Also, it helps to have the thorough 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 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 (476.1 units) would be lesser by a third than that produced at 25mm incision of the single-incision surgery (1540.6 units). A recent meta-analysis of 13 randomized trials (including 923 patients) that studied comparisons between single-incision laparoscopic cholecystectomy and conventional cholecystectomy reported higher failure rate, operative time, and blood loss with the former [19].
The two approaches were found comparable in terms of conversion to open surgery, length of hospital stay, postoperative pain, port-site infections, or hernias. The cosmetic outcomes were better for the former especially when 10mm ports were used in the latter. However, we feel that, with the technical modifications described Anacetrapib in this paper, we could achieve acceptable results.