Single-Port Laparoscopic Surgery in Gynecology B Ramesh, Madhuri Vidyashankar, Pooja Sharma Dimri
Chapter Notes

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1Basic Principles, Instruments and Techniques
Section Outline
Evolution of Laparoendoscopic Single-Site Surgery in Gynecology
Indications of Laparoendoscopic Single-Site Surgery
Abdominal Access in Laparoendoscopic Single-Site Surgery
Instruments and Ports
Optics for Laparoendoscopic Single-Site Surgery
Suturing Techniques in Laparoendoscopic Single-Site Surgery
Specimen Retrieval
Benefits of Laparoendoscopic Single-Site Surgery
Technical Challenges and Limitations of Laparoendoscopic Single-Site Surgery
Skill Training

Evolution of Laparoendoscopic Single-Site Surgery in GynecologyCHAPTER 1

“It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.”
—Charles Darwin
The last two decades has shown rapid advances in the field of surgery. The trend has been to make the surgery more minimally invasive. Laparoscopic surgery has many benefits for the patient, i.e. reduced size of the incision, resulting in less pain and wound complications with reduced hospitalization, faster recovery and better cosmesis. Further enhance these benefits; the concept of surgery through a single incision access was developed.
Two recent innovations, which have been developed are:
  1. Laparoendoscopic single-site surgery (LESS) or single-port laparoscopic surgeries through the umbilicus as the single access site. The concealment of the scar within the umbilicus, which is a natural cicarix makes the surgery virtually scarless. This approach has also been described as embryonic natural orifice transumbilical endoscopic surgery (E-NOTES).
  2. Natural orifice transluminal endoscopic surgery (NOTES), whereby intraperitoneal access is gained through the mouth, anus, vagina or urethra and the viscus-of-entry is perforated to reach the surgical target tissue.1
Single-port laparoscopic surgeries are being developed as an alternative to conventional multiport laparoscopy to enhance the benefits to patient following the same surgical principles. Now, more and more gynecological procedures are being performed by single-port laparoscopy successfully. It currently stands between standard laparoscopy and NOTES in the armamentarium of minimal access surgery.2 As this field is poised to move forward, a complete understanding of its evolution and nomenclature is essential.
Many surgical specialties like general surgery, urology and bariatric surgery are using single-port in various procedures.1,35 In gynecology, single-port surgery was performed as early as 1969, which was laparoscopic tubal ligation was described by Wheeless.6 That may be described as the earliest use of single incision surgery in gynecology. Many gynecologists later performed laparoscopic tubal ligation through a single incision. Pelosi and Pelosi described the first report of a single-port hysterectomy with bilateral salpingo-oophorectomy in 1991.7
Single-incision Laparoscopic Tubal Ligation
Clifford Wheeless was the first one to establish single-incision laparoscopic technique in gynecology.6 This was done in the outpatient department with local anesthesia and sedation. A laparoscope with an offset eyepiece was inserted after insufflation through a 1-cm infraumbilical incision. Uterine manipulation was done through the vagina. The fallopian tubes were grasped and cauterized using biopsy forceps. Later he published a series of 3600 cases with this method.18 This technique was adopted by many gynecologists for laparoscopic tubal ligation. In another method an operative laparoscope with an inbuilt side channel (single-puncture LAPAROCATOR) is used. A ring applicator is inserted through side channel of the laparoscope and is used to apply fallope rings. This ring applicator has prongs to catch the tube. As the applicator is pulled, a loop of tube is made and the ring is applied.4
Table 1   Single-port laparoscopic surgeries in gynecology—initial reports
Tubal ligation
Outpatient procedure with sedation
Hysterectomy with BSO
Pelosi et al7
Through operative laparoscope with standard instruments
Supracervical hysterectomy with BSO
Pelosi et al8
Coined the term ‘minilaparoscopy’
Ovarian cystectomy
Kosumi et al9
First report of LESS ovarian cystectomy in an infant
Ghezzi et al10
For ectopic pregnancy
Robotic assisted LESS
Escobar et al11
Reduced difficulty of lack of triangulation and instrument collision
Sacral colpopexy with mesh
White et al12
Initial results comparable to other approaches
Gynecologic oncology
Fader et al13
LESS in selected cases of malignancies
Combined hysterectomy with BSO with appendicectomy
Concurrent gynecologic and surgical procedure
Combined hysterectomy with cholecystectomy
Hart et al15
Concurrent gynecologic and surgical procedure
Pelvic and para-aortic lymphadenectomy
Escobar et al16
To determine feasibility of LESS in oncology
Endometrial cancer
Fanfani et al17
Extrafascial LESS hysterectomy in early endometrial cancer
Hysterectomy, Supracervical Hysterectomy with Adnexectomy
Pelosi et al performed the first hysterectomy procedure with single-puncture technique way back in 1991.7 In 1992, a single-puncture technique was used for supracervical hysterectomy and termed as ‘minilaparoscopy’ by them.8 Standard laparoscopic instruments were inserted through the side channel of an operative laparoscope with offset eyepiece with transvaginal uterine manipulation. The advantages of the procedure as described by the authors were simplicity, lower cost, decreased trocar-site-related complications, improved cosmesis and ability to convert to standard laparoscopy or open surgery when required. Later single-port hysterectomy and laparoscopic-assisted vaginal hysterectomy was described using specialized multichannel access ports.19,20 Recently, single-port laparoscopic total and assisted vaginal hysterectomy has been compared to hysterectomy by conventional multiport laparoscopy.21,22
Adnexal Procedures
The first single-port ovarian cystectomy in an infant aged 2 months was reported in 2001 by Kosumi et al.9 In this, through a single 10-mm umbilical trocar through the working channel of a Wolf cerebral endoscope (Panoview telescope, Richard Wolf, Knittlingen, Germany) the 6 mm cyst was grasped and delivered to the umbilical incision where the cyst was aspirated and enucleated. Single-port laparoscopic salpingectomy for ectopic pregnancy through a single umbilical trocar was reported in 2005 in 10 cases.10 This was described as ‘marionette-like’ technique. A midline percutaneous sling suture was placed through the affected tube, suspending the fallopian tube and obviating the need for a second trocar. Other case series for LESS in benign adnexal masses are described.23,24
Other Procedures
Laparoendoscopic single-site surgery is now being used in pelvic reconstructive procedures like sacral colpopexy and in gynecological procedures with concurrent surgical procedures like cholecystectomy and appendectomy. Now single-port surgeries have even been tried for oncological procures for early malignancies with encouraging results.5
Single-port laparoscopic surgeries have been continually evolving over the last few years with lot of general surgical, urologic, gynecologic and bariatric surgeries being done with this approach. There has, but been a lot of confusion about the nomenclature and terminology associated with single incision access. Individuals and organizations have floated various names to represent this technique (Table 1).
One of the more commonly used names is single-incision laparoscopic surgery (SILS), trademarked by Covidien, Inc. Ethicon EndoSurgery, Inc proposed the name single-site laparoscopy (SSL). Drexel University has also trademarked its own name, calling this technique single-port access (SPA).25,26 Similarities to NOTES have led to names like natural orifice transumbilical surgery (NOTUS)27 and Embryonic NOTES (E-NOTES)28,29 denoting the umbilicus as a natural orifice. Other names have also revolved around the umbilical access such as Transumbilical endoscopic surgery (TUES),30 advocated by the Chinese laparoscopic community and one-port umbilical surgery (OPUS).31 This led to a need for a consensus on the nomenclature a single incision access laparoscopic surgery. This standardization was essential so that the scientific communication and literature becomes clear and unambiguous. Also, there was a need for a scientific group to represent these procedures for logical development and growth of the entity as was done for NOTES (natural orifice transluminal endoscopic surgery) by NOSCAR (Natural orifice surgery consortium for assessment and research).
In view of the need to standardize and streamline single incision access laparoscopic surgeries, in July 2008, a multidisciplinary consortium of 28 experts from United States and around the world was convened (The laparoendoscopic single-site surgery consortium for assessment and research (LESSCAR) in Cleveland, Ohio. The purpose was to formulate an international multidisciplinary ad-hoc organization to advance the field of laparoendoscopic single-site (LESS) surgery and to establish nomenclature for single-incision laparoscopic surgery,32,33 which could be widely accepted. The experts from various surgical specialties of urology, gynecology, bariatric, general and colorectal surgery—focused on charting a course forward regarding innovations in surgical techniques, instrumentation, technology, collection of data and collaboration with other societies with standardization.
1. LESSCAR Terminology
For selection of a consensus terminology for this minimally invasive approach, LESSCAR reviewed an exhaustive list of more than 20 existing names for single-port surgery that had appeared in the literature.
Table 1   Nomenclature for single-port laparoscopic surgeries
Single-site laparoscopy
Single-port laparoscopic surgery
Single-incision laparoscopic surgery
SPA surgery
Embryonic natural orifice transumbilical surgery
Natural orifice transumbilical surgery
One port umbilical surgery
Transumbilical endoscopic surgery
Transumbilical laparoscopic assisted surgery
Single laparoscopic incision transabdominal surgery
Single-site-access laparoscopic surgery
Laparoendoscopic single-site surgery
The consortium concluded that laparoendoscopic single-site surgery (LESS) is the term most suitable to describe accurately the philosophical and practical aspects of the field. The consortium selected the name to indicate and encompass the following broad criteria.32,33
  1. Single-entry portal.
  2. Location: abdomen, pelvis, thorax.
  3. Laparoscopic, endoscopic or robotic surgery.
  4. Umbilical or extra-umbilical.
  5. Extraluminal or transluminal (percutaneous single-portal access) surgery.
  6. Have a broad reach so as to be inclusive, not exclusive.
2. Technical Clinical Issues
Initial work in LESS was with the use of instruments, which were used in conventional multiport laparoscopy. Use of conventional instruments pose technical challenges for LESS surgeons like loss of triangulation, instrument collision or sword fighting and reduce operative working space. It may be possible to do the simpler procedures with the same instruments with some effort, but limits the successful completion of more complex procedures.
The need was felt for the development of instrumentation and techniques specific to LESS. To make this possible, LESSCAR will seek to identify advantages, disadvantages, proposed modifications and ideal designs of single-port instrumentation and platforms.
3. Skills Training
LESSCAR is not involved in certification, licensing, credentialing or granting of formal approvals for surgeons to perform LESS procedures. This responsibility rests with individual surgeons and their institutions. It is recommended that only those laparoscopic surgeons who are reasonably trained in conventional laparoscopy and have undergone LESS training should perform LESS procedures.
4. Web-based Secure database Registry
It was proposed that all clinical LESS cases would be entered prospectively into an international database open to all LESSCAR members and associated organizations, which will ensure necessary checks and data accuracy32.
5. Collaboration with other Surgical Societies
LESSCAR will seek to coordinate and collaborate with various established professional surgical societies for research and development in the field of LESS.32
The era of minimally invasive surgery has witnessed the evolution of single-port access laparoscopy. This evolution includes innovation in terms of surgical technique and skill, optics and instrumentation. Therefore, it is important to emphasize in the beginning that surgerons who are adequately trained in multiport lasproscopy should venture into LESS. Unless one is familiar with all tenets of multiport laparoscopy, it would be nearly impossible to perform laparoendoscopic single-site surgery. The reader should note that the accepted nomenclature for this approach is laparoendoscopic single-site surgery or LESS, but since most of the people are familiar with the term single-port surgery, the title of the book was chosen as ‘Single-port Surgery in Gynecology’.7
The use of single incision to perform laparoscopic tubal ligation, laparoendoscopic single-site surgery (LESS) has come a long way. Innovation in technique and instrumentation and scientific research would play a defining role in further evolution and development of this minimally invasive approach.
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  1. Kaouk JH, Goel RK. Single-port laparoscopic and robotic partial nephrectomy. Eur Urol. 2009;55:1163–169.
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  1. Wheeless CR Jr A rapid, inexpensive and effective method of surgical sterilization by laparoscopy J Reprod Med. 1969. 3:65–69.
  1. Pelosi MA, Pelosi MA 3rd Laparoscopic hysterectomy with bilateral salpingo-oophorectomy using a single umbilical puncture N J Med. 1991;88(10):721–26.
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  1. Kosumi T, Kubota A, Usui N, et al. Laparoscopic ovarian cystectomy using a single umbilical puncture method. Surg Laparosc Endosc Percutan. Tech-2001;11:63–5.
  1. Ghezzi F, Cromi A, Fasola M, et al. One-trocar salpingectomy for the treatment of tubal pregnancy: a ‘marionette-like’ technique. BJOG. 2005;112:1417–9.
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  1. Escobar PF, Fader AN, Rasool N, et al. Single-port laparoscopic pelvic and para-aortic lymph node sampling or lymphadenectomy: development of a technique and instrumentation. Int J Gynecol Cancer. 2010 Oct; 20(7): 1268–73.
  1. Fanfani F, Rossitto C, Gagliardi ML, Gallotta V, et al. Total laparoendoscopic single-site surgery (LESS) hysterectomy in low-risk early endometrial cancer: a pilot study. Surg Endosc. 2012 Jan; 26(1): 41–6.

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