Surgical Science, 2012, 3, 503-505 Published Online October 2012 (
Single Incision Laparoscopic Surgery—An Overview
and Current Status
Amit Goel
Army College of Medical Sciences, New Delhi, India
Received August 15, 2012; revised September 30, 2012; accepted October 9, 2012
Single incision laproscopic surgery is an alternative to conventional multiport laproscopy. Natural orifice transluminal
endoscopic surgery term coined by a Consortium in 2005 remains a research technique with few clinical cases. Single
incision surgery offers advantage of better cosmesis, reduced incisions, lesser hernias, decreased pain and infections.
Long learning curves and cost of instrumentation are the difficulties encountered in its propagation. Single incision la-
proscopic surgery is an evolving technique for advanced laproscopic centers. This article outlines the overview of de-
vices and instruments and the techniques, feasibility of single in cision laproscopic surgery.
Keywords: Notes; Sils; Ports; Endoscopy; Laparoscopy
1. Introduction
Conventional multiport minimal access surgery has been
established as gold standard for many abdominal surgical
procedures. In its endeavor to reduce scarring and trauma,
surgeon and instrument industry combined their ingenuity
to promote two new approaches for laparoscopic surgery,
Natural orifice transluminal endoscopic surgery (NOTES)
and Single incision laparoscopic surgery. NOTES leaves
no scar but requires entry into peritoneal cavity with use
of flexible endoscopes by perforation of a hollow viscus
the stomach, oesophagus, colon and bladder whereas
SILS requires a single port of entry with multiple articu-
lating instruments introduced through that port with op-
tics to perform various abdominal procedures which were
earlier performed by multiple ports in conventional la-
proscopic surg ery.
2. Material and Methods
It requires various types of endoscopes, instrumentation
and techniques. Single incision laparoscopic surgery
performs these procedures as multiport through one inci-
sion at umbilicus. A vast variety of hand instruments
have evolved which are curved, coaxial and articulating
having greater degree of freedom. NOTES interventions
can be classified as “hollow visceral transperitoneal”
which may be transgastric, transoesophageal, transcolo-
nic, transvesical access to peritoneal cavity by planned
perforation of a hollow viscus. The second approach
“squamous conduit intraperitoneal” is transvaginal or a
transanal-direct access to the peritoneal cavity. Hollow
visceral transperitoneal requires interventional flexible
technologies. Squamous conduit intraperitoneal is per-
formed with existing laparoscopic instrumentation with
rigid optics. Concept of SILS is attributed to Dr. Raimund
Wittmoser, the father of modern thoracoscopic surgery.
Many instrument companies have produced single in-
cision laparoscopic surgery port. Vast majority of these
are disposable with exception of two reusable SILS ports
and ENDOCONE designed and developed at Institute of
medical science and technology in Dundee in association
with Storz. ENDOCONE has a detachable bulk which
contains six lateral valved inlets that allow the insertion
of large instruments including staplers. The surgeon is
able to use three instruments and an optic at any one time
during the course of operation. The instrumentation for
SILS has improved with development of proximally de-
viated curved coaxial articulating instruments. Intracor-
poreal suturing is greatly facilitated with introduction of
5 mm hand held surgical manipulators with six degree of
freedom. SILS procedure has been used for wide range
of laparoscopic operations like colorectal resections,
bariatric operations, nephrectomies, cholecystectomy and
3. Discussion
The first description of procedure to be known as natural
orifice transluminal endoscopic surgery is credited to
Kallo et al. in 2000 where they demonstrated the feasibil-
ity of peroral transgastric endoscopic approach to perito-
neal cavity [1]. Gettman and colleagues in 2002 reported
opyright © 2012 SciRes. SS
series of transvaginal porcine nephrectomies [2]. Rao and
Reddy reported the f irst human cases of NOTES in 2004
with transgastric appendicectomy [3]. In July 2005, there
was meeting of American Society of Gastrointestinal
Endoscopy (ASGE) and Society of American Gastroin-
testinal and Endoscopic Surgeons. The deliberations of
this group called Natural Orifice Surg ery Consortium for
Assessment and Research (NOSCAR group) was pub-
lished as a white paper of ASGE/SAGES group on
NOTES [4]. Pure NOTES is that which is only per-
formed through natural orifices like transgastric, transe-
sophageal, transcolonic and transvescical routes. NO-
SCAR group emphasized the need for institutional re-
view for doing any human cases. Rend evous NOTES has
been used to describe an approach where more than one
portal of entry is used [5]. Robotic NOTES is new de-
velopment using Da Vinci surgical robot (INTUITIVE
SURGICAL, SUNNYVALE, CA) in animals to perform
reconstructive surgery [6].
Gastrointestinal endoscopists are most familiar with
transgastric route. The primary difficulty is tedious ori-
entation after retroflexing the scope for cholecystectomy
and upper abdominal procedures [7]. Vaginal routes have
had most success as closure of vagina is easy and possi-
ble with rigid laproscopic instruments. The act of causing
perforation to viscus may be detrimental if closure of the
hollow viscus is insecure.
Single incision laproscopic surgery for cholecystec-
tomy was described by Navarre et al. in 1997 and later
Piskin et al. in 1999 [8]. The first cases of single port
access device in form of prototype of R-Port was done by
Rao et al. and reported to world congress endourology in
2007 [9]. The R-Port was single gel interphase th at could
be perforated to get the instruments inside the abdomen.
This led to development of triports and quad ports avail-
able today. The articulating instruments could be intro-
duced through these ports for better angulation and tri-
angulation. A multidisciplinary consortium of surgeons
met at Cleveland clinic in July 2008 suggested stan-
dardization for reporting these surgeries [10]. Since the
introduction of single port access in 2007 hundreds of
cases have been performed. The only randomized study
conducted between SILS and laparoscopic surgery showed
improvement in pain scales in SILS [11].
The Vinci robot system has been used with some suc-
cess in single incision laproscopic surgery enabling three
dimensional visualization thereby reducing the technical
challenges posed by single site surgery [12].
Large series of SILS had been report ed by R e was et al.
in 2009 comprising of hundred cases with conversion in
13% and no complication using SILS port [13]. White in
2009 published 6% conversion and 4% complications in
his series of 100 cases [14]. Er bella in 2010 reported 100
cases with 2% conversion using similar technique [15].
Curcillo in 2010, had a conversion rate of 8.7% in 297
cases [16]. Antonio et al. reported a meta-analysis of 29
studies of 1166 patients undergoing SILS for cholecys-
tectomy with conversion in 0.4% cases [17].
Only 3 SILS laproscopic colorectal surgeries have been
reported. Leroy et al. reported SILS colorectal surgery
with no conversions [18]. Larger series of SILS spleenec-
tomy has been published by Targorona et al. In his series
of 8 cases, conversion was required in 2 cases, the blood
loss was <100 ml and the spleen weight < 500 g. It offered
better cosmesis, fewer complications, enhanced patient
recovery but evidence was scarce [19].
Lee et al. described single port access laproscopic as-
sisted vaginal hysterectomy in 4 cases and concluded that
it was safe and effective [20]. Langebrekke and Ovistad
described total laproscopic hysterectomy through single
port as a better cosmetic alternative to conventional la-
proscopi c hysterect omy [21].
4. Conclusion
Single port surgery has left its mark in Minimal Access
Surgery. All initial studies showed it to be feasible, rea-
sonably safe and cosmetically better than standard lapro-
scopy. Experienced laproscopic skills are needed to ac-
complish safe single port surgery. The cost factor of the
access devices and instrumentation is significantly more.
Even with the best SILS instrumentation currently avail-
able the SILS approach imposes restriction on instrument
manipulation, retraction and limits triangulation. It re-
quires training and should be practiced in centers per-
forming advanced laproscopic surgery. The advantages
of single access surgery are better cosmesis, less bleeding,
reduced infection and herniations. The existing evidence
suggests that SILS is similar to standard laparoscopic
surgery in terms of complication rates, completion rates
and post-operative pain scores. Sils procedure has better
cosmesis and decreased pain but cost is a limiting factor.
Sils procedure should be practiced at advanced laparo-
scopic and minimal access centres and requires training
for surgeon and proper instrumentation.
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