Editorial Comment on: Transumbilical Single-Port Surgery: Evolution and Current Status

Abstract

Canes and colleagues focus our attention on a further modification of laparoscopic surgery: the transumbilical single-port surgery [1]. Their historical overview demonstrates clearly that this is an old technique pioneered by gynecologists in the 1960s using an operative laparoscope with an offset eyepiece comparable to the rigid nephroscopes used during percutaneous renal surgery [2,3]. However, in the year 2008, it seems that things have to be more fancy. Whereas laparoscopists initially used the umbilicus as an easy-to-hide entrance for the trocar, in the era of natural orifice transluminal endoscopic surgery (NOTES), the umbilicus has gained more importance, being recognized as an ‘‘embryonic natural orifice.’’ This has resulted in the new term ‘‘E-NOTES.’’ But the reader should be aware of the distinct differences between NOTES and the transumbilical laparoscopic single port technique. NOTES has been pioneered by gastroenterologists and surgeons who used the technology of a flexible gastroscope with different working channels to perforate the stomach and then to reach the peritoneal cavity. In the peritoneal cavity, complex procedures such as appendectomy and cholecystectomy have been carried out using specialized flexible endoscopes and devices (ie, intraluminal clip appliers). After transoral removal of the organ, the gastric wall was closed with intraluminal suturing techniques [4]. Single-port surgery is completely different and goes back to the operative resectoscope developed by Buess in the 1980s for transanal endoscopic microsurgery [5]. This device consists of a rectoscope 40 mm in diameter with up to five ports for insertion of the telescope and curved instruments. The principle of this device has been modified for transumbilical laparoscopy with three ports for insertion of a rigid or flexible telescope and flexible or bent instruments. Although the necessity and importance of an operative nephroscope, a complex gastroor coloscope, and an operative resectoscope has been proven over decades for intraluminal surgery, the role of such devices for transluminal and laparoscopic surgery remains uncertain. It is impressive to see what type of laparoscopic procedures have been carried out, but in my view, there is still no argument for not using the standard trocar technique, which provides efficient solutions to the main problems of E-NOTES, such as triangulation, retraction, instrument crowding, and in-line vision. However, endoscopic surgey will definitely benefit from the technological input (ie, flexible instruments, staplers) of these ‘‘new old’’ techniques.