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INTRODUCTION: Knot tying is difficult but important for laparo-endoscopic single-site surgery (LESS). There are several techniques for LESS knot-tying. However, objective assessment of these skills has not yet been established. The aim of this study was to assess three different knot-tying techniques in LESS using mechanical methods. MATERIALS AND METHODS: The subject tied 24 knots, eight knots with each of the three techniques in an inanimate box laparoscopic trainer while the movements of their instruments were evaluated using a LESS mechanical evaluation platform. The operations were assessed on the basis of the time, average load of the dominant hand. Then, forces caused the knots to rupture were measured using a material testing system and used to compare the knots's strength. RESULTS: The intracorporeal one-hand knot-tying technique presented significantly better time and average load scores than the extracorporeal knot-tying technique (P < 0.01), and the intracorporeal "side winding" technique was more time and average load consuming in comparison to other techniques during the performance of knot-tying (P < 0.01). The intracorporeal one-handed knot-tying knots can tolerate better distraction forces compared with the intracorporeal "side winding" knot-tying knots and the extracorporeal knot-tying knots (P < 0.05). CONCLUSIONS: The intracorporeal one-hand knot-tying technique and knots showed better results than the intracorporeal "side winding" technique and the extracorporeal knot-tying technique in terms of the time, average load taken and the force caused the knot to rupture. [ABSTRACT FROM AUTHOR]

The major barrier to transumbilical endoscopic surgery is external interference between the instrument handles around the umbilicus. We describe technique of totally transumbilical endoscopic cholecystectomy using improved instruments. New trocars (5 and 3 mm in diameter, respectively) without proximal seal system on the sleeves were designed for this procedure. The maximum diameters of the trocars were reduced to 8 and 5 mm, respectively. The instruments used in this study were 5 cm longer than commercially available instruments. Ten cases of totally transumbilical cholecystectomy were performed successfully. All the gallbladders were removed successfully without severe bleeding during dissection, except one case of gallbladder wall perforation by cautery. Mean operating time was 62 ± 25 min (range 45–110 min). All patients were satisfied with abdominal cosmetic results, discharged 48 h after the operation, and returned to work within seven postoperative days. External interference between trocars and instruments can be partially avoided by using the improved instruments. Totally transumbilical endoscopic cholecystectomy becomes feasible with this technique. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented regarding natural orifice transluminal endoscopic surgery (NOTES) new technique in endoscopic surgery.