Multichannel Single Port Research Articles

Single-port retroperitoneoscopic partial nephrectomy: Initial description and standardisation of technique.

Minimally invasive surgery has been established as the gold standard for the treatment of localised renal tumours. A retroperitoneal approach is a feasible option with advantages in posterior tumours and patients with previous abdominal surgeries. In this context, single-port retroperitoneoscopic partial nephrectomy (SPOR-PN) has not been widely explored and developed. We present this technique's description and our first results. We present a case series of nine patients undergoing SPOR-PN in a single institution. We used a multi-channel single-port access dispositive through a 35 mm incision below the 12th rib, a 30° two-dimensional laparoscope, curved graspers and needle drivers on the left hand and standard rigid material in the right hand. In all surgeries, we performed a complete renorrhaphy with the sliding-clip technique. The pain was evaluated through visual analogue scale (VAS) the day after surgery. Patients' age ranged from 44 to 78 years. The median RENAL score was 5p, and the mean surgical time was 134 min. We performed an 'off-clamp' procedure on three patients. Among the patients who had renal artery clamped, the median ischaemia time was 18 min. The median in-hospital stay time was 48 h. Median VAS the day after surgery was 2. None of the anatomical pieces had positive borders. Only one complication was reported (Clavien IIIa). SPOR-PN is a feasible minimally invasive and nephron-sparing technique. The advantages of this procedure may not be only a better cosmetic appearance but also less post-operative pain. Further development and larger studies are needed.

Single-Port Video-Assisted Thyroidectomy via Anterior Cervical Approach

Introduction: Conventional open thyroid surgery has been the standard approach for thyroidectomy and normally requires a long incision of 4 to 8 cm.1 The aim of this video is to describe single-port video-assisted thyroidectomy through anterior cervical approach (also called Huang procedure). Materials and Methods: This video presentation illustrates the technical points of the Huang procedure, which I developed in February 2021. Besides general introduction of the Huang procedure, a case of this procedure is presented in detail. A 36-year-old female patient with a body mass index of 24.6 had a solid nodule of about 1.5 cm in the right lobe, cytologically suspicious for a follicular neoplasm (Bethesda category IV). She underwent right thyroid lobectomy. The patient was positioned supine with neck mildly extended. A mini-incision ~3.0 cm long at about two finger breadths above the sternal notch on the anterior neck was made, and a working space under the strap muscles was created with a single multichannel port and CO2 insufflation. Under endoscopy the superior and inferior poles were dissected with laparoscopic instruments and the recurrent laryngeal nerve was exposed. Then the thyroid lobe was delivered out of the wound, and finally the thyroid lobectomy was completed under direct vision. Postoperative pathology report confirmed a follicular tumor of uncertain malignant potential. The patient recovered well with no complication. She was satisfied with the cosmetic result of the incision at the follow-up 2 months after operation. Results: The technical aspect of the Huang procedure with a step-by-step description is demonstrated in this video. The Huang procedure is able to provide shorter incision and better cosmetic results while maintaining adequate exposure. Conclusions: Thyroidectomy can be done by the Huang procedure with a mini-incision to obtain minimally invasive and cosmetic effects. No competing financial interests exist. Author has received and archived patient consent for video recording/publication in advance of video recording of procedure. Runtime of video: 10 mins 43 secs

A retrospective multicenter study on evaluation of perioperative outcomes of single port robotic cholecystectomy comparing the Xi and SP version of da Vinci Robotic Surgical System

Single-incision-robotic cholecystectomy (SIRC) using the da Vinci Xi system (Xi) (Intuitive, Sunnyvale, CA, USA) is a safe and effective operation. Recently, the da Vinci SP system (SP) (Intuitive) which is a new platform specialized for single-port surgery has been released. The study aimed to compare perioperative outcomes of Xi and SP in regards to SIRC. In this multicenter retrospective cohort study, patients who underwent SIRC with benign gallbladder disease between 2019 and 2020 were enrolled. In Seoul National University Hospital, Xi was used with 3 separate arms of instruments inserted through the single incision made in umbilical area. In Ewha Womans University Seoul Hospital, SP was used with single multi-channel port through the umbilical incision. Patient's demographics, intraoperative factors, postoperative complications, and postoperative pain were investigated. 258 patients underwent SIRC with Xi, and 72 patients with SP. There were significant differences between Xi and SP groups in operation time at console (23.1 vs. 20.3 min, p = 0.018), numbers of postoperative analgesic injection (4.0 vs. 3.2, p < 0.001), NRS at day of operation (5.7 vs. 4.9, p < 0.001), but no difference in total operation time (43.4 vs. 45.9, p = 0.155) and postoperative complication (0.8% vs. 0.0%, p > 0.999). SP group showed more estimated blood loss (14.3 vs. 19.2 mL, p = 0.031). Although operation time at console was shorter and pain was less in SP group statistically, clinical benefit appears to be minimal. Both Xi and SP can be a safe and feasible platform to perform SIRC, but further investigation is needed as prospective study.

Early experience and the learning curve for robotic cholecystectomy using da Vinci SP

The cholecystectomy by da Vinci Xi is gradually increasing and this operation is proven to be a safe and effective operation. Furthermore single port robotic cholecystectomy (SIRC) is a newly attempted surgical procedure, and is rarely used worldwide. For this reason, early experience with SIRC with da Vinci SP is needed to be shared and discussed about the early results. This study is single center retrospective cohort study, total 72 patients underwent SIRC with benign gallbladder disease between 2019 and 2020. Da Vinci SP is used with single multi-channel port though the 2.5 cm sized umbilical skin incision, cholecystectomy is done using some SP devices like cadiere, Maryland forceps. Patient's demographics, operation time, and postoperative factors were analyzed in each 10 cases. There was no intra operative injury, early postoperative complication and un-expected hospital visit. The operation time involving preparation time and console time was gradually decreased, every 10 cases showed 37.5, 34.14, 35.9, 29.2, 28.4, 24.83, 20.12 in console time. Compared to the first 30 cases, the last 10 cases showed a significantly shorter time. Demographics, the estimated blood loss and postoperative factors like pain score, hospitalization showed no significant difference in each group. SIRC using da Vinci SP showed comparable outcome regarding intra-operative factors and postoperative complication, pain and hospitalization. SIRC using da Vinci SP is a surgery that easily develops, although it requires some training and time for beginners to achieve good results such as shortening the operation time.

Single-Incision Laparoscopic Sigmoidectomy With Boari Flap Construction for Advanced Colon Cancer With Ureteric Invasion: A Case Report

Urinary tract resection is the only procedure that can cure colorectal cancer that directly invades the ureter. In these cases, open surgery is commonly used. Here, we describe our experience of a case of sigmoidectomy following Boari flap construction with single-incision laparoscopic surgery (SILS) for advanced colon cancer with ureteric invasion. A 68-year-old woman was referred to our hospital with left flank pain. Left hydroureteronephrosis was detected on ultrasonography. Computed tomography revealed a solid mass in the sigmoid colon and hydroureteronephrosis due to swelling of a mesenteric lymph node. Computed tomography detected no signs of distant metastasis. Colonoscopy revealed an ulcerated, bleeding, and stricturing lesion in the sigmoid colon, which was identified as an adenocarcinoma with a moderate degree of differentiation at histological examination. Under general anesthesia, the patient was placed in the Trendelenburg semi-right lateral position. An umbilical incision was made for the insertion of a single multichannel port for SILS. Sigmoidectomy and Boari flap reconstruction were performed. There were no perioperative complications. The total operating time was 572 minutes (including Boari flap procedure of 174 minutes), and estimated blood loss was 200 mL. Single-incision laparoscopic sigmoidectomy with Boari flap construction is technically feasible with sigmoid cancer and ureteral invasion.

Single-Port Laparoscopic Interval Appendectomy for Perforated Appendicitis With a Periappendiceal Abscess.

PurposeNonoperative management followed by an interval appendectomy is a commonly used approach for treating patients with perforated appendicitis with abscess formation. As minimally-invasive surgery has developed, single-port laparoscopic surgery (SPLS) is increasingly being used to treat many conditions. We report our initial experience with this procedure using a multichannel single-port.MethodsThe study included 25 adults who underwent a single-port laparoscopic interval appendectomy for perforated appendicitis with periappendiceal abscess by using a single-port with or without needlescopic grasper between June 2014 and January 2016.ResultsOf the 25 patients, 9 (36%) required percutaneous drainage for a median of 7 days (5–14 days) after insertion, and 3 (12%) required conversion to reduced-port laparoscopic surgery with a 5-mm port insertion because of severe adhesions to adjacent organs. Of 22 patients undergoing SPLS, 13 underwent pure SPLS (52.0%) whereas 9 patients underwent SPLS with a 2-mm needle instrument (36.0%). Median operation time was 70 minutes (30–155 minutes), and a drainage tube was placed in 9 patients (36.0%). Median total length of incision was 2.5 cm (2.0–3.0 cm), and median time to soft diet initiation and length of stay in the hospital were 2 days (0–5 days) and 3 days (1–7 days), respectively. Two patients (8.0%) developed postoperative complications: 1 wound site bleeding and 1 surgical site infection.ConclusionConservative management followed by a single-port laparoscopic interval appendectomy using a multichannel single-port appears feasible and safe for treating patients with acute perforated appendicitis with periappendiceal abscess.

Minimally Invasive Interval Appendectomy for Perforated Appendicitis With a Periappendiceal Abscess.

See Article on Page 105-110 Acute appendicitis is the one of the most common conditions requiring surgical intervention, and an appendiceal abscess or phlegmon has an incidence rate of about 3.8% among patients with a perforated appendicitis [1]. An immediate appendectomy for the treatment of a periappendiceal abscess (PAA) or phlegmon is technically demanding with adhesive loops of the bowel and a distorted anatomy, and the appendiceal stump is difficult to close due to the presence inflamed tissues [2]. In actual practice, not infrequently, even an early laparoscopic surgery will be converted to a more extensive open surgical procedure, such as an ileocecal resection or a right hemicolectomy, due to technical problems or distorted anatomy [3]. In the management of perforated appendicitis with a well-defined abscess and an inflammatory phlegmon seen on an image study, an alternative treatment may be nonsurgical management, including intravenous antibiotics and selective percutaneous drainage. Currently, a treatment widely accepted among surgeons is initial nonoperative management followed by an interval appendectomy rather than an immediate appendectomy, but the management of the appendiceal mass remains a matter of major controversy in current practice. However, many surgeon still agree that an interval appendectomy is to be preferred because the risk for recurrent acute appendicitis is reported to be about 10% and because a definite diagnosis needs to be established to rule out any underlying malignancy [4,5]. The advantage of the interval appendectomy is that the operation is performed at a time when peritoneal contamination has been resolved, potentially resulting in fewer intraoperative and/or postoperative complications. Although this advantage has led to the widespread application of drainage/interval appendectomy, published data describing how these patients fare during the interval between percutaneous abscess drainage and minimally invasive surgery are rare. The superiority of an early laparoscopic appendectomy (LA) over an interval LA has been shown in some reports on patients with a well-formed abscess [6,7]. This pilot randomized trial found no major differences in outcomes when comparing an early LA with an interval LA [6]. In another randomized study on appendiceal phlegmon, Blakely et al. [7] concluded that, compared to an interval LA, an early LA significantly reduced the time away from normal activities and the rates of overall adverse events and had a conversion rate comparable to that of an open appendectomy. Schurman et al. [8] also reported that their patients managed with an interval LA were likely to suffer a more negative impact on their quality of life than those managed with an immediate LA. Based on these studies, the issue of whether an interval LA is superior to an early LA for the treatment of an appendiceal phlegmon remains a topic of debate. As experience with the single-incision technique grows, the role of immediate surgery in the treatment of patients presenting with an abscess deserves to be reconsidered. Conservative management followed by a single-incision laparoscopic interval appendectomy using a multichannel single port appears feasible and safe for the treatment of patients with acute perforated appendicitis with a PAA, as this study shows [9]. However, this study has several limitations, including its retrospective nature, small number of patients, and lack of data on surgical outcomes such as quality of life and pain or cosmesis for both single-port and multiport surgeries. Therefore, further large-scale comparative studies are needed to prove the advantages of this procedure by comparing the outcomes for initial nonoperative management followed by an interval appendectomy to the outcomes for an early laparoscopic appendectomy in patients with perforated appendicitis and a PAA.

Single-Port Laparoscopy-Assisted Appendectomy in Children: A Method Described

Single-incision laparoscopic appendectomy (SILA) has gained popularity in children, and several different techniques have been described, including intracorporeal and extracorporeal techniques and single-channel and multi-channel single-port techniques. However, there has been a concern that exteriorizing an infected appendix through the umbilical channel would increase the risk of postoperative wound infections. This report aims to describe a technique for single-port laparoscopy-assisted appendectomy (SPLAA) using an operative laparoscope and conventional laparoscopic instruments, as well as a VersaStep™ sheath to protect the wound edge while removing the appendix from the abdomen.

Robotic single-site versus laparo-endoscopic single-site surgery for adnexal tumours: a propensity score-matching analysis.

The aim of this study was to compare the surgical outcomes of robotic single-site (RSS) and laparo-endoscopic single-site (LESS) surgery for adnexal tumours and evaluate the feasibility of RSS surgery. RSS surgery was performed using the da Vinci Single-Site® surgical platform and LESS surgery using a single multi-channel port system. Surgical outcomes were compared between RSS (n = 20) and LESS (n = 228) after 1:4 propensity score matching. After the propensity score matching, the RSS group showed longer operating times than the LESS (91.1 vs 66.1 min; p = 0.001). While the LESS showed 1.3% of major complication rates, the RSS group had no perioperative complication. For the LESS, 2.5% of patients needed additional port insertion. The RSS surgery for adnexal tumours could be performed safely without complications or additional port insertion. Although it showed a longer operating time, further experience and technical refinements will continue to improve operative results. Copyright © 2015 John Wiley & Sons, Ltd.

Single-Incision Plus One Port Laparoscopic Total Pelvic Exenteration After Neoadjuvant Chemotherapy for Advanced Primary Rectal Cancer: A Case Report

Limited data on laparoscopic and robotic total pelvic exenteration (TPE) for gynecologic, urologic, and rectal malignancies have been published in the literature. Single-incision laparoscopic surgery (SILS) has been successfully introduced for colon cancer. Here, we describe our experience of TPE with SILS + 1 port (SILS+1) for advanced rectal cancer. A 64-year-old man was referred to our hospital with anemia. Computed tomography (CT) revealed a rectal tumor that was contiguous with the seminal vesicle and bladder. Rectoscopy revealed an ulcerated, bleeding, and stricturing lesion in the rectum, which was defined as an adenocarcinoma with a moderate degree of differentiation on histologic examination. The patient received neoadjuvant chemotherapy using capecitabine, oxaliplatin, and bevacizumab. After 3 courses of chemotherapy, a rectovesical fistula was suspected from examination of CT images. CT demonstrated intramural gas in the urinary bladder, which suggested a diagnosis of emphysematous cystitis. Thus, we constructed a transverse loop colostomy. Two months after the last administration of chemotherapy, we performed SILS+1 TPE. The procedure involved a 35-mm incision in the right side of the umbilicus for the insertion of a single multichannel port, and insertion of a 12-mm port into the right lower quadrant. Total operating time was 751 minutes, and estimated blood loss was 1100 mL (including urine). SILS+1 TPE is a technically promising alternative method for the treatment of selected patients with advanced rectal cancer.

PTH-044 Single port laparoscopic ileoanal pouch surgery: is this the end of the era of open surgery for ulcerative colitis?

Introduction Ileoanal pouch surgery is still being done as an open procedure in many centres in spite of advancement of skills in laparoscopic colorectal surgery. There is plenty of evidence to show the early advantages of laparoscopic colorectal surgery but we believe that even the long term outcomes are likely to be better for pouch surgery. Single port laparoscopic ileoanal pouch surgery through the stoma site is a very attractive option. Method All patients undergoing restorative proctocolectomy or completion proctectomy and ileoanal pouch surgery since 2011 were included. Retrospective analysis performed from a prospectively collected database after confirmation by reviewing patient case notes. All operations were performed laparoscopically by using a multichannel single port device through ileostomy site. Specimen removed from the port site and 20 cm J pouch anastomosed to the anal canal. Results A total of 14 patients (M:F –7:7) with a median age of 27 years (range 17–52 years) underwent single port laparoscopic Ileal pouch anal anastomosis. Their median BMI was 25.75 (range 19.5–40) with a median ASA of 2 (range 1–3). The procedure was completed laparoscopically through the stoma site in all patients except two who required suprapubic incision for division of anorectal junction. The median operating time was 230 mins (range 130–420 mins). The median hospital stay was 4 days (range 3–10). All the patients started taking normal diet by day 2 and stoma started functioning at a median of day 2. Two patients had readmission within 30 days due to stoma related complications. Median interval of reversal of ileostomy was 11 weeks (range 5–20 weeks) with one patient still awaiting reversal as it was done recently. Median stool frequency was 4/24 h, one patient had recurrent pouchitis which settled with probiotics. All patients are satisfied with their recovery, pouch function and continence. Conclusion Ileoanal pouch surgery can be done safely as a single port laparoscopic procedure through the ileostomy site with very good pouch function. Open surgery with long incision is not required for these patients as better results can be achieved by single port laparoscopic surgery. Disclosure of interest None Declared.

Single-Incision Laparoscopic Splenectomy Using the Suture Suspension Technique for Splenomegaly in Children with Hereditary Spherocytosis.

With increasing laparoscopic surgery experience and improved new vessel-sealing equipment, single-incision laparoscopic surgery (SILS) for splenectomy has emerged as an alternative to multiport laparoscopy, but the application of SILS for splenomegaly is still challenging due to technical difficulties. The aim of this study was to describe the suture suspension technique contributing to SILS for hereditary spherocytosis (HS). A retrospective review was conducted to evaluate all SILS for splenomegaly performed by a single surgeon. On preoperative ultrasonography, the spleen size index ranged from 0.67 to 0.82. An umbilical incision was used for the placement of a multichannel single port. To provide excellent exposure of the splenic hilum, a needle with a 1-0 suture was percutaneously introduced from the left hypochondriac region and then penetrated out the anterior chest wall for suspending the enlarged spleen. Dissection was facilitated by the use of a 5-mm curved reusable grasper and a 5-mm Harmonic(®) scalpel (Ethicon Endo-Surgery, Cincinnati, OH), and the splenic vessels were ligated with 5-mm Weck(®) Hem-o-lok(®) clips (Teleflex(®), Morrisville, NC). The resected spleen was placed in an endosurgical bag, morcellated, and removed from the abdomen via the umbilical incision. Nine children underwent SILS during the study period without conversion to open procedures or requiring additional ports. The suture suspension technique was successfully used and markedly improved the exposure of the splenic hilum. The operative time was 122.6 ± 31.2 minutes, and the extracted spleen weight was 562 ± 74.5 g (range, 420-1260 g). No intraoperative or postoperative complications were recorded. The umbilical incision healed well with a satisfactory cosmetic effect. Our outcome shows the suture suspension enables safe and feasible usage of SILS for the management of splenomegaly in children with HS. More experience is needed to assess advantages and disadvantages compared with the standard laparoscopic approach.

Single site robotic sentinel lymph node biopsy and hysterectomy in endometrial cancer

Sentinel lymph node (SLN) biopsy has been proposed as a safe and less morbid approach to full lymphadenectomy in endometrial cancer (EC) [1,2]. The role of single incision robotic surgery (SIRS) remains unclear in this setting [3,4]. The aim of this video is to demonstrate the feasibility of SLN biopsy utilizing the SIRS platform and near infrared imaging in EC. The patient was a 67 year old with FIGO grade I endometrial adenocarcinoma. Body mass index was 23.6 kg/m2 and the uterus was 10 cm on bimanual exam. Two milliliters of ICG was diluted to 1.25 mg/mL and was injected into the cervical stroma. The patient underwent pelvic washings, SLN biopsy, and extra fascial hysterectomy utilizing the daVinci Si Surgical System (Intuitive Surgical, Sunnyvale, CA) through a single multichannel port inserted through a 2.5 cm umbilical incision. SLNs were mapped bilaterally to the hypogastric lymph node chains.Total operative time was 88 min and estimated blood loss was 50 mL. The patient was discharged home from the recovery room and no postoperative complications were noted. Swapping instruments to keep graspers on the medial aspect of the field improved visualization and minimized instrument clash while utilizing a vertical pexy of the vaginal cuff allowed for a more rapid cuff closure. SLN biopsy and hysterectomy utilizing the SIRS are feasible and may offer some benefits over traditional robotic surgery. However, patients need to be carefully selected to minimize the risk of requiring complete lymphadenectomy and injury due to poor visualization.

Single-port laparoscopic colorectal cancer surgery in Korea: retrospective analysis of the multicenter, pooled database.

Single-port laparoscopic surgery (SPLS), one of the advanced techniques of laparoscopic surgery, is performed through a single multichannel port. Regarding colorectal surgery, several colorectal procedures, including right colectomy, sigmoidectomy, and total proctocelectomy with ileal pouch anal anastomosis, have been performed successfully. The aim of this study was to elucidate the feasibility and safety of SPLS for the treatment of the patient with colorectal cancer in Korea. Data were collected retrospectively from six hospitals through a Web-based case reporting form, which requested baseline characteristics of the patient, intraoperative findings, postoperative course, pathologic results of the tumor, and postoperative surveillance. From May 2009 to June 2012, 257 patients were included in this study. Anterior resection was performed in 117 patients, low anterior resection in 66 patients, and right colectomy in 53 patients. The primary entry incision site was umbilicus in all patients except for 2 cases; in these, stoma sites were used for the entry of the single port. The total mean incision length was 3.8±2.3 cm. Among 257 initially SPLS-attempted patients, 45 (17.5%) patients needed additional ports (one additional port in 44 patients), and 2 patients (0.78%) had to be converted to open laparotomy. Intraoperative complications were noted in 5 patients, including anastomotic failures in 3 patients and bleeding in 1 patient. Postoperative complications were noted in 34 patients (13.2%). Anastomotic leak developed in 11 patients, urinary retention in 5 patients, and wound complications in 4 patients. Re-admission was needed in 15 patients (5.8%). SPLS could be performed safely and appropriately in selected colorectal cancer cases by experts in laparoscopic colorectal surgery in Korea. Prospective randomized trials to demonstrate the benefit and effectiveness of SPLS in colorectal cancer surgery with long-term oncologic results are needed.

Single-Incision Robotic Supracervical Hysterectomy With a Single Multichannel Port as a Lower Cost Alternative to Laparoscopic Supracervical Hysterectomy

Single-Incision Robotic Supracervical Hysterectomy With a Single Multichannel Port as a Lower Cost Alternative to Laparoscopic Supracervical Hysterectomy

Two Hundred Seventy-Five Single-Incision Laparoscopic Gastric Band Insertions: What Have We Learnt?

Single-incision surgery in the morbidly obese patient has not been widely adopted, but remains a popular choice amongst patients. In the bariatric patient, it presents its own surgical challenges with hepatomegaly and increased abdominal adiposity. Here, we present our experience of 275 single-incision laparoscopic gastric bands.Between June 2009 and April 2013, 275 obese patients underwent single-incision laparoscopic adjustable gastric banding through a single incision using a multichannel single port and via a pars flaccida approach. Prospective data collection was undertaken including operating time, additional ports and additional procedures undertaken.In this series, median operative time was 60 (range 34-170) min. An additional port was placed in 15 patients (5%), including two conversions to four-port technique (0.7%). Of these patients (n = 15), the majority were male (p < 0.0001). Reasons for additional port placement included bleeding and anatomical abnormalities. Additional port placement occurred more often within the first 50 cases (5/50, 10% vs 10/225, 4%). An umbilical incision resulted in more wound-related complications than a transverse incision in the upper abdomen (p < 0.001). There were no 30-day mortality and minimal morbidity with two wound infections resulting in band removal.Single-incision laparoscopic adjustable gastric banding can be performed safely with minimal morbidity in the morbidly obese patient, and our technique has a high rate of success for all BMIs. Following 275 single-incision band insertions additional port placements were more commonly required in male patients, BMI >45 and earlier in the learning curve.

Laparoscopic Vaginoplasty Using a Sigmoid Graft Through the Umbilical Single-Incision Hybrid Transperineal Approach: Our Initial Experience

For better cosmetic appearance, attempts to reduce the number of laparoscopic wounds have been sought. Investigators have thus begun to carry out procedures through a single incision or natural orifice endoscopic surgery instead of using conventional laparoscopic surgery. The authors here describe transumbilical single-incision hybrid transperineal laparoscopic surgery as a novel approach for vaginoplasty using a sigmoid graft. From August 2010 to October 2012, 15 young females with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome underwent laparoscopic sigmoid vaginosplasty using a combined transumbilical single-incision and transperineal approach. A multichannel single port was placed through the umbilical incision for the main laparoscopic procedures. A 12-mm trocar as an assisting working port was inserted into the pelvic cavity through the transvaginal dimple between the rectum and urethra. A functioning vagina 12-15 cm in length and approximately 4 cm in width was created in all the patients. The average operative time and hospital stay were 151.5±34.2 minutes and 7.4±3.2 days, respectively. The only perioperative complications were 1 case of stress ulcer and 1 case with umbilical infection. All patients were satisfied with the surgery, and 12 of them had subsequent sexual activity. Transumbilical single-incision hybrid transperineal laparoscopic sigmoid vaginoplasty offers a feasible scarless approach for females with MRKH syndrome. The favorable cosmetic results would favor use of this type of vaginoplasty as an alternative to the conventional laparoscopic approach.

Needlescopic-Assisted Surgery: Single-Incision or Multi-Incision Laparoscopic Surgery?

See Article on Page 42-46 Appendicitis is a common disease with a variety of clinical courses. The tip of appendix can be found in retrocecal, pelvic, and retroperitoneal location, and its symptoms are related to the varying location of the appendix. Surgical treatment includes two types of approaches: open and laparoscopic surgery. Since the first laparoscopic appendectomy by Semm in 1981 [1], a variety of laparoscopic procedures have been performed. Classically, surgeons generally use three ports to perform an appendectomy: an umbilical port from 10 mm to 12 mm and two others of 5 mm. The appendix can be removed using an endoscopic stapler or endoloop. Recently, with the rising popularity of single-incision laparoscopic (SILS), the adoption of this method for an appendectomy has been rapidly increasing. or a minilaparoscopy has been tried by many surgeons as an attractive option to reduce scars and limit tissue trauma [2]. Needlescopic surgery was first described by Gagner and Garcia-Ruiz [3] in 1998. All surgical procedures were cholecystectomies. They defined as those instruments that had a diameter of 3 mm or less. However, until now, the use of those instruments has been limited because of their insufficient strength and durability. In addition, small-diameter laparoscopes make it more difficult for surgeons to get clean images. What is the ideal application of needlescopic instruments? Lee et al. [4] presented the ideal application of a needlescopic instrument. Ideal application means that surgeons ideally use needlescopic instruments with their inherent limitations of strength and durability. I think that an ideal application would not be for dissection but for traction. The authors used a needlescopic instrument with a small-diameter (less than 3 mm), a Mediflex disposable suture grasper closure device, as a percutaneous organ-holding device. The authors compared clinical outcomes between a single-port laparoscopic appendectomy (SPA) using a glove port with a percutaneous organ-holding device (group 1) and a SPA using a commercially-available multichannel single port (group 2). In group 1, a percutaneous organ-holding device at the right lower quadrant abdomen was used to grasp the appendix. The umbilical incision length was 10 mm in group 1 and 20 mm in group 2. Postoperative pain scores during the first 24 hours were significantly lower in group 1 than in group 2 (P < 0.001). The authors concluded that a SPA using a percutaneous organ-holding device could reduce postoperative pain by shortening the length of the incision. They used a needlescopic instrument just for traction. However, in the near future, surgeons may be able to use improved needlescopic laparoscopes and instruments with strengths that have been increased through technologic advances. Surgeons are often obsessed with definitions. For example, if some surgeons absolutely follow the definition of SILS, they will make just one incision. To them, the difficulty and complexity of the is not so important. Instead, the definition may be the main goal and main purpose. However, SILS has serious drawbacks: (1) the is performed in a confined space, (2) all the laparoscopic instruments in a single space can cause excessive stretching of the wound, and (3) the stretching may lead to increased postoperative pain. Is needlescopic-assisted single-incision or multi-incision laparoscopic surgery? The proponents of SILS may consider it to be needlescopic-assisted SILS. Conversely, the opponents of SILS may consider it to be multiport or multi-incision laparoscopic surgery. Because of this, defining the new technique is sometimes very difficult, and attempts at its definition are often very confusing. With new laparoscopic surgical procedures emerging daily, we surgeons should not be obsessed with making and following a specific definition, but should try to find the best surgical procedure for the patient. Conclusively, although the definition of SILS is still being debated, needlescopic-assisted seems to be a useful procedure for overcoming the difficulties of pure SILS.

Outcomes of a Single-Port Laparoscopic Appendectomy Using a Glove Port With a Percutaneous Organ-Holding Device and Commercially-Available Multichannel Single-Port Device

PurposeA laparoscopic appendectomy is now commonly performed. The push in recent years toward reducing the number of ports required to perform this surgery has led to the development of a single-port laparoscopic appendectomy (SPA). We compared postoperative pain after an SPA using a glove port with a percutaneous organ-holding device (group 1) with that of an SPA using a commercially-available multichannel single-port device (group 2).MethodsBetween March 2010 and July 2011, a retrospective study was conducted of a total of 77 patients who underwent an SPA by three surgeons at department of surgery, Kangbuk Samsung Medical Center. Thirty-eight patients received an SPA using a glove port with a percutaneous organ-holding device. The other 39 patients received an SPA using a commercially-available multichannel single port (Octo-Port or SILS Port). Operative details and postoperative outcomes were collected and evaluated.ResultsThere were no differences in the mean operative times, times to pass gas, postoperative hospital stays, or cosmetic satisfaction scores between the two groups. The pain score in the first 24 hours after surgery was higher in group 2 than group 1 patients (P < 0.001). Furthermore, the trocar used in group 2 was more expensive than that used in group 1.ConclusionAn SPA using a glove port with a percutaneous organ-holding device was associated with a lower pain score during the first 24 hours after surgery because of the shorter fascia incision length and a cheaper cost than an SPA using a commercially-available multichannel single-port device.

LaparoEndoscopic Single Site Orchidopexy for Intra-Abdominal Testes in the Pediatric Population with a Multichannel Single Port and Flexible Tip Laparoscope

To assess the outcomes of pediatric LaparoEndoscopic Single Site (LESS) orchidopexy using a commercially available multi-channel single port (MCSP) and flexible tip laparoscope (FTL). A retrospective cohort study was performed of children who underwent LESS orchidopexy by a single surgeon at a pediatric institution. A commercially available MCSP was utilized at the umbilicus. A 5 mm FTL and 3 mm and 5 mm instruments were used for the dissection. Follow-up visits were performed 2-4 weeks and 6-12 months after surgery to assess position and size of the testes. A total of 17 patients were identified. Median age was 11 months (range 3-43). Sixteen patients underwent primary orchidopexy, including two bilateral procedures and five primary Fowler-Stephens (FS) procedures. One patient underwent a staged FS orchidopexy, with the LESS technique utilized during the second stage. Median laparoscopic dissection time for each testis was 35 minutes (range 22-40). There was no blood loss or intraoperative complications. All testes were noted to be in the scrotum without testicular atrophy. Our initial experience with this technique was favorable with excellent outcomes. LESS orchidopexy is facilitated with a MCSP and FTL.