Nevertheless, some authors advocate for abandoning transparietal stitches for exposure, as they may be associated with accidental puncture and a potential oncological risk [21]; therefore, they prefer an intracorporeal grasper placed through a transumbilical port or a SILS port to gain dynamic exposure. Also, the use of an selleckchem additional 1.8 to 3mm grasper introduced through the skin has been used to assist cephalad retraction and has not been considered as conversion in recent clinical trials [18, 19]. There is also a report of extracorporeal retraction using magnet forceps attached to the gallbladder [29]. 2.1.4. Calot’s Triangle Dissection One should always consider that a less invasive procedure must also be safe.
Therefore, every effort must be made to comply with the requirements of the critical view of safety for laparoendoscopic cholecystectomy [30], that comprises dissection of the neck of gallbladder off the liver bed to achieve conclusive identification of the two structures to be divided: the cystic duct and the artery. Instruments used for this purpose are very similar to those of 4-port laparoscopic cholecystectomy and include 5mm hook, dissector scissor, and angle dissector. The cystic duct and artery are then dissected free, secured with clips, and divided [22]. 2.1.5. Gallbladder Bed Dissection Although gallbladder dissection can be accomplished with a fundus-first technique [19], we encourage to do it after preparation of the cystic duct and artery (Strasberg critical view). Dissection is usually performed with a hook type electrocautery device [24]. 2.
1.6. Extraction After cholecystectomy has been completed, the gallbladder can be extracted through the LESS port, as it acts as a wound protector [17], or using a specimen bag that is introduced through the umbilical port when traditional laparoscopic instruments are being used. When using laparoscopic instruments, extraction through 5mm ports is unfeasible and they will need to be increased to 10 or 12mm [6]. 2.1.7. Wound Closure The fascial incision is closed with a figure of eight stitch [18]. Deep dermis of the umbilicus is reapproximated to ensure cosmesis [23]. 2.2. Current Application The current status of single-site surgery poses several technical difficulties for the surgeon [9], and cholecystectomy has not been the exception.
Current consensus recommends that LESS procedures are only performed in centers with adequate laparoscopic experience and by surgeons with a certain amount of LESS surgical training [9]. Nevertheless, Mutter et al. have shown that LESS cholecystectomy can be safely implemented in a teaching hospital with both senior and junior laparoscopic surgeons Drug_discovery [31]. For surgeons that are proficient with multi-incision laparoscopic cholecystectomy, the learning curve for LESS cholecystectomy begins near proficiency with infrequent complications and conversion rates [32]. 2.3.