Applying single-incision laparoscopic surgery to gyn practice: What’s involved

The benefits of minimally invasive surgery—including less pain, faster recovery, and improved cosmesis—are well known.^1,2 Standard laparotomy has been replaced by multiple-port operative laparoscopy for a great array of procedures, and advances in medical technology allow for a minimally invasive surgical approach even when a surgeon is faced with complex pathology.

Single-port laparoscopic surgery (SPLS) represents the latest advance in minimally invasive surgery. Using flexible endoscopes and articulating instruments, the surgeon can complete complex procedures through a single 2-cm incision in the abdomen. The incision is usually placed in the umbilicus, where it is easily hidden.^3-8

Since the first laparoscopic hysterectomy through a single incision was performed 20 years ago, SPLS has been used successfully to perform nephrectomy, prostatectomy, hemicolectomy, cholecystectomy, splenectomy, intussusception reduction, gastrostomy tube placement, thoracoscopic lung biopsy, thoracoscopic decortication, and appendectomy.^4-7

In gynecology, SPLS has been used to perform oophorectomy, salpingectomy, bilateral tubal ligation, ovarian cystectomy, surgical treatment of ectopic pregnancy, and both total and partial hysterectomy.^7-11 At least two recent studies have concluded that SPLS is an acceptable way to treat many benign and malignant gynecologic conditions that are currently treated using multiport laparoscopy.^3,11

This article outlines our approach to SPLS in the gynecologic patient and provides an overview of instrumentation, with the aim of allowing you to consider whether this approach might be feasible in your surgical practice, at your institution.

Unique setup required

When SPLS is performed through the umbilicus, the instruments must be held closer to the midline and more cephalad than during conventional laparoscopy to permit adequate visualization and manipulation. For this reason, the surgeon needs to assume a position higher over the torso and thorax of the patient, and both of the patient’s arms need to be tucked. Place the patient in a dorsal lithotomy position with a uterine manipulator in place to facilitate surgery—even when the uterus will be preserved and surgery involves only the adnexae.

With appropriate equipment and positioning, visualization and manipulation of anatomy are comparable to those of standard multiport laparoscopy.

New instruments simplify SPLS

Innovative surgical instruments allow for appropriate hand positioning outside the abdomen and minimize the internal collision of instruments brought through a single midline incision (FIGURE 1). A variety of single-port options are available, each with a unique patented design and method of insertion. In fact, the development of ports with multiple instrument channels has revolutionized SPLS.

FIGURE 1 Setup
Desired triangulation of instruments in SPLS setup.Before true single ports became available, it was necessary to place three 5-mm low-profile trocars in the fascia at three separate sites through a single skin incision. Pneumoperitoneum was established with a Veress needle, but the fascial incisions gradually merged with repeated cannula manipulation, producing air leaks.

Today, multiple-channel ports are placed using an open technique into a single skin and fascial incision. Trocars and instruments of varying size can be exchanged with ease without jeopardizing pneumoperitoneum.

Among the options:

• the SILS Port (Covidien) – a soft, flexible, three-channel port that allows for placement of blunt trocars ranging in size from 5 mm to 12 mm (FIGURE 2)
• the TriPort (Olympus America) – two flexible rings joined by a sleeve and multiple-channel port (FIGURE 3)
• GelPOINT Advanced Access Platform (Applied Medical) – a system constructed of synthetic gel material and consisting of a “GelSeal” cap, cannulas, and seals to accommodate 5-mm to 10-mm instrumentation (FIGURE 4).

We have found that all three devices allow for good range of motion while maintaining pneumoperitoneum.

(A recent article from Korea reports an inventive technique to perform single-incision laparoscopy using standard instrumentation: The authors fitted a self-retaining ring retractor with a surgical glove that had three of the fingers cut off and replaced by trocars.¹²)

FIGURE 2 SILS Port
The SILS Port is a soft, flexible, three-channel port that allows for placement of blunt trocars ranging in size from 5 mm to 12 mm.

FIGURE 3 TriPort
The TriPort system comprises two flexible rings joined by a sleeve and multiple-channel port.

FIGURE 4 GelPOINT
The GelPOINT Advanced Access Platform is constructed of synthetic gel material and accommodates 5-mm to 10-mm instrumentation.

A flexible laparoscope improves visualization

The ability to visualize the operative field is vital to any surgery, including SPLS. Use of a flexible laparoscope facilitates uncompromised visualization of the entire pelvis (FIGURE 5). Outside the abdomen, the flexible camera can be held laterally and away from the midline to help reduce the clashing of instruments and hands.