This might be the result of the rising demand of such surgeries producing good cosmetic results (even from the rural population like our center) coupled against the backdrop of the difficulty in learning and affording the NOTES. The single-port transumbilical laparoscopic surgery entails incising the skin and the fascia selleck Imatinib for up to 3.5cm at the umbilicus [10, 11]. Raising the skin flap remains the unavoidable step which may contribute to the subcutaneous seroma formation and/or the skin necrosis. This potentially results in poor wound healing and inferior cosmetic results. On the contrary, the SSMPPLE eliminates this step. We used the standard port-closure needle (coupled with catgut loop) to retract the gallbladder fundus in 46 cases of SSMPPLE.

It mirrors the fourth retracting port of conventional laparoscopic cholecystectomy which allows achieving the ��critical view of safety�� of Strasberg and Soper [12]. Also, it helps to have the perpendicular cystic duct clipping rather than the tangential��an important step to minimize the postoperative bile leak [13]. As the gallbladder wall is not traversed by the needle, it does not violate the basic principles [13]. Further, this site can also be used for the miniscope to visualize umbilical adhesions (if any) before porting. Small drain tube can also be inserted through it, if required. However, its negligent movement can traumatize the diaphragm or the other viscera. Also, for large liver, one should avoid force retraction and opt for an additional 5mm trocar for safe dissection.

We used such an additional 5mm trocar in the SSMPPLE group for 18 out of 46 patients. We feel that all the three fascial punctures of the ports should be closed under vision. Although the cases discussed here need further long-term followup, none of our patients developed port-site herniation. Port closure under direct vision adds further to the safety. Umbilical sepsis in the single-port transumbilical laparoscopic surgery is reported in the range of 0 to 14% [14]. We had six patients (1.9%) from the SSMPPLE group that developed umbilical sepsis; three of them were diabetic. All of them recovered completely with antibiotics. As reported earlier, we always use endobags for the gallbladder extraction [15]. This potentially reduces the umbilical contamination.

The conversion rates reported in the literature are 0�C24% for the single-port transumbilical laparoscopic cholecystectomy [14, 16]. In our series, it was 1.9%. However, we should keep GSK-3 a low threshold for conversion to standard multiport laparoscopy or open surgery [14, 17]. Furthermore, Blinman has elegantly discussed the relationship of tension (and hence pain) at the incision site to the lengths of the incision; the tension is directly proportional to the square of lengths of incisions and not the addition of the lengths [18]. Hence, the projected amount of tension acting at the three ports of SSMPPLE technique (476.