The procedure’s average length was 50 minutes (ranging from 35 to 80mn). During this study, there were two per operative difficulties: a very short cystic duct and an acute cholecystitis. These two procedures were brought to a successful conclusion. There were four failures. One was the impossibility of placing the nasogastric kinase inhibitor Tofacitinib tube into the stomach, two were due to the presence of very large gall stones (3.3 and 4cm wide), and one patient had an acute macro multilithiasis cholecystitis and a right hepatic artery. We carried out a standard laparoscopic cholecystectomy. 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.

4. Discussion 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 = 10mm) 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 10mm have been employed. So we can reduce the rate of incisional hernia. 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 [9�C11].

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 5mm 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 gastric wall usually heals very quickly and well. In this way, the simple laparoscopic closure becomes the Batimastat reference procedure with peptic ulcer perforation [13] 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]. We prescribe a 10-day IPP treatment after this procedure. Our N.O.S.E.