How to meet the challenge of flexible exposure of the Calot triangle in SILS cholecystectomy.

Single-incision laparoscopy was developed to further reduce the operative trauma in routine laparoscopic procedures. However, the method remains challenging because the exposure of the Calot triangle is more difficult as the use of a singular traction device does not allow the flexible 3-dimensional mounting of the structures. We introduce a technical improvement involving both exposure and traction. After installation of the technical devices for single-incision laparoscopy cholecystectomy, as usual, a suture on a Keith needle is inserted subcostally from the right side of the patient, passed midway through the infundibulum, and extracted subcostally on the left side of the patient. The suture is fixed with 2 metal clips on each side of the gallbladder. The gallbladder can be tilted both medially and laterally on a horizontal line and the Calot triangle can be dissected from medial and lateral aspects following the "critical view of safety" criteria used in conventional laparoscopy.