, Framingham, MA, USA) which allow six degrees of motion that correlated with the operator’s Lenalidomide mechanism wrist motion. An Olympus 5mm EndoEYE video laparoscope was used for visualization (Olympus Europa GmbH, Wendenstrasse, Hamburg, Germany, Figure 1). Figure 1 Operative placement of umbilical TriPort. In the small corners, the size of the skin incision does not exceed 2.5cm. Following access and port placement, the operating surgeon and the assistant stood on the patient’s left side. Our first exposure to the concept of single-incision laparoscopic surgery had come through the SILS Port (Covidien, Inc., Norwalk, CT, USA), and 15 of the patients for whom single-port laparoscopic surgery was attempted were offered the procedure using this device.

TriPort (Advanced Surgical Concepts, Bray, Co, distributed by Olympus, Wicklow, Ireland) was used for the rest of the patients. A prior description of the mechanical aspects of these types of ports had been published [13]. The device is rotated so that there is a port at the 10, 5, and 2 o’clock positions [10]. One patient had previously undergone laparotomy. Adhesiolysis via the single port was successful enough to clear an operative field for safe visualization of the gallbladder and surrounding structures. After the fundus of the gallbladder was visualized, a 2-0 Prolene suture on a straight needle was introduced through the abdominal wall using a technique described previously by Romanelli and colleagues [13, 14]. The suture was grasped and passed through the fundus of the gallbladder, then passed back through the abdominal wall.

Traction on the suture, which was clamped at the skin level, retracted the gallbladder. This technique was used in one-third of patients in this cohort. No fundal traction suture was used in the rest 20 cases; the author found that procedure could be performed safely without it. Next, a reticulating grasper was used to retract the infundibulum to the right and slightly cephalad; then the handle of the grasper rotated to the surgeon’s right side, away from the other instruments. The procedure usually began with a straight Maryland dissector or a hook with or without electrocauterization. The intention was to isolate the cystic duct and artery, clear the hepatocystic triangle, and separate the lower part of the gallbladder from the liver bed.

This technique makes visible the cystic plate and enables the surgeon to have a critical, clear view, before clipping any ductal structures. Once the cystic duct and artery were clearly visible, both were double ligated with clips using an Ethicon Ligamax 5mm clip applier and then transected with scissors. Electrocautery was used to remove the gallbladder from the liver bed, and GSK-3 the specimen was removed in a specimen bag along with the port. The fascial defect was then repaired with PDS sutures in a continuous fashion, and skin was closed with Dermabond (distributed by Ethicon, Inc.