[TULC - total umbilical laparoscopic cholecystectomy]

Except for some few cases only symptomatic cholecystolithiasis constitutes an indication for operative treatment. The gold standard meanwhile has been the laparoscopic cholecystectomy, because the method shows good results with short hospital stay. Recently there has been an intensive discussion about combination of laparoscopic techniques with natural body orifice using surgery (NOTES). These techniques permit further reduction of surgical trauma and enhancing of cosmetic results. However, the technical effort is significant and most of the times a combination (hybrid procedure) of NOTES with standard laparoscopic procedure is performed, so that we concentrated on performing a laparoscopic cholecystectomy using a single incision through the umbilicus.

A 5-mm incision left deep in the umbilicus and a 10-mm incision directly below were used for creating a pneumoperitoneum and for inserting the ports for the optic and the dissector. Exposition of the gallbladder was carried out by sutures, that were penetrated from outside through the abdominal wall into the abdominal cavity and transfixed through the gallbladder in order to hang up the gallbladder like a puppet by penetrating the abdominal wall again to the outside. Removal occurred through the umbilical incision.

We successfully operated on 90  patients in a 12-month period. Mean operating time was 48 (39-71) min whereby no conversion to open surgery was necessary. No intra- or postoperative complications occurred in any patient. Average hospital stay was 2.5 (2-4) days, postoperative examination showed no differences to the usual laparoscopic cholecystectomy with a good cosmetic result and no visible scars.

The purpose of our study was to further improve the cosmetic results of minimally invasive surgery of the gallbladder by operating totally through the umbilicus, using 2  ports deep in the umbilicus. We thereby avoid further surgical trauma due to creating an access through another organ as is done in the NOTES technique. For this operation no special equipment like flexible endoscopes was needed as common laparoscopic instruments were used.