The practice of endoscopic surgery spread quickly around the world after an endoscopic cholecystectomy was performed in the late 1980s, and the number of organs to which endoscopic surgery is applied has increased steadily. Endoscopic treatment was actually introduced in the 1960s in the field of gynecology, and it was implemented in the form of single-port laparoscopic surgery (SPLS). The application of SPLS to many different organs is, however, something that began to emerge only a few years ago, and the recent rapid spread of SPLS is due largely to technological advances in endoscopic surgery over the past few years. The umbilical incision used in SPLS is subject to scar contraction; after surgery the scar shrinks so that it is almost unnoticeable. From a cosmetic perspective, the procedure offers greater advantage to patients than any other surgical method currently in general use. For surgeons, who are constantly required to reduce the cosmetic impact and implement minimally invasive approaches, SPLS is worthy of serious consideration. This chapter reviews the history of, and transitions in, SPLS, per the organ(s) to which it is applied.

Keywords

Single-port laparoscopic surgery (SPLS)History of single-port surgerySingle-port access (SPA)

1.1 Introduction

1.2 Transitions in SPLS

SPLS began in 1969, when Wheeless et al. [1] reported a successful tubal ligation via a 1-cm wound, through which carbon dioxide gas was introduced into the abdomen through an endoscope equipped with an eyepiece lens. In 1991, Pelosi et al. [2] reported the use of an endoscope with a working channel in performing a total hysterectomy, including removal of the fallopian tubes and ovaries. The same group also reported the first appendectomy achieved by this method [3]. Since then, endoscopes with working channels have become—and are still—widely used for SPLS. In 1997, Navara et al. [4] performed a single-port cholecystectomy, in which internal sutures were used for displaying the surgical field and for traction.

To maintain a good surgical view, Curcillo et al. [5] introduced, in 2007, a method by which straight grasping forceps can be used by direct puncture so that the surgical procedure does not rely on a single incision. In the following year, Cuesta et al. [6] used a Kirschner wire or a Mini Loop Retractor II™ (Covidien, New Haven, CT, USA) percutaneously, and Leroy et al. [7] subsequently reported a method of displaying the surgical view with the use of magnetic force for the tissue retraction.

Platforms changed over time. In 2007, Ates et al. [8] applied a 5-mm, 2-channel trocar (11-mm trocar, Applied Medical Resources Corp., Rancho Margarita, CA, USA) in SPLS. In the same year, the R-port was developed as a dedicated platform for SPLS, and the TriPort™ system (trademark pending, Advanced Surgical Concepts, Wicklow, Ireland), the Uni-X™ single laparoscopic port system (Pnavel Systems, Morganville, NJ, USA), and the SILS™ port (Covidien) followed as multi-channel ports.

The roticulator forceps that were made commercially available in 1991 (Roticulator Endo Grasp II™, Covidien) became popular once again for the use in SPLS due to their effectiveness in reducing “friction” in the surgical area, but in 2007, the multi-joint RealHand^® (Novare Surgical Systems, Cupertino, CA, USA) forceps were developed, and in the following year, further improvements were seen in the prebent forceps (S-Portal Instruments, Karl Storz Endoskope, Tuttlingen, Germany). The addition of various energy devices to these platforms and forceps has meant that SPLS has gradually, SPLS has become applicable to an increasing number of organs.

1.3 Gallbladder

SPLS gallbladder surgery began in 1997, when Navara et al. [4] reported single-port endoscopic cholecystectomy. Two 10-mm trocars were inserted via the umbilical region, and three transabdominal sutures were used to retract the gallbladder and expose the triangle of Calot. The surgery was performed in 30 patients, taking an average of 123 min, with infection as the only complication in one case and no cases requiring opening of the abdomen.

In 2008, Cuesta et al. [6] reported ten cases in which two 5-mm trocars were inserted via an umbilical wound, and a Kirschner wire (φ1 mm) was inserted percutaneously, bent into a hook within the abdominal cavity, and used to pull the gallbladder. Average surgery time was 70 min. The gallbladder was perforated in three cases, but no infection was noted after surgery.

In 2008, Rao et al. [9] reported use of a dedicated SPLS port (R-port, Advanced Surgical Concepts), transabdominal stitches, and multi-joint forceps in 20 cases, three of which required the addition of a trocar.

Romanelli et al. [10, 11] reported performing cholecystectomies with the use of a dedicated SPLS port (TriPort, Advanced Surgical Concepts). Of 22 cases, one required the addition of a trocar.

Curcillo et al. [5, 12, 13] reported a method in which three 5-mm trocars were inserted from the umbilical region, and 5-mm forceps were directly inserted via the umbilical region to retract the gallbladder without the use of sutures. Subsequently, the same authors [13] reported 297 cases in which the umbilical incision measured 1.4–2 cm, the average surgical time was 71 min, and opening of the abdomen was required in only four cases.

1.4 Small Intestine and Colon

In 2007, Cobellis et al. [14] reported nine cases in which part of the intestinal tract was removed via a 10-mm wound in the umbilical region. The 10-mm wound facilitated both resection and reconstruction of the small intestine, and no case required hemostasis in the intestinal tract.

Single-port laparoscopic colectomy was reported by both Remzi et al. [15] and Bucher [16] in 2008. Remzi et al. [15] used a dedicated Uni-X™ (Pnavel Systems, NY USA) port to treat appendix polyps by means of right hemicolectomy. The wound measured 3.5-cm, and surgical time was 115 min. At the same time, Bucher et al. [16] carried out a right hemicolectomy using an endoscope with a working channel and transabdominal stitches. The incision was 3 cm, the surgery took 158 min, and reconstruction was carried out externally. Internal reconstruction was reported by Bucher et al. [17, 18] in a case of left colectomy. The incision was 2 cm, and the surgery took 213 min because it was performed concomitantly with cholecystectomy.

The reconstruction of the bowel was performed by a totally intracorporeal method [17, 18]. The anvil of the circular stapler was introduced in the abdominal cavity via the port wound. The anvil was then inserted in the bowel through an enterotomy near the anastomotic line in the segment to be resected. The central shaft of the anvil was exteriolized through a hole on the anti-mesenteric teniae. A linear stapler was applied to resect the specimen. The next steps were same as those of the standard double-stapling technique. Leroy et al. [7] reported using the magnetic force to retract the organ in a sigmoid colectomy. Access was established via a Triport™ (Advanced Surgical Concepts). A flexible scope inserted through the anus was utilized to insert the anvil. An external magnet was used to move the bowel intracororeally.

1.5 Stomach

In 2006, Kawahara et al. [19] reported performance of 22 single-site gastrostomies. After insertion of a single 10-mm trocar and introduction of an endoscope with a working channel, the abdominal cavity was observed, the anterior gastric wall was checked, and straight grasping forceps inserted via the working channel were used to pull out a part of the gastric wall via the trocar wound, after which a gastrostomy was created.

In 2008 Bucher et al. [20] reported performing a gastrojejunostomy in which three trocars (one 12-mm trocar and two 5-mm trocars) were inserted via a 2-cm incision in the umbilical area, and an abdominoscope with a working channel was used. Transabdominal sutures were used to lift the stomach and small intestine, and a linear stapler was used to attach the stomach and jejunum laterally, with the entry hole also being stapled and closed with the linear stapler. The surgery lasted 117 min.

Nissen surgery for GERD was reported by Hamzaogolu et al. [21] in 2010, with access gained via a SILS™ port (Covidien). The liver was retracted with the use of a Penrose drain 8-cm long and 1-cm wide, and it was lifted in a hammock fashion. Once the field of view of the esophagogastric junction was established, suturing was performed with SILS™Stitch (Covidien). The average surgical time was 190 min, and blood loss was 30 mL. Henckens et al. [22] reported partial gastric resection for gastrointestinal stromal tumor. A TriPort™ (Advanced Surgical Concepts) was inserted via a 2-cm incision in the umbilical area, and prototype multi-jointed forceps and a “gooseneck” videolaparoscope were used in the surgery, which took 140 min, and resulted in 10 mL blood loss. No post-surgical complications were reported, and the patient left the hospital 4 days after the surgery.

1.6 Appendix

Twenty-five cases of single-port appendectomy were reported in 1992 by Pelosi et al. [3]. In all cases, the appendix was mobilized with the use of a laparoscope with a working channel, and the appendix was resectioned externally. D’Alessio et al. [23] reported application of the same method in 116 cases, 22 (19 %) of which required the addition of a trocar, and 5 (4 %) of which required an abdominal incision. The average surgery time was 35 min. In 2007, Ates et al. [8] reported use of an 11-mm-diameter trocar with two 5-mm forceps openings in 35 cases of appendectomy. A laparoscope with a working channel was used to dissect the area around the appendix and to pull out the mesoappendix percutaneously to create a field of view before internal ligation of the appendix root. The surgery took 38 min, and no post-operative complications were noted.

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