We read with interest the article by Dunning and Kohli1 that described their technique for laparoscopic transumbilical cholecystectomy. We agree with the authors' concept that this intervention usually does not require specially designed laparoscopic equipment; however, we would like to add some comments.
The study objective and results can be obtained with minimal modification of the surgical technique, without excluding patients with stones larger than 5 mm and/or acute cholecystitis. We use a single continuous incision within the umbilical folds, 2 ports placed through that incision—one 10 mm and one 5 mm—and a single 10-mm 30° camera. The main difference in our approach comes from the concept of the retracting suture through the infundibulum of the gallbladder. We transfixed the latter with 2 or 3 stitches in a figure-of-eight fashion, with one end of the suture passed through the abdominal wall at the midline and the other at the anterior axillary line. This allows retracting the gallbladder in a desired lateral direction by maneuvering different ends of the suture, thus greatly facilitating exposure (video). When necessary, more retracting sutures can be passed in a similar way. This technique helps overcoming difficulties in exposure when adhesions or inflammation is present. The use of a flexible-end Maryland dissector facilitates dissection in such cases. In cases of large stones, we cut the fascial bridge between ports to remove the gallbladder and always close the fascia with sutures. No skin incision enlargement was necessary in our experience with 13 similar consecutive operations.
Julianov A, Karashmalakov A. Transumbilical Laparoscopic Cholecystectomy. Arch Surg. 2010;145(4):402. doi:10.1001/archsurg.2010.31