A procedure can be considered necessary safe only if the rate of complications is similar to that of the current gold-standard. When comparing the rate of complications between SILC and LESS cholecystectomy numerous studies have reported both, no significant difference with regard to complication rate [6, 15, 17, 22] or an increased complication rate when comparing SILS/LESS cholecystectomy to LC [14, 18]. With regard to the study by Phillips et al. [14] it is interesting to note that this is the same cohort of patients as an initial report by Marks et al. In the original report by Marks et al. [13] there was no significant difference in complications. However in the report by Phillips et al. [14], the number of patients increased and so did the complications associated with single-incision surgery [14].

This is the largest case series published so far and in theory the learning curve has leveled off, indicating that the complications are inherent to the procedure itself, questioning the feasibility of widespread application of the SILC/LESS cholecystectomy. One of the complications that has been discussed the most is the increased risk of a postincisional hernia after SILS/LESS surgery due to an increase in size of the defect in the fascia. This complication has tried to be avoided by turning multiple fascial defects into a single incision, however, results have been inconclusive. [6, 14, 25, 35]. Previous data on patient outcomes after SILC/LESS cholecystectomy suggest that this new procedure is reproducible and safe [9], however this does not seem to agree with the results from the recent RCTs (see above).

The literature on SILS/LESS cholecystectomy has been recently reviewed by Antoniou et al. [6]. They analyzed the results of 29 different articles reporting the realization of a SILC/LESS cholecystectomy with a total of 1166 patients. Among the reported results there is 9.3% of unsuccessful surgery, generally due to a lack of proper identification of Calot’s triangle, along with a cumulative intraoperative complication rate of 2.7% (range 0�C20%) with the most common being gallbladder perforation/bile spillage (2.2%) and hemorrhage (0.3%). The most common postoperative Carfilzomib complications were wound infection and hematoma in 2.1% of patients [6]. In more recent articles Duron et al. and Mutter et al. reported series of 55 and 58 patients, respectively, who underwent SILC/LESS Cholecystectomy [31, 36]. Duron et al. [36] reported a series of 55 cases performed in a single institution, in which a ��learning curve�� effect was present with regard to shorter operating times and the inclusion of more technically difficult patients as surgeon experience increased [36]. Mutter et al.