6 units) A recent meta-analysis of 13

6 units). A recent meta-analysis of 13 Brefeldin A 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 in this paper, we could achieve acceptable results. Further, we need to state at this point that the only similarity between SSMPPLE and single-incision laparoscopic cholecystectomy is the very site of access (i.

e., the umbilicus). Rest all the elements in this technique (like the number, the placement and the sizes of incisions, the instruments used, the ergonomics, etc.) differ largely. Thus it tends to amalgamate the operative site (umbilicus) of the single-incision laparoscopic cholecystectomy and the instrumentation with operative techniques of the gold-standard��CMLC. Hence it should not be considered a modification of the single-incision laparoscopic cholecystectomy but should rather be taken as a distinct laparoscopic cholecystectomy technique. A similar technique described in literature [17] used all 5mm ports and joined the two port sites for the specimen extraction. However, we think that 10mm laparoscope should always be used right from the commencement of the surgery as it gives much brighter, clearer, and wider vision.

Also, it can be used for the 10mm clip applier and the specimen extraction. For initial few cases of our series, the operative time was longer as our surgical team was under the learning curve of this technique. As the number of cases and the experience increased, the operative time went on decreasing. Another recently reported method uses three ports at periumbilical location to carry out cholecystectomy [20]. Although the reported technique achieved triangulation, the port placement was away from the umbilical fold. Thus, the scars did not recede within the umbilicus. The SSMPPLE helps the scars to recede at the umbilicus to produce better aesthetics. However, the SSMPPLE has certain limitations.

(i) If not precisely and strategically placed, the ports can lie too close to each other leading to extracorporeal clashing. (ii) Although it may be technically easy in wide umbilicus, a narrow or a ��slit-like�� umbilicus may pose a real challenge. In fact, we should keep a very low threshold for conversion to the CMLC in these cases. (iii) If the cutaneous and the fascial portal punctures lie in vertical line (rather Brefeldin_A than oblique), one may end up in having the instruments lying parallel to each other leading to difficulty in dissecting.

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