The potential challenge with SILC is that it will require purchase of proprietary instrumentation and additional equipments in some cases which http://www.selleckchem.com/products/Gemcitabine-Hydrochloride(Gemzar).html increase overall operative cost. Although potential benefits including fewer conversions, a shorter postoperative recovery or LOS, and less morbidity would make SILC more cost effective, demonstration of any economic benefit over LAC can be difficult. Waters et al. [35] reported that the port itself was purchased at a cost of 550�C650USD compared with average cost of 80USD of the ports used in the standard LAC cases. The marginal increase in direct operative cost was 310�C410USD per case. With similar operative time and LOS, it can be inferred that the total increase in cost is only that of the port device itself.

Concerning surgical instruments and techniques, SILS has several disadvantages compared with multiport laparoscopic surgery. Standard laparoscopic surgeries are performed through multiports allowing variation of scope placement and angling when met with obstructions. In SILS, no additional ports exist for placement of the scope and maneuvering is greatly restricted by nearby instruments. Therefore SILS requires an experienced surgeon to overcome the difficulties of triangulation, pneumoperitoneum leaks, and instrument crowding. In fact, according to our paper, as many as 9 cases needed to be converted to either open or multiports laparoscopic procedure to get better retraction or aid in colonic mobilization.

Some investigators recommend utilizing articulating instruments or since obesity was found to be a common reason for conversion, variable length tools including a bariatric-length bowel grasper or an extra-long laparoscope to minimize external clashing are also recommended [19, 30]. One of the most challenging factors for SILC in attaining widespread use is the additional learning curve required for this technique. The SILC is essentially a one-operating surgeon technique which has a potentially detrimental impact upon resident education, affecting the training of future surgeons as well. Because most surgeons are still performing open colectomy (the prevalence of even standard LAC procedure is still under 25% in the US [44, 45]) or are on their own learning curve for laparoscopy, it requires further analysis to determine the impact that introducing a more technically demanding procedure has on training these surgeons. 5. Conclusions SILC is a challenging procedure but seems to be feasible and safe when performed by surgeons highly skilled in laparoscopy. SILC may have potential benefits over other types of minimally Entinostat invasive surgeries (LAC or HALC), however this has not yet been objectively shown.