While modern single-site laparoscopy is considered relatively new, the origins of laparoscopy were in fact in single-site procedures. In 1961 Platteborse described access to the abdominal cavity with a 12 mm trocar and a working channel [27], allowing biopsies of the liver and gall bladder. Around the same time Steptoe began gynaecological laparoscopic procedures [28], which would culminate in his collaboration with Edwards and the birth of in-vitro fertilisation. Using his technique of access, a series of 25 laparoscopic sterilisations was subsequently carried out at Johns Hopkins Hospital by Wheeless in 1969 [29].

As interest in laparoscopy grew it became apparent that multiple instruments and ports would be necessary to achieve the required retraction and triangulation in more complex procedures, as well as to reduce the potential for instrument clashes. The progression to multi-port laparoscopy enabled the technique to emerge as not only a viable alternative to traditional methods of open surgery, but eventually as the preferred surgical approach in many procedures today. There was still, however, interest in single-port surgery by some pioneers. Notably, the American gynaecologist Pelosi, who performed the first major extirpative single-site procedure in 1991—a hysterectomy with bilateral salpingo-oophrectomy via a single transumbilical port [30]. His group subsequently reported a supracervical hysterectomy and the earliest series of single-port appendectomies [31, 32]. In 1997 Navarra published his report of a single-port laparoscopic cholecystectomy [33]. Over the next decade, the indication and complexity of reported cases increased. Emergency procedures such as salpingectomy for ectopic pregnancy were carried out and described as “feasible and safe” by Ghezzi et al. in 2005 [34]. A series of paediatric procedures was reported by Cobellis et al. in 2006, where a single 10 mm transumbilical trocar was used to identify a Meckel’s diverticulum and bring it to the skin, where the diverticulum was excised [35].

Single-port urological procedures were first described in the early twenty-first century. Hirano et al. reported a series of single-port adrenalectomies in 2005 [36]. These were performed using a large (4 cm) port inserted into the retroperitoneum, with no gas insufflation. However, significant complications were reported, including fulminant hepatitis, pulmonary embolism and death. The first successful laparo-endoscopic single-site urological procedure (a simple nephrectomy in a 36 year old man) was presented by Rane et al. at the World Congress of Endourology in 2007 [37]. A multichannel port (the R-port, Advanced Surgical Concepts, Wicklow, Ireland) was used via a single flank incision to insert a 5 mm telescope, two further 5 mm instruments and a 10 mm clip applier. The same group subsequently reported successful ureterolithotomy, orchidopexy and orchiectomy [37]. Raman et al. reported a series of nephrectomies in 2007, utilising multiple trocars and articulating instruments via a single umbilical incision [38]. These were performed for both benign as well as malignant disease. Radical nephrectomies as well as pyeloplasties were reported by Desai et al. in 2008, this time using custom-designed curved instruments and the R-port; a supplementary 2 mm needle port was also used [39].

The range and complexity of single-port urological procedures grew rapidly. Kaouk et al. reported laparoscopic renal cryoablation, wedge renal biopsy and sacrocolpopexy in 2008, and further experiences with LESS reconstructive procedures were reported including dismembered pyeloplasty, ureteral reimplantation with psoas hitch, ileal ureter construction and urteroneocystostomy [40, 41]. A series of live donor nephrectomies via a LESS approach was reported in 2008 by Gill et al., with no complications and excellent graft outcome [42]. This was followed by highly complex extirpative procedures successfully performed via a LESS approach, including radical prostatectomy and radical cystectomy with pelvic lymph node dissection [43, 44] (Table 21.2).