title: Reduced-port surgery: preservation of the critical view in single-port-access cholecystectomy.
abstract: BACKGROUND
  Over the past 3 years, minimal-access surgery has seen movement toward single-port-access (SPA) surgery. Since its inception in the spring of 2007, a number of differing approaches and technologies for reduced-port surgery have become available to move the field toward "scarless" surgery. As with any advance, a cautious eye needs to observe changes with respect to the risks and benefits of new procedures or devices. Although the adoption of reduced-port techniques in cholecystectomy may move the field of surgery forward, there is a need to ensure that basic tenets of safety are not left behind. In cholecystectomy, one of the gold standards for safety is preservation of the critical view of safety during cystic duct dissection and transection.
  
  
  METHODS
  Early in the development of SPA surgery, a standardized procedure was sought that could be extended safely to laparoscopic surgeons. With this ideal in mind, the technique of SPA cholecystectomy was evaluated early. Deeming exposure to be critical, specifically the view of the cystic-to-common duct relationship beneath the liver, the authors aimed to evaluate whether this critical view of safety can be maintained during the procedure and before the cystic port is clipped and transected. To determine reproducibility, the authors did a simple comparison of their initial 10 two-instrument SPA cholecystectomies with their subsequent 10 three-instrument cholecystectomies by reviewing the videos of each case.
  
  
  RESULTS
  The authors' review confirmed that the critical view of safety was obtained in all the three-instrument cases but was difficult to obtain in the two-instrument procedures. In addition, they were able to demonstrate the critical angle of clip placement in all three-instrument cases.
  
  
  CONCLUSIONS
  The authors present their initial results in an attempt to demonstrate that as new procedures develop, there is a need to ascertain their safety and adherence to underlying principles already established before advancing them further at the risk of compromise and complication.
authors.affiliation: Department of Surgery, Drexel University College of Medicine, 219 North Broad Street, 10th Floor, Philadelphia, PA 19107, USA.
authors.forename: Erica R
authors.initials: ER
authors.lastname: Podolsky
authors.forename: Paul G
authors.initials: PG
authors.lastname: Curcillo
mesh_terms: D017081:Cholecystectomy, Laparoscopic / Q000379:methods*; D006801:Humans; D014741:Video Recording
references.citation: Ann Surg. 2009 Jun;249(6):908-12
references.pmid: 19474690
references.citation: HPB (Oxford). 2008;10(5):336-40
references.pmid: 18982149
references.citation: Surg Endosc. 2009 Nov;23(11):2631-4
references.pmid: 19266233
references.citation: Surg Endosc. 1997 Feb;11(2):133-8
references.pmid: 9069144
references.citation: J Endourol. 2008 Aug;22(8):1573-6
references.pmid: 18681804
references.citation: Surg Endosc. 2010 Jul;24(7):1791-2
references.pmid: 20054569
references.citation: Panminerva Med. 2000 Mar;42(1):87-90
references.pmid: 11019611
references.citation: Surg Endosc. 2009 May;23(5):1142-5
references.pmid: 19263125
references.citation: J Hepatobiliary Pancreat Surg. 2008;15(3):284-92
references.pmid: 18535766
references.citation: J Gastrointest Surg. 2009 Jun;13(6):1125-8
references.pmid: 18709423
references.citation: J Am Coll Surg. 1995 Jan;180(1):101-25
references.pmid: 8000648
references.citation: Arch Surg. 1992 May;127(5):596-601; discussion 601-2
references.pmid: 1533509
references.citation: Surg Clin North Am. 2008 Dec;88(6):1295-313, ix
references.pmid: 18992596
references.citation: Surg Endosc. 2009 Apr;23(4):896-9
references.pmid: 18815836
references.citation: Gastrointest Endosc. 2004 Jul;60(1):114-7
references.pmid: 15229442
references.citation: Am Surg. 2009 Aug;75(8):681-5; discussion 685-6
references.pmid: 19725290
references.citation: Surg Technol Int. 2009 Apr;18:19-25
references.pmid: 19579186
references.citation: Surg Endosc. 2010 Jun;24(6):1403-12
references.pmid: 20035355
references.citation: Br J Surg. 1997 May;84(5):695
references.pmid: 9171771
references.citation: Arch Surg. 2007 Mar;142(3):295-7
references.pmid: 17372056
references.citation: Surg Endosc. 2008 Jul;22(7):1715-6
references.pmid: 18322746
references.citation: Surg Endosc. 2009 Jul;23(7):1419-27
references.pmid: 19347400
references.citation: Surg Endosc. 2009 Jul;23(7):1680
references.pmid: 19360366