Natural orifice transluminal endoscopic surgery (NOTES) is a new concept and technique that has emerged in recent years. The basic concept is to reduce or conceal surgical scars, reduce postoperative pain, and promote postoperative recovery [13]. Endoscopic surgical techniques via the stomach, rectum, vagina, and urethra are still in the experimental stage due to many objective constraints, such as safe abdominal access, safe closure of the cavity organ puncture opening, infection, and suturing techniques. The umbilicus is a natural embryonic orifice and an inherent scar in the human body, so transumbilical surgery should also fall into the NOTES category. This procedure can achieve the effect of hiding the abdominal scar, avoiding the problem of infection through the stomach, vagina or rectum, and allowing the use of traditional laparoscopic instruments, making transumbilical single-port laparoscopic surgery the most feasible NOTES technique at this stage. I. Nomenclature of transumbilical single-port laparoscopic surgery There is no unified international nomenclature for single-port laparoscopic surgery. Some of the current names come from individual physicians, some from research institutions, and some from industrial manufacturers. Drexel University College of Medicine was an early adopter of single-port laparoscopic surgery, and they named the technique singleport access (SPA), which has become a trademark of Drexel University. Several industrial companies involved in the development of single-port laparoscopic instruments have also named this technology. For example, Covidien calls it singleincision laparoscopic surgery (SILS); Johnson & Johnson endoSurgery (I nc), calls it singlesite laparoscopy (SSL). . Because single-site laparoscopy is performed primarily through the umbilicus, some surgeons include “transumbilical” in the name. For example: oneport umbilical surgery (OPUS), transumbilical endoscopic surgery (TUES), natural orifice transumbilical surgery (NOTUS), etc, NOTUS) and so on. At present, the more common name is laparoendoscopic singlesite surgery (LESS). In China, there is no clear name for it, but it is usually called “transumbilical singleincision laparoscopic surgery (TUSILS)”. In 1969, Clifford Wheeless [4] first reported transumbilical laparoscopic tubal ligation. Thereafter, Wheeless performed the procedure in 85 outpatients under local anesthesia within 2 years. In 1991, Pelosi et al [5] performed a successful uterine and bilateral tubal oophorectomy using a single-port technique. This was the first combined multivisceral resection with a single orifice. The following year, they performed a single-port laparoscopic supracervical hysterectomy in a patient with benign uterine lesions [6]; in the same year, they reported 25 cases of single-port laparoscopic appendectomy. 2007 Raman et al [7] first reported 3 cases of transumbilical single-port laparoscopic nephrectomy, and in 2008 Gill et al [8] successfully performed 4 cases of transumbilical single-port donor nephrectomy in living kidney transplant donors. In 2009, Canes et al [9] performed a controlled chart study of single-port laparoscopic and conventional laparoscopic left-sided donor nephrectomy and showed that patients who underwent single-port laparoscopic surgery had a faster postoperative recovery. Early transumbilical single-port laparoscopic cholecystectomies mostly required an assisted poke in the abdominal wall. transumbilical single-port cholecystectomy was first reported by Navarra [10] in 1997. In 1999, Bresadola et al [11] reported a group of two-port laparoscopic cholecystectomies via the umbilicus and subcostal arch with an auxiliary operating hole. Cuesta et al [12] performed 10 single-port laparoscopic cholecystectomies through the umbilicus by using a 1 mm diameter kleptoplasty needle to suspend and tract the gallbladder through the subcostal arch. In India, Palanivelu et al [13] reported 10 cases of transumbilical laparoscopic cholecystectomy assisted by a 3 mm diameter grasper placed under the costal arch, and in May 2007, Podolsky et al [14] from Drexel University College of Medicine performed the world’s first complete transumbilical uniportal laparoscopic cholecystectomy without any auxiliary poking, marking the maturity of uniportal laparoscopy. In 2008, Bucher et al [15] reported a right hemicolectomy. At this point, the use of single-port laparoscopy in general surgery began to receive attention. In addition, other procedures performed with transumbilical single-port laparoscopic techniques include ovarian cystectomy [16], salpingo-oophorectomy [17], and Meckel diverticulectomy [18]. The development of single-port laparoscopic surgery in China The start of transumbilical single-port laparoscopic technology in China is slightly later than that in Europe and the United States, but it is developing rapidly. This was the first completely transumbilical single-port laparoscopic operation without any auxiliary poking in China. To date, we have performed more than 100 transumbilical uniportal laparoscopic cholecystectomies. On this basis, we were the first in China to perform combined cholecysto-appendicectomy [21], hepatic cystotomy on August 4, 2008, intrahepatic biliary cystadenoma on April 14, 2009, ileal resection on August 6, 2009, and splenic cystotomy on August 11, 2009. On August 1, 2009, under the leadership of the Chinese Society of Surgery, the Chinese Group for Transnatural Orifice Endoscopic Surgery (CNOTES) was established, marking the beginning of active exploration of the NOTES technique by Chinese surgeons. Under the organization and advocacy of CNOTES, laparoscopic surgeons in China have carried out transumbilical single-port laparoscopic surgery, which has been carried out in Beijing, Shanghai, Guangzhou, Zhejiang, Sichuan, Yunnan, Guizhou, Jiangxi, Shandong, Liaoning, Henan, Fujian, Hubei and other provinces and cities one after another. The types of surgery are mainly laparoscopic cholecystectomy, but also include liver cyst windowing and hernia repair. On this basis, the first domestic symposium on single-port laparoscopic surgery was hosted by CNOTES in Shanghai from September 11, 2009 to November 12, 2009, which demonstrated the latest achievements of single-port laparoscopic surgery in China and conducted in-depth discussions on related issues. Improvements in single-port laparoscopic instruments The surgical procedure of transumbilical single-port laparoscopic surgery technique is basically the same as that of traditional laparoscopic surgery, but under single-port conditions, the laparoscope and various instruments enter the abdominal cavity almost parallel to each other, causing a series of operational difficulties [12]. Such as inline vision IV, difficulty in forming triangulation of the instruments, and crowding of the Trocar and instrument handles in the external part of the abdominal cavity (EIC). Therefore, the difficulty of the procedure can be significantly reduced if the puncture instruments can be modified. In the early days of transumbilical single-port laparoscopic cholecystectomy, we used a homemade 3-channel anti-air leakage device, which was relatively rudimentary and prone to air leakage. After continuous exploration, a small incision about 3 cm long was made at the upper edge of the umbilical port, the skin was incised, the subcutaneous fat was separated to the anterior rectus abdominis sheath, and one 10-mm and two 5-mm Trocar were inserted directly through the incision in sequence, using the rectus abdominis muscle and the rectus abdominis sheath to prevent air leakage with good results. After completion of the procedure, the 2 poke holes were connected, the specimen was removed, and the poke holes and incision were routinely sutured, with no complications such as umbilical hernia to date. This approach is simple and easy to perform, using reusable conventional laparoscopic instruments, without increasing the financial burden on the patient. Moreover, this approach has been used to perform routine surgical operations such as cholecystectomy, appendectomy, and hepatic cyst windowing, and has some clinical value. At present, most foreign countries use multiple orifice puncturers, such as Triport (Olympus), S ILS Por (t Covidien) and UniX (Pnavel Systems, Morganville, NJ, USA). These puncturers alleviate the mutual interference between surgical instruments to a certain extent, which makes the operating angle larger and the operation less difficult, and are suitable for application in more complex single-port laparoscopic surgery. We performed the first transumbilical single-port laparoscopic ileal resection in China with the Triport. In order to increase the operating angle of instruments in the abdominal cavity, various manufacturers have developed corresponding surgical instruments, such as bendable grasping forceps, separating forceps, scissors; 5 mm laparoscopes with bendable tips, etc. The RealHand series of surgical instruments has multiple joints that allow for greater flexibility in a variety of operations, and its 5 mm diameter is a great space saver. Curcillo [22] at Drexel University College of Medicine in Philadelphia, USA, has performed nearly 100 transumbilical single-port laparoscopic procedures including appendectomy, hernia repair, cholecystectomy, bariatric surgery, splenectomy, and some gynecologic and urologic procedures with this device. The Covidien autosuture series laparoscopic instruments are used in our hospital, and they are easily applied by forming different bending angles according to the operation needs. Some doctors also make their own instruments according to their needs. It is the pursuit of all surgeons to minimize surgical trauma while ensuring the safety and effectiveness of treatment, and it is also the development direction of surgery. In the past 20 years, laparoscopic surgery has developed rapidly, involving almost all organs in the abdominal cavity; lesions of all organs in the abdominal cavity can be done through laparoscopy. At the same time, laparoscopic surgery has achieved minimally invasive results that are incomparable to open surgery (laparoscopic cholecystectomy, for example, can be discharged on the first day or even the same day after surgery). However, it is still impossible to completely replace open surgery with laparoscopic surgery, and the two are bound to coexist in the long term. Similarly, the single-port laparoscopic technique is a product of the continuous development of laparoscopy in a minimally invasive direction and is the most feasible technique in the NOTES field at this stage. With advances in instrumentation and equipment, uniportal surgery will certainly take its place in abdominal surgery, but it is not yet foreseeable that it will completely replace conventional laparoscopic surgery, and the relationship between the two should be long-term coexistence and mutual complementarity. At this stage, single-port laparoscopic surgery should have stricter indications for benign intra-abdominal lesions (including gallbladder stones, gallbladder polyps, hepatic hemangiomas, liver cysts, hepatic cystic adenomas, benign spleen tumors, etc.), early tumors of the gastrointestinal tract (including mesenchymal tumors), and bariatric surgery. Whether a new technology can be widely used and promoted in clinical practice must go through 3 stages of examination: (1) the preclinical research stage (i.e., exploration of new technology), which gradually improves instrumentation and equipment and skilled operation skills; (2) the clinical research stage (i.e., controlled research with traditional surgery), which provides scientific theoretical basis for clinical application; and (3) the clinical promotion stage, which makes the new technology gradually popular and benefit the majority of patients. At present, we are planning to conduct a clinical control study of transumbilical single-port laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy. In conclusion, with the advancement of technology and the maturity of instruments and equipment, based on clinical studies, uniportal surgery will definitely occupy a certain position in the treatment of benign abdominal lesions and early tumors. For benign intra-abdominal lesions that can be accomplished by single-port surgery, it should be advocated to use single-port surgery as much as possible.