41.

    Article  PubMed  Google Scholar 

  54. Senft JD, Gath P, Dröscher T, Müller PC, Carstensen B, Nickel F, et al. New device for transrectal trocar placement and rectal sealing for NOTES: a porcine in vivo and human cadaver study. Surg Endosc. 2016;30:4383–8.

    Article  PubMed  Google Scholar 

  55. Bulian DR, Knuth J, Cerasani N, Sauerwald A, Lefering R, Heiss MM. Transvaginal/transumbilical hybrid-NOTES-versus 3-trocar needlescopic cholecystectomy: short-term results of a randomized clinical trial. Ann Surg. 2015;261:451–8.

    Article  PubMed  Google Scholar 

  56. Pohlen U, Feller A, Holmer C. Transvaginal hybrid NOTES cholecystectomy: a single-centre long-term experience on sexual function. World J Surg. 2018;42:1960–4.

    Article  CAS  PubMed  Google Scholar 

  57. Bulian DR, Knuth J, Thomaidis P, Rieger A, Seefeldt CS, Lange J, et al. Does obesity influence the results in Transvaginal Hybrid-NOTES cholecystectomy? Surg Endosc. 2018;32:4632–8.

    Article  PubMed  Google Scholar 

  58. Bulian DR, Walper S, Richards DC, Schulz SA, Seefeldt CS, Thomaidis P, et al. Comparative analysis of postoperative pain after transvaginal hybrid NOTES versus traditional laparoscopic cholecystectomy in obese patients. Surg Endosc. 2022;36:4983–91.

    Article  PubMed  Google Scholar 

  59. Bulian DR, Sauerwald A, Thomaidis P, Seefeldt CS, Richards DC, Schulz SA, et al. Does a prior hysterectomy complicate transvaginal/transumbilical hybrid NOTES cholecystectomy?—a comparative analysis of prospectively collected data. Langenbecks Arch Surg. 2022;407:655–62.

    Article  PubMed  Google Scholar 

  60. Aguayo E, Dobaria V, Nakhla M, Seo YJ, Hadaya J, Cho NY, et al. National trends and outcomes of inpatient robotic-assisted versus laparoscopic cholecystectomy. Surgery (United States). 2020;168:625–30 Mosby Inc.

    Google Scholar 

  61. Huang Y, Chua TC, Maddern GJ, Samra JS. Robotic cholecystectomy versus conventional laparoscopic cholecystectomy: a meta-analysis. Surgery (United States). 2017;161:628–36.

    Google Scholar 

  62. Kane WJ, Charles EJ, Mehaffey JH, Hawkins RB, Meneses KB, Tache-Leon CA, et al. Robotic compared with laparoscopic cholecystectomy: a propensity matched analysis. Surgery (United States). 2020;167:432–5.

    Google Scholar 

  63. Strosberg DS, Nguyen MC, Muscarella P, Narula VK. A retrospective comparison of robotic cholecystectomy versus laparoscopic cholecystectomy: operative outcomes and cost analysis. Surg Endosc. 2017;31:1436–41.

    Article  PubMed  Google Scholar 

  64. Tao Z, Emuakhagbon VS, Pham T, Augustine MM, Guzzetta A, Huerta S. Outcomes of robotic and laparoscopic cholecystectomy for benign gallbladder disease in veteran patients. J Robot Surg. 2021;15:849–57.

    Article  PubMed  Google Scholar 

  65. Byun Y, Choi YJ, Kang JS, Han Y, Kim H, Kwon W, et al. Robotic extended cholecystectomy in gallbladder cancer. Surg Endosc. 2020;34:3256–61.

    Article  PubMed  Google Scholar 

  66. Tschuor C, Lyman WB, Passeri M, Salibi PN, Baimas-George M, Iannitti DA, et al. Robotic-assisted completion cholecystectomy: a safe and effective approach to a challenging surgical scenario – a single center retrospective cohort study. Int J Med Robot Comp Assist Surg. 2021;17(6):e2312.

    Article  Google Scholar 

  67. Peters BS, Armijo PR, Krause C, Choudhury SA, Oleynikov D. Review of emerging surgical robotic technology. Surg Endosc. 2018;32:1636–55.

    Article  PubMed  Google Scholar 

  68. Han DH, Choi SH, Kang CM, Lee WJ. Propensity score-matching analysis for single-site robotic cholecystectomy versus single-incision laparoscopic cholecystectomy: a retrospective cohort study. Int J Surg. 2020;78:138–42.

    Article  PubMed  Google Scholar 

  69. Jones VS. Robotic-assisted single-site cholecystectomy in children. J Pediatr Surg. 2015;50:1842–5.

    Article  PubMed  Google Scholar 

  70. Svoboda S, Qaqish TR, Wilson A, Park H, Youssef Y. Robotic single-site cholecystectomy in the obese: outcomes from a single institution. Surg Obes Relat Dis. 2015;11:882–5.

    Article  PubMed  Google Scholar 

  71. Klazura G, Graf A, Sims T, Rojnica M, Koo N, Lobe TE. Assessment of the da Vinci single port robotic platform on cholecystectomy in adolescents. J Laparoendosc Adv Surg Tech A. 2022;32(4):438–41 https://home.liebertpub.com/lap.

    Article  PubMed  Google Scholar 

  72. Kang YH, Kang JS, Cho YS, Kim HS, Lee M, Han Y, et al. A retrospective multicentre study on the evaluation of perioperative outcomes of single-port robotic cholecystectomy comparing the Xi and SP versions of the da Vinci robotic surgical system. Int J Med Robot Comp Assist Surg. 2022;18(1):e2345.

    Article  Google Scholar 

  73. Wang G, Yi B, Li Z, Zhu L, Hao L, Zeng Y, et al. Micro-hand robot-assisted versus da vinci robot-assisted cholecystectomy: a multi-centre, randomized controlled trial. World J Surg. 2022;46:2632–41.

    Article  PubMed  Google Scholar 

  74. Kelkar DS, Kurlekar U, Stevens L, Wagholikar GD, Slack M. An early prospective clinical study to evaluate the safety and performance of the versius surgical system in robot-assisted cholecystectomy. Ann Surg. 2023;277:9–17.

    Article  PubMed  Google Scholar 

  75. Barbash GI, Glied SA. New technology and health care costs — the case of robot-assisted surgery. N Engl J Med. 2010;363:701–4.

    Article  CAS  PubMed  Google Scholar 

  76. Rosemurgy A, Ryan C, Klein R, Sukharamwala P, Wood T, Ross S. Does the cost of robotic cholecystectomy translate to a financial burden? Surg Endosc. 2015;29:2115–20.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

Clinical trial number

This study was not registered, and has no clinical trial number.

Funding

This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (Ministry of Science and ICT, Grant number: RS-2022-NR071874).

Author information

Authors and Affiliations

  1. Kyungpook National University Medical College, Daegu, Republic of Korea

    Changjin Nam

  2. Department of Surgery, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea

    Jun Suh Lee, Ji Su Kim, Tae Yoon Lee & Young Chul Yoon

Authors
  1. Changjin Nam
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. Jun Suh Lee
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. Ji Su Kim
    View author publications

    You can also search for this author inPubMed Google Scholar

  4. Tae Yoon Lee
    View author publications

    You can also search for this author inPubMed Google Scholar

  5. Young Chul Yoon
    View author publications

    You can also search for this author inPubMed Google Scholar

Contributions

C.N. and J.L. wrote the main manuscript text. J.K., T.L. and Y.Y. prepared figures and tables. All authors reviewed the manuscript.

Corresponding author

Correspondence to Jun Suh Lee.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Nam, C., Lee, J.S., Kim, J.S. et al. Evolution of minimally invasive cholecystectomy: a narrative review. BMC Surg 24, 378 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12893-024-02659-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12893-024-02659-x

Keywords

BMC Surgery

ISSN: 1471-2482

Contact us