A well-organized operating room is a prerequisite not only for the success of the intervention but also to optimize the timing of surgery and to lower related costs. Surgical team position radically changes during LESS surgery compared with standard laparoscopy, because single-site incisions force surgeons to change their position to maximize mobility of the instruments. In this case, the first surgeon, after inserting the port, stands behind the shoulders of the patient, at the level of the head, the place usually occupied by the anesthesia team. The assistant is positioned at the right shoulder of the patient. An appropriate Trendelenburg position is required to decrease the distance between the surgeon and the patient, which is more extreme than in standard laparoscopy. A third surgeon may be placed between the legs of the patient to manipulate the uterus.

Surgical procedures are performed through a single multiport reusable or disposable trocar (LESS) inserted into the umbilicus. We generally use an Olympus multiport trocar (Olympus Winter & IBE GMBH; Hamburg, Germany). This device consists of three components: the introducer, the fixing valve, and the trocar itself. The trocar, made of a doubled-over cylindrical sleeve of pliable film material fixed to the proximal ring, flows down around the distal ring and then back up and out. To introduce the trocar, the distal ring is passed through an open access into the abdominal cavity using the introducer. A 1.5– 2-cm longitudinal transumbilical skin incision is made. The subcutaneous fat is opened, with exposure and incision of the abdominal fasciae for approximately 2 cm. The parietal peritoneum is smoothly dissected with blunt scissors, achieving access into the peritoneal cavity. After the skin incision is made, the distal ring is mounted on an introducer, an instrument used to insert and push the distal ring through the abdominal wall. Then the introducer is removed, the retractable sleeve is gripped to the proximal end, and the outer ring is pushed down to create a perfect seal with the abdominal wall. The excess sleeve is finally cut off. Through the adjustable length of the sheath, the outer part of the trocar can be positioned in contact with the skin regardless of the thickness of the abdominal wall or body mass index of the patient, making it comfortable even in obese patients. Triport (Olympus Winter & IBE GMBH; Hamburg, Germany) has two channels for the transit of gas and three ports for surgical instruments: two measuring 5 mm and one measuring 12 mm. Although a model with four ports is available, three ports seem sufficient to perform any gynecologic-oncologic procedure. The cannula positions are adjustable within the flexible port, and a separate channel allows for carbon dioxide insufflation. In order to maintain the pneumoperitoneum, the ports are sealed with a gelatinous plastic material, which prevents the escape of gas during surgical maneuvers; this does make it necessary to lubricate the instruments to avoid excessive friction. Once pneumoperitoneum (12 mmHg) is achieved, intra-abdominal visualization is obtained with a 5-mm 30° telescope or, alternatively, a 5-mm 0° laparoscope with a flexible tip (EndoEYE; Olympus Winter & IBE GMBH; Hamburg, Germany) (Fig. 13.1). Straight conventional 5-mm instruments are inserted into the remaining two ports, namely, the surgeon’s choice of graspers, scissors, suction/irrigation, bipolar coagulator, and a multifunctional versatile laparoscopic device that grasps, coagulates, and transects simultaneously. The combination of one standard 33-cm long instrument with a 43-cm long instrument is preferred to prevent excessive contact between the surgeon’s instruments outside the abdominal cavity and to facilitate stripping and traction maneuvers (Fig. 13.2). Changes in the positions of the instruments and camera are performed according to the needs of the surgeon. A steep Trendelenburg position is usually needed to complete the surgery (about 30°). At the end of the procedure, each layer of the access port is separately sutured to prevent subsequent umbilical hernia occurrence. In particular, the abdominal fascia is closed by separate delayed reabsorbable sutures, and the skin is repaired with rapid absorbable suture.

The following table describes some of the most common surgical procedures performed in gynecologic oncology (Table 13.2).