The equipment needs for SILS colorectal operations are similar to equipment needs for any standard laparoscopic procedures. There are a few notable exceptions, and these equipment needs are directly related to co-linear instrument management and the visualization challenges with the camera on the same axis as the instruments. There are multiple options for laparoscopic stapling devices and SILS access platforms, which may be left up the surgeon discretion. The single-site multiport concept of SILS colorectal surgery may hinder ergonomics and create technical challenges for effective visualization, dissection, triangulation, and retraction. It has been our experience that successful completion of SILS colorectal operations is dependent upon availability and use of a few standardized surgical tools that can help the surgeon overcome the challenges associated with co-linear instrument management in a confined space. In this section, we will focus on what we feel are necessary equipment and instruments for SIL colorectal surgery.

The challenge with visualization in SILS is the on-axis view obtained when using a single incision as the site for multiport access of the camera and instruments (Fig. 3.2a–c). Use of reverse triangulation and a bariatric length camera can improve visualization (Fig. 3.2b). Camera options also exist that can help overcome this obstacle and provide a side view of instruments, which include a flexible tip, or rigid 30 or 45 degree 5 or 10 mm camera, with possible addition of a right angle adaptor (shaft size of the camera will depend on the multiport SIL platform used) (Fig. 3.2d). In our experience, we prefer a high-definition flexible tip, 5 mm camera (ENDOEYE, Olympus Medical Center Valley, PA) as it allows precise adjustment of the camera angle to obtain an optimal view, adequate space to reduce collision between instruments, and avoids crowding of the surgeons hands and the camera driver (Fig. 3.3a–c). Depending on the access device utilized, use of a 5 mm camera frees up a 10 mm port for a stapling device. Rigid 30° or 45° cameras can be effective, but we suggest using a bariatric length camera (45 cm) as it places the camera driver’s hands a distance away from the surgeon’s hands to further avoid external collision. If a rigid scope is preferred or all that is available, we recommend cameras with in-line light cords to avoid hindrance. If a camera that requires insertion of the light cord into the shaft is utilized, a right angle adapter is advantageous to create a lower profile [35]. Camera optics are illustrated in Fig. 3.2.

Crowding or clashing of instruments and hands around the port site can be frustrating occurrence with SIL surgery. There are some basic steps that can be taken to minimize clashing which starts with the use of low-profile trocars and staggering of the heights of the trocars to minimize crowding (Fig. 3.4). The surgeon can avoid hand collisions with the camera by inverting the handles of the instruments to 90° or 180° to increase operative space (Fig. 3.3a). Bariatric length atraumatic bowel graspers (45 cm shafts versus conventional 34 cm shafts) may be particularly useful to minimize external collisions and for dissection of flexure regions (Fig. 3.5) [37, 38]. Additional triangulation can be obtained by the use of a single-bariatric length grasper in the nondominant hand and further allow more space externally between the surgeon’s right and left hand [39]. However, necessity of extra-long instruments can often be avoided by simple reinsertion of the instruments and camera into different port locations (if a fixed one piece platform is used) or rotation of the port device (if a two-piece access port device is used) to gain proximity to the dissection area [37, 40].

Laparoscopic surgery emphasizes the use of triangulation , which results from insertion of the camera and working ports through separate incisions to allow optimal visualization and traction. Initial SILS experience can result in technical difficulties with instruments working in line with the camera due to lack of range of motion and triangulation creating a chopstick or sword fighting effect [37]. Advocates of SILS have introduced a technique of inverse triangulation where instruments are crossed upon insertion resulting in the working ends of the two instruments not encountering each other but resulting in improved traction and ultimately visualization (Fig. 3.2) [37]. Other dissection techniques that can be utilized during SILS include avoidance of left to right traction in favor of up and down or in and out traction and countertraction.

Articulating instruments have been developed as an alternative to the use of standard laparoscopic instruments [37–39]. The use of two articulating instruments was originally adapted to enhance triangulation. Articulating instruments often sacrifice the transmission of constant force, ability to maintain retraction, and tactile feedback [37]. Reliance on these instruments also adds additional financial cost to the case. Furthermore, use of two articulating instruments can be technically challenging. This can be overcome by the use of one articulating instrument with one straight instrument. We have not found that articulating instruments add value to SILS colectomy or successfully overcome some ergonomic and technical challenges.

Use of extracorporeal sutures and magnetic retraction has also been described to enhance triangulation [19, 37]. This has been reported to be useful in patients with a narrow pelvic cavity requiring a total mesorectal excision or in women with a uterus obstructing the pelvic view [37, 41]. Specialized retractors such as the 10-mm Endo Retract (Covidien, Mansfield, MA, USA) or the Snowden-Pencer® laparoscopic articulating retractors (CareFusion, Waukegan, IL) can be useful to gain additional exposure [14]. Transrectal placement of an assistant’s digit, stapler or a colonoscope can also assist in visualization, tension, and dissection in the pelvis [37].

There are several options for vessel sealing devices such as the Harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH, USA), Enseal (Ethicon Endo-Surgery, Cincinnati, OH, USA), or Ligasure™ (Covidien, Mansfield, MA, USA), which all work well in a SILS procedure and can largely be left up to surgeon preference. In our experience, we have used all three and found there is no difference in outcome or quality of vessel sealing if the instruments are used correctly and as indicated. We do prefer the Enseal or Ligasure as these instruments can be used as graspers and for blunt dissection when needed. In addition, these multiuse instruments eliminate the need to remove and reinsert different instruments, which can effectively improve efficiency and reduce operative time.

Depending on the chosen access device, a wound protector may be incorporated into the port (GelPort, Applied Medical, Rancho Santa Margarita, CA, USA). If using another platform, then a wound protector, such as the Alexis wound protector (Applied Medical, Rancho Santa Margarita, CA, USA), should be utilized to protect the wound during specimen extraction and extracorporeal anastomosis when applicable. We routinely use this type of retractor and find it very useful to maintain small access incisions and effectively extract the specimen. When using the wound protector, assure you do not dial down on the abdominal wall too tightly or necrosis could occur.

Patients are initially placed supine on the operating table for induction of general anesthesia. We routinely insert an orogastric tube and Foley catheter for all laparoscopic colorectal procedures. Positioning of the patient’s perineum is important to allow for access to the anus for stapling when necessary [4].

Arms should be tucked whenever possible. If one arm must be out on an arm board due to body habitus or need for anesthesia IV access, the arm ipsilateral to the colonic pathology should be chosen to allow enough room for the assistant to stand beside the surgeon, if needed [4].

Optimal patient positioning can minimize the lack of triangulation. Care should be taken to ensure the patient is secured to the operating table, as exposure can be greatly improved with the use of steep Trendelenburg and rotation of the patient away from the operative location to utilize gravity to facilitate countertraction [14]. A standard process to secure the patient should be developed for your surgical team and may include a combination of vacuum bean bags [20]. Velcro straps and tape can be effective. We suggest you perform a trial of extreme positioning before prepping and draping the patient as this will allow the surgical team to test the patient’s stability on the bed and alleviate any fears that the patient will fall from the table during the operation.