laparoscopic cholecystectomy was first performed by mouret in lyon , france , in march , 1987 . since then it gained wide acceptance among surgeons and is now considered the standard treatment of cholecystolithiasis . the position of the patient and the arrangement of the operating team and the position of the ports and instruments vary in the american and european techniques . in this study we present our experience with a modified convenient and economic layout for patients undergoing laparoscopic cholecystectomy using three ports only . a total of 119 patients with gallbladder stones were offered laparoscopic cholecystectomy by one surgical team , over a period of 24 months ( april , 1994 , through march , 1996 ) . endoscopic retrograde cholangiopancreotography ( ercp ) and sphincterotomy was performed preoperatively in patients suspected to have common bile duct stones based upon their laboratory and ultrasonographic findings . the surgeon stands on the left side of the patient , as in the american technique . there is no need for a second assistant and no need for a second monitor . a third port is inserted in the anterior axillary line some 5 - 7 centimeters below the costal cartilage . the assistant may modify the point where the gallbladder is grasped as the procedure progresses . if the gallbladder is unusually long the fundus can be stitched to the undersurface of the diaphragm . operative cholangiography is not done routinely and where stones in the common bile duct are suspected an endoscopic retrograde cholangiopancreotography and sphincterotomy is performed prior to gallbladder removal . the surgeon stands on the left side of the patient , as in the american technique . there is no need for a second assistant and no need for a second monitor . a third port is inserted in the anterior axillary line some 5 - 7 centimeters below the costal cartilage . the assistant may modify the point where the gallbladder is grasped as the procedure progresses . if the gallbladder is unusually long the fundus can be stitched to the undersurface of the diaphragm . operative cholangiography is not done routinely and where stones in the common bile duct are suspected an endoscopic retrograde cholangiopancreotography and sphincterotomy is performed prior to gallbladder removal . sixteen patients with suspected common bile duct stones had endoscopic retrograde cholangiography done before attempting gallbladder removal . one patient required insertion of a fourth trocar to control bleeding from the cystic artery . two patients , who had long and redundant gallbladders , needed suture of the fundus of the gallbladder to the undersurface of the diaphragm . four patients ( 3.3% ) required conversion to an open laparotomy and conventional cholecystectomy was performed via a right subcostal incision . in two patients acute inflammation of the gallbladder coupled with dense adhesions of the edematous gallbladder which hindered accurate identification of the cystic duct necessitated conversion to open laparotomy . the fourth patient , who presented with acute cholecystitis , suffered a bile duct injury in the form of partial avulsion of the cystic duct at its junction with the common bile duct . this injury was detected intraoperatively and managed by repair of the common bile duct around a t - tube . the mean operative time for the laparoscopic procedure , measured from skin incision to skin closure , was 35.7 minutes ( range 17 to 85 minutes ) . the patient who suffered a bile duct injury remained in the hospital for nine days . patients were followed up for a mean period of 14 months ( range 2 to 29 months ) . one patient presented with trocar site hernia 5 months after the procedure and did not elect to undergo repair . the morbidity rate was 4.2% ( 5/119 ) and all complications were minor except for the patient who suffered bile duct injury ( table 1 ) . this change to a laparoscopic access is attributed to its obvious advantages , including less postoperative pain , a better cosmetic result , a shorter hospital stay , and an early return to normal activities . laparoscopic cholecystectomy on the other hand utilizes expensive technologically advanced equipment , including costly disposable instruments . it requires more personnel than are required for open operations . in the american technique , which is more commonly adopted , the surgeon and the camera operator stand on the left side of the patient while the assistant and the nurse stand on the right side of the patient . the surgeon stands between the patient 's legs with the first and second assistants on the left and right sides of the patient respectively . in our modified layout the surgeon has more space and he can work either single - handed , giving the right lateral port to his assistant - camera operator , or use both hands , manipulating the gallbladder himself . the lesser number of trocars inside the abdomen prevents so - called " sword fighting . " the omission of the midclavicular port and the use of the anterior axillary port instead may improve the safety of the procedure . the same port can be used for superior traction to aid in dissection of the gallbladder from its bed . the surgeon can modify the point where the forceps holds the gallbladder according to operative circumstances . the direction of cephalic traction exerted by the midclavicular port distorts the anatomy and alters the position of the common hepatic duct to simulate the cystic duct , hence making it more vulnerable to injury . the single anterior axillary port we recommend permits traction on hartmann 's pouch in a lateral direction resulting in excellent exposure of the calot 's triangle ( figure 3 ) . most surgeons will exhaust themselves to detect the junction of the cystic duct to the common hepatic duct . the detection of the junction of the cystic duct to the infundibulum of the gallbladder is more important to help reduce the incidence of such injury . we used the modified technique in both chronic and acutely inflamed gallbladders and found that it can be easily used in both settings . the only occasion we needed a fourth port was when there was unusual bleeding from the cystic artery . the technique we adopted builds on the advantages of the laparoscopic approach and adds to them . the results of this series compare favorably to results of studies done using the  classical  technique . there is no need for a second assistant , and no need for a second monitor . laparoscopic cholecystectomy can be safely performed using only three trocars in the modified position described . the layout is more convenient to the surgical team , more economic to the patient and to the hospital .
objective : the aim of this study is to present an economic and convenient modification of the layout for laparoscopic cholecystectomy , utilizing a three - port technique.methods:the surgeon stands on the left side of the patient , while the assistant stands between the patient 's legs . 
 the scrub nurse stands on the right side of the patient facing the surgeon . 
 the assistant also operates the camera . 
 only three ports are used . 
 this technique was used in 119 consecutive patients over a 24-month period . 
 endoscopic retrograde chlolangiopancreotography ( ercp ) was done preoperatively in patients suspected to have choledocholithiasis.results:sixteen patients had ercp done preoperatively and in 12 of them sphincterotomy and stone removal was carried out . 
 laparoscopic cholecystectomy was successfully completed in 115 patients . 
 the mean operative time was 35 minutes . 
 four cases were converted ( 3.6% ) , one due to bile duct injury , two others due to extensive adhesions , and a fourth due to cholecystoduodenal fistula . 
 the total morbidity rate was 4.2% . 
 the mean hospital stay was 1.8 days.conclusions:laparoscopic cholecystectomy can be safely and conveniently done using only three ports in the modified position described . 
 you need only one assistant , only one monitor and one less trocar . 
 there is no prolongation of the operative time and the results are comparable to the classic four - trocar technique .