Sils port

A straight forceps (Yida Medical Device Co. Ltd, Hangzhou, Zhejiang province, China) and a universal testing machine (BZ2.5/TSIS, Zwick GmbH, Ulm, Germany) were included in this study. The measurement system based on DIC was composed of a box trainer (Model 200, Ruihong Laboratory Equipment Co Ltd, Shanghai, China), a SILS Port (Covidien, Mansfield, Massachusetts), and a charge-coupled device camera type CV-A1 (Jai, Copenhagen, Denmark) (Figure 1).

The surgical techniques for nSILC were standardized and described in a previous report.1 (link),2 (link) Briefly, nSILC was performed routinely through a SILS port (Covidien) with a snake liver retractor for pushing up the hepatic hilum in a cephalad direction and ENDOPATH^® electrosurgery probe plus system composed of suction, irrigation unit, and hook electrode for dissection. A snake liver retractor can help to clearly expose the triangle of Calot and shorten the time needed to identify the critical view of safety (CVS).1 (link) To get clear visualization of the triangle of Calot and secure the CVS, lateral traction of the gallbladder was performed using an additional 2 mm needlescopic grasper (Minilap Grasper, Stryker, San Jose, CA) which was punctured directly on the right abdomen (Fig. 1, 2). The key point of this technique was to clearly visualize and identify important structures through adequate traction of the gallbladder without crossing or conflicting operating instruments. In almost all cases, CVS could be secured safely by this technique. After achieving CVS, the cystic duct and artery were ligated using a 5 mm hemolock clip and transected using laparoscopic scissors.

The platform was set up by a box trainer (Model 200, RUIHONG laboratory equipment Co. Ltd, Shanghai, China), a single incision laparoscopic surgery (SILS) Port™ (Covidien, Mansfield, MA, USA), two load cells and the weighing accessories [Figure 1]. The top of the simulator was modified to introduce the port around which two load cells were layed. The analog signal of load cells will be magnified after adding by the junction box, which will be dealt with by micro controller unit after analog to digital conversion, then will output to PC software by RS232-RS485 module. The weighing systems (Model FN-D3 Stainless Steel Single Point Load Cell, AD750 high precision digital weighing transmitter, RS232-RS485 passive converter, data record analyzer 2.0) were manufactured or provided by ANRUI Automatic Instrument Co. Ltd, Shanghai, China.

For the first patient, two trocars were used: The SILS port (Covidien, Hamilton, Bermuda) and R-port (Olympus Surgical, Orangeburg, NY). For the subsequent six procedures, standard trocars were used (one 12 mm, one 10 mm, and two 5 mm). Then, for the remaining ones, we used either the SILS port or the Gelpoint (Applied Médical, Rancho Santa Margarita, CA).

A full-bowel mechanical preparation was administered the day before surgery. All patients received preoperative antibiotics (cephalosporin+metronidazole) and thromboembolic prophylaxis with low-molecular-weight heparin. In case of peritoneal perforation, antibiotics were continued for 3 days. All but one patient underwent general anaesthesia. A single-incision laparoscopic surgery port (SILS PORT, Covidien) was used in 19 cases and a Gelpath (Applied Medical Corp.) was used 12 cases performed since 2015. Surgery was performed with the patient placed in the Lloyd-Davies position, also in cases of anterior lesion. After platform insertion, a pneumorectum at 10–12 mmHg was set. Wet gauze was used above the lesion to reduce cranial colonic distension. Conventional laparoscopic instruments were used. A hook-type monopolar electrocautery or the harmonic scalpel was used for dissection and coagulation. After marking the area of resection, the dissection was started on health tissue ∼1 cm all around the lesion margins and carried to obtain a full-thickness excision. The rectal full-thickness defects were always closed by interrupted or running barbed sutures (monofilament 3-0); for this purpose, a pneumorectum reduction (7–8 mm Hg) is useful to avoid increasing the tension during suturing. In one case, the lesion was closed with a GIA universal stapler with a 60-mm purple cartridge.

Access to the abdominal cavity was obtained by a 2- to 3-cm incision through the umbilicus. The linea alba was incised, and either a SILS port (Covidien, Mansfield, Massachusetts) or GelPoint device (Applied Medical, Rancho Santo Margarita, California) was placed in the abdominal cavity. Visualization was obtained with either a 5-mm 30° angled laparoscope (Karl Storz, Tuttlingen, Germany) or a 5-mm flexible-tip Olympus Endo Eye laparoscope (Olympus, Tokyo, Japan). The procedure was carried out in standard laparoscopic fashion, both by mobilizing the retroperitoneal attachments to the right colon and distal small bowel and by taking the mesenteric vessels with a radiofrequency energy device (Enseal; Ethicon Endo-Surgery, Cincinnati, Ohio). A primary vascular (medial-to-lateral) approach was preferred. After completion of the dissection, the specimen was extracted through the periumbilical incision and a stapled side-to-side functional end-to-end anastomosis performed. The periumbilical incision was lengthened to allow for extraction of larger specimens.