title: Single-trocar cholecystectomy using a flexible endoscope and articulating laparoscopic instruments: a bridge to NOTES or the final form?
abstract: BACKGROUND
  NOTES cholecystectomy, may eliminate complications related to abdominal incisions. However, the nonmandatory gastrotomy and its safe closure is the main controversy accompanying this approach. Transvaginal access has minimal closure consequences but the safety of inserting extralong instruments between the intestines and having the angle of approach from below rather than from above is questionable. We conducted a study for performing cholecystectomy using a single laparoscopic trocar.
  
  
  METHODS
  The single-trocar cholecystectomy technique was developed on five porcine animal models weighing 35-40 kg each. A 15-mm trocar was used, inserted transumbilicaly. Retraction of the gallbladder was achieved using an endoloop and transabdominal anchoring. Hartman's pouch was manipulated with an endoscopic grasper, which was passed through the working channel of the endoscope, while dissection of the triangle of Callot was performed using articulating laparoscopic instruments.
  
  
  RESULTS
  Single-trocar cholecystectomy was successfully performed in four of five porcine models. Average surgery time was 90 min (35-180 min). The technique was modified and improved throughout the study. No intraoperative complications occurred.
  
  
  CONCLUSIONS
  Single-trocar cholecystectomy is feasible and offers safe approach to this procedure. We assume that a single incision at the umbilicus generates minimal somatic pain, and achieves excellent cosmetic results. The translation of this technique to human subjects seems straightforward and raises the question of whether NOTES is the preferred technique for cholecystectomy.
authors.affiliation: Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel. ramelazary@hadassah.org.il
authors.forename: Ram
authors.initials: R
authors.lastname: Elazary
authors.forename: Abed
authors.initials: A
authors.lastname: Khalaileh
authors.forename: Gideon
authors.initials: G
authors.lastname: Zamir
authors.forename: Michael
authors.initials: M
authors.lastname: Har-Lev
authors.forename: Gidon
authors.initials: G
authors.lastname: Almogy
authors.forename: Avraham I
authors.initials: AI
authors.lastname: Rivkind
authors.forename: Yoav
authors.initials: Y
authors.lastname: Mintz
mesh_terms: D000818:Animals; D017081:Cholecystectomy, Laparoscopic / Q000295:instrumentation / Q000379:methods*; D019723:Endoscopes; D005240:Feasibility Studies; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D023421:Models, Animal; D013525:Surgical Instruments; D013552:Swine