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We thank Drs Julianov and Karashmalakov for their comments. With regards to patient selection, we chose to include only patients with small stones without cholecystitis while we developed our technique. Just as laparoscopic cholecystectomy was used for uncomplicated cases during its advent and eventually expanded to include acute cholecystitis, we presented our series to demonstrate the technique, not necessarily to say it could only be used in patients with noninflamed disease. In theory, retracting sutures that are placed in an acutely inflamed gallbladder wall may be more likely to be pulled through. While the technique does not exclude large stones, we felt that it would defeat the purpose to make small port incisions just to open them to remove very large gallstones. We found that a simple figure-of-eight suture was faster to place than multiple bites and still was sufficient to allow the gallbladder to be retracted by either end of the suture and thereby to allow adequate visualization. We applaud the authors' continued pursuit to use new techniques to broaden the application to benefit as many patients as possible.
Dunning K. Transumbilical Laparoscopic Cholecystectomy—Reply. Arch Surg. 2010;145(4):402-403. doi:10.1001/archsurg.2010.32