title: Single-incision laparoscopic cholecystectomy using a modified dome-down approach with conventional laparoscopic instruments.
abstract: BACKGROUND
  Single-incision laparoscopic cholecystectomy (SILC) may increase the risk of bile duct injury due to compromised operative exposure. Dome-down laparoscopic cholecystectomy provides the ability to evaluate the cystic duct circumferentially prior to its division, thus minimizing the risks of bile duct injury. This study assesses the feasibility and safety of SILC using a modified dome-down approach with all conventional laparoscopic instruments.
  
  
  METHODS
  Three low-profile 5-mm trocars are placed via a single transumbilical incision. The two working trocars are aimed laterally via the rectus to achieve adequate triangulation. An extralong 5-mm 30º laparoscope with an L-shaped light-cord adaptor is used to yield more external working space. Cephalic liver retraction is achieved with one transabdominal suture through the gallbladder fundus. Leaving the gallbladder fundus attached to the liver bed, a window is first created between the gallbladder body and the liver. The dissection is then carried down retrograde toward the porta hepatis. A 360º view of the gallbladder-cystic duct junction is achieved prior to transecting the cystic duct. The gallbladder is then freed by separation of the fundal attachments. The specimen is retrieved by enlarging the fascial incision. All fascial defects are then primarily closed.
  
  
  RESULTS
  Sixteen patients (mean age 31 years, mean BMI 26.3 kg/m(2)) were enrolled in this study. Thirteen had elective surgery for symptomatic cholelithiasis, and three had emergency surgery for acute cholecystitis. Mean operating time was 80.3 min, and blood loss was minimal. All patients were discharged within 24 h without complications. Follow-up at 1 month revealed a barely visible scar within the umbilicus.
  
  
  CONCLUSIONS
  SILC using a modified dome-down approach is technically feasible with all straight instruments, and it is safe because of good delineation of ductal anatomy. Adoption of this approach may minimize the risk of bile duct injury during early experience of SILC.
authors.affiliation: Department of Surgery, University of Massachusetts Medical School, UMass Memorial Medical Center, 67 Belmont Street, Suite 201, Worcester, MA 01605, USA. cuih@ummhc.org
authors.forename: Hongyi
authors.initials: H
authors.lastname: Cui
authors.forename: John J
authors.initials: JJ
authors.lastname: Kelly
authors.forename: Demetrius E M
authors.initials: DE
authors.lastname: Litwin
mesh_terms: D000328:Adult; D017081:Cholecystectomy, Laparoscopic / Q000295:instrumentation / Q000379:methods*; D041881:Cholecystitis, Acute / Q000601:surgery*; D002769:Cholelithiasis / Q000601:surgery*; D004210:Dissection / Q000379:methods; D004638:Emergency Treatment; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D013536:Suture Techniques; D000267:Tissue Adhesions / Q000601:surgery; D055815:Young Adult
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