Curved and or articulated instruments have been used according to the surgeon’s preference [14], as they Ixazomib proteolytic 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) 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. In this respect several prospective studies comparing LC and SILC/LESS Cholecystectomy have now been published [12�C20] (Table 2). Table 2 Comparison of clinical trials comparing SILC versus 4PLC��SILC/LESSC (single-incision laparoscopic cholecystectomy/laparoendoscopic single-site cholecystectomy), 4PLC (four port laparoscopic cholecystectomy). There are several blinded randomized trials comparing standard LC to SILC/LESS cholecystectomy with varied results regarding patient outcomes.

An outcome that has had a significant difference in several studies comparing SILC/LESS cholecystectomy versus LC is the cosmetic result. Patients are more satisfied with the hidden or infraumbilical single surgical scar than the four scars created by the LC [13, 17, 19]. In an attempt to try and reduce the bias associated with cosmetic evaluation, Marks et al. and Bucher et al. used body image scale, a scar scale photo series 10-point scoring questionnaire in order to compare results between SILC/LESS and LC patients. However regardless of the scale used, there is still an element of personal preference and opinion involved with the evaluation of cosmetic results. Aside from cosmetic perception, the only consistently reproducible and statistically significant result among series is a prolonged time of surgery for the SILC/LESS cholecystectomy groups versus standard LC groups [12�C14, 16�C20]. A study by Qiu et al. [34] focused specifically on the learning curve phenomenon associated with SILC/LESS cholecystectomy and saw an improvement in operative times as experience was gained [34] this Drug_discovery was similar to what was observed by others [18�C20].