46 Principles of single site laparoscopy

Abstract

The objective of this video is to display the adaptation of laparoscopic principles for single site surgery. The primary challenges with single site laparoscopy include lack of multiple trocars to facilitate triangulation and restricted instrument movement. In laparoscopic surgery, depth perception must be achieved with the aid of monocular cues. In traditional laparoscopy, a multiport configuration facilitates triangulation. The surgeon maintains a visual angle of >30 degrees between the camera and the tip of the operating instruments. In single site laparoscopy, because both instruments are parallel on entry into the abdomen, this monocular cue is diminished. To mitigate this, the camera is positioned as lateral as possible to the instruments. If both instruments are positioned at an optimal angle to the camera, they will be parallel to each other. This can lead to frequent intracorporeal collision. The two instruments should be maintained in different vertical planes. Another strategy is to use one instrument in a dynamic fashion while the other provides counter-traction. The limited workspace afforded by single site laparoscopy can result in frequent extracorporeal instrument collision as well. To minimize this, the surgeon can modify instrument handgrip by rotating the instrument handles 90 degrees. This hand positioning allows for the most freedom of movement. Slow deliberate movements increase surgical efficiency. Limit instrument exchanges to facilitate orientation within the visual field. A 30-degree scope assists with optimal visualization. Use of a uterine manipulator facilitates more complex procedures like ovarian cystectomy, excision of endometriosis, and hysterectomy. Single site laparoscopy does have inherent challenges, but these can be managed by facilitating triangulation, avoiding instrument collision, and adapting general laparoscopic principles.