The frequency of gallstones is on the rise in Europe and North America, according to ultrasonography studies. Gallstone disease is the second most costly digestive condition in the United States, and about 700,000 cholecystectomies are performed in the US each year (1), while 190,000 patients with gallstones have surgery in Germany (2, 3). Over the last two decades, the attitudes and expectations of patients have been significantly impacted by celebrities and social media. As a result, the drive for scar reduction and the growing acknowledgment of patient satisfaction have led to the advancement of traditional laparoscopic surgery. As surgeons have gained more experience, both the number of ports and the size of each port have decreased. Numerous clinical studies have linked variables such as the number and size of ports, the site of the skin incision on the torso, the method of occluding the cystic duct and artery, the method of closing the fascia, the retrieval side of the specimen, and even the exact routing of ports in relation to anatomical landmarks like the falciform ligament to the safety of the treatment and the incidence of complications (4). However, the suprapubic laparoscopic cholecystectomy was initially reported in 1995 in Italy by Degano et al. (5). Today, only a few published articles can be found in the medical literature about this simple technique. This may be related to the widespread interest in alternative minimally invasive methods, such as natural orifice endoscopic translumenal surgery (NOTES) and single-incision laparoscopic cholecystectomy (SILC) (6–8). The mini laparoscopic cholecystectomy (MLC) is another method worth mentioning in this context. Even with the more recent generation of mini instruments, MLC does not offer any clear advantages over conventional laparoscopic cholecystectomy. This is especially true due to the hybrid use of 5 and 10 mm trocars for the camera and the removal of thick-walled gallbladders or large stones, making a pure MLC inapplicable and keeping the technique reserved for only a few selected cases (9). However, considering the global surgical community's strong interest in NOTES and SILC procedures, and significant concerns about the steep learning curve for MLC, safety and cost persist. These factors may help explain why there has been a recent global increase in demand for suprapubic cholecystectomy (10). Because of the low cost of this method without the need for any disposable or specific instruments, and the fact that it maintains the fundamental principles of laparoscopic cholecystectomy, this innovative version makes for a fascinating option that merits more investigation (11).

In this paper, we provide the findings of a retrospective case-matched analysis that evaluated the safety and cost-effectiveness of conventional laparoscopic cholecystectomy (CLC) vs. the endoscopic minimally invasive reduced appliance technique (Emirate).

In this study we compared the outcomes of Emirate cholecystectomy (“E-group”) and conventional laparoscopic cholecystectomy (“CLC”) in a tertiary care private hospital in Abu Dhabi, United Arab Emirates, using a retrospective matched cohort analysis of 280 patients treated between January 2019 and December 2022. The patients were matched 1:1 by sex, rationale for surgery, surgeon expertise, and preoperative bile duct imaging. In order to eliminate any possibility of selection bias, the coordinator of the operating room used digital logbooks to conduct a random selection of patients for the control group. Informed consent was obtained from all the patients included in the study. Exclusion criteria were ASA > 3, pregnancy, or refusal to participate in the study. OR-cost, operative time, length of hospital stay, postoperative liver function laboratory test, and conversion to an open or four-port cholecystectomy were evaluated in both groups. A standard case record worksheet was used to gather data on demographic characteristics, pre-operative investigations, and intra- and postoperative parameters.

In the last two decades, scarless, non-invasive cosmetic treatments have become more popular worldwide. Social media may indeed be driving the public's increased interest by offering a variety of information, from online teaching tools and physician-managed accounts to patient experiences and marketing. Promotions from celebrity accounts have been proven to have an impact on general interest. Surgeons could enhance their expertise and add innovative services by understanding more about their patients' particular interests. This is the situation with cholecystectomy, which has gradually evolved to be safer and less invasive. Furthermore, several novel laparoscopic techniques aim to improve aesthetic results while maintaining or improving therapeutic effects. Within this context, MLC, SSS, and NOTES are among the most popular and innovative minimally invasive techniques (12–14).

These techniques initially showed great promise; however, there are still some drawbacks. For example, Ma et al. (15) found that SILC had no effect on overall patient satisfaction. In addition, it has been shown that surgeons with CLC competence need additional training to perform SLIC surgery safely owing to the higher collision of surgical tools due to a lack of triangulation and the restricted number of devices that may be employed (16).

Hoyuela et al. found that SILC is linked with a statistically substantially greater long-term incisional hernia rate at the umbilical port site than CLC. According to their statistics, there was no significant advantage in terms of postoperative course, hospital stay, or aesthetic satisfaction. Ultimately, they concluded that SILC should not be used routinely (17). In a recent systematic review and meta-analysis conducted by Cirag and Schankar, it was shown that SILC had a considerably longer operational duration and more complications in comparison to CLC (18).

Despite the fact that transvaginal cholecystectomy as a NOTES procedure currently only applies to female patients, it nevertheless has several drawbacks that are equivalent to those of SILC. A further drawback of transvaginal cholecystectomy is that the majority of institutions execute transvaginal cholecystectomy as a hybrid technique, employing an abdominal trocar for the optic due to issues with instrument triangulation and the lack of flexible tools with acceptable intraperitoneal navigation. A benefit of transvaginal cholecystectomy is the decrease in postoperative pain and the need for opioids. Even for experienced laparoscopic surgeons, however, a steep learning curve using transvaginal cholecystectomy can result in a considerable lengthening of the surgery, in addition to the need for expensive specialized equipment (19). Similar issues are applicable for mini laparoscopy.

A precedent has been set for the suprapubic cholecystectomy, as demonstrated by the work of Degano et al., who described it in 1995 (20). Numerous studies comparing the suprapubic technique to the standard cholecystectomy used a variety of port sizes and numbers. Despite the use of four ports, two of which were 10 mm in the umbilical fold and 12 mm in the suprapubic region, a recent study by Taha et al. demonstrated that the aesthetic effect of the suprapubic method is superior to that of the standard cholecystectomy in a standard context, as judged not by the patient or practitioner directly involved in the therapy, but by those unrelated to the treatment process (21–23).

In the current study we analyzed 280 patients who underwent surgery because of benign gallbladder disorders at our institution (140 ELC vs. 140 CLC). The results show that the two techniques are comparable in terms of preoperative demographics, surgeon expertise, gallbladder stone size, stage of gallbladder inflammation, and preoperative bile duct diagnostics. The perioperative outcomes show that there was a statistically significant difference in the average duration of surgery; however, the ELS had an approximately 9-minute shorter operating time which is related to faster introduction of 5 mm intraumbilical optic trocar and waiving the facia closure by using pure blunt 5 mm trocar, while CLC required Hasson open technique for 10–12 mm perumbilical trocar with consecutive necessarily facia closure. Also waiving a fourth trocar as well as clipping of the artery save time when compared to CLC.

ELS also saved US$265 on average per case. Moreover, in comparison to the CLC, the laboratory parameter demonstrated much lower alkaline phosphatase serum levels. These lower AP levels, even if they have no clinical relevance, could be an expression of reduced manipulation of the gallbladder as a result of direct grasping of the infundibulum and waiving the fourth port that is usually used in the CLC to grasp the fundus with assistance.

The Emirate cholecystectomy, as a modified suprapubic laparoscopic cholecystectomy, has been designed to have a shorter running time and a less steep learning curve than SILC or NOTES. The possibility of using typical CA devices with fewer appliances makes the technique simple and cost-effective to execute. Furthermore, the entire process flow, including the patient position and order of anesthesia equipment, assistant surgeons, and the instrumenting nurse in the surgical setup, remains the same as in a conventional laparoscopic cholecystectomy. In addition to this, it is the responsibility of the academic hospital to keep laparoscopic cholecystectomy simple and easy to learn in order to ensure an adequate residency training curriculum. This is not always the case with SILS and NOTES cholecystectomies, which may be complicated and difficult to learn (24–27).

The current study is not without shortcomings. The study, which was retrospective in nature, was carried out in a single setting. In spite of this, our findings indicate that ELC is both safe and feasible in comparison to CLC, with no statistically significant differences in postoperative morbidity or mortality between the two procedures. However, this paper details the results for a sizable sample of patients who underwent ECL, and those results are similar to those for individuals who underwent CLC. Despite the fact that ELC appears to be more technically demanding than CLC at first glance because of the limited appliances, reduced number of ports, and unusual location of the optic at the suprapubic site, ELC demonstrated faster surgery times and lower costs.

In our study, the results of the Emirate laparoscopic cholecystectomy were similar to the results of the standard laparoscopic cholecystectomy. However, new research shows that a suprapubic cholecystectomy is less painful than a regular laparoscopic cholecystectomy. The unique technique hides the suprapubic scar with hair or clothing, which makes patients more satisfied with the cosmetic results of surgery. In order to confirm that Emirate laparoscopic cholecystectomy results in less postoperative discomfort and less visible scarring than standard laparoscopic cholecystectomy, a randomized controlled investigation is required.