Single-Incision Multiport Laparoendoscopic (SIMPLE) Cholecystectomy

We thank you for your most astute comments regarding our article. We address these comments based not only on our original article on a series of 10 procedures, submitted in September 2008, but also on our experience that well exceeds 100 procedures in the past 1 years. Our method has changed with our experience. For example, we no longer perform this procedure during lithotomy. We have moved from a three-port trocar technique to a more stable and flexible port platform (Gelpoint; Applied Medical, Rancho Santa Margarita, CA, USA), which allows the insertion of multiple ports. We continue to use straight instruments preferentially, with occasional need for a right-angled instrument and even less need for articulating instruments. We also continue to use a rigid 30 angled scope. These technique changes address the issues raised in your letter. First, a critical view of safety is obtained in all cases. We have found that for most procedures this indeed can be achieved with a two-instrument technique [1] (Fig. 1). Retraction is imperative to obtaining this maneuver. Instead of reflecting the fundus of the gallbladder superolaterally and the infundibulum inferolaterally, as with the three-instrument dissection technique, we retract the only the infundibulum. But we grasp the infundibulum as close to the cystic duct as possible. This is important for two reasons. First, we create sufficient tension to achieve the dissection, thereby opening up Calot’s triangle, pulling the cystic duct and artery away from the liver’s edge and the underlying common bile duct. Second, internal retraction as close as possible to the area of dissection minimizes exterior lateral hand movement, thereby eliminating hand crisscrossing and clashing. Positioning the patient in the reverse Trendelenburg and slightly left laterally recumbent position has aided us in this maneuver. However, as you point out, a two-instrument technique is not possible in all cases, most notably when the patients have a high body mass index (BMI), fatty or enlarged liver, or acute cholecystitis. In these circumstances, we add a fourth port and proceed with the traditional three-instrument dissection. Often, we add this through our single umbilical incision, but occasionally we add it through an additional port, transforming the single-incision multiport laparoendoscopic (SIMPLE) procedure into a reduced-port procedure (or in our vernacular, a ‘‘DIMPLE’’). The second issue you raised questions the maneuverability restrictions of three trocars. We have found that extending the skin incision at the time of pneumoperitoneum, using the locking trocars, minimizes restriction and preserves the small single incision. A 4-cm skin incision with maximal abdominal distention decreases to a 2– 2.5 cm incision at desufflation. Nonetheless, our early experience with the locking trocars, as you mentioned, was limiting. We have since found that the Gelpoint system allows for much more freedom of movement through the same small skin incision. The fascial incision is a single incision as well, not the ‘‘Swiss cheese’’ type of penetration from closely approximated trocars, which can be problematic [2]. Also, the fascial incision can be as large as 5 cm or more through a small 2.5-cm skin incision. In addition, the fulcrum of the instruments is more external, at the level of the concaved Gelpoint, which is located 5 cm above skin level. Finally, four ports can be placed comfortably through the Gelpoint platform. All these factors contribute to minimal restriction of movement. B. M. Molinelli (&) A. Petrotos Department of Surgery, Greenwich Hospital, Greenwich, CT, USA e-mail: ssg06830@hotmail.com