An important selleck Gemcitabine factor with laparoscopic approaches to the gallbladder is the ability for the surgeon to obtain a ��critical view of the Calot’s triangle.�� Most surgeons who routinely perform laparoscopic cholecystectomy would consider the critical view as a basic requirement and would be greatly concerned by any new technique that compromised it. Departure from some of the basic tenets of laparoscopic surgery is a major disadvantage of this operation. Most important is the virtue of placing both the laparoscopic camera port and all dissecting instruments through a single umbilical incision, causing lost of triangulation between the camera and the working ports [19]. This leads to collision of instruments, cross-handedness, and restriction of movement and viewing, as well as dissecting angles.

In addition, placing a suture directly through the gallbladder to provide retraction and exposure leads to some degree of bile spillage from the suture punctures with this technique. Because of instrument collision and cross-handedness, we tended to struggle at the beginning of our experience. The surgeon must cross hands to obtain a reasonable angle of distraction of the tissues in the operative field. However, in all cases in this cohort of patients, the critical view required was obtained, using a combination of traction sutures, an articulating grasper, and bendable angled laparoscope. When the critical view was compromised in one of our patients, an additional port was added to help in visualization of this view. Thus, the critical-view principle was followed.

This study was performed nonselectively on all presentations of biliary disease, whether acute or chronic. We shared some of the contraindications considered by Kuon et al. [20] such as a BMI >30kg/m2, suspicion of a malignancy, and the presence of a cystic duct stone. However, acute cholecystitis and previous upper abdominal surgery were not considered contraindications to our group. Our mean operative time was 104 minutes, longer than the time required for classical 4 ports cholecystectomy. The extra time reflected the degree of the procedure complexity and the learning curve of the operating surgeon, and there was a trend to decreasing operative time as more cases were done. All the patients had normal liver function tests, a normal common bile duct diameter on ultrasound imaging, and no anatomic questions at the time of surgery.

Therefore, cholangiography was not indicated in this series and was not considered. We share the same concern as other authors on whether the approach from the umbilicus would be appropriate for cholangiography and how clear the ultimate Anacetrapib image obtained would be, although successful use of cholangiography with a single-port approach has been reported previously [21]. Adding cholangiography would certainly increase the operative time.