the laparoscopy became the main surgical technique for cholecystectomy with a rate of laparoscopic performances of about 99% for some french teams . the development of recent innovative and experimental surgical techniques ( n.o.t.e.s . ) [ 14 ] reduces the abdominal wall trauma and complication by using ports and removal of the gall bladder or any other abdominal organs . the risk of incisional hernia increases when using a 10  mm or more port [ 5 , 6 ] . the removal of an inflamed gall bladder with or without very large gallstones usually requires enlarging one of the abdominal incisions . it will be closed of course , scrupulously [ 7 , 8 ] , but there is always a risk of complication ( infection , bruising , incisional hernia [ 911 ] ) and that is the same problem with the single port access surgery as it is also difficult to get back to normal physical activity quickly , without risk of trocar - site incisional hernia ( especially for patients who practise sport , manual workers or if , for example , they have to look after a dependant relative ) . the n.o.t.e.s . has stimulated the surgeons ' ingeniosity and the engineering department of medical laboratories . the standardization of the laparoscopic cystic duct dissection resulted in a reduction of the rate of common bile duct injuries which lead us to develop a combined procedure of a standard dissection using existing miniaturised instruments ( 3,5  mm wide ) , a 5  mm wide angle optic , and a gall bladder removal with a short gastrotomy . these 3,5  mm wide instruments were used in pediatric surgery , so we just had to increase their length [ 7 , 8 ] . currently , the 5  mm wide angle optic allows us to have a very good operative view thanks to the latest camera generation on the market . the transgastric gall bladder removal and its lithiasis can be performed under gastroscopic control or to tie the infundibulum to a nasogastric tube . the gastric incision is stitched up without difficulty and is safer than the endoscopic approach ( clips , loop , etc . ) was offered to any patient who had a symptomatic gallstone without emergency , acute cholecystitis , or common bile duct lithiasis . we chose not to take into account : age , bmi , and unusual medical contraindications for laparoscopy . it was agreed with the patients that we would perform this procedure if we did not encounter any surgical difficulties . we first put the 5  mm optic port in place in the peri umbilical or para and sus umbilical side of the abdominal wall according to the surgeon 's normal routine . we put two or three , 3,5  mm ports in place on vision control in the left hypochondrium , in the right side of the abdominal wall and in the epigastrium if necessary . the left hypochondrium port could be changed for a 5  mm one if we decided to use pediclar clips . we start with a standard cystic pediclar dissection and we always try to do a systematic per operative cholangiography as we usually do in our surgical team groupe de recherche et d'etude en chirurgie coelioscopique de l'ouest ( grecco ) ( coeliogrecco.com ) . we tie up the infundibulum with a 2/0 monofilament stitch .       a gall bladder bipartition with another loop can sometimes be required to avoid the agglutination of the gall stones to the bottom as it could hamper its removal . we must locate the large nasogastric tube ( 16 to 20 french which is put in place at the beginning of the procedure ) or the end of the gastroscope . we then carry out a longitudinal or vertical gastrotomy on the anterior side of the lower part of the stomach ( 2 to 3  cm long ) . afterwards we tie the gall bladder with a stitch at the end of the nasogastric tube or at the end of the gastroscope : gall bladder removal . hand sew the short gastrotomy with braided or monofilament absorbable suture ( 30 or 20 ; 26  mm  1/2  c needle ) . we then carry out a peritoneal washing , exsufflation , and removal of the ports . next morning , the patient can resume eating without restriction and takes one capsule of proton - pump inhibitor ( ipp ) for 10 days . this procedure was performed on 63 patients from april 2008 to july 2009 , during which period there were 4 failures of the complete procedure . these 63 patients were 14 men and 49 women , with an average age of 46,7 years ( ranging from 22 to 77 ) and an average bmi of 27,3 ( ranging from 22 to 36 ) . 31 patients had at least one 10  mm wide lithiasis ; 18 patients had at least one 15  mm wide lithiasis ; 9 patients at least one 20  mm wide lithiasis . 49 patients required the use of a second 5  mm port to put pediclar clips . on 14 occasions only , we used a single 5  mm port when we put a stitch . on 10 occasions , we carried out a gall bladder bipartition when there was a large number of lithiasis . the gastrotomy was stitched up 40 times with absorbable monofilament and 23 times with absorbable braided suture : 9 times these were separated stitch and 54 times overcast seams . the procedure 's average length was 50 minutes ( ranging from 35 to 80  mn ) . during this study , there were two per operative difficulties : a very short cystic duct and an acute cholecystitis . one was the impossibility of placing the nasogastric tube into the stomach ,   two were due to the presence of very large gall stones ( 3.3 and 4  cm wide ) , and one patient had an acute macro multilithiasis cholecystitis and a right hepatic artery . no gastric or abdominal wall complication occured during the hospitalization or during the 6 weeks postoperative consultations . the majority of the patients ( 61/63 ) could resume normal physical activity after leaving our hospital . the development of the laparoscopic surgery since the 1990s , allowed the abdominal wall trauma reduction . in 2007 , 88 000 laparoscopic cholecystectomies were performed in france in opposition to 7770 laparotomies ( pmsi french data ) . however , it is well known that all of the trocar site hernia occurred through large ( > or = 10  mm ) port defect . according to the literature , the overall incidence of trocar site hernias is expected to be around 1% [ 5 , 6 ] . the fascia closure should be done when ports > or = to 10  mm have been employed . of course , the abdominal organ removal ( as the gall bladder and its lithiasis ) often requires enlarging the fascia incision with a high rate of incisional hernia , bruise , and infection [ 911 ] . this abdominal wall trauma , even limited , prevents the patients from resuming normal physical activity very quickly especially for patients who practise sport , manual workers , or for example , if they have to look after a dependant relative . we thought that to use miniaturised instruments for dissection with ports less than 5  mm could be more beneficial . so the risk of trocar site incisional hernia is almost zero and allows resuming normal activity upon hospital discharge . to the contrary of the natural orifice transluminal endoscopic surgery ( n.o.t.e.s . ) , our pediclar dissection is standardized and identical to the usual procedure without risk of increasing the rate of biliary complication ( common in this kind of procedure ) . , the simple laparoscopic closure becomes the reference procedure with peptic ulcer perforation   with an average rate of complication less than 1% in the context of a gastroduodenal pathology . we carry out a hand sewn gastrotomy surgical closure of greater quality than the endoscopic closure [ 3 , 4 , 12 ] . procedure is simple and reproducible , using existing miniaturised instruments that we have adapted to adult surgery ( long 3  mm wide instruments ) . the 5  mm wide angle optics allows having a very good operative view equivalent to a usual 10  mm optic used in laparoscopic surgery . the length of this procedure is slightly longer than the usual technique due to the transgastric removal and the gastric closure . in our experience , the after effects are very simple without early or late abdominal wall and gastric complications in the followup . the risk of gastric complications is very low in the context of a nonpathological gastric wall but will be the object of a more accurate assessment . there are some difficulties with the gall bladder removal in cholecystitis and very large gall stones ( larger than 3  cm ) . it could be overcome by carrying out endoscopic control of the removal with or without a specific cover . this endoscopic control could also be interesting in the presence of a hiatus hernia , an oesophagitis , and so forth . our procedure ( laparoscopic cholecystectomy using micro instruments and a 5  mm optic in a transgastric gall bladder removal ) allows abdominal wall trauma reduction and to resume as soon as possible normal physical activity without risk of incisional hernia . the cystic pediclar dissection is a usual and standardized procedure .
background . 
 the laparoscopic cholecystectomy is a perfectly codified surgical procedure . 
 the development of recent innovative and experimental surgical techniques natural orifice transluminal endoscopic surger ( n.o.t.e.s . ) which reduces the abdominal wall trauma leads us to develop a combined procedure of a standard dissection using miniaturised instruments already existing on the market ( 3 and 5  mm wide ) and a gall bladder removal through a short gastrotomy natural orifice specimen extraction ( n.o.s.e . ) 
 . methods . our objective was to evaluate the safety , the feasibility , and the reproducibility of our new approach . after reviewing existing products on the market and a feasibility study , we put in place a protocol in our structure for patients on whom the procedure was performed . 
 we carried out a gall bladder removal by a short gastrotomy , located on the anterior gastric wall , which then reduced the abdominal wall trauma and allowed them to resume normal physical activity quickly without risk of trocar site hernia . 
 results . 
 we performed the procedure described in this paper on 63 patients , between april 2008 and july 2009 . 
 there were 14 men and 49 women with an average age of 46.8 years ( ranging from 28 to 77 ) and an average bmi of 27.2 . 
 30 patients had at least one gallstone larger than 10  mm . 
 there was no postoperative gastric or abdominal wall complication and a fast recovery for all the patients in our study . 
 conclusions . 
 this procedure is feasible , reproducible , with good results and minimal abdominal wall trauma . 
 it is also safer than n.o.t.e.s . and endoscopic clipping and recovery , allowing normal physical activity , fast and , without risk of incisional hernia .