Author's Response

Dr. Ugarte apparently did not carefully read my article. I never said that the surgeon will stand between the patient's legs. It is clear in the text and obvious in the figures that he stands on the patient's left side. Therefore, there is nothing far to reach as he suggested. In our technique the surgeon can, if he likes, use both hands in manipulating the two working ports. If he chooses to let the nurse handle the camera, he will need no assistant. The fourth port in the "standard" technique is not inserted, as Dr. Ugarte suggested, below the xyphoid but in the right abdomen and is not meant to hold the infundibulum but the fundus of the gallbladder. It is meant to improve exposure and if you can get excellent exposure with three ports, I do not see the value of any extras. Furthermore, there is no harm in making minimally invasive surgery even less invasive, provided safety is not compromised. Otherwise we would not have heard about microlaparoscopy and office laparoscopy. Regarding difficult gallbladders we already used the same technique in acute cholecystitis with good results. Insertion of a T-tube requires skill but a fine tube inserted in the common bile duct for one week will not greatly increase the rate of stricture formation, I believed it was justified in this particular case.