In May 2007, the husband-and-wife team of Paul Curcillo, MD, FACS, and Stephanie King, MD, performed the first total transumbilical cholecystectomy in the United States. Today, Dr. Curcillo is helping to spearhead an evolution aimed at making single incision surgery accessible to all surgeons across all specialties. The many acronyms we have to describe the various single port approaches — SPA, SILS, OPUS — might suggest that leading surgical minds don't see eye-to-eye on which technique is most effective, but they all agree that reducing the number of ports through which surgeons operate is shaping up to be surgery's next big thing.

Let's take a look at how surgeons can perform a typical lap chole with the leading single port techniques, highlighting the approaches, equipment requirements and potential benefits of each.

Single port access (SPA). Dr. Curcillo, an associate professor, vice chairman of the department of surgery and director of robotic and minimally invasive surgery at Drexel University College of Medicine in Philadelphia, Pa., says the key to his single port access technique is the 5mm hole centered in a standard incision made through the umbilicus. That small hole creates 2 skin flaps that the surgeon raises, turning the original oval incision into a circle cut, which provides enough space to place 2 low-profile trocars around a clear central trocar.

With an eye toward cost containment, Dr. Cur-cillo focused on developing a technique that can be performed with standard trocars and non-articulating instrumentation. He says his method requires fewer trocars than multi-port surgery does, which shaves approximately $85 off per-case expenses. "We wanted to develop a single port approach that would control costs and maintain safety, and we wanted surgeons to enter the abdomen and operate like they do now," so the technique is repeatable, learnable and conducive to large-scale training.

"Without using a multi-trocar device, we're able to move instruments up to 180 degrees without affecting the other instrumentation," says Dr. Curcillo, adding that maintaining independent movement of instrumentation is vital to performing successful surgery through a single port.

Dr. Curcillo has performed numerous appendectomies, colon resections, ventral hernias, splenectomies, adrenalectomies, oophorectomies, hysterectomies and pelvic node dissections, among other procedures, through initial umbilical incisions of 1.8cm or less in length. He believes the true benefit of his technique is that it lets surgeons use standard laparoscopic instruments and equipment to identify the critical view of safety (visualization of the cystic duct and artery), which he believes is essential to performing safe and effective laparoscopy.

Single incision laparoscopic surgery (SILS). This technique employs a transumbilical approach to place 2 5mm trocars through a single initial incision and 2 secondary fascial incisions that are made in close proximity to each other and connected at the end of the procedure to remove the specimen. A specialized multi-channel port can also be used, which may make access more standardized and decrease trauma, according to Homero Rivas, MD, MBA, FACS, an assistant professor in the gastrointestinal endocrine division of the department of surgery at the University of Texas Southwestern Medical Center in Dallas. Intra-abdominal or transabdominal sutures are used to retract the gallbladder, which Dr. Rivas says provides excellent exposure of the critical view.

He uses conventional laparoscopic instrumentation in most of his cases, but recognizes the potential benefits of working with specialized roticulating and articulating instruments. "Certainly most instrumentation that we already have available may be used on this technique, especially because we know how to use it," explains Dr. Rivas. "Having said that, we should consider novel devices especially designed for this approach. We must evolve and embrace innovation."

He says multi-channel port devices run between $400 and $500, a flexible tip endoscope might demand a capital investment of $20,000, plus $40,000 for its tower, and articulating and roticulating instruments range from $80 to $450. But even in an era of cost containment, Dr. Rivas doesn't consider specialized instrumentation to be cost-prohibitive and suggests that articulating instruments can increase efficiency.

According to Dr. Rivas, basic general surgery procedures (lap chole, appendectomy) and gynecological procedures (oophorectomy, tubal ligation, hysterectomy) are currently best suited for the SILS approach, but more complex operations (colon resections, adrenalectomies, splenectomies and gastric bypass) have already been completed successfully.

One Port Umbilicus Surgery (OPUS). Prasanth Rao, MD, FACS, chief of minimal access surgery and GI surgery at the Institution-Mamata Hospital in Mumbai, India, pioneered a single-incision technique using a specially designed, double-layered, flexible plastic cylinder that fits snugly against the abdominal wall and holds open an incision at the umbilicus or elsewhere on the abdomen. The unique port has an external multi-valve disc, which allows for the placement of 3 or 4 instruments through a single open channel, explains Dr. Rao.

He says using a single, specialized port to insert standard instrumentation eliminates the need for multiple fascial incisions beyond the initial entry. The port also expands to fill the surgical opening, which lets surgeons work through desired incision lengths instead of planning incisions around port sizes. The port used to perform this technique runs about $500, a price that Dr. Rao notes is equivalent to the expense of purchasing the multiple ports needed for standard laparoscopy.

Dr. Rao says this technique is best suited for cholecystectomy, appendectomy, hysterectomy, nephrectomy and pyeloplasty, and it's also being tried in colorectal and bariatric surgery with encouraging results. However, he warns that the limitations of current instrumentation may prevent adequate retraction during some procedures. Until better instrumentation is developed, Dr. Rao suggests surgeons consider adding needles or an extra port for retraction when needed rather than compromising patient safety.

And since all instrumentation goes through a single port, surgeons may have to maneuver devices through a crowded access point. This is can be offset with specialized equipment such as a video laparoscope with integrated camera chip and light source as well as curved and reticulating instruments, which Dr. Rao says can make the procedure easier to perform but are not essential to its success.

Flexible endoscopy. In the August 2009 issue of the Archives of Surgery, Julio Teixeira, MD, FACS, an associate clinical professor of surgery at Columbia University College of Physicians & Surgeons and chief of the division of minimally invasive surgery at St. Luke's-Roosevelt Hospital Center in New York, N.Y., says working with a flexible endoscope through a single incision offers several advantages over standard laparoscopy and expands the surgery's potential beyond the limitations of rigid surgical tools.

He points to the cleaning mechanism on the endoscope's tip that lets surgeons refresh the lens and improve visibility of the surgical site without removing the scope, and multiple working channels that allow for smoke aspiration and other operative tasks without having to exchange instruments in and out of the port. And since the camera is on the endoscope's tip and all instruments are in the scope, surgeons are able to zero in on target organs and work in close proximity to them throughout a procedure.

Dr. Teixeira admits that surgeons must develop an entirely new skill set before performing flexible endoscopy through a single incision, but he believes the technique lets surgeons develop the skills necessary for performing natural orifice surgery without the current risks associated with those approaches, making the technique a valuable stepping stone between conventional laparoscopy and the future potential of minimally invasive techniques.

Slow down curve ahead
Dr. Curcillo says a single-port approach is ideal, but emphasizes that the ultimate message of the reduced port evolution is that surgeons should consider any reduction in the number of access points a success. He advises docs interested in single-incision surgery to progress slowly along the learning curve, gradually eliminating ports — from 4 to 3 to 2 to 1 — only as their comfort and skill levels grow. He'd rather a surgeon add a trocar mid-procedure than try to complete a single port surgery using poor technique. Above all, he says, these procedures have to be performed safely. The potential of single incision surgery is evident. Where the movement will eventually lead is less certain. "Technology and technique usually go hand-in-hand and chase each other," says Dr. Rao. "For once, I think the technique is ahead of the technology. Better and proper instrumentation will help make single incision surgery easier, safer and cheaper in the long run."