Transumbilical Cholecystectomy Research Articles

Feasibility of the Conventional Laparoscopic Set-up in Trans Umbilical Cholecystectomy in Low Economic Country

Feasibility of the Conventional Laparoscopic Set-up in Trans Umbilical Cholecystectomy in Low Economic Country

Nutritional support for patients in general surgery

The modern stage of development of surgery, especially minimal invasive technologies, has significantly changed the surgeons' thoughts about the perioperative period. Until the end of the twentieth century, pre‑ and postoperative fasting was the most important requirement in planned surgery. It was believed that it could help to avoid complications both during surgery and in the early postoperative period. H. Kehlet in his fundamental work outlined the factors that allowed to accelerate the patient's recovery after surgery, namely: the absence of preoperative fasting.
 Objective — to evaluate the effectiveness of nutritional support for surgical patients within ERAS (Enhanced Recovery After Surgery) and ESPEN (European Society for Clinical Nutrition and Metabolism) protocols.
 Materials and methods. This research included both traditional laparoscopic cholecystectomy (177 cases) and single‑port transumbilical cholecystectomy (8); among laparoscopic bariatric interventions, the major part was represented by classical Roux‑Y gastric shunting (28), as well as sleeve gastrectomy (5) and mini‑gastric shunting (4); among 123 different laparoscopic hernioplasties, in 64 cases transabdominal preperitoneal (TAPP) was performed for bubonocele, intraperitoneal onlay mesh (IPOM) for postoperative ventral and umbilical hernias (59), laparoscopic crurography and fundoplication with and without alloplasty (33). For each type of surgery two groups we identified: control and experimental. Both groups were followed by ERAS protocols in addition to nutritional support. With the prior consent of patients before surgery: the experimental group received full perioperative nutritional support according to our local protocols using protein‑enriched sip feeding formula Nutridrink Protein, the control group followed the traditional scheme of fasting during 12 hours before surgery and received regular drinking water instead of protein mixtures at the first postoperative day.
 Results. We found statistically significant difference between control and experimental groups in assessing of two important parameters as hunger and weakness. The hunger after laparoscopic cholecystectomy was 1.5 times (p < 0.001), after laparoscopic hernia repair — 1.7 times (p < 0.001), after laparoscopic crurography and fundoplication — 1.26 times (p < 0.001), after laparoscopic bariatric intervention — 1.43 times, and after laparoscopic colon intervention — 1.9 times lower in the experimental group. The weakness after laparoscopic cholecystectomy was 1.8 times (p < 0.001), after laparoscopic hernia repair — 1.31 times (p < 0.001), after laparoscopic crurography and fundoplication — 1.68 times (p < 0.001), after laparoscopic bariatric intervention — 1.67 times (p < 0.001), and after laparoscopic colon intervention — 1.38 times (p = 0.006) stronger in the control group.
 Conclusions. Traditional long‑term preoperative fasting is inappropriate. Combined with other ERAS postulates, perioperative nutritional support for surgical patients has a great chance of success. In our research, early restoration of oral nutrition significantly decreases hunger and general weakness in the early postoperative period, which allows the patient quickly return to full life.

TRANSUMBILICAL LAPAROSCOPIC CHOLECYSTECTOMY VERSUS STANDARD 4-PORT LAPAROSCOPIC CHOLECYSTECTOMY – RESULTS FROM PROSPECTIVE RANDOMIZED TRIAL AND 7 YEARS OF FOLLOW-UP

PURPOSE: Laparoscopic cholecystectomy is a standard of care for patients with benign gallbladder disease. Recently single-incision techniques gained popularity in order to decrease surgical trauma and to improve cosmetic results and patient satisfaction. The aim of this study is to compare the results of our own modification of transumbilical cholecystectomy versus standard 4-port cholecystectomy in patients with uncomplicated gallstone disease. METHODS: 80 patients (14 male, 66 female) at a mean age of 35±2,5 years (range 18-80) were randomly assigned to either standard 4-port cholecystectomy (n=40) or transumbilical cholecystectomy (n=40). Operative times, intraoperative complications, conversion rate, postoperative complications, pain, vomiting and cosmetic results were compared between two groups. RESULTS: The total mean operative time in the SILC group was 43.63 ± 7.49 min., while in the SLC group it was 37.95 ±8.06 min., (p=0.002). Intraoperative complications and conversions were not recorded in this series. The mean postoperative pain assessed by VAS was: at 6th hour 3.35 (2-5) vs. 3.53 (2-6) (p=0.439), at 24th hour 2.58 (1-4) vs. 2.2 (1-5) (p=0.04), at 48th hour 1.63 (1-3) vs. 1.78 (1-5) (p=0.544). The mean 10-point pain scores for SILC patients at 6 hours was 5.78 (3-9) vs. 6.33 (1-10) in SLC (p=0.161), at 24 hours 4.05 (1-7) vs. 3.58 (1-5) (p=0.122), at 48 hour 2.83 (1-5) vs. 2.4 (1-5) (p=0.093). Postoperative vomiting was observed in 2 (5%) of patients with SILC and 3 (7.5%) of those with SLC by the end of the second hour after surgery. In the early postoperative period up to 72h, no complications were reported. In the late postoperative period up to 7 years 1 (2.5%) operative wound surgery in the area of umbilical incision was reported in the SLC group and the presence of an umbilical hernia in 2 (5%) of patients with SILC. Results of the cosmetic result evaluation at the end of the first month - Body Image Score - mean score of 10.35 ± 1.48 (min. 7, max. 12) for SILC and 10.38 ± 1.41 (min. 6, max. 13) for SLC (p = 0.776). Cosmetic score - mean of the sum of points 20 ± 1,87 (min.17-max. 24) for SILC and 19.08 ± 2,1 (min. 14-max. 23) for SLC (p = 0,577). On a scale of 1 to 10, where 1 is "very ugly" and 10 is "almost imperceptible" (question N8), the mean for patients in the SILC group is 8.3 ± 0.79 (min. 7-max. 10) and at SLC 7.93 ± 0.73 (min. 6-max. 9) (p = 0.125). CONCLUSION: The results of this study demonstrated that both transumbilical cholecystectomy and standard 4-port cholecystectomy are equally safe and effective in the treatment of uncomplicated gallstone disease.

Novel Hybrid (Magnet Plus Curve Grasper) Technique During Transumbilical Cholecystectomy: Initial Experience of a Promising Approach

The use of magnets in transumbilical cholecystectomy (TUC) improves triangulation and achieves an optimal critical view. Nonetheless, the tendency of the magnets to collide hinders the process. In order to simplify the surgical technique, we developed a hybrid model with a single magnet and a curved grasper. All TUCs performed with a hybrid strategy in our pediatric population between September 2009 and July 2012 were retrospectively reviewed. Of 260 surgical procedures in which at least one magnet was used, 87 were TUCs. Of those, 62 were hybrid: 33 in adults and 29 in pediatric patients. The technique combines a magnet and a curved grasper. Through a transumbilical incision, we placed a 12-mm trocar and another flexible 5-mm trocar. The laparoscope with the working channel used the 12-mm trocar. The magnetic grasper was introduced to the abdominal cavity using the working channel to provide cephalic retraction of the gallbladder fundus. Across the flexible trocar, the assistant manipulated the curved grasper to mobilize the infundibulum. The surgeon operated through the working channel of the laparoscope. In this pediatric population, the mean age was 14 years (range, 4-17 years), and mean weight was 50 kg (range, 18-90 kg); 65% were girls. Mean operative time was 62 minutes. All procedures achieved a critical view of safety with no instrumental collision. There were no intraoperative or postoperative complications. The hospital stay was 1.4±0.6 days, and the median follow-up was 201 days. A hybrid technique, combining magnets and a curved grasper, simplifies transumbilical surgery. It seems feasible and safe for TUC and potentially reproducible.

Prospective, randomized clinical trial comparing the use of a single-port device with that of a flexible endoscope with no other device for transumbilical cholecystectomy: LLATZER-FSIS pilot study

Natural orifice transumbilical endoscopic surgery (NOTES) is a technique still in experimental development that requires clinical trials to assess its safety and efficacy. We present a pilot prospective, randomized, three-arm clinical trial of 1-year duration that was conducted as a noninferiority trial comparing single-incision laparoscopic surgery (SILS) and flexible single-incision surgery (FSIS) with conventional laparoscopy for elective cholecystectomy (NCT01558414). Sixty patients between aged 18 and 65 years who were eligible for elective cholecystectomy were randomly assigned in a 1:1:1 ratio (n = 20 per group): group A (SILS), single-incision endoscopic surgery using a transumbilical SILS™ device; group B (FSIS), single-incision transumbilical surgery using a flexible endoscope; and group C (CL), conventional laparoscopy. The main outcome variable of the study was "parietal complications" (wound infection, bleeding, and ventral hernia). The analysis was by intention to treat and attritions were not replaced. Cholecystectomy was performed in 100 % of the cases; perioperative complications occurred in only 1.6 % of the cases, and umbilical surgical wound infection in 3.33 %, with no differences between groups. After a minimum follow-up of 1 year, no differences were noted in the frequency of parietal complications and no ventral hernias occurred. Postoperative pain, hospital length of stay, and downtime from work were similar in all three groups. Surgical time was longer in cases in which a single-incision transumbilical approach was used (58.95 min for SILS and 54.15 for FSIS vs. 49.21 for laparoscopy). Single-incision transumbilical approaches are not inferior for safety or effectiveness compared with conventional laparoscopy. The transumbilical approach using a flexible endoscope is just as effective and safe as the other two procedures and is a promising single-incision approach.

Trans-umbilical endoscopic cholecystectomy with a water-jet hybrid-knife: A pilot animal study

To investigate the feasibility and safety of Natural orifice trans-umbilical endoscopic cholecystectomy with a water-jet hybrid-knife in a non-survival porcine model. Pure natural orifice transluminal endoscopic surgery (NOTES) cholecystectomy was performed on three non-survival pigs, by transumbilical approach, using a water-jet hybrid-knife. Under general anesthesia, the following steps detailed the procedure: (1) incision of the umbilicus followed by the passage of a double-channel flexible endoscope through an overtube into the peritoneal cavity; (2) establishment of pneumoperitoneum; (3) abdominal exploration; (4) endoscopic cholecystectomy: dissection of the gallbladder performed using water jet equipment, ligation of the cystic artery and duct conducted using nylon loops; and (5) necropsy with macroscopic evaluation. Transumbilical endoscopic cholecystectomy was successfully completed in the first and third pig, with minor bleedings. The dissection times were 137 and 42 min, respectively. The total operation times were 167 and 69 min, respectively. And the lengths of resected specimen were 6.5 and 6.1 cm, respectively. Instillation of the fluid into the gallbladder bed produced edematous, distended tissue making separation safe and easy. Reliable ligation using double nylon loops insured the safety of cutting between the loops. There were no intraoperative complications or hemodynamic instability. Uncontrolled introperative bleeding occurred in the second case, leading to the operation failure. Pure NOTES trans-umbilical cholecystectomy with a water-jet hybrid-knife appears to be feasible and safe. Further investigation of this technique with long-term follow-up in animals is needed to confirm the preliminary observation.

Single-Incision Cholecystectomy in about 200 Patients

Background and Aims. We describe our experience of performing transumbilical single-incision laparoendoscopic cholecystectomy as standard procedure for acute and chronic gallbladder diseases. Methods. Between September 2008 and March 2010, 220 patients underwent laparoscopic single-incision surgery. A single port was used for 196 patients and two conventional 5 mm and one 10 mm port in 24 cases. All operations were performed with straight instruments. Results. Single-incision surgery was successfully performed in 215 patients (98%). Three patients (1.4%) required conversion to a three-port technique and two patients (0.9%) to an open procedure. Average age of 142 women (65%) and 78 men (35%) was 47 years (range: 15–89), average ASA status 2 (range: 1–3) and BMI 28 (range: 15–49). Mean operative time was 62 minutes (range: 26–174) and 57 patients (26%) had histopathological signs of acute cholecystitis. Eleven patients (5%) developed to surgery-related complications and nine (4%) of these required a reoperation. The mean followup was 331.5 (range: 11–590) days. Conclusion. Transumbilical single-incision cholecystectomy is a feasible and safe new approach for routine cholecystectomy. After a short learning curve, operation time and complication rate are comparable with standard multiport operation. In addition, most cases of acute cholecystitis can be performed with this technique.

Transummhilical laparoscopic cholecystectomy with improved instruments

Objective The major barrier to transumbilical endoscopic surgery is from external interference between the instruments handles around the umbilicus. We describe the technique of totally transumbilical endoscopic cholecystectomy by using improved instruments. Methods 54 cases of transumbilical laparoscopic cholecystectomy were performed with improved instruments in patients with gallbladder polyps (13 cases) and gallstones (41 cases). The new trocars without the proximal seal system on the sleeves were designed for this procedure. The instruments used in this study were 5 cm longer than commercially available ones. Results All the gallbladders were removed successfully without severe intraoperative bleeding during and postoperative complications. Mean operating time was 25-56 min (average 34±28 min). All the patients were satisfied with the abdominal cosmetic results, discharged 48 h after the operations, and returned to work within seven postoperative days.Conclusions The external interference between trocars and instruments can be partially avoided by using the improved instruments. Totally transumbilical laparoscopic cholecystectomy becomes feasible by this technique. Key words: Endoscopy; Transumbilical; Surgery; Cholecystectomy; TUES

Laparoscopic transumbilical cholecystectomy. Results with the gel device and literature review

IntroductionThe appearance of single transumbilical incision surgery has opened a new era in the minimally invasive approach of cholecystectomy. Specific ports for this technique have made it easier to perform.We report our initial experience, from July 2008 to June 2009 and give an updated bibliographic review. Patients and methodsA prospective, longitudinal and interventional study that included 30 patients with symptomatic cholelithiasis, from 10 July 2008 to 30 June 2009, on whom a single transumbilical incision laparoscopic cholecystectomy was performed (LESS technique), without other minilaparoscopic ports or traction stitches.A gel port was used for all surgeries (R-Port, Tri-Port®), as well as straight and roticulating laparoscopic graspers.Surgical time, analgesia requirements, postoperative hospital stay, conversions and complications were registered. ResultsThe median age was 34.8 years (range, from 21 to 53), with a BMI between 21kg/m2 and 39.5kg/m2 (mean 25.8kg/m2). Surgical time was 65.1 minutes (ranging from 40 to 150) and postoperative length stay was less than 24 hours. Postoperative pain was measured with the VAS scale, giving a low score. Up to now, two wound infections and a bile leak have been observed. ConclusionsLESS cholecystectomy is a safe and feasible technique performed by experienced surgeons in minimally invasive surgery, and requires a greater learning curve than that of the conventional laparoscopic cholecystectomy.

Optimized transumbilical endoscopic cholecystectomy: a randomized comparison of two procedures

Natural orifice transluminal endoscopic surgery (NOTES) and transumbilical endoscopic surgery (TUES) are being developed to improve minimally invasive surgery further. In 2006, the authors developed TUES using a single triple-channel trocar or single-trocar (ST) technique. To minimize the risk and improve the surgical efficiency further, the procedure was optimized using a two-trocar (TT) technique, with both trocars in the umbilicus. This study compared the clinical results for the TT and ST techniques. For this study, 32 patients with chronic gallbladder disease and indications for cholecystectomy were randomly assigned to undergo surgery with either the TT technique (17 patients) or the ST technique (15 patients). With the TT procedure, two modified 5-mm trocars with small handles were inserted through the navel, one above and one below the umbilicus. Another 2-mm trocar was inserted for a grasper in the right upper abdomen. With the ST procedure, one 15-mm umbilical incision was made for insertion of a previously developed triple-channel trocar to apply the laparoscope, grasper, and dissector individually. Operation time, postoperative hospital stay, and postoperative pain were compared between the two procedures. The mean operative time was significantly shorter with the TT technique (35.71 +/- 9.74 min) than with the ST technique (125.25 +/- 18.9 min (p < 0.001). Use of analgesics after surgery also was less in the TT group than in the ST group (0 vs. 7, respectively; p < 0.05). The postoperative hospital stay did not differ significantly between the two groups (p > 0.05). Although both procedures were based on the transumbilical approach, the TT approach was found to be faster and less painful than the ST approach. The difference in the cosmetic result was minimal.

Single-Port Transumbilical Laparoscopic Cholecystectomy: A Preliminary Study in 37 Patients with Gallbladder Disease

Since the introduction of laparoscopic surgery, surgeons have not only been concerned about clinical outcomes, but also surgical scars. Although natural orifice transluminal endoscopic surgery (NOTES) is promising, it is not applicable to clinical practice thus far due to safety concerns. As a transitional procedure between standard laparoscopic surgery and NOTES, single-port transumbilical laparoscopic surgery might be an ideal alternative. The main advantage of single-port transumbilical laparoscopic surgery is that it is performed with existing instruments. Thus, we applied single-port surgery for cholecystectomies and the clinical outcomes were analyzed. Between July and October 2008, 37 adults with gallbladder pathologies were enrolled in this study. Only one transumbilical incision was made for accessing the abdominal cavity and a multichannel port system was assembled with existing devices. Standard laparoscopic instruments were used to perform the cholecystectomy. There were 13 males and 24 females. The mean age of the patients was 47.5 +/- 12.2 years. Twenty-nine patients had gallbladder stones, 7 patients had gallbladder polyps, and 1 patient had biliary dyskinesia. The mean operative time was 83.6 +/- 40.2 minutes. Gallbladder perforations occurred in 11 patients. In 5 patients, the procedure was converted to a standard laparoscopic technique due to technical difficulties. Complications occurred in 2 patients; specifically, a mesenteric injury was caused by the inadvertent grasping of the small-bowel mesentery during the removal of the wound retractor and an inadvertent injury of the right hepatic duct. The mean hospital stay was 2.7 +/- 1.5 days. Our series has demonstrated the feasibility and safety of single-port transumbilical laparoscopic cholecystectomy. When technical difficulties arise, early conversion to a standard laparoscopic technique is advised to avoid serious complications. Additional studies randomizing standard laparoscopic cholecystectomy and single-port transumbilical cholecystectomy are necessary for defining the exact role of this procedure.

Single-Port, Laparoscopic Cholecystectomy and Inguinal Hernia Repair: First Clinical Report of a New Device

To report the initial clinical cases of single-port, transumbilical cholecystectomy and inguinal hernia repair using a novel operating device. One patient each underwent single-port transumbilical cholecystectomy and transabdominal pre-peritoneal (TAPP) inguinal hernia repair using the Uni-X Single Port System (Pnavel Systems, Inc.). The device was placed through a single infraumbilical incision in both cases. Novel, specialized instruments, bowed in the shaft for triangulation, were used in addition to standard laparoscopic instrumentation. During cholecystectomy, a single stab incision was made and a laparoscopic suture passer was used for additional cephalad retraction of the gallbladder. Both procedures were technically successful without placement of additional trocars. Operative times were 59 and 47 minutes for the cholecystectomy and inguinal hernia, respectively. Blood loss was minimal, and there were no intraoperative complications. The patient who underwent cholecystectomy had a previously placed infusion pump for chronic pain management and was kept overnight. The patient who underwent TAPP hernia repair was discharged the same day. Follow-up at three weeks postoperatively demonstrated the patients to be without complaints. Transumbilical, single-port cholecystectomy and TAPP inguinal hernia repair are technically feasible. The first initial clinical experience with these procedures using this device is reported.

Single-incision laparoscopic cholecystectomy using flexible endoscopy: saline infiltration gallbladder fossa dissection technique

The introduction of natural orifice translumenal endoscopic surgery has led to the development of new techniques to accomplish minimally invasive procedures using flexible endoscopic instruments. This study evaluated a technique used in endoscopic mucosal resection and applied it to dissection of the gallbladder from the liver bed. Eight patients underwent an elective transumbilical single-incision cholecystectomy using a flexible endoscope at the authors' institution from August 2007 to February 2008. An endoscopic injection needle was used to inject 20 ml of saline strategically into the gallbladder fossa. After infiltration, dissection of the gallbladder and hilum was performed with endoscopic instruments, whereas the cystic duct and artery were clipped using laparoscopic instruments. None of the eight patients had inadvertent perforation of the gallbladder during dissection. The technique of infiltrating the potential space between the gallbladder and the liver bed leads to a significantly improved visualization of the plane between them. The injection of saline to develop surgical planes is an effective tool in performing a cholecystectomy using flexible endoscopic instrumentation. The enhancement of this potential space improved visualization in all patients. This technique has great potential value for dissections and requires further evaluation of its effectiveness in other applications.

Advances in Minimally Invasive Surgery

Advances in Minimally Invasive Surgery

Laparoscopic Transumbilical Cholecystectomy: Surgical Technique

Laparoscopic cholecystectomy is generally performed using 4 ports by transperitoneal access. Recent developments regarding laparoscopic surgery have been directed toward reducing the size or number of ports to achieve the goal of minimally invasive surgery, by minilaparoscopy, natural orifice access, and the transumbilical approach. The aim of this article is to describe our laparoscopic transumbilical cholecystectomy technique using conventional laparoscopic instruments and ports. The Veress needle was placed through the umbilicus, which allowed carbon dioxide inflow. A 5-mm trocar was placed in the periumbilical site for the laparoscope followed by the placement of 2 additional 5-mm periumbilical trocars. The entire procedure was performed using conventional laparoscopic instruments. At the end of the surgery, trocars were removed, and all 3 periumbilical skin incisions were united for specimen retrieval. Five transumbilical cholecystectomies were performed following this technique. The mean BMI was 26.6 kg/m(2). The mean operative time and blood loss were 46.2 minutes and 55 mL, respectively. No intraoperative complications occurred. Analgesia was performed using dipyrone (1g IV q6h) and ketoprofen (100 mg IV q12 h). Time to first oral intake was 8 hours. Mean hospital stay was 19.2 hours. Laparoscopic transumbilical cholecystectomy seems to be feasible even using conventional laparoscopic instruments and can be considered a potential alternative for traditional laparoscopic cholecystectomy.

Totally transumbilical endoscopic cholecystectomy without visible abdominal scar using improved instruments

The major barrier to transumbilical endoscopic surgery is external interference between the instrument handles around the umbilicus. We describe technique of totally transumbilical endoscopic cholecystectomy using improved instruments. New trocars (5 and 3 mm in diameter, respectively) without proximal seal system on the sleeves were designed for this procedure. The maximum diameters of the trocars were reduced to 8 and 5 mm, respectively. The instruments used in this study were 5 cm longer than commercially available instruments. Ten cases of totally transumbilical cholecystectomy were performed successfully. All the gallbladders were removed successfully without severe bleeding during dissection, except one case of gallbladder wall perforation by cautery. Mean operating time was 62 +/- 25 min (range 45-110 min). All patients were satisfied with abdominal cosmetic results, discharged 48 h after the operation, and returned to work within seven postoperative days. External interference between trocars and instruments can be partially avoided by using the improved instruments. Totally transumbilical endoscopic cholecystectomy becomes feasible with this technique.

Transumbilical Endoscopic Cholecystectomy With the Trichannel Trocar Technique: A Porcine Feasibility Study

The aim of this study is to verify the feasibility of another option: transumbilical endoscopic cholecystectomy by using the trichannel trocar technique. Eight domestic pigs were submitted to transumbilical endoscopic cholecystectomy by using the trichannel trocar technique. A fine grasper of 2 mm in diameter was inserted through a small skin incision on the right upper abdomen for grasping the gallbladders. The natural scar of the umbilicus was restored after extract of the specimen. All the gallbladders were removed successfully without severe bleeding during dissection, intraoperative, and postoperative complications. Postmortem examination revealed that the gallbladder fossa was clean, the clips on the cystic duct and artery were secure, and neither bile nor blood leakage was found at the operative field. The feasibility and safety of transumbilical endoscopic cholecystectomy are demonstrated by this study. It is possible to use this approach in patients with gallbladder diseases.

Transumbilical flexible endoscopic cholecystectomy in humans: first feasibility study using a hybrid technique

Natural-orifice transluminal endoscopic surgery (NOTES) procedures have been tested using numerous approaches, mainly in animals. In humans, only cholecystectomy has been assessed, using a combined transvaginal and transumbilical approach. We present another variant of a hybrid technique for cholecystectomy, namely the combination of a flexible transumbilical double-channel endoscope and a 3-mm rigid transcutaneous trocar placed in the left hypochondrium for liver retraction. The procedure was attempted in 10 well-selected young patients (M : F = 4 : 6, mean age 29.5 years). Instruments used through the two working channels of the endoscope were either a grasping forceps or snare for grasping and pulling and a hot-biopsy forceps for cold and hot preparation and dissection. Endoclips were used for cystic duct and artery closure. Postoperative analgesia consisted of one intravenous dose of analgesic, followed by oral administration for one further day. Follow-up visits were scheduled at 7 days, 30 days, 90 days, and 6 months. In 4 of the 10 cases the operation had to be converted to conventional laparoscopic cholecystectomy due to difficulty in dissection (in 2 cases) or uncontrollable hemorrhage (2 cases). The mean operating time was 148 minutes. Of the 6 cases in which the procedure was finished by the new approach, cystic artery bleeding occurred in 1 and was successfully clipped. One further patient had a postoperative cystic duct leak with a bilioma, successfully treated by endoscopic retrograde cholangiopancreatography with stenting. Five of the six patients reported themselves as satisfied at 3- or 6-month follow-up. So far, our endoscope-based transumbilical cholecystectomy technique has not yielded satisfactory results in humans. Further instrument and accessory improvements may increase both success rate and acceptance. Scarless surgery without the inherent risks of a transluminal approach may then become feasible.