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Single-Port Laparoscopy:Market-Driven or True AdvancementVirgilio George, MD

Minimally invasive procedures such as laparoscopy are increasingly used and constantlyimproving with advances in surgical instrumentation and operative technique. As a steptoward less-invasive laparoscopy, single-incision laparoscopic surgery (SILS) through theembryonic scar of the umbilicus has been proposed by multiple surgery specialties. Ageneral overview suggests SILS colorectal surgery seems to be safe and feasible in majorcolorectal surgery in experienced hands; however, more trials are needed to demonstratethe benefits over conventional laparoscopic surgery. This article will examine the issuesand data surrounding SILS in an attempt to distinguish its true and potential benefits fromthose hyped by market-driven declarations.

Semin Colon Rectal Surg 24:24-27 Published by Elsevier Inc.

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Minimally invasive procedures such as laparoscopy areincreasingly used and constantly improving with ad-

ances in surgical instrumentation and operative technique.aparoscopic surgery has been widely used as a minimally

nvasive modality to treat multiple benign diseases and min-mize surgical injury. Jacobs et al1 reported the first techni-ally feasible laparoscopic colectomy in 1991, and multipleuthors since then have solidified its place as a feasible andafe approach for colorectal disease.

The benefits of laparoscopy as compared with open sur-ery have been well delineated and include decreased mor-idity and pain, faster recovery, shorter hospital stay, androbable reduced immunosuppression.2,3 Although this has

been confirmed over a wide range of operations on variousorgan systems, colorectal disease poses a unique set of con-siderations.4 Laparoscopic colorectal surgery is technicallycomplex, as it involves laparoscopic mobilization of the colonover a wide area, intracorporeal division of major vessels,extraction of specimens, and a bowel anastomosis. As such,both expertise and experience are necessary to ensure per-ceived benefits become a reality. Several prospective ran-domized clinical trials comparing laparoscopy versus opencolorectal procedures have been undertaken with long-termfollow-up and large sample sizes.5-9 These trials have re-

orted that laparoscopic colectomy results in shorter lengthf stay, faster return of bowel function, decreased use of

Colon and Rectal Surgery, Department of Surgery, Indiana University Schoolof Medicine, Indianapolis, IN.

Address reprint requests to Virgilio George, MD, FACS, FASCRS, ColorectalSurgery, Richard L Roudebush VA Medical Center, Indiana University,

tIndianapolis, IN. E-mail: vigeorge@iupui.edu

24 1043-1489/$-see front matter Published by Elsevier Inc.http://dx.doi.org/10.1053/j.scrs.2012.10.007

arcotics, and lower rates of wound complications10,11 com-pared with open surgery.

Furthermore, the Clinical Outcomes of Surgical TherapyTrial in the United States,6,7 Leung et al,8 and the UnitedKingdom Medical Research Council Conventional VersusLaparoscopic-Assisted Surgery in Colorectal Cancer (MRCCLA-SICC)9 in Europe demonstrated that overall survivaland recurrent cancer rates were similar with either laparo-scopic or open surgery for colon cancer.

In standard laparoscopic intraperitoneal surgery, 3-6 portsare used. Although only a skin incision is made with bluntintroduction of the ports, patients have temporary pain andmuscle spasm postoperatively, which has been poorly docu-mented in studies. Epigastric vessel injury at the site of thelateral port insertion is also a potentially common injury.

Several platforms have been developed in an attempt toaddress these concerns. Natural orifice transluminal endo-scopic surgery (NOTES) might have been an answer to theseproblems, but the initial interest seems to diminish owing tosafety issues related to trauma to uninvolved organs (vagina,stomach, rectum, others), potential complications related tothe entry organ, difficulty in training, and suboptimal instru-mentation. On the other hand, the umbilicus is an embryo-logic natural orifice that can conceal a surgical scar. As a steptoward less-invasive laparoscopy, single-incision laparo-scopic surgery (SILS) through the embryonic scar of the um-bilicus has been proposed by multiple surgery specialties anddefined as ENOTES (embryonic natural orifice transumbili-cal endoscopic surgery).12 The fundamental idea is to have allhe laparoscopic working ports entering the abdominal wall

hrough the same incision, which does challenge the funda-

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Single-port laparoscopy 25

mental rule of laparoscopic surgery: “triangulation.” Thisdrawback can be resolved by an adequate learning curve anduse of novel instruments and devices tailored for an on-lineviewing.

To date, unlike NOTES, multiple names and devices havebeen developed for the single-site surgery, and are constantlychanging to improve this developing technique of minimallyinvasive single-port surgery. One of the early names to gainpopularity is single-port access (SPA) surgery, trademarked byDrexel University.13 Covidien Inc has named this new techniquesingle-incision laparoscopic surgery (SILS), whereas EthiconEndo-Surgery, Inc, has proposed the name: single-site laparos-copy (SSL). Some additional proposed names involve theumbilicus, such as 1-port umbilical surgery (OPUS)14 orransumbilical endoscopic surgery (TUES),15,16 embryonicOTES (eNOTES),17-21 and natural orifice transumbilical

surgery (NOTUS),20 with the embryonic notation referring tohe umbilical opening in utero. Other names suggested in-lude single laparoscopic port procedure (SLAPP),21 single-ort laparoscopic surgery (SPLS),22 single-port laparoscopySPL),23 and single laparoscopic incision transabdominal

(SLIT) surgery.24 A recent symposium convened to arrive at aonsensus regarding the single-port concept has suggestedhe name laparo-endoscopic single-site (LESS) surgery.25

As the acronyms proliferate, the devices used to performthis technique also proliferate. A brief overview of some of themost popular includes the following:

The Triport has 3 channels, allowing up to 1 instrumentmeasuring 12 mm and 2 instruments measuring 5 mm. TheQuadport has 4 lumens, permitting up to 1 instrument mea-suring 15 mm, 2 measuring 10 mm, and 1 measuring 5 mm.

The Gelpoint (Applied Medical, Rancho Santa Margarita,CA) is similar to the Gelport device, consisting of 2 pieces, awound protector and gel apparatus. This allows for up to 4trocars 5 or 10 mm in size through a resealable platform.

The SILS port (2009) (Covidien, Inc, Norwalk, CT) ismade from an elastic polymer, is slightly hourglass shaped,and can be deployed through a 2-cm fascial incision. It con-tains 4 openings: 1 for insufflation through a right-angledtube and 3 that can accommodate trocars 5-12 mm in size.

The uni-X single-port laparoscopic device (Pnavel Sys-tems, Morganville, NJ) is a system designed to allow thesimultaneous use of 3 laparoscopic instruments 5 mm in sizethrough a single fascial incision. It requires fascial fixationsutures and curved laparoscopic instruments. The uni-X sys-tem has been used primarily in urology procedures.23,26-28

Ethicon Endo-Surgery SSL Access System (2009) consistsof 2 seals 5 mm in size and a larger 15-mm seal in a low-profile design. Unique to the device is the 360° rotation of theseal cap that enables quick reorientation of instruments dur-ing procedures and reduces the need for instrument ex-changes.

The ASC ports (Advanced Surgical Concepts, Wicklow,Ireland), also known as the “R-port,” is Food and Drug Ad-ministration -approved and available in the United States. Itrequires a fascial incision approximately 1.5-2 cm long. TheASC ports use a fascial retractor system with an internal distal

ring advanced into the abdomen with a blunt introducer and

an external proximal ring, joined by a plastic sleeve, which isretractable with a removal ring. A sheath is placed throughthe fascial opening, and the peritoneal surface of this sheathhas a self-expanding ring, allowing the port to remain insidethe peritoneum. The sheath with adjustable size allows thesurgeon to position the port regardless of the thickness of theabdominal wall.

Review of LiteratureIn literature, there are still only a few publications reportingexperiences with laparoscopic single-port intraperitonealprocedures in series of 100 patients or more, despite �606publications describing the use of single-port laparoscopicaccess. In a recent systematic review, Pfluke et al29 found 219

anuscripts about single-port surgery experience collec-ively representing 4585 operations. Seventy-three percent159 of 219) of these publications report experiences with20 patients, only 6% (13 of 219) with at least 100 patients.uring the past 2 years, numerous reports of transumbilicalILS procedures have been published showing the feasibilityf this approach for even complex urological, gynecologic,nd thoracic and abdominal visceral procedures.17,18,22,30

Through May 2012, 418 colorectal resections throughSPLS were published in 42 articles, including both colonicprocedures and rectal procedures. Half the procedures wereperformed for malignant disease. All types of colorectal pro-cedures were performed, including appendectomy, ileocecalresection, right colectomy, left colectomy, sigmoidectomy,low anterior resection, proctectomy, ileal loop rectal restora-tion, and total proctocolectomy. This still represents a largeincrease, as in May 2010, there were only 15 publicationsabout single-port colectomy in 113 patients.29 Esposito31 firsteported a 1-trocar technique for a “colonic operation,” thats, appendectomy in a series of pediatric patients using anperating telescope to exteriorize the appendix. It was notntil October 2008, when a report on single-port right hemi-olectomy was published by Bucher in Europe and by Remzin the United States. Bucher et al30 performed a single-portight hemicolectomy for a large colonic polyp using conven-ional laparoscopic instruments. A 10-mm laparoscope with6-mm working channel was used through a 12-mm umbil-

cal port and right colon suspension, and exposure waschieved by placing transparietal stitches anchored to theolon wall with a 5-mm Johann grasper. An extracorporealnastomosis was performed. Oncological surgical principlesere respected, as the specimen had margins �10 cm and 33

ymph nodes. The case report by Remzi et al22 describes aright hemicolectomy performed using the uni-X system in-troduced by a single 3.5-cm incision at the site of the umbi-licus. A 5-mm laparoscope with a flexible steerable tip wasused. The ileocolic anastomosis was performed after exteri-orization of the bowel through the incision. Other authorssoon followed with their own experience, still mostly consist-ing of case reports or series. Waters and colleagues,32 whopublished a series of right colectomies, concluded, “In can-didates for standard laparoscopic right colectomy, [single

incision] is adequate with regard to: safety using morbidity,

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26 V. George

mortality, blood loss. Efficiency compared operative time,conversion, cost. Also, including the short term outcomes:length of stay, and oncologic parameters.”

Although the vast majority of the early literature consistedof right colectomies, 2 cases of left colectomy were reportedby Bucher. The first described a transumbilical single-inci-sion laparoscopic sigmoidectomy for recurring pelvic endo-metriosis in a 34-year-old female patient with sigmoid steno-sis. Transumbilical SILS sigmoidectomy was performed bythe same technique previously reported for right colectomy.The total operative time was 125 minutes. The surgical colonpathology specimen was 23 cm long with 14 lymph nodes.Conventional side-to-end colorectal anastomosis wasachieved by transanal insertion of a 31-mm circular stapler.SILS treatment of recurring pelvic endometriosis was under-taken by cauterization. No intraoperative or postoperativecomplications were recorded. The patient did not requestopiate analgesia, except in the recovery room during the first2 hours after surgery. Bowel function returned on day 1.Normal low-residue diet was started on postoperative day 1.The patient was discharged on postoperative day 2.33 Thesecond case described a radical left colectomy for a sigmoidcolon adenocarcinoma in situ associated with cholecystec-tomy for chronic cholecystitis. The procedure again re-spected proper surgical oncological principle with a 39-cmpathology colon specimen with sufficient margins and 34lymph nodes. Time for colectomy was 213 minutes. No in-traoperative or postoperative complications were recorded.34

After studies in porcine models,35,36 Leroy published about asingle-incision access laparoscopic sigmoidectomy for diver-ticulitis. The multichannel single-port (Advanced SurgicalConcepts Triport system) was placed at the umbilicus. Thesigmoid was retracted by both intraluminal sigmoidoscopyand magnetic anchoring.35,36

As more experience was gathered, technically more diffi-cult cases followed. A total intracorporeal anastomosis dur-ing single-port laparoscopic right hemicolectomy was re-ported by Morales-Conde,37 and this is the first case of anadenocarcinoma of the cecum stage IIA (T3, N0) treated by asingle-port technique and with a total intracorporeal anasto-mosis. A SILS port device (Covidien) was used with flexibleinstruments and a flexible endo-stapler to perform the anas-tomosis without any additional trocar. Operative time was140 minutes; no intraoperative or postoperative complica-tions were reported.37

DiscussionSome of the purported benefits of laparoscopic surgery arethat it is associated with less pain, decreased length of stay,and fewer risks of wound complications compared with opensurgery. In major colorectal laparoscopic surgery, often 5 or 6ports are needed. Single-port laparoscopic surgery may allowcommon laparoscopic procedures to be performed entirelythrough the umbilicus. Furthermore, this still permits thesurgeon to “convert” the procedure to a conventional laparo-scopic surgery at any point during the operation, if needed,

by adding conventional laparoscopic port(s). Modification of

operative technique can allow a colectomy to be performedwithout any additional access site and without any mini-laparotomy, using the single-port access site as an extractionsite. An optimal indication for SILS procedure could be thelaparoscopic-assisted right hemicolectomy, where theplanned extracted site can be used from the start as the site ofthe single-port device. The same can be done in patients whoneed an ileostomy or colostomy, using the site chosen for thestoma to insert the SILS device. SILS colectomy decreasesparietal trauma and offers cosmetic advantage comparedwith a standard laparoscopic approach.

Among the other potential advantages of single-incisioncolectomy compared with the standard laparoscopic colec-tomy is cosmesis.38,39 The perspective of body image is im-

ortant in young patients, and there is a significant propor-ion of young patients with inflammatory bowel disease thatould be another indication for using single port for reopera-ions in patients receiving steroids and/or anti-inflammatoryedications that impair incision wound healing. However,ostoperative pain and recovery could also be improved byhis approach.10,14,29,30 In addition, the risk associated withort placement and incidence of incisional hernia may beeduced with the use of single access.30,40,41 Tsimoyiannis et

al42 demonstrated a significantly lower postoperative analge-sic requirement comparing the single-incision laparoscopicwith the conventional laparoscopic patients.

There are drawbacks to SILS. In a review made by Pfluke etal,29 operative time was significantly longer in the single-incision group compared with the conventional group. Thecost for SILS did not differ significantly from that for conven-tional laparoscopy when standard materials were used andthe duration of the procedure was considered. Convertedcases were significantly more expensive than completed SILSand laparoscopic colectomy (LC) cases.43,44

Currently, there are no data related to prospective ran-domized trials comparing single-incision laparoscopy withconventional laparoscopy, and little data about posthospital-ization outcomes and benefits over existing techniques. Con-sidering this, it is difficult to recommend widespread imple-mentation of this technology, but we have to remember thatin the beginning of conventional laparoscopic surgery, cos-metic result was the only benefit conferred.

SILS colectomy, as opposed to laparoscopic colectomy,can be harder to teach, especially to residents who have notmastered the use of both hands simultaneously. Only 1 per-son can work at a time during a SILS case. It is an ergonomicchallenge to get the camera person and the surgeon posi-tioned so the case can proceed. Despite these challenges, itstill represents an emerging platform with potential advan-tages in appropriately selected patients.

ConclusionsIn conclusion, single-incision colorectal surgery seems to besafe and feasible. When applying this technique for majorcolorectal surgery, experienced hands are typically necessaryto provide optimal outcomes. Despite the reported successes,

limited data are available outside of case series. More trials are

Single-port laparoscopy 27

needed to demonstrate the benefits over conventional lapa-roscopic surgery. Only time will tell if this is more of a “mar-ket-driven” procedure or if it represents a true advancementin the surgical care of colorectal patients.

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