The TriPort™ (Olympus) was the first available access system approved by the US Food and Drug Administration (FDA). Since Rane et al. [12] reported the first clinical use of the TriPort, it has been used in such common operations as single incision cholecystectomy but also more complex operations as adrenalectomy, hemicolectomy, distal pancreatic resection and finally in bariatric surgery [13, 14]. Recently, the next generation of their products, which named as TriPort+™ and QuadPort+™ are unveiled [15]. The TriPort+™ has four channels, allowing up to one 10-mm and three 5-mm instruments, while the QuadPort+™ has five lumens, permitting up to one 15-mm, one 12-mm, one 10-mm and two 5-mm instruments. The TriPort+™ is designed for standard laparoscopic surgeries, whilst the QuadPort+™ is constructed for more complicated types of surgical procedure that require large amounts of tissue to be removed and employ up to four instruments. Each channel has the duckbill/lipseal valve which allow for the smooth introduction and removal of instruments while maintaining pneumoperitoneum. Flexible instrument ports enhance access to the surgical site and accommodate different types and sizes of laparoscopic instruments: straight, curved and articulating. Reducer caps at the larger ports allow the insertion of 5-mm instruments without loss of pneumoperitoneum. The retraction sleeve provides wound protection and helps streamline specimen removal. It is self-adjusting to different incision length (TriPort+™/TriPort15: 12–25-mm, QuadPort+™: 20–60-mm) and abdominal wall thicknesses (up to 100-mm).

Some negative aspects of the TriPort+™/QuadPort+™ were encountered. One was the “chimney effect”, where the pneumoperitoneum was leaking along the space between the port’s sleeve and the wound. Moreover, retraction system is complicated with multiple steps including cinching of the sleeve attachment of two retainer clips, and removal of excess sleeve. Also, the sheath can easily be torn, which may result in a need to replace the device. These devices require crossing of curved or roticulating instruments.

The SILS™ Port (Covidien) is a blue flexible soft-foam port that conforms to the patient’s abdominal wall to maintain pneumoperitoneum. The soft-foam minimizes abdominal bruising and provides stability/support to hand instruments. But no wound protection is brought to this port device. Although it recommends that the port is lubricated and inserted using a large Kelly clamp through a 20 mm incision, slightly larger fascial incision needed to accommodate port in most cases. It includes three cannula access channels, which can accommodate three 5-mm cannulas or two 5-mm cannulas and one 12-mm cannula. It’s possible, but may not be easy to use 12-mm cannula because of relatively narrow trocar separation (1.5-mm). Using this device, crossing of roticulating or curved instruments is required. In obese patients, use of this port is difficult due to its foam design. Since Fader et al. [16] reported the first clinical use of the SILS™ Port, it has been used in such common operations as single incision cholecystectomy but also more complex operations as adrenalectomy, hemicolectomy, distal pancreatic resection and finally in bariatric surgery [17–22].

Burgos et al. [23] described their initial experience with the SILS™ Port in performing laparoscopic prostatectomy. They compared their experience with their previous experience with the TriPort (Olympus) and noted that the SILS™ Port was easier to place, had less leakage of pneumoperitoneum. Conversely, Brown-Clerk indicated the SILS™ Port’s difficult insertion and lack of abdominal wall adjustability [24].

The GelPOINT™ system (Applied Medical) consists of the Alexis^® wound retractor, GelSeal cap, and 10 or 12-mm self-retaining trocars. The Alexis^® wound retractor includes a distal and proximal ring that can accommodate a 1.5–7-cm (GelPOINT™) and 1.5–3-cm incisions (GelPOINT Mini), and a wide range of abdominal wall thicknesses. Trocars can be positioned anywhere within the GelSeal cap. This facilitates triangulation of standard instruments and provides additional procedural and instrumentation flexibility. Removable GelSeal cap streamlines specimen removal.

GelSeal cap bows outward during insufflation providing a flexible fulcrum for improved instrument articulation, but cannot provide stability/support to instruments. Use of this port in obese patients is restrictive secondary to the increased abdominal wall thickness. Endoscopic staplers can insert with included 12-mm trocar. There are many clinical reports using GelPOINT™ [25–28].

The ENDOCONE^® (Karl Storz-Endoskope) system is manufactured from stainless steel with a design that facilitates both insertion and retention within the anterior abdominal wall. Additionally the system includes coaxially curved instruments designed to facilitate triangulation, provide traction and counter-traction during dissection of tissue planes and maximize their range of motion within the operating space.

X-CONE (Karl Storz-Endoskope) is a reusable metallic conical structure consisting of two half cones, to which a plastic cap is attached which have four instrument ports and an insufflation port [29]. The port insertion through a mini-laparotomy is quick and easy. They allow the insertion of curved or straight 3-mm to 12.5-mm (X-Cone) and up to 15-mm (ENDOCONE^®) instruments. However, significant leakage and restricted mobility have been reported [30, 31].

S-PORT^® (Karl Storz-Endoskope) is a modular system which is developed to improve these issues. It consists of the basic ring, upper part ring, and the wound protector. The upper part ring is compatible with the sealing caps of X-CONE and ENDOCONE^®. Other merit of the S-PORT^® is reusable except for the wound protector and simple recovery of resected tissue.

The OCTO™ Port (Dalim Surgnet) consists of an inferior base plate that sits under the skin edge in the peritoneum, an external disc with self retractor, and a detachable port cap. It is capable of holding one to four working channels. The cap is easy to remove, thus allowing easy specimen extraction. The 360° port cap rotation during the surgery enables the surgeon to change the location of ports. The cannulas are of different heights, which reduce external clashing of instruments. The silicone cover cap supplies a flexible fulcrum for improved instrument articulation, while cannot provide stability/support to instruments. This port device requires crossing of curved or roticulating instruments [32].

The SPIDER™ (TransEnterix) consists of a retractable sheath, two laterally placed instrument delivery tubes that can operate in three dimensions, and two rigid channels. It is designed to allow multiple flexible instruments to be manipulated through a single cannula. Surgeons who use the SPIDER Surgical System benefit from single site triangulation with true left and true right control over flexible, articulating instruments. One of the demerits of the SPIDER™ is the cost. It costs $875.00 for main unit and $40-$95 for each instruments. It also provides articulation of instruments, which is useful, yet may limit retraction of tissues and torque due to force dissipation. Furthermore, the SPIDER™ flexible or rigid 5-mm ports are not large enough to allow for ≥10-mm Hem-o-lok clip application or a laparoscopic stapler. Moreover, no wound protection is ensured at the specimen retrieval with this device [33].

The E•Z Access™ (Hakko) is made from a silicone-rubber cap and designed to be applied to an existing incision margin protector (LAPPROTECTOR) [34–36]. Trocars can be positioned anywhere within the cap, providing additional procedural flexibility and stability/support to hand instruments. Three size variations are currently available in E•Z Access™ (round type). Each of them is applied depending on the length of the skin incision (1.5–5 cm) in various LESS/RPLS procedures.

E•Z Access Oval type, which is one of the product lines of E•Z Access, is designed exclusively for use with the LAP PROTECTOR™ Oval type device [37].