2.1.5. Gallbladder Bed Dissection Although never gallbladder dissection can be accomplished with a fundus-first technique [19], we encourage to do it after preparation of the cystic duct and artery (Strasberg critical view). Dissection is usually performed with a hook type electrocautery device [24]. 2.1.6. Extraction After cholecystectomy has been completed, the gallbladder can be extracted through the LESS port, as it acts as a wound protector [17], or using a specimen bag that is introduced through the umbilical port when traditional laparoscopic instruments are being used. When using laparoscopic instruments, extraction through 5mm ports is unfeasible and they will need to be increased to 10 or 12mm [6]. 2.1.7. Wound Closure The fascial incision is closed with a figure of eight stitch [18].

Deep dermis of the umbilicus is reapproximated to ensure cosmesis [23]. 2.2. Current Application The current status of single-site surgery poses several technical difficulties for the surgeon [9], and cholecystectomy has not been the exception. Current consensus recommends that LESS procedures are only performed in centers with adequate laparoscopic experience and by surgeons with a certain amount of LESS surgical training [9]. Nevertheless, Mutter et al. have shown that LESS cholecystectomy can be safely implemented in a teaching hospital with both senior and junior laparoscopic surgeons [31]. For surgeons that are proficient with multi-incision laparoscopic cholecystectomy, the learning curve for LESS cholecystectomy begins near proficiency with infrequent complications and conversion rates [32].

2.3. Technical Strategies In order to overcome the limitations of triangulation with the LESS approach, several approaches have been proposed. Curved and or articulated instruments have been used according to the surgeon’s preference [14], as they may allow to work on the operative field without a straight approach from the access port. Using these instruments requires the instrument from the right hand to be on the left side of the screen and the left-hand instrument to be on the right side of the screen [6, 33]. One can choose an instrument with handles that are articulated so they are away from each other at the access port or use ports with a lower external or internal profile for a wider range of instrument motion.

Also, instruments of variable lengths allow for external manipulation so that they are operated in different planes, thus avoiding collisions [25]. 3. Patient Outcomes: SILC/LESS cholecystectomy versus Four-Port Cholecystectomy In spite of numerous reports regarding the safety and efficacy of the SILS/LESS cholecystectomy approach, laparoscopic cholecystectomy (LC) Carfilzomib still remains the gold-standard for the surgical removal of the gallbladder [6]. Thus the comparison of patient outcomes between both procedures is of key importance.