Immunological Response of Postcholecystectomy: Single Incision Laparoscopic Surgery (SILS) vs Natural Orifice Transluminal Endoscopic Surgery (NOTES)

Introduction: Surgery evokes complex metabolic, neuroendocrine and immunological responses. These are reparatory but when exaggerated may cause immunosuppression with morbidity and mortality. It is well-known that these responses are attenuated in laparoscopic cholecystectomy, which is the gold standard for treatment of cholelithiasis. Current novel minimal access techniques of natural orifice transluminal endoscopic surgery (NOTES) and single incision laparoscopic surgery (SILS) consolidate on the gains of better cosmesis, reduced postoperative pain and rapid recovery; however, they are yet to be fully evaluated in terms of comparative advantage on immunological basis. Aims: This study aims to compare the immunological changes following the techniques of NOTES and SILS in cholecystectomy with a view to ascribe relative advantage. Methods: Literature review of immunological changes following NOTES and SILS from Medline, Cochrane Database, Google and SpringerLink. Cross references from list of major articles on subject were read with other relevant journals from a laparoscopic research institute library. Results: Pneumoperitoneum affects the local peritoneal immune environment resulting in alterations in cytokine production and phagocytic function. Interleukin-1 (IL-1), tumor necrosis factor and particularly IL-6 are potent systemic mediators of the immune and acute phase response following surgery. Various animal model studies have shown that NOTES and SILS evoke similar levels of inflammatory cytokine profiles but for a late-phase tissue necrosis factor-alpha (TNF-alpha) depression with NOTES. Conclusion: Minimal access techniques of cholecystectomy have reduced immune response compared to open surgery. There is limited immunological data available comparing NOTES and SILS postcholecystectomy. Large randomized studies are needed to ascribe immunological advantage between these two techniques of cholecystectomy.