Several studies have reported an improvised technique to access the abdominal cavity through a single incision, with the application of a surgical glove. Hayashi et al. and Livraghi et al. reported on a series of SPLS (mainly cholecystectomies and appendectomies) using a standard wound protector covered with a surgical glove with several small incisions made on the tips of the glove-fingers to induce pneumoperitoneum and to create working channels for the laparoscopic instruments [16, 17]. The authors described this technique as having multiple advantages: easy to use, simply accommodated to the abdominal wall even in overweight patients, allows simultaneous passage of a maximum of 5-mm instruments and allows a wide axis of movements and hence minimizes instrument collision. The low cost of the application of this technique is mentioned as a potential advantage as well. Eumatsu et al. as well as Ishida et al. applied a similar technique for SPLS colectomies and concluded it is safe and feasible [18, 19].

Although the glove port technique may be safe and feasible, in the era of standartization and strict FDA control of medical devices, this technique may be used only in countries free from FDA/CE mark device approvals.

A variety of dedicated access devices are available. These devices offer different solutions to the challenges mentioned above. Some are reusable, but most are disposable and thus increase the overall OR cost.

The SILS™ port (Covidien, New Haven, CT, USA) is a disposable access port. It has a firm foam-like consistancy and is inserted through a 2-cm fascial incision. The port adjusts to the wound edges and retracts the abdominal wall to provide an airtight seal. Through this port 5/12-mm trocars and instruments can be passed into the peritoneal cavity (Fig. 9.2).

The GelPOINT^® (Applied Medical, Rancho Santa Margarita, CA, USA) has a disposable gel platform connecting to an adjustable polyethilene sheath which has an inner and external rings (Fig. 9.3). This sheath serves also as a standard wound protector while extracting organs. The gel platform enables insertion of several dedicated or standard trocars wide apart from each other lowering the incidence of instrument collision.

The Triport^® and Quadport^® (Advanced Surgical Concepts, Wicklow, Ireland) are disposable devices. Both have a similar adjustable plastic sleeve which is inserted through a 2-cm fascial incision using a special introducer. The sleeve is then connected to an external cap with different configurations of several valves allowing passage of rigid and curved instruments into the abdominal cavity (Fig. 9.4).

The X-Cone™ (Karl Storz-Endoscope, Tuttlingen, Germany) is a rigid reusable port, which consists of two metallic parts and a reusable silicone cap (Fig. 9.5). The port is assembled following the positioning of both metallic parts through the incision, thereby creating an air tight seal and maintaining constant fascial incision length. The silicone cap contains three flexible ports enabling the passage of rigid and curved instruments, and two more ports, which have no profile height to reduce the space occupied by the ports. In total the port offers introduction of five instruments. The special rigid hourglass configuration facilitates the use of curved instruments to achieve adequate retraction and triangulation.

The Single Site Laparoscopy Access System (Ethicon Endosurgery Inc., Cincinnati, OH, USA) is a disposable port. It has a plastic sheath in various sizes that is inserted through the incision using a dedicated introducer. A unique rigid cap is then connected to the external ring of the sheath, which has three entry ports (Fig. 9.6). These ports are the seal mechanisms only without any tubing or trocars thereby maximizing the space offered for instruments and motion around the cap.

Several other devices are on the market like the ENDOCONE™ (Karl Storz-Endoscope), the S-Port^® (Karl Storz-Endoscope), the X-Gate (Ethicon) and more. Most have similar designs with minor changes that differentiate them.

As mentioned above, the view is compromised in SPLS, due to the common point of entry of instruments and camera into the abdominal cavity. The passage of instruments within the camera’s visual field obscures the surgical field and creates a challenge. Excellent coordination and communication between the surgeon and the camera operator is crucial to the success of SPLS, but sometimes it is not enough. The consortium for LESS surgery has stated in their consensus statement that “the surgeon should be able to visualize structures from differing perspectives, preferably offline from the axis of the instruments” [15]. In an attempt to overcome the challenge of a compromised view, different cameras and endoscopes were evaluated.

One of the basic requirements of any kind of surgery is retraction. Retraction enables the surgical field to be visible to the surgeons in both open and laparoscopic surgery and enhances surgical dissection. As procedures become less invasive, adequate retraction must often be sacrificed, as ports designated for retraction are invariably the first to be waived. Nevertheless, surgeons must find ways to provide adequate retraction even though they use a reduced number of ports. Inadequate retraction undoubtedly serves as an obstacle when performing SPLS, especially when the anatomy encountered is less than “textbook” [31]. Aside from its inevitable prolongation of operative time, inadequate retraction can potentially convert a technically straightforward case into a complex ordeal, lead to the conversion of a single-port surgical procedure to conventional laparoscopy or open surgery, and eventually increase morbidity. As such, the achievement of optimal retraction without additional ports is an everlasting pursuit.

Traditional laparoscopic instruments are straight and rigid. The mobility of straight instruments is limited and when a few straight instruments are inserted through a common entry point in the abdominal wall, their maneuverability is lacking. In addition, in these circumstances triangulation of the instruments and camera towards the surgical field is limited as well, which turns even a simple surgical procedure into a technically demanding ordeal. This problem is even more prominent if the single-port access device is bulky and long [20]. Many efforts have been made to develop instruments that would simplify the technical challenge and would achieve triangulation, mainly curved and articulating instruments. Even though the use of straight laparoscopic instruments comes with technical difficulty, all laparoscopic instruments can still be used for SPLS. The main pros for the use of straight (“conventional”) laparoscopic instruments is the reduced cost associated with their use by eliminating the need to buy new instruments, and the elimination of a learning curve for the use of a new type of instruments [38]. Some studies have shown the feasibility and safety of large series of SPLS using standard laparoscopic instruments [38, 39].