TOOLS ON HAND The ability to marshal and manipulate the scope and instruments while preventing interference is key to single-incision success.

A single incision at the umbilicus can provide access to the entire abdomen with minimally invasive techniques. While single-site surgery advocates admit it's more challenging than traditional multi-site laparoscopy, they also note it's in a state of evolution. "Advances make it a whole different story," says Jeffrey L. Ponsky, MD, who chairs the department of surgery at University Hospitals Case Medical Center in Cleveland. As experience and technology increase efficiency and safety, "single incision may be the way we do it in the future."

See your way clear
Operating through a single incision requires the mastery of a significant learning curve. One fundamental skill involves lining up the tools in use to prevent crowding and clashing at the surgical site inside, says Sharona B. Ross, MD, director of minimally invasive surgery and surgical endoscopy at Florida Hospital's Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive and Robotic Surgery in Tampa. This can prove particularly challenging at the intersection of instrumentation and visualization.

"We use 5mm deflectable tip laparoscopes," she says, which can be laid flat, yet still view another angle on demand. "Can you do single-incision with a rigid scope? Yes, you can, but then you can't move the other instruments out of the way."

What could be better than a scope that circumvents traffic at the site? Well, three-dimensional imaging would be, and the past year has seen the introduction of a 3D laparoscope with a deflectable tip, but it's a 10mm scope, which is too wide of an instrument for single-incision operations. "If you need that and a stapler, there's not enough room in the port," says Dr. Ross.

Safety in sight
In the big picture, the surgeon who performs laparoscopic procedures through a single incision must remain focused on patient safety. It is not, after all, a shortcut procedure. "It's not how we get in that's most important," says Dr. Ponsky, "it's what we do when we get there. When we take out an organ, we want to do it safely."

Paul Curcillo II, MD, FACS, agrees, noting that the single-incision method lends itself to clinical caution in trained hands. "One of the biggest improvements of single-port access has been that we've re-recognized the importance of the critical view," says the director of minimally invasive surgical initiatives and development at Fox Chase Cancer Center in Philadelphia. "You're maintaining safety, seeing what you need to see before placing the clip and cutting. Single-port, when done safely, has brought safety back to the forefront."

Dr. Ross suggests a change in instrument handling techniques. Surgeons should hold scopes themselves, not leave them in assistants' or techs' hands. That way they're in control of the image, choosing and confirming what they're seeing, so they're assured of safety when they make the cut.

A PARTICULAR PORT The multi-trocar port used for a surgery depends on the type of surgery, and the type of instruments used.

Ports that support
Dr. Ross and her colleague, Alexander Rosemurgy, MD, have converted all of their center's multi-incision laparoscopy cases into laparo-endoscopic single-site (LESS) surgeries. They've been able to accomplish this primarily due to the availability of multi-purpose, multi-access ports, which fit through small incisions to do the job of several trocars.

There are several multi-purpose port products on the market, each designed to different specifications and each optimally suited to the needs of different surgeries, says Dr. Ross.

For instance, she and Dr. Rosemurgy do their lap choles with a 4-trocar port that features a wound protective sleeve but not much in the way of length extending past the fascia. This allows their rigid, bent instruments access to and movement in the peritoneal cavity, which a longer trocar would restrict.

On the other hand, straight instruments with articulation at the end tend to be required for the suturing involved in Nissen fundoplication, and a 4-trocar port that transverses the abdominal wall is more useful in preventing instruments from interfering with each other. Also, for cases in which specimen extraction is not necessary, there's less of a need for the wound protective sleeve.

Multi-port matters aside, Dr. Ross recommends surgeons opt for bariatric-sized instruments in single-incision cases, no matter what size their patients are, as they offer your hands some working distance. "In single-incision, you don't want to be working too close to the port," she says. "The longer length removes you from the patient and gives you space."

Inside and outside
Internal retraction is an advance that Drs. Curcillo, Ross and Ponsky all see as potentially making a huge difference in efficiency for the single-incision surgeon.

The exhibit hall at a recent general surgery conference saw the introduction of 2 internal retraction products deployed through ports, neither of which monopolizes trocars the way manual retractors or graspers do. One of them, a single-use device, lifts and holds organs against the abdominal wall through the use of articulating, atraumatic clips. The other is a dynamic system that uses a removable 5mm device to manipulate tissue at the site through adjusting internal tension lines. "If you can eliminate hand-held retraction," says Dr. Curcillo, "it gives you more room to work."

Dr. Ross agrees. "If you're doing dissection during gastric reflux reconstruction, you don't have enough trocar ports to retract the fat. Internal retractors can make the work a lot easier."