title: Providing more through less: current methods of retraction in SIMIS and NOTES cholecystectomy.
abstract: BACKGROUND
  As the field of minimally invasive surgery continues to develop, surgeons are confronted with the challenge of performing conventional laparoscopic surgeries through fewer incisions while maintaining the same degree of safety and surgical efficiency. Most of these methods involve elimination of the ports previously designated for retraction. As a result, minimally invasive surgeons have been forced to develop minimally invasive and ingenious methods for providing adequate retraction for these procedures. Herein we present our experience using endoloops and internal retractors to provide retraction during Single Incision Minimally Invasive Surgery (SIMIS) and Natural Orifice Transluminal Endoscopic Surgery (NOTES) cholecystectomy. We also present a review of the alternative retraction methods currently being employed for these surgeries.
  
  
  METHODS
  SIMIS was performed on 20 patients and NOTES was performed on 5 patients at our institution. Endoloops or internal retractors were used to provide retraction for all SIMIS procedures. Internal retractors provided retraction for all NOTES procedures.
  
  
  RESULTS
  Successful cholecystectomy was accomplished in all cases. One SIMIS surgery required conversion to standard laparoscopy due to complex anatomy. There were no intraoperative complications. Although adequate retraction was accomplished in all cases, the internal retractors were found to provide superior and more versatile retraction compared to that of endoloops.
  
  
  CONCLUSIONS
  Adequate retraction greatly simplifies SIMIS and NOTES surgery. Endograb internal retractors were easy to use and were found to provide optimal retraction and exposure during these procedures without complications.
authors.affiliation: Department of Surgery, Hadassah-Hebrew University Medical Center, P.O. Box 12000, Jerusalem, 91120, Israel. avi.schlager@gmail.com
authors.forename: Avraham
authors.initials: A
authors.lastname: Schlager
authors.forename: Abed
authors.initials: A
authors.lastname: Khalaileh
authors.forename: Noam
authors.initials: N
authors.lastname: Shussman
authors.forename: Ram
authors.initials: R
authors.lastname: Elazary
authors.forename: Andrei
authors.initials: A
authors.lastname: Keidar
authors.forename: Alon J
authors.initials: AJ
authors.lastname: Pikarsky
authors.forename: Avi
authors.initials: A
authors.lastname: Ben-Shushan
authors.forename: Oren
authors.initials: O
authors.lastname: Shibolet
authors.forename: Santiago
authors.initials: S
authors.lastname: Horgan
authors.forename: Mark
authors.initials: M
authors.lastname: Talamini
authors.forename: Gideon
authors.initials: G
authors.lastname: Zamir
authors.forename: Avraham I
authors.initials: AI
authors.lastname: Rivkind
authors.forename: Yoav
authors.initials: Y
authors.lastname: Mintz
mesh_terms: D000328:Adult; D000818:Animals; D017081:Cholecystectomy, Laparoscopic / Q000379:methods*; D002769:Cholelithiasis / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures; D023421:Models, Animal; D013536:Suture Techniques; D013552:Swine