title: Single-incision laparoscopic cholecystectomy: initial experience with critical view of safety dissection and routine intraoperative cholangiography.
abstract: BACKGROUND
  Single-incision laparoscopic cholecystectomy (SILC) is emerging as a potentially less invasive alternative to standard laparoscopic cholecystectomy and natural orifice transluminal endoscopic surgery cholecystectomy. As this technique is more widely used, it is important to maintain well-established practices of the critical view of safety (CVS) dissection and intraoperative cholangiography (IOC). We present our initial experience with SILC using CVS dissection and routine IOC.
  
  
  METHODS
  Fifty-four patients with biliary colic were offered SILC, which was performed through the umbilicus. CVS with photo documentation was attained before clipping and transecting the cystic structures. IOC was done using various needle puncture techniques. Assessment of CVS was carried out by independent surgeon review of operative still photos or videos using a 3-point grading scale: visualization of only 2 ductal structures entering the gallbladder; a clear triangle of Calot; and separation of the base of the gallbladder from the cystic plate.
  
  
  RESULTS
  SILC was performed in 54 patients (15 male and 39 female). Six patients required 1 supplementary 3- or 5-mm port. Complete IOC was successful in 50 of 54 patients (92.6%). CVS was achieved at the time of operation in all 54 patients. Photo documentation review confirmed 3 of 3 CVS criteria in 32 (64%) patients, 2 of 3 in 12 patients (24%), 1 of 3 in 3 patients (6%), and 0 in 3 patients (6%).
  
  
  CONCLUSIONS
  As laparoscopic cholecystectomy becomes less invasive, proven safe dissection techniques should be maintained. Dissection to obtain the CVS should be the goal of every patient and IOC can be accomplished in a high percentage of patients. This approach places patient safety considerations foremost in the evolution of minimally invasive cholecystectomy.
authors.affiliation: Department of Surgery and Institute for Minimally Invasive Surgery, Washington University School of Medicine, St Louis, MO 63110 , USA.
authors.forename: Arthur
authors.initials: A
authors.lastname: Rawlings
authors.forename: Steven E
authors.initials: SE
authors.lastname: Hodgett
authors.forename: Brent D
authors.initials: BD
authors.lastname: Matthews
authors.forename: Steven M
authors.initials: SM
authors.lastname: Strasberg
authors.forename: Mary
authors.initials: M
authors.lastname: Quasebarth
authors.forename: L Michael
authors.initials: LM
authors.lastname: Brunt
mesh_terms: D000328:Adult; D000368:Aged; D001657:Biliary Dyskinesia / Q000000981:diagnostic imaging / Q000601:surgery*; D002758:Cholangiography; D017081:Cholecystectomy, Laparoscopic / Q000379:methods*; D002769:Cholelithiasis / Q000000981:diagnostic imaging / Q000601:surgery*; D004210:Dissection; D005260:Female; D006801:Humans; D007430:Intraoperative Care; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011677:Punctures; D012189:Retrospective Studies; D012449:Safety; D016896:Treatment Outcome; D014472:Umbilicus