Single-port Access System Research Articles

Maneuverability of the Scope and Instruments within Three Different Single-Incision Laparoscopic Ports: An Experimental Pilot Study.

Simple SummarySingle-port access systems, used to perform endoscopic surgery through a single incision, are currently used in many human and veterinary surgeries. These systems present some technical challenges as they offer limited space for manipulation. No objective study has evaluated the degree of possible movement within different single-port access systems. This study aimed to measure and compare the possible movements of the endoscope and instruments within three single-port access systems: the Covidien SILS-port, Storz Endocone, and glove port. The glove port consists of a surgical glove and an O-ring retractor. A clear acrylic box with artificial skin was used to mimic the abdominal wall and cavity. A motion capture system with 18 cameras was used to trace the possible movements of the endoscope. The volume of the cone-shaped three-dimensional figure described by the scope when circled 360° was used to compare maneuverability across the three systems. The glove port showed higher maneuverability than the two commercially available ports when an endoscope alone, or an endoscope and instrument, was or were inserted. A higher degree of maneuverability is positively associated with easier handling of the endoscope and instruments during surgical procedures. The findings of this study may benefit students and young professionals by helping them to select an easy-to-use single-port access system when beginning single-incision endoscopic surgery.Single-port access systems (SPASs) are currently used in human and veterinary surgeries. However, they pose technical challenges, such as instrument crowding, intra- and extracorporeal instrument collision, and reduced maneuverability. Studies comparing the maneuverability of the scopes and instruments in different SPASs are lacking. This study aimed to compare the maneuverability of three different SPASs: the Covidien SILS-port, Storz Endocone, and glove port. A clear acrylic box with artificial skin placed at the bottom was used to mimic the abdominal wall and cavity. The three SPASs were placed from below, and a 10-mm endoscope and 5-mm instrument were introduced. A motion analysis system consisting of 18 cameras and motion analysis software were used to track the movement of the endoscope and instrument, to determine the volume of the cone-shaped, three-dimensional figures over which movement was possible, with higher values indicating greater maneuverability. The Mann–Whitney U test was used for the analysis. The maneuverability of the endoscope alone was significantly higher in the glove port system than in the other two SPASs. When inserting an additional instrument, the maneuverability significantly decreased in the SILS-port and Endocone, but not in the glove port. The highest maneuverability overall was found in the glove port.

Laparoscopic Cholecystectomy with Single Port Access System in 15 Dogs

To evaluate the outcome of laparoscopic cholecystectomy performed with a single port access system (SPAS) in dogs. Retrospective study. Fifteen client-owned dogs with nonobstructive gallbladder disease. Medical records were reviewed for signalment, clinical signs, diagnostic imaging, surgical findings, and outcome until suture removal. The SPAS was placed 1 cm caudal to the umbilicus. The procedure was completed with the SPAS alone in two cases. An additional cannula was added in 12 cases. In the last 10 cases, the additional cannula was placed at the beginning of the procedure. Dissection began at the cystic duct in 11 dogs (73%). In three cases (20%), the SPAS procedure was converted to a laparotomy; two of these conversions were elective, and one was emergent. The risk of conversion was affected by the experience of the surgeon (odds ratio = 0.53; P = .0105), and the rate of conversion was reduced when a cannula was added at the beginning of the procedure (P = .022). Fourteen dogs were discharged from the hospital. One dog died after being discharged due to severe cholangiohepatitis, and another dog died due to leakage of a gastrostomy tube. The use of SPAS for cholecystectomy in dogs has an acceptable outcome. The experience gained by the surgeon and the addition of a cannula reduced the risk of conversion. Laparoscopic cholecystectomy can be performed with a SPAS. The placement of an additional cannula at the beginning of the procedure is highly recommended.

Laparoscopic Gastropexy Using Knotless Unidirectional Suture and an Articulated Endoscopic Suturing Device: Seven Cases.

To describe a technique for laparoscopic incisional gastropexy using an articulated endoscopic suturing device with knotless unidirectional barbed suture in healthy large breed dogs. Prospective case series. Healthy client-owned dogs presented for prophylactic gastropexy and weighing >20 kg (n=7). Incisional gastropexy was performed using a single port access system with an articulated endoscopic suturing device. An additional 5 mm cannula was placed in the right caudal abdomen. A 2-0 knotless unidirectional barbed suture was used to complete the gastropexy with 2 separate simple continuous suture lines. All dogs underwent a focal abdominal ultrasound to evaluate the gastropexy site 3-12 months postoperatively. Median weight of the dogs was 33.5 kg (range, 20-51 kg) and the median age was 2 years (range, 0.6-8.5 years). Median surgical time was 60 minutes (range, 39-88). The articulated suturing device malfunctioned twice. On abdominal ultrasound between 3 and 12 months, all gastropexy sites were intact. No motion was detected between the stomach and body wall during distal antral contractions or respiratory motion and a focal thickening of the gastric wall was present in dog. No complications were reported in the postoperative periods as of the 2 week suture removal visit or as of the time of their ultrasound appointment. This technique using an endoscopic articulated suturing device with a knotless unidirectional barbed suture provides a feasible technique to perform laparoscopic gastropexy.

Reusable single-port access device shortens operative time and reduces operative costs

In recent years, single-port laparoscopy (SPL) has become an attractive approach for performing surgical procedures. The pitfalls of this approach are technical and financial. Financial concerns are due to the increased cost of dedicated devices and prolonged operating room time. Our aim was to calculate the cost of SPL using a reusable port and instruments in order to evaluate the cost difference between this approach to SPL using the available disposable ports and standard laparoscopy. We performed 22 laparoscopic procedures via the SPL approach using a reusable single-port access system and reusable laparoscopic instruments. These included 17 cholecystectomies and five other procedures. Operative time, postoperative length of stay (LOS) and complications were prospectively recorded and were compared with similar data from our SPL database. Student's t test was used for statistical analysis. SPL was successfully performed in all cases. Mean operative time for cholecystectomy was 72 min (range 40-116). Postoperative LOS was not changed from our standard protocols and was 1.1 days for cholecystectomy. The postoperative course was within normal limits for all patients and perioperative morbidity was recorded. Both operative time and length of hospital stay were shorter for the 17 patients who underwent cholecystectomy using a reusable port than for the matched previous 17 SPL cholecystectomies we performed (p < 0.001). Prices of disposable SPL instruments and multiport access devices as well as extraction bags from different manufacturers were used to calculate the cost difference. Operating with a reusable port ended up with an average cost savings of US$388 compared with using disposable ports, and US$240 compared with standard laparoscopy. Single-port laparoscopic surgery is a technically challenging and expensive surgical approach. Financial concerns among others have been advocated against this approach; however, we demonstrate herein that using a reusable port and instruments reduces operative time and overall operative costs, even beyond the cost of standard laparoscopy.

Transumbilical Single-Port Splenectomy

Laparoscopic approach is now considered the gold standard technique for the treatment for many hematologic diseases requiring splenectomy, both in case of a normal or enlarged spleen. During the last few years, new surgical approaches such as natural orifice transluminal endoscopic surgery and single-port laparoscopic surgery have been described. We describe details of the surgical technique for transumbilical single-port splenectomy. A 55-year-old man was referred to our department for spleen removal, a treatment of idiopathic thrombocytopenia and immune anemia. He had no previous significant medical history. Reusable single-port device and coaxial curved instruments were used to perform splenectomy, reproducing the same technique used in the standard laparoscopic approach. For single-port laparoscopic splenectomy, we use a reusable single-port access system (Endocone® Karl Storz GmbH & Co. KG) that was designed to enable instrument triangulation. The proximal conical section of the Endocone® is capped with a separate seal cap (bulkhead), which houses eight valved instrument seals: two along large midline (for instruments up to 15 mm in diameter) and six (three on either side) for instruments up to 5 mm in diameter. The patient is placed in right lateral decubitus as in standard laparoscopic splenectomy, and the surgeons second the camera assistant stand on the side of the bed. The pneumoperitoneum is established using a Veress needle inserted in the umbilicus; at this point, a 5-mm-longitudinal incision is performed right through the umbilical scar and a standard trocar inserted for exploration of the abdominal cavity to evaluate the local condition and contraindications to the single-port approach such as severe adhesions and abnormal anatomy. At this point, the umbilical scar is pulled out using toothed forceps, and the incision is enlarged for up to 3 cm longitudinally: this technique will later allow to hide the scar inside umbilicus itself. A size small surgical wound protector (Alexis O; Applied Medical Rancho Santa Margarita) is inserted through the incision to protect the abdominal wall as well as to improve the stability of the port system and facilitate its introduction. As in standard laparoscopic splenectomy, the procedure starts with division of the small vessels of the lower pole of the spleen by means of combination of bipolar electrocautery and harmonic scalpel (Ethicon Endosurgery). The procedure carries on with the isolation of the main splenic artery that can be then closed by endoscopic clips and divided; surgical stapler can also be used according to surgeon's preferences. Once the artery is divided, the main vein is dissected gently and then closed and divided with an endoscopic surgical stapler with a vascular cartridge (Ethicon Endosurgery). At this point, the short gastric vessels are divided using the harmonic scalpel, and finally the spleen is mobilized by division of the splenodiaphragmatic, splenogastric, and splenocolic ligaments. A large endobag is then introduced through the Endocone®, and the spleen retrieved inside it through the incision. The surgical filed is finally checked for hemostasis, and the incision is carefully closed with an interrupted reabsorbable suture. The operative time was 95 minutes, and there were no intra- or postoperative complications. The patient was discharged on postoperative day 2. No competing financial interests exist. Runtime of video: 6 mins 11 secs

Single-Port Laparoscopic Cholecystectomy Using the Innovative E. K. Glove Port: Our Experience

The technique of laparoscopic cholecystectomy continues to evolve with a trend towards decreasing use of working ports. One of the emerging concepts of 21st century is single-port surgery. It has further minimized the minimally invasive surgery. However, the main drawbacks of this technique are the lack of “triangulation” to which the laparoscopic surgeons have grown accustomed to, the clustering of instruments, and the costly multichannel ports, which are very costly and, in fact, are not affordable by the majority of the population in a developing country like India. From September 2009 to December 2011, 210 patients identified as having biliary colic, chronic cholecystitis, and previous biliary pancreatitis or obstructive jaundice due to stones (managed by ERCP) underwent single-port laparoscopic cholecystectomy using the E. K. glove port. The operating time was reasonable and can be lessened with experience. Excellent exposure of the critical view was obtained in all cases. This technique is safe, feasible, reproducible, cheap, and easy to learn. It may be an alternative to the currently available single-port access system, especially in a developing country like India. If required, placement of the remaining two to three ports for a more conventional laparoscopic cholecystectomy can be done.

Improvised Transumbilical Glove Port: A Cost Effective Method for Single Port Laparoscopic Surgery

Innovations in technology has changed the traditional laparoscopy to be less invasive. Singleport transumbilical laparoscopy has emerged to enhance the cosmetic benefits and to decrease the morbidity of the minimally invasive surgery. It has further minimized the minimally invasive surgery. However, this technique requires a specialized multichannel port (for introducing laparoscope and instruments) which is very costly and in fact, is not affordable by the majority of the population in a developing country like India. We have improvised a single-port access system using readily available materials like surgical gloves, towel ring, inner flexible ring and conventional laparoscopic trocars with no added cost burden to the patient. We have performed 40 single port surgeries using this method without any complications.

Transumbilical single-port access versus conventional total laparoscopic hysterectomy: surgical outcomes

The objective of the study was to compare surgical outcomes and postoperative pain between transumbilical single-port access total laparoscopic hysterectomy (SPA-TLH) and conventional 4-port total laparoscopic hysterectomy (TLH). We retrospectively reviewed 157 patients who underwent SPA-TLH (n = 52) or conventional TLH (n = 105). A single-port access system consisted of a wound retractor, surgical glove, 2 5 mm trocars, and 1 10/11 mm trocar. The SPA-TLH group had less intraoperative blood loss (P < .001), shorter hospital stay (P = .001), and earlier diet intake (P < .001) compared with the conventional TLH group. There was no difference in perioperative complications. Immediate postoperative pain score was lower in the SPA-TLH group (P < .001). Postoperative pain after 6 and 24 hours was lower in SPA-TLH with marginal statistical significance. SPA-TLH is a feasible method for hysterectomy with lower immediate postoperative pain and better surgical outcomes with respect to recovery time compared with conventional TLH.

Single-port cholecystectomy with the TransEnterix SPIDER: simple and safe

IntroductionSingle-port or single-incision cholecystectomy with current rigid laparoscopic devices is limited by in-line visualization, restricting the ability to approach the surgical site with proper angles and instrumentation. A single-port access system with articulating arms and strong instrumentation should minimize these issues. The TransEnterix system may facilitate safe and straightforward single-port surgery.MethodsThe TransEnterix single-port surgery system was used in both survival and nonsurvival porcine laparoscopic cholecystectomies under animal use committee approval. Nonsurvival procedures compared four standard laparoscopic with four single-port cholecystectomies from a histologic perspective. Five single-port swine laparoscopic cholecystectomy procedures were completed in sterile conditions, and all animals survived for 1 week postoperatively. Standard surgical clips were used for both cystic duct and artery ligation. At sacrifice, both gross and microscopic histology were obtained for assessment of surgical complications.ResultsAll cholecystectomies were successfully completed with the TransEnterix single-port system. Operative time for the survival procedures averaged 39.4 (range 18–66) min. Histology of the acute specimens showed less inflammation at the single-port site compared with the trocar sites from the standard cholecystectomy. At sacrifice, no complications were identified.ConclusionsThe TransEnterix system is safe and straightforward for completing single-port cholecystectomy in this limited porcine series. Port site inflammation is reduced compared with standard laparoscopic trocars.

Embryonic natural orifice transumbilical endoscopic surgery (E-NOTES) for adnexal tumors

Embryonic natural orifice transumbilical endoscopic surgery (E-NOTES) has shown promise as a minimally invasive laparoscopic surgery technique. To investigate the feasibility and surgical outcome of E-NOTES for adnexal tumors. We performed E-NOTES in 12 patients with adnexal tumors through a 2-cm intraumblical incision. A single-port access system comprising a wound protractor and a surgical glove was used. A prospective data registry was used in this study. Since 1 July 2008, 12 patients have undergone E-NOTES for adnexal tumors. E-NOTES in all 12 cases was completed successfully without conversion to standard laparoscopic approach. Median operative time for creating an E-NOTES access system and the ensuing operative procedures was 6 min (range 5-15 min) and 73 min (range 25-110 min), respectively. Median blood loss was <10 ml. No complications requiring treatment occurred. E-NOTES is a feasible alternative method for resection of adnexal tumors with better cosmetic outcome. More experience and instrumental improvement suitable for E-NOTES are needed.