Today laparoscopic single-incision surgery is an everyday occurrence in many surgical facilities across the country. A single cut and a nearly invisible scar around the umbilicus make single-incision procedures such as laparoscopic cholecystectomy attractive to surgeons and, more importantly, their patients.

Patients, especially here in Florida where people spend more time in a bathing suit than in other parts of the country, like these procedures because there's virtually no scar. Physicians like single-incision procedures because there's less tissue trauma, less post-op pain, lower infection rates and fewer incisional hernias. All this translates to better patient satisfaction because patients, even if they don't run around in a bathing suit, don't have multiple scars on the abdomen.

If your surgeons have started to show interest in single-incision surgery, here's what you need to know about the instruments, equipment and training surgeons and staff will need.

With single-incision surgery, it's important to remember that aside from the tiny scar, there's little difference between a single- and a multi-incision procedure. The big change is that the surgeon and assistant need to get used to working from a new angle since all the instruments pass through a 12mm to 15mm incision. Otherwise, it's the same procedure once you're inside the abdominal cavity.

Besides cholecystectomies, a single-incision approach can be used for anti-reflux procedures (such as Nissen or Toupet fundoplications and hiatal hernia repairs), Heller myotomies for treating achalasia and inguinal hernias. Single-incision is well suited for gynecological procedures such as total abdominal hysterectomy and bilateral salpingo-oophorectomies.

If you're just beginning with single-incision procedures, I recommend lap chole as your first offering. I can usually complete a single-incision cholecystectomy with the following recommended setup in 20 to 30 minutes.

Imaging is key
As with all laparoscopic procedures, the surgeon's eyes become extensions of the hands. The surgeon needs to be able to differentiate between the various tissues, blood vessels and organs. So the best possible image is key. Single-incision surgery requires a good endoscopy imaging system and monitors. Of course, a high-definition imaging system creates a crisper image than a standard definition unit.

In single-incision procedures, all the instruments pass through a multi-trocar port and enter the peritoneal cavity at similar angles. In order to better see around structures at this tight angle, I use a 5mm laparoscope with a deflectable tip. Because the laparoscope passes through the multi-trocar port, rather than off to the side in a multi-incision procedure, I can hold and control the camera with my left hand rather than having an assistant hold it. In my right hand, I usually hold a dissecting instrument or energy device.

Depending on the manufacturer, deflectable tip cameras are available in high-definition and standard-definition and can articulate up to 100 ?, letting you look around and behind structures with more ease than with a straight camera. Using an articulating camera rather than a straight one will prevent the camera from crossing or "sword fighting" with other instruments in the peritoneal cavity because only the tip of the camera moves while the rest of the shaft stays in place, flat on the patient's abdominal wall. This positioning of the camera provides a greater range of movement for the surgical instruments and allows better triangulation, which is how the surgeon perceives where the working tip of each instrument is located during surgery.

Single-incision toolbox
Besides the multi-trocar port, which can let up to 4 instruments pass through a single incision, the surgeon's toolbox for cholecystectomies is fairly standard. It includes:

• bariatric-size rigid locking grasper for retraction of the fundus of the gallbladder in the cephalad direction;
• bent or articulating grasper for lateral retraction of the infundibulum;
• Maryland dissector for dissection of the cystic duct and artery;
• 5mm clip applier for ligation of the cystic duct and artery;
• laparoscopic scissors to divide the cystic duct and artery; and
• hook monopolar cautery device to dissect the gallbladder off the liver bed.

I also have a few personal preferences. For example, to retract the gallbladder fundus I use a rigid bariatric-size locking grasper and then use a Kocher instrument to attach the grasper to the patient's drapes. Once it's in place, this anchoring technique for the gallbladder fundus retractor gives you or your assistant one less instrument to have to hold in your hands.

During the procedure, I hold the 5mm deflectable tip laparoscope in my left hand and keep it flat on the patient's abdomen. My thumb moves the dials up and down, left and right, while my index finger keeps the camera in the locking position. In my right hand, I hold the Maryland dissector, the 5mm clips applier, the laparoscopic scissors and the hook cautery device when appropriate. The only assistance I require during the operation is someone to hold the articulating or bent grasper after I position it laterally to retract the infundibulum.

OR staff considerations
Since you need fewer hands during a single-incision procedure, you'll need fewer people in the OR, too. However, everyone who works in the OR should be familiar with the procedure and understand how it's different from a multi-incision laparoscopic procedure. Each team member should be able to follow the procedure on the monitor and anticipate the next step in order have the next instrument ready. Each team member should also know how to load and operate each instrument.

During your setup, you'll also need to be prepared with additional trocars in case you have to covert the case to a multi-incision procedure. This happens, although rarely (about 1% to 2% of the time). Whenever a single-incision approach makes the surgeon uncomfortable, it's OK to convert. Conversion to conventional laparoscopy is not failure. It's good judgment. Safety comes first!

Where to start?
Any surgeon who wishes to undertake single-incision procedures should learn from experienced surgeons who have perfected their technique. My partner, Alexander Rosemurgy, MD, and I have taught more than 300 surgeons from around the country to successfully perform single-incision operations. Learning from others in courses and hands-on training sessions is the best way to learn the tips and tricks that will save you time and help you progress. There's no need to reinvent the wheel when you can learn from someone who's already got it figured out. Their single-incision success can become yours, too.