With the idea of “scarless surgery” and the rise of natural cavity endoscopic surgery, it is the desire of every surgeon to reduce medical trauma and make the surgical approach more and more minimally invasive. Since its introduction into the field of minimally invasive surgery, the single-port laparoscopic technique, which not only has the advantages of conventional laparoscopic surgery but also hides the surgical scar, has received increasing attention. This paper reviews the origin of the term single-port laparoscopy; the development process and current application status at home and abroad, especially in gynecology; introduces the characteristics and technical improvements of single-port laparoscopy, and provides an outlook on the future of single-port laparoscopy.
I. Origin of LESS designation
As the application of transumbilical single-port single-port laparoscopy continues to expand, there are many different titles for this surgical modality. Drexal University Hospital was the first to perform single-port laparoscopic surgery, and they named the technique single-port access SPA, which became a trademark of Drexal University. Some surgeons include “transumbilical” in the name because single-port laparoscopy is done primarily through the umbilicus.
For example, single-port umbilical surgery, transumbilical access endoscopy. Because the umbilicus is the natural lumen of the embryonic period, some call it embryonic transnatural lumen endoscopic surgery or transnatural lumen transumbilical approach surgery.
In July 2008, a multidisciplinary panel of experts (the Single Site Laparoscopic Endoscopic Surgery Research and Assessment Society [LESSCAR]) determined that the term “single site laparoscopic endoscopic surgery (LESS)” is more scientific and accurate, and easy to understand. It is also easy to understand. Currently, LESS has been approved by the NOTES Working Group of the International Society for Endoscopy.
II. Development and application of single-port laparoscopy in foreign countries
The first case of transumbilical single-port laparoscopy was reported in gynecology: Clifford Wheeless first reported transumbilical single-port laparoscopic tubal ligation in 1969. A pneumoperitoneum was created through an incision approximately 1 cm below the umbilicus and a laparoscope with an eyepiece was placed. The fallopian tubes were exposed intraperitoneally by vaginal assisted retraction of the uterus, and the tubes were grasped and electrocauterized using a biopsy forceps. Subsequently, single-port transumbilical sterilization was performed on 3600 women.
A Brazilian gynecologist performed the first single-port tubectomy in 1975, and in 1991 Pelosi et al. first described laparoscopic uterine and bilateral tubo-ovarian resection, the first combined multi-vessel resection under single-port conditions. The following year, they performed a single-port laparoscopic next total hysterectomy in a patient with benign uterine lesions.
These are precedent reports of single orifice in our gynecology department and precedents for single orifice in the entire field of surgery. Although single-port originated in gynecology, ovarian cyst debridement and tubal pregnancy resection have been reported since then. However, due to technical shortcomings and perceptions, this technique has not been recognized by the majority of gynecologists and has not been further promoted.
After nearly 10 years of exploration, the development of single-port laparoscopic technique in the field of surgery has progressed rapidly. In 2007, Podoisky et al. from Drexel University School of Medicine completed the world’s first completely transumbilical single-port laparoscopic cholecystectomy without any auxiliary poke hole, marking the maturity of single-port laparoscopic technique. With the widespread use of single-port in general surgery and urology, LESS has once again attracted the attention of gynecologists under the guidance of the new concept of NOTES minimally invasive surgery and has been explored initially. There are numerous reports.
In 2008, Sotelo et al. reported the experience of hysterectomy performed by LESS. Fagotti et al. performed removal of three patients with giant ovarian cysts. Kim et al. operated on 24 patients with adnexal disease and 22 were successful, of which two failed because of severe pelvic adhesions and the other because of ovarian malignancy requiring an extended operation. yoon [21] performed tubectomy in 20 patients with ectopic pregnancy. Yoon [21] performed tubectomy in 20 patients with ectopic pregnancy.
III. Current development of single-port laparoscopic surgery in China
Single-port laparoscopic technology in China started late but developed rapidly, and on May 28, 2008, a 25-year-old patient with chronic cholecystitis underwent cholecystectomy at Friendship Hospital of Capital Medical University in Beijing, which was the first completely transumbilical single-port laparoscopic surgery without any auxiliary poke hole in China. In recent years, there have been many reports of single-port laparoscopy in general surgery and urology, such as: cholecystectomy; combined cholecysto-appendicectomy; nephrectomy; and adrenalectomy.
Single-port laparoscopy in gynecology is still in the preliminary exploration stage, and there are not many clinical reports. Gao Shusheng et al. performed single-port laparoscopic salpingo-oophorectomy in eight cases of tubal pregnancy. Gao et al. concluded that category 1 procedures in the Canadian Society of Obstetrics and Gynecology classification of laparoscopic surgery can be performed with transumbilical single-port laparoscopy, including laparoscopic tubal ligation, simple ovarian cyst aspiration by puncture, ovarian biopsy, microscopic adhesion separation, linear tubal dissection or tubectomy for ectopic pregnancy, electrocautery for stage 1 and 2 endometriosis, and perforation for polycystic ovary syndrome surgery.
Subsequently, Gao reported another 15 cases of ovarian cyst dissection. Li Lifang et al. reported one case of transumbilical single-port laparoscopic ovarian cyst debridement; Meng Yuanguang et al. performed two cases of single-port laparoscopic surgery, one for ovarian teratoma debridement and one for uterine fibroids with single-port laparoscopic-assisted cathartic total hysterectomy.
IV. Characteristics of transumbilical single-port laparoscopy
Compared with traditional multiport laparoscopy, the advantages of single-port laparoscopy include smaller intraoperative incision by concealing the incision in the navel, which results in a more aesthetic postoperative incision, and also reduces the potential morbidity caused by multiple incisions, reduces the risk of damage to intra-abdominal organs and blood vessels during perforation, and reduces postoperative incisional infection, formation of ventral hernia, and avoids postoperative adhesions at the perforation site;
Compared with NOTES, single-port has lower surgical difficulty, simpler instrumentation requirements, absence of abdominal contamination and potential risks inherent in crossing the natural cavity, and is more easily accepted by patients. However, compared to standard laparoscopic surgery, there is not sufficient literature support and evidence-based medical evidence such as intraoperative pain and complications.
The technical difficulties of single-port surgery are.
1, instrumentation: first, the interference of surgical instruments, all instruments of single-port surgery are entered into the abdominal cavity by an incision, extraperitoneal trocar and instrument handle crowding, which seriously affects the operation; second, various instruments behave as a linear field of view, which is more difficult for the operator to judge the distance and depth, and its violation of the principle of triangular distribution, poor exposure of the field of view; further, the endoscope used in traditional laparoscopic surgery and light sources mostly use optical tubes into the abdominal cavity, although there is also a certain angle in the design, but it is far from meeting the lighting requirements in single-hole surgery, especially in some cases when crossing the near organs to operate on distant surgical sites, it is more limited to the illumination of the surgical area.
2. In terms of case selection: for obese patients, it is difficult to expose the field of view because of the thick abdominal wall and the lack of effective traction at the surgical site. Compared with conventional laparoscopy, single-port does have many disadvantages in terms of instrumentation operation, so it has higher technical requirements for the operator, requiring the operator to first be familiar with mastering conventional laparoscopic techniques, and on this basis to gradually adapt to bendable instruments and different surgical views.
V. Improvement of transumbilical single-hole laparoscopic techniques
Single-port has a great dependence on surgical instruments, and the development of its technology must start from the improvement and application of various instruments. In this regard, many gynecologists and instrument companies at home and abroad have carried out extensive attempts and innovations.
1) Application of porous Trocar: The introduction of porous Trocar has played a good sealing effect and maintained the stability of the pneumoperitoneum. Moreover, most of the porous Trocar on the market nowadays are made of flexible tube sleeves made of elastic polymer, which increases the swing of the operating instruments and improves the operating space of the instruments.
2) The emergence of joint-linked rod: The biggest obstacle of single hole mentioned earlier is that all instruments enter the abdominal cavity by one hole, which is against the principle of triangular distribution, and in order to achieve an angular distribution between instruments there must be a soft bendable operating rod. The joint linkage rod is a bendable operating rod, its distal end is like a human wrist, the operator can operate the proximal end to drive the distal end bend through the linkage rod, the maximum bendable 80 degrees.
RealHand is a kind of joint linkage rod with more applications, including 11 different kinds of operating rods. The use of the joint linkage bar can meet can meet in a small space to complete the retraction, separation operation, conducive to the exposure of the field of view. Curcillo et al. at Drexel University College of Medicine have used this device to complete nearly 100 cases of transumbilical single-port single-port laparoscopic techniques including appendectomy, hernia patching, cholecystectomy, bariatric surgery, splenectomy, and some gynecological and urological surgeries.
3) Magnetic Anchoring Guidance System MAGS: MAGS is also an instrument designed to facilitate the exposure of the surgical site by retraction. The MAGS consists of an external magnetic anchor, an internal camera system, a passive tissue retractor and a robotic arm. Currently, the system is still in the animal testing phase.
VI. Outlook
The continuous development and evolution of the single-port laparoscopic concept in recent years, along with the rise of technologies such as robot-assisted laparoscopy the cross-fertilization of these technologies may lead to some new surgical modalities.
1 ) Combination of single-port laparoscopic techniques with robot-assisted laparoscopic techniques
The robot-assisted laparoscopic surgery system has advantages in terms of operational flexibility and can perform some difficult operations. The operational advantages can compensate for some operational difficulties in single-port laparoscopic techniques and reduce the difficulty of single-port. Currently, robotic-assisted single-port laparoscopic total hysterectomy with bilateral tubal and ovarian resection has been reported abroad.
2 ) Combination of single-port laparoscopy with NOTES
Kim et al [39] reported 43 cases of laparoscopic-assisted negative total hysterectomy under single-port laparoscopy and conventional laparoscopy respectively, comparing the two in terms of operative time, bleeding, decreased values of hemoglobin on the first and second postoperative day, and postoperative pain, which showed no significant difference between the two.
The uterus is a free organ of the pelvic cavity and is located close to the umbilicus, its unique “geographic location”, together with the hysterectomy lift, should be considered more advantageous than general surgery and urology.
The single-port laparoscopic technique differs from the traditional laparoscopic technique in terms of surgical instruments and operating techniques, and is a further development of the traditional laparoscopic technique, which is in line with the development trend of minimally invasive surgery and the humanistic aim of cosmetic wounding. At this stage, single-port is not a negation of the traditional laparoscopic technique of surgery, but a development and supplement to the traditional technique.
Single-port is currently in the clinical research stage, and there is no large sample, multicenter, prospective randomized controlled study to determine whether patients benefit from this technology, although it is also uncertain whether it is a developmental process of NOTES, but we believe that in the near future, it will take us into a new minimally invasive era.