Most of the literature for minilaparoscopy, however, has evolved from the nongynecologic specialties, particularly general surgery. It has been well documented that minilaparoscopy is safe for splenic and liver biopsies, as well as helpful in reducing port sizes and hernias when utilized in cholecystectomies and colorectal resections.
Most recently, the authors of a literature review spanning the last 30 years concluded that minilaparoscopy has been shown in almost all urologic indications to be feasible and safe, with better cosmetic results and reduced postoperative pain (Arch. Esp. Urol. 2012;65:366-83).
Collectively, these studies provide us with a solid body of evidence on the safety, feasibility, and benefits of minilaparoscopy. The findings noted in the surgical literature for minilaparoscopy include operative times, morbidity, and hospital lengths of stay that are comparable to those of conventional laparoscopy; improved cosmesis; a decrease in postoperative pain; and reductions in port-site complications such as bleeding, infection, and herniation.
Surpassing SIL
Single-incision laparoscopy (also known as "scarless" surgery, with the umbilicus viewed as a natural scar) was developed to improve cosmesis. An incision approximately 25 mm in size at the umbilicus allows a scope and two or three instruments to pass into the abdominal cavity.
A main challenge – and a limitation for many surgeons – is the lack of triangulation because of the parallel entry. Instruments are crossed, which is counterintuitive to conventional laparoscopic training, and hands and instruments can clash, which limits the use of instrumentation.
An array of curved and EndoWrist instruments (with flexible joints at the tips) was developed to help ease the technical difficulties of single-port surgery. Many advanced endoscopic surgeons have performed simple to complex single-incision procedures with low complication rates and with operative times and rates of blood loss that are comparable with those of conventional laparoscopy. One advantage to single-incision surgery is that the incision size allows the removal of larger tissue that has been resected from the abdomen.
A recent study in the Netherlands suggests that single-incision surgery may not be all that more difficult to learn (Surg. Endosc. 2012;26:1231-7). The simulation study looked at the performance/learning curves of 20 medical interns (none with laparoscopic experience) who were randomly assigned to perform single-incision or conventional laparoscopy. Each participant practiced each task 11 times. There were no significant differences between the two groups in terms of error or time in performing the tasks, and participants improved significantly in both laparoscopy settings.
There are still many concerns, however, that single-incision laparoscopy is indeed more technically challenging, and that a sizable learning curve for the single-incision approach –in addition to the learning curve of conventional laparoscopy – does exist. Without surgical volume and patience, this technique may be a struggle for many to adapt and teach.
Moreover, as shown in the study at Newton-Wellesley Hospital, the scars remain a concern for many women. The umbilicus is the easiest place to try to "hide" an incision and scar when the incision is made at its base, but a 2-1/2 cm incision can be difficult to hide in a shallow umbilicus; for some women, the larger single scar becomes a focal point of their abdomen and, thus, disfiguring.