As SLS has evolved, devices have been developed to assist surgeons in overcoming technical challenges. These range from access devices to flexible instruments and scopes. Multiple access devices currently exist that allow multiple instruments to be inserted at one site, with variable degrees of flexibility which may improve maneuverability and allow adjustment of angulation to overcome external parallel instrumentation [6].

To date, surgeons have used various methods to improve the cosmetic results of laparoscopic surgery. Smaller instruments are available, such as the Stryker MiniLap instrument line (Kalamazoo, MI, USA), which is 2.3-mm and uses a retractable needle tip for percutaneous entry, leaving only a needle sized skin defect. Retraction has been accomplished with transabdominal sutures that decrease the number of port site incisions. At our institute, we prefer to use a Lap Protector with EZ access system (Hakko Co., Tokyo, Japan) and insert small head trocars because these trocars can be placed as required to prevent incision related trauma (Fig. 43.1). Furthermore, Covidien (New Haven, CT, USA) developed several 5-mm laparoscopic instruments that have flexible tips that can be angled relative to the shaft, but there is some loss of rigidity because of this added flexibility. The Autonomy Laparo-Angle (Cambridge Endo, Framingham, MA, USA) offers 360-degree flexibility, but has a larger handle. RealHand (Novare Surgical Systems, Cupertino, CA, USA) also has a wide range of motion tip and ergonomic handle. Olympus (Tokyo, Japan) has curved instruments which are not fully adjustable, but have the benefit of being more rigid [6]. Although standard laparoscopic instrumentation can still be used for single site surgery, especially for simple procedures, more specialized instruments may help overcome some of the technical challenges that are encountered when single site surgery is applied to more advanced procedures.

Today, SLS is being used widely in children for appendectomies and cholecystectomies to minimize surgical trauma and scarring and adopted for selected cases of pyloromyotomy, splenectomy, choledochal cystectomy [7], nephrectomy, inguinal hernia repair, high ligation of varicocele, Nissen fundoplication, and endorectal pull-through procedures.

Despite the potential benefits to patients, the single site approach has potential risks. The operative challenges imposed are unique to SLS and differ from those encountered in general surgery. The proximity of instruments restricts the range of movement of both a surgeon’s hands and the instruments themselves; in particular, parallel alignment of instruments during SLS limits triangulation which is a founding principle of safe and effective laparoscopic surgery [6], and in line placement of the scope narrows the visual field, with the result that the view is both dependent on and limited by instrument mobility. These factors could affect the safety of a procedure, be implicated in longer operating times, and increase the risk for complications. With SLS a substantial fascia-splitting incision is required, which may be associated with more surgical infections, more pain, and an increased risk for postoperative hernias. These disadvantages would be counter to the progressive spread of MIS. Thus, the relative advantages of single-site procedures would appear to be few, compared with standard laparoscopy, and might prove only to be improved cosmesis. Reports in the literature focus primarily on feasibility and there are no reports comparing benefits currently available.