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1 DOI: /jkma pissn: eissn: Continuing Education Column Single port laparoscopic surgery Woo-Jung Lee, MD Department of Surgery, Yonsei University College of Medicine, Seoul, Korea Received July 7, 2010 Accepted July 21, 2010 Abstract Minimally invasive surgery and laparoscopic surgery have been used for more than 30 years, and are now popular even for some malignant diseases. There have been two developments in technology; one is robotic surgery and the other is less minimally invasive surgery like natural orifice transluminal endoscopic surgery (NOTES) and single port laparoscopic surgery. NOTES, using the current platform of a conventional fiberscope and side channel instruments for surgery, suffers many limitations, including image quality, flexibility of the fiberscope, size of the side channel, and difficulty of closing the opening. Due to the above-mentioned limitations, single port laparoscopic surgery has many advantages over. This review aims to define single port laparoscopic surgery and describe its terminology and technology. To perform single port laparoscopic surgery efficiently, new instruments (e.g., a laparoscopic camera, ports, laparoscopic instruments) and combining other innovative methods into surgery are both helpful. Even though there have been many developments in laparoscopic cameras, ports, and laparoscopic instruments to enhance single port laparoscopic surgery, further improvements are needed. Motorized instruments or using a robotic platform in combination with single port laparoscopic surgery will be another way to overcome the limitations of current single port laparoscopic surgery. Single port laparoscopic surgery is a technique that has recently emerged, but will be performed in a wider range of surgical procedures based on developments in laparoscopic cameras, ports and laparoscopic instrument technology. Keywords: Single port laparoscopic surgery; Laparoscopic surgery; Minimally invasive surgery c Korean Medical Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 793

2 Lee WJ 794

3 Single port laparoscopic surgery Table 1. The acronyms single port laparoscopic surgery enotes Embryonic NOTES a) LESS Laparo-Endoscopic Single-site Surgery NOTUS Natural Orifice Trans Umbilical Surgery OPUS One Port Umbilical Surgery SPA Single Port Access SPAS Single Port Access Surgery SPL Single Port Laparoscopy SPLS Single Port Laparoscopic Surgery SIMPL Single Instrument Port Laparoscopic Surgery SIMPLE Single Incision Multi-Port Laparo-Endoscopic SILS Single Incision Laparoscopic Surgery SLIT Single Laparoscopic Incision Transabdominal SLAPP Single Laparoscopic Port Procedure SSL Single Site Laparoscopy TUES Trans-Umbilical Endoscopic Surgery TUSPLS Trans-Umbilical Single Port Laparoscopic Surgery a) NOTES: Natural Orifice Transluminal Endoscopic Surgery 795

4 Lee WJ Table 2. Common problems of single port laparoscopic surgery Loss of conventional triangulation offered with conventional multi-port laparoscopic surgery Crowding between camera&instrument (intracorporeal & extracorporeal crowding) Crowding between instruments (intracorporeal&extracorporeal) Poor ergonomic position Steep learning curve Problem of conventional trocars (number of trocars, insertion, secure placement, gas leak) Patient related limitation (obesity, poor angle&distance problem using umbilicus for entry) 796

5 Single port laparoscopic surgery Figure 1. Picture of 45 cm 45 angled bariatric length laparoscope with right angle light cable adapter and Instrument (upper) and 34 cm Standard 45 angled laparoscope and instrument. 797

6 Lee WJ Figure 2. Picture of making Glove port with Wound retracter and globe and conventional trocars (A, B, C) and (D) Outside view of single port laparoscopic cholecystectomy. A C B D 798

7 Single port laparoscopic surgery Figure 3. Picture of OCTO TM Port (Dalim SurgNET Corp, Korea: 799

8 Lee WJ Figure 4. Picture of TriPort TM (ASC port, Olympus: Figure 5. Picture of SILS TM Port (Covidien Inc, Norwalk, CT, USA: 800

Single port laparoscopic surgery Figure 6.

9 Single port laparoscopic surgery Figure 6. Uni-X TM Single Port Access with three working channels (Pnavel System, Inc). Figure 8. Picture of Glove Port (Nelis, Seoul, Korea). Figure 7. Picture of AirSeal TM Port and Insufflator (SurgiQuest, Orange, CT, USA: 801

10 Lee WJ A B Figure 9. (A) Picture of outer view during Single Port Laparoscopic Cholecystectomy using Glove port with 45, 45 cm bariatric laparoscope and two 45 cm long instrument for retraction of GB fundus and Hartman's pouch and one Laparoangle instrument for dissection. (B) Picture of inner view during same operation. 802

Single port laparoscopic surgery Figure 10. Picture of Roticulator TM (Covidien, Norwalk, CT, USA : www.sils.com). Table 3.

11 Single port laparoscopic surgery Figure 10. Picture of Roticulator TM (Covidien, Norwalk, CT, USA : Table 3. Technical tip of using instrument for easy single port laparoscopic surgery 1. Slim and small sized handle 2. Articulating instruments (tip and handle) 3. Curved instruments (tip and handle) 4. Use long length instruments (using instrument of variable lengths) 5. Idea of crosshanded instrumentation 803

Model for Single Port Laparoscopic Surgery (CambridgeEndo, MA, USA: www.

12 Lee WJ Figure 11. (A) Picture of Handle of Autonomy Laparoangle and (B) Picture of Slim Handle Model for Single Port Laparoscopic Surgery (CambridgeEndo, MA, USA: Figure 12. Picture of Realhand (Novare Surgical, CA, USA: idgeendo, MA, USA: A B 804

13 Single port laparoscopic surgery Figure 13. HiQ LS curved 5 mm Hand Instruments (Olympus, Japan; nr091013lesse.html). 805

14 Lee WJ REFERENCES 11. Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointes Endosc 2004; 60: Kim HJ, Lee JI, Lee YS, Kang WK, Lee SK, You YK, Oh ST. A case of single port laparoscopic appendectomy and cholecystectomy in a fresh cadaver: A feasible procedure. J Korean Soc Coloproctol 2009; 25: Jung YW, Kim SW, Kim YT. Recent advances of robotic surgery and single port laparoscopy in gynecologic oncology. J Gynecol Oncol 2009; 20: Goel RK, Kaouk JH. Single port access renal cryoablation (SPARC): a new approach. Eur Urol 2008; 53: Peer Reviewers Commentary 806

DBPIA-NURIMEDIA

DBPIA-NURIMEDIA 27(2), 2007, 96-121 S ij k i POP j a i SEXR j i AGER j i BEDDAT j ij i j S ij S ij POP j SEXR j AGER j BEDDAT j k i a i i i L ij = S ij - S ij ---------- S ij S ij = k i POP j a i SEXR j i AGER j i BEDDAT