Endoloop

Open surgery was performed through McBurney, para median, or midline incision. Appendectomy was completed by transection of the mesoappendix, and ligation and resection of the appendix at the radix. The appendix stump was embedded and the incision closed in layers with or without a drainage tube. When usual appendectomy was impossible due to inflammation, appropriate resection including cecectomy and ileocecal resection was performed. During laparoscopic surgery, a multichannel access device was fitted into a 2 to 3‐cm vertical skin incision in the umbilicus, after which three 5‐mm ports were inserted for the camera and instruments. Additional ports were inserted in cases with severe adhesion and inflammation if necessary. The appendix was ligated using an Endoloop (Ethicon) and the appendix stump was not embedded. The umbilical incision was used to pull out the specimen.

With a patient placed supine and the surgeon and camera assistant positioned on the patient's left side and a monitor located on the patient's upper right side, a 1.5–2-cm transumbilical skin incision is made, and then a Gloveport 431-AS (Meditech Inframed, Seoul, Republic of Korea) is inserted through the wound. After carbon dioxide insufflation, exploration is performed using a 50-cm-long 5.5-mm camera at an angle of 30°. Decisions regarding the use of an additional port are usually made at this time. When required, a 5-mm first additional port is located in epigastrium to function as a right-hand-working port (Figure 1). When required, a second 5-mm trocar is inserted into the right subcostal region to obtain the desired field of view. When a critical safe view is convincingly achieved (Figure 2), the cystic duct and artery are separately ligated with a clip and a Hem-o-lok (Weck Surgical Instruments, Teleflex Medical, Morrisville, NC, USA). If the cystic duct is enlarged by obstruction, it is ligated using an Endoloop (Ethicon Endosurgery, Cincinnati, OH, USA). Sometimes, retrograde cholecystectomy is performed when Calot's triangle is not fully exposed. A drain is inserted through the epigastric port when drainage is required.

A standard LRYGB, indicated by body mass index (BMI), was performed with a 50-cm biliopancreatic and 100-cm antecolic antegastric alimentary limb, or the patient underwent a standard LSG. Six trocars were used, and, when necessary, an additional 5-mm trocar was inserted into the right subcostal area, to proceed with conventional cholecystectomy. In contrast, no additional trocar was needed during the Glissonian approach. For conventional cholecystectomy, once the critical view of safety was convincingly achieved, the cystic duct and the artery were separately ligated with medium-sized clips, using a 5-mm clip applier inserted through the right-hand working port located in the epigastrium, before dividing them between the clips, and then the gallbladder was dissected completely from its fossa. In the Glissonian approach, the gallbladder was first dissected from its fossa, and then the cystic duct and the artery were ligated together with an endoloop (Ethicon Endosurgery, Cincinnati, Ohio) without separation (Figure 1). A drain was routinely inserted in the right subhepatic space, regardless of whether a cholecystectomy was performed.