Laparoscopic cholecystectomy (LC) has replaced open surgery as the preferred treatment for symptomatic gallstone disease. The open operation, first performed by Carl Langenbuch in 1882, remained the standard for more than a century until Philippe Mouret performed the first laparoscopic cholecystectomy in France in 1987, after which the technique spread rapidly worldwide (1). Gallstones are a common global problem, with a prevalence of roughly 10–15% among adults in Western populations that rises with age and is higher in women (2). Current consensus guidelines recommend LC as the first-line operation for symptomatic cholelithiasis (3). The operation is performed through three or four small abdominal incisions, which reduce wound trauma, postoperative pain and hospital stay and allow many patients to return to routine activity within one to two weeks (4). Selected patients can now be managed as day cases (5). Conversion to open surgery, needed in a small minority of patients because of severe inflammation, anatomical difficulty, dense adhesions or bleeding, is reported in the range of 2–5% in contemporary series (6). Because the physiological burden of the operation is low, attention has shifted from survival and major morbidity to patient-centred outcomes such as pain, wound complications, scar appearance and speed of recovery (7). Gallbladder retrieval is the final and often under-appreciated step of LC. After the gallbladder has been dissected from the liver bed and the cystic duct and artery have been secured, it must be extracted through one of the port sites, most commonly the umbilical (10 mm) or the epigastric (subxiphoid) port. Extraction through a limited fascial opening can stretch and traumatise the abdominal wall, and spillage of bile or stones during this manoeuvre can seed the peritoneal cavity or the wound; the sequelae of lost gallstones range from trivial to abscess formation (8, 9). For this reason retrieval in an endoscopic bag is widely advocated to limit wound contamination (10), and port-site morbidity, including infection, bleeding and hernia, remains an important determinant of the overall quality of the operation (11). Surgeons choose between the two sites mainly on habit and on the size and condition of the gallbladder. The umbilicus is a natural scar with a thin abdominal wall, and a wound hidden within it is cosmetically attractive; the epigastric port passes through a thicker musculo-aponeurotic layer in a region of denser somatic innervation, which has been proposed as an explanation for greater pain at that site. Against this, the umbilical fascial defect is larger and has been linked to a higher incidence of port-site hernia and, in some series, wound infection. Individual patient-level and aesthetic preferences also matter, because scar appearance and satisfaction have become recognised outcomes of minimally invasive biliary surgery (12). The comparative literature has not produced a uniform answer. Several randomized trials and meta-analyses have found less port-site pain after umbilical retrieval (13–17). Others have found that the two routes are equivalent for pain, retrieval time and wound infection (18, 19), while a different group of studies has reported higher rates of wound infection or hernia with the umbilical route and has therefore favoured epigastric retrieval (20–23). A number of smaller comparative studies from India, Nepal and Pakistan have added further, sometimes discordant, observations (24–31). Because the studies differ in bag use, analgesic regimens, pain scales, case mix and the definition of retrieval time, the choice of port still rests largely on surgeon preference rather than on firm evidence. Against this background we undertook a prospective randomized comparison of umbilical and epigastric gallbladder retrieval in patients undergoing elective LC. The primary aim was to compare postoperative port-site pain and wound infection between the two techniques. The secondary aims were to compare retrieval time, total duration of surgery, intraoperative events (bile or stone spillage and injury to other organs), nausea and vomiting, and early postoperative vital signs.

Study design, setting and duration This was a prospective, randomized, comparative study with outcome data collection, conducted in the Department of General Surgery, K.D. Medical College, Hospital & Research Center, Mathura, Uttar Pradesh, over a period of 24 months. Patients admitted for elective laparoscopic cholecystectomy during the study period were screened for eligibility. Participants Adults older than 18 years with symptomatic cholelithiasis, or with a solitary gallbladder polyp larger than 6 mm or multiple gallbladder polyps, who gave written informed consent were included. The diagnosis was confirmed by imaging of the abdomen. Patients with common bile duct stones, cholecystitis or empyema of the gallbladder, acute cholangitis, carcinoma of the gallbladder or of the hepatobiliary system were excluded. Patients in whom the operation had to be converted to open surgery and those in whom technical failure of instruments occurred were also excluded from the analysis. Sample size The sample size was calculated with the help of the Department of Medicine of the institution using the formula for comparison of two means, N = 2σ²(Zα/2 + Zβ)² / (μ₁ − μ₂)², where Zα/2 = 1.96 (95% confidence), Zβ = 0.84 (80% power), σ² = 8.12 and the expected mean pain scores of the two groups were 4.94 and 3.24. This gave 44.05, rounded up to 45 patients per group, a total of 90 patients. Randomization and blinding Eligible patients were randomized by simple random sampling into Group A (gallbladder retrieval through the epigastric port) or Group B (retrieval through the umbilical port). The allocation sequence was computer generated and concealed in sealed opaque envelopes, each of which was opened intraoperatively only after dissection of the gallbladder was complete. The surgeon necessarily knew the retrieval site; however, the research assistant who collected the postoperative data was blinded to the port used, and all patients received the same postoperative analgesia protocol. Pilot study A pilot study of 10 patients (five in each group) was performed before the main study to test the feasibility of randomization, to standardise pain scoring, to identify logistic problems and to validate the clarity of the data-collection proforma. No major modification of the protocol was required, and the pilot patients were not included in the final analysis. Procedure and data collection All patients underwent standard laparoscopic cholecystectomy. After the gallbladder had been freed, the envelope was opened and the specimen was extracted through the epigastric port (Group A) or the umbilical port (Group B). Data were recorded on a pre-designed proforma whose content validity had been checked by experts from the Departments of Surgery and Anaesthesiology. Pre-operative variables were age, sex, body mass index (BMI), diabetes, hypertension, previous abdominal surgery and the indication for surgery (gallstones or polyps). Intraoperative variables were the presence of adhesions, bile or stone spillage, injury to any other organ, blood vessel or regional artery, retrieval time and total duration of surgery. Postoperative variables were pulse rate, blood pressure, temperature, respiratory rate and oxygen saturation (SpO₂) at 1 hour, pain on a 10-point Visual Analogue Scale (VAS, 0 = no pain, 10 = worst imaginable pain) at 1, 4, 12 and 24 hours at both the epigastric and the umbilical port sites, nausea and vomiting, and signs of wound infection. Histopathological examination of the specimen was performed in all patients. Outcome measures The primary outcomes were postoperative port-site pain (VAS at 1, 4, 12 and 24 hours) and port-site wound infection. The secondary outcomes were retrieval time, duration of surgery, bile or stone spillage, injury to other organ systems, postoperative nausea and vomiting, and vital signs at 1 hour. Statistical analysis Continuous variables are presented as mean ± standard deviation (SD) or as median with range or interquartile range, and categorical variables as numbers and percentages. The chi-square test was used for comparison of categorical variables, with Fisher's exact test where expected cell counts were small, and the independent-samples t-test for continuous variables. VAS scores at the two port sites were compared between groups at each time point. Because each group was assessed at its own retrieval site as well as at the non-retrieval site, a post hoc comparison of pain at the retrieval site itself (epigastric site in Group A versus umbilical site in Group B) was additionally calculated by an independent-samples t-test from the summary statistics (mean, SD and n) of the two respective VAS series. A p-value below 0.05 was considered statistically significant. Ethical considerations The study was conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice guidelines. The study protocol was reviewed and approved by the Institutional Ethics Committee before enrolment, and informed consent, in the patient's own language, was obtained from every participant.

Study population and baseline characteristics A total of 90 patients were enrolled and analysed, 45 in each group. The mean age was virtually identical in the two groups (31.09 years in Group A and 30.96 years in Group B), as was the median (30 and 31 years). The age range was wider in Group A (18–53 years) than in Group B (18–43 years), with relatively more patients aged 40–49 years in Group A (22.2% vs 6.7%) and more aged 30–39 years in Group B (40.0% vs 33.3%) (Table 1). Females formed two-thirds of each group (30 of 45; 66.7%), so the sex distribution was identical. Table 1: Age distribution of patients in the epigastric (Group A) and umbilical (Group B) retrieval groups Age group (years) Group A (epigastric) n (%) Group B (umbilical) n (%) 10–19 7 (15.6) 4 (8.9) 20–29 11 (24.4) 15 (33.3) 30–39 15 (33.3) 18 (40.0) 40–49 10 (22.2) 3 (6.7) 50–59 2 (4.4) 0 (0.0) Total 45 (100) 45 (100) Mean age (years) 31.09 30.96 Median age (years) 30 31 Range (years) 18–53 18–43 Interquartile range (25th–75th percentile) 23–36 27–37 Percentages are of the 45 patients in each group. The baseline clinical characteristics are summarised in Table 2. Mean BMI, the proportion with diabetes, previous abdominal surgery and intraoperative adhesions were comparable. Hypertension was numerically more frequent in Group B (31.1% vs 15.6%) but the difference was not statistically significant. The indication for surgery differed: gallstones were the pathology in 82.2% of Group A and 95.6% of Group B, and polyps in 17.8% and 4.4% respectively (χ² = 4.05, p = 0.044). Table 2: Baseline clinical characteristics of the two groups Characteristic Group A (epigastric) n = 45 Group B (umbilical) n = 45 p-value Demographic and anthropometric Female sex, n (%) 30 (66.7) 30 (66.7) 1.000 Mean BMI (kg/m²) 25.33 24.76 0.47 Indication for surgery Gallstones, n (%) 37 (82.2) 43 (95.6) 0.044* Gallbladder polyps, n (%) 8 (17.8) 2 (4.4) Comorbidity and surgical history Diabetes, n (%) 9 (20.0) 10 (22.2) 0.80 Hypertension, n (%) 7 (15.6) 14 (31.1) 0.081 Previous abdominal surgery, n (%) 9 (20.0) 11 (24.4) 0.59 Intraoperative finding Adhesions present, n (%) 11 (24.4) 11 (24.4) 1.000 BMI, body mass index. *Statistically significant (chi-square test; p < 0.05). Operative parameters and intraoperative events Retrieval time was significantly shorter in Group A, with a mean of 3.07 minutes (median 3.27; interquartile range 2.17–4.04) against 5.35 minutes (median 5.41; interquartile range 4.27–6.62) in Group B (p < 0.001); the 25th percentile of Group B was higher than the 75th percentile of Group A, indicating a shift of the entire distribution (Table 3, Figure 1). The total duration of surgery, however, did not differ (57.10 vs 55.86 minutes; p = 0.35). Bile or stone spillage occurred in 13.3% of Group A and 15.6% of Group B (p = 0.76), and injury to another organ system in 4.4% of each group (p = 1.000). Table 3: Operative parameters and intraoperative events Variable Group A (epigastric) n = 45 Group B (umbilical) n = 45 p-value Retrieval time (min), mean 3.07 5.35 <0.001* median (IQR) 3.27 (2.17–4.04) 5.41 (4.27–6.62) Duration of surgery (min), mean 57.10 55.86 0.35 median (IQR) 57.1 (49.4–61.8) 54.5 (50.2–63.9) range 40.0–81.3 40.1–78.0 Bile / stone spillage, n (%) 6 (13.3) 7 (15.6) 0.76 Injury to other organ system, n (%) 2 (4.4) 2 (4.4) 1.000 IQR, interquartile range (25th–75th percentile). *Statistically significant. Postoperative pain Pain scores at the epigastric port site are shown in Table 4 and Figure 2A. At every time point the epigastric-site VAS was significantly higher in Group A, in which the gallbladder had been extracted through that port, than in Group B (p < 0.001 at 1, 4, 12 and 24 hours). The mean score in Group A was 7.0 at 1 hour and 7.3 at 4 hours and fell to 5.6 at 24 hours, whereas in Group B it fell from 4.7 to 2.7 over the same period; the gap between the groups was 2.3 points at 1 hour and 2.9 points at 24 hours. Table 4: Postoperative pain (VAS) at the epigastric port site Time Group A (epigastric) mean ± SD (median; range) Group B (umbilical) mean ± SD (median; range) p-value 1 hour 7.0 ± 1.4 (7; 4–10) 4.7 ± 1.4 (5; 2–7) <0.001* 4 hours 7.3 ± 1.4 (7; 4–10) 4.4 ± 1.2 (4; 2–6) <0.001* 12 hours 6.2 ± 1.5 (6; 2–9) 3.3 ± 1.6 (3; 0–7) <0.001* 24 hours 5.6 ± 1.4 (6; 2–8) 2.7 ± 1.5 (2; 0–5) <0.001* VAS, Visual Analogue Scale (0–10). Independent-samples t-test at each time point. *Statistically significant. A mirror-image pattern was found at the umbilical port site (Table 5, Figure 2B). Here the VAS was significantly higher in Group B, in which the specimen had been extracted through the umbilicus, than in Group A at all time points (p < 0.001). The mean umbilical-site score in Group B declined from 5.78 at 1 hour to 4.00 at 24 hours, while that in Group A declined from 4.49 to 2.33. Thus, in both groups, pain was greatest at the site through which the gallbladder had been removed. Table 5: Postoperative pain (VAS) at the umbilical port site Time Group A (epigastric) mean ± SD (median; range) Group B (umbilical) mean ± SD (median; range) p-value 1 hour 4.49 ± 1.33 (5; 1–6) 5.78 ± 1.27 (6; 4–9) <0.001* 4 hours 4.27 ± 1.28 (4; 0–6) 5.40 ± 1.32 (5; 3–8) <0.001* 12 hours 3.36 ± 1.39 (3; 0–6) 4.84 ± 1.14 (5; 2–7) <0.001* 24 hours 2.33 ± 1.55 (2; 0–6) 4.00 ± 1.44 (4; 1–7) <0.001* Independent-samples t-test at each time point. *Statistically significant When pain at the retrieval site itself was compared (epigastric site in Group A with umbilical site in Group B), the post hoc analysis showed that pain after epigastric retrieval was more intense than pain after umbilical retrieval throughout the first 24 hours, with a mean difference of 1.22 points at 1 hour, 1.90 at 4 hours, 1.36 at 12 hours and 1.60 at 24 hours (p < 0.001 at each time point; Table 6, Figure 3). Table 6: Post hoc comparison of pain at the retrieval site (epigastric site in Group A versus umbilical site in Group B) Time Group A: epigastric site mean ± SD Group B: umbilical site mean ± SD Mean difference t p-value 1 hour 7.0 ± 1.4 5.78 ± 1.27 1.22 4.33 <0.001* 4 hours 7.3 ± 1.4 5.40 ± 1.32 1.90 6.62 <0.001* 12 hours 6.2 ± 1.5 4.84 ± 1.14 1.36 4.84 <0.001* 24 hours 5.6 ± 1.4 4.00 ± 1.44 1.60 5.34 <0.001* Independent-samples t-test calculated from the summary statistics (n = 45 per group) of Tables 4 and 5. *Statistically significant. Wound infection, nausea and vomiting, and vital signs Wound infection was uncommon: two patients (4.4%) in Group A and one patient (2.2%) in Group B developed it, a difference that was not significant (Fisher's exact test, p = 0.56). Nausea and vomiting occurred in 6 patients (13.3%) of Group A and 4 (8.9%) of Group B (χ² = 0.46, p = 0.50) (Table 7, Figure 4). At 1 hour after surgery, systolic and diastolic blood pressure, temperature, respiratory rate, SpO₂ and pulse rate were all similar between the groups and within normal limits (Table 8). Table 7: Postoperative complications Outcome Group A (epigastric) n = 45 Group B (umbilical) n = 45 p-value Wound infection, n (%) 2 (4.4) 1 (2.2) 0.56 Nausea and vomiting, n (%) 6 (13.3) 4 (8.9) 0.50 Wound infection: Fisher's exact test; nausea and vomiting: chi-square test. Table 8: Vital signs one hour after surgery Parameter Group A (epigastric) mean (range) Group B (umbilical) mean (range) p-value Systolic blood pressure (mmHg) 121.5 (79–153) 117.9 (88–149) 0.28 Diastolic blood pressure (mmHg) 79.5 (61–98) 78.0 (60–102) 0.42 Temperature (°C) 37.30 (36.2–38.5) 37.18 (36.0–37.7) 0.26 Respiratory rate (per min) 18.2 (12–24) 18.2 (13–21) 1.000 SpO₂ (%) 97.2 (93–100) 97.1 (94–100) 0.82 Pulse rate (beats per min) 86.8 (64–104) 87.3 (63–104) 0.81 Independent-samples t-test. SpO₂, peripheral oxygen saturation.

In this randomized comparison of 90 patients the port chosen for gallbladder extraction determined where postoperative pain was felt and how severe it was. Pain was greatest at the port used for retrieval in both groups, but it was more intense after epigastric than after umbilical extraction, and the difference was statistically significant at every point in the first 24 hours. Epigastric retrieval was quicker by about two minutes, but this saving did not translate into a shorter operation, and wound infection, intraoperative safety, nausea and vomiting and early vital signs did not differ between the techniques. The mean age of about 31 years and the two-thirds female predominance in both groups are consistent with the well-known epidemiology of symptomatic gallstone disease, in which women and younger to middle-aged adults are affected more often (2). Randomization produced balanced groups for BMI, diabetes, previous abdominal surgery and adhesions. Previous abdominal surgery and adhesions are recognised determinants of operative difficulty and outcome and their similar frequency in the two groups (adhesions in 24.4% of each) removes an important potential confounder from the comparison of operative time. Two imbalances were noted. Polyps as the indication were more frequent in Group A (17.8% vs 4.4%; p = 0.044), and hypertension was numerically more frequent in Group B (31.1% vs 15.6%; p = 0.081). Polypoid lesions of the gallbladder include cholesterol polyps, adenomyomatosis and true neoplasms, and symptomatic polyps, larger lesions and coexisting stones are accepted indications for cholecystectomy (3-5). With so many baseline variables examined, one nominally significant difference is the expected play of chance, and neither the indication nor hypertension has a plausible direct effect on port-site pain; nevertheless the imbalance should be borne in mind when interpreting the results (6,7). Our main finding agrees with the larger body of evidence that umbilical retrieval is associated with less port-site pain than epigastric retrieval. A meta-analysis of five randomized trials and one prospective cohort including 2,394 patients found reduced pain at 24 hours after umbilical extraction (8-10), and an updated meta-analysis of eight randomized trials with 2,676 patients likewise found less pain at 24 hours with the umbilical route. Individual randomized trials have reported significantly lower pain scores at all assessed time points after umbilical retrieval, for example in a trial of 120 patients in which the 24-hour VAS was 2.15 ± 0.87 after umbilical and 3.05 ± 0.87 after epigastric retrieval (14), in a 100-patient trial (15), in an 80-patient trial (16) and in a 100-patient study with 50 patients per arm (17). In our trial the epigastric-site VAS after epigastric retrieval exceeded the umbilical-site VAS after umbilical retrieval by 1.2 to 1.9 points, a difference that is clinically meaningful on a 10-point scale and that persisted at 24 hours. Not every study agrees. A randomized comparison of 106 patients found no significant difference in pain between the two sites (18), and a meta-analysis of randomized trials involving 1,036 participants likewise found no significant difference in postoperative pain or surgical site infection (19). Our design differs from most earlier trials in one respect that may help to reconcile such results: we scored pain separately at both port sites. This showed that the retrieval port becomes the dominant source of pain wherever it is placed, so that a single global pain score, or a score taken at only one site, can mask or exaggerate a difference depending on which site is examined. The absolute scores in our cohort were also higher than the 24-hour means reported by Siddiqui and colleagues differences in the analgesic regimen, in patients' pain thresholds and in the way the VAS is explained and recorded are likely explanations, and they underline that comparisons between studies should concentrate on the direction and relative size of the difference rather than on absolute scores. The anatomical explanation usually offered is that the umbilicus is a natural scar with little muscle, so that extraction requires less force and causes less trauma, whereas the epigastric port traverses a thicker musculo-aponeurotic layer with denser somatic innervation, so that pulling a stone-filled gallbladder through it stretches more sensitive tissue. Our data are in keeping with this idea, since pain was higher at whichever site was used, and more severe where the abdominal wall is thicker, but the present study was not designed to test the mechanism, and the explanation remains a hypothesis. The pain scores in both groups fell steadily during the first 24 hours, but the difference between the groups was still present at the final assessment, so that umbilical retrieval was not merely associated with a faster return to comfort but with a lower pain level throughout. Retrieval was about 2.3 minutes faster through the epigastric port (3.07 vs 5.35 minutes; p < 0.001). This is consistent with a randomized study of 100 patients in which the umbilical extraction took longer than the epigastric one (4.94 ± 1.56 vs 3.24 ± 1.29 minutes) and with an updated meta-analysis in which epigastric retrieval was associated with a shorter operative duration. Other studies are discordant: a meta-analysis found a significantly shorter retrieval time with the umbilical route a trial of 100 patients reported shorter retrieval with umbilical extraction and the 106-patient comparison found no difference (about 9 minutes in each arm) . The heterogeneity probably reflects differences in the use of a retrieval bag, in stone load and gallbladder size, in the size of the fascial opening, in the experience of the operating team and, above all, in how retrieval time is defined and timed. The total duration of surgery in our study was nearly identical in the two groups (57.10 vs 55.86 minutes), and the difference of about two minutes in retrieval time was clearly absorbed within the natural variation of the operation. In clinical terms the time penalty of umbilical retrieval is small, particularly when compared with the persistent difference in pain. Wound infection was infrequent in both groups (4.4% after epigastric and 2.2% after umbilical retrieval) and the difference was not significant. The published literature on this outcome is inconsistent. A randomized trial that used a glove bag reported significantly more infection after umbilical (5.7%) than after epigastric (1.6%) extraction (p = 0.006) (20), and a series of 1,800 patients in which umbilical retrieval was done with an endobag reported more wound infection (5.11% vs 1.55%) and more port-site hernia (3.66% vs 0.11%) than epigastric retrieval without a bag (21). The pooled analyses are less clear: epigastric retrieval was associated with a lower risk of infection and hernia in one meta-analysis, although some of the differences did not reach statistical significance (22), whereas others found no significant difference in infection between the sites (23-27). A further randomized trial was designed specifically to compare postoperative port-site infection between the two routes (28). Our infection rates therefore lie within the range of the earlier studies, but the trial was not powered to detect a difference in so uncommon an event, and with only three infections in 90 patients no conclusion on infection risk can be drawn beyond the observation that no large difference was apparent (29-30). Bile and stone spillage is a recognised risk factor for infection. In a cross-sectional study of 120 patients, bile spillage occurred in 22.5% and the surgical site infection rate was 25.9% in patients with spillage against 2.2% in those without, an almost sixteen-fold difference in odds (31-34). Spillage occurred in 13.3% and 15.6% of our two groups, without a significant difference, and injury to other organs occurred in 4.4% of each group, indicating that neither route compromised intraoperative safety. The low and similar spillage rates support the view that it is the manner of extraction, including careful bagging and gentle handling, rather than the site alone that determines contamination (35). Hernia could not be assessed because follow-up was limited to 24 hours, and this is the principal reason why the pain advantage of the umbilical route cannot be regarded as the whole story. A multicentre retrospective analysis of 1,756 patients found that trocar-site hernia requiring repair was significantly more frequent after umbilical (3.2%) than after epigastric (0.7%) extraction (p < 0.001). The same direction has been reported in other series and meta-analyses and a population-based study has shown that susceptibility to abdominal-wall hernias, including umbilical and epigastric hernias, is partly familial (36). Meticulous fascial closure of the umbilical port is therefore important when this route is used, and our findings should be applied with the understanding that a better early pain profile may be purchased at the price of a higher risk of later hernia, an outcome that only long-term follow-up can address. Nausea and vomiting were more frequent in Group A (13.3% vs 8.9%), but the difference was not significant. Because pain and the opioid requirement it generates are recognised contributors to postoperative nausea, this trend may be an indirect consequence of the higher pain scores, although the study was not designed to test that and the numbers are small. Vital signs at 1 hour were comparable and within normal limits in both groups, which shows that the two techniques are equally safe in terms of early haemodynamic and respiratory stability; the slightly higher mean systolic pressure and temperature in Group A were small and not significant and are best explained by the greater pain. Patient-reported outcomes such as scar appearance and satisfaction have become important end points of laparoscopic biliary surgery. The umbilical scar is hidden in the navel and is usually considered more acceptable than an epigastric scar, which may be conspicuous in some patients. We did not measure cosmesis or satisfaction, but this consideration, together with lower early pain, would also tend to favour the umbilical route in elective surgery, especially in young patients, who made up most of our cohort. Taken together, the findings define a trade-off that can be discussed openly with patients. Umbilical retrieval offers less intense early pain at the cost of roughly two additional minutes at retrieval and, probably, a higher long-term hernia risk that must be managed by careful fascial closure. Epigastric retrieval is quicker and may be preferable when the umbilical port is needed uncontaminated, when the gallbladder is large or heavily stone-filled and the umbilical defect would need considerable enlargement, or when the patient is at high risk of umbilical hernia, but it should be accompanied by planned analgesia. In an era of day-case surgery and enhanced recovery. where postoperative pain frequently determines discharge, the umbilical route seems a reasonable default in uncomplicated elective cases. Strengths and limitations The strengths of this study are its randomized design with concealed allocation, a sample size calculated in advance, a pilot phase, a uniform postoperative analgesia protocol, blinding of the data collector, and repeated pain scoring at both port sites over 24 hours, which allowed the site-specific nature of the pain to be recognised. Several limitations must be acknowledged. The study was conducted in a single tertiary-care centre, which limits generalisability. Although the sample size was adequate for the primary pain outcome, the study was underpowered for rare events such as wound infection and hernia, and follow-up lasted only 24 hours, so chronic pain, hernia and long-term cosmetic results were not captured. The operating surgeon could not be blinded to the retrieval site, and patients might have inferred their allocation from dressings or from remarks by staff; pain, being subjective, may be influenced accordingly. The details of bagging and extraction technique were left to the operating surgeon, and surgeon experience was not analysed, and either could affect retrieval time and pain. Randomization left an imbalance in the indication for surgery and, to a lesser degree, in hypertension. Finally, the VAS was the sole measure of pain, and analgesic consumption, which would have given an objective correlate, was not analysed. The retrieval-site comparison was a post hoc analysis and should be regarded as hypothesis-supporting.

In patients undergoing elective laparoscopic cholecystectomy, the port used for gallbladder retrieval becomes the main site of early postoperative pain, and the pain is more intense after retrieval through the epigastric port than through the umbilical port. Wound infection was rare and was not significantly affected by the choice of port, and bile spillage, injury to other organs, nausea and vomiting and early vital signs were similar. Epigastric retrieval is faster by about two minutes, but this does not shorten the operation overall. Retrieval through the umbilical port can therefore be recommended as the preferred technique when minimising early postoperative pain is a priority, provided that the umbilical fascia is closed securely, while the epigastric port remains a valid, quicker alternative that should be accompanied by appropriate analgesic planning. Multicentre randomized trials with longer follow-up, objective analgesic end points and assessment of hernia and cosmesis are needed to confirm these findings.

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