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BJU Online Article

(20 Oct 2007)

Single-incision laparoscopic surgery: initial urological experience and comparison with natural-orifice transluminal endoscopic surgery


·         Jay D. Raman,


·         Jeffrey A. Cadeddu,


·         Pradeep Rao**Mamata Hospital, Mumbai, India, and and


·         Abhay Rane†Department of Urology, East Surrey Hospital, Redhill, UKAbhay Rane, Department of Urology, East Surrey Hospital, Canada Avenue, Redhill RH1 5RH, UK.
e-mail: a.rane@btinternet.com

  • Department of Urology University of Texas Southwestern Medical Center, Dallas, TX, USA, *Mamata Hospital, Mumbai, India, and †Department of Urology, East Surrey Hospital, Redhill, UK
Abhay Rane, Department of Urology, East Surrey Hospital, Canada Avenue, Redhill RH1 5RH, UK.
e-mail: a.rane@btinternet.com

: NOTES , natural-orifice transluminal endoscopic surgery ; SILS , single-incision laparoscopic surgery ; SPA , single-port access ; OPUS , one-port umbilical surgery ; MAGS , magnetic anchoring and guidance system.




Laparoscopic approaches have increasingly assumed a central role in the management of benign and malignant surgical diseases. While laparoscopy is less morbid than open surgery, it still requires several incisions, each ≥1–2 cm long. Each incision risks morbidity from bleeding, hernia and/or internal organ damage, and incrementally decreases cosmesis. An alternative to conventional laparoscopy is single-incision laparoscopic surgery (SILS), in which articulating or bent instrumentation with specialized multi-lumen ports is used. These technical innovations obviate the need to externally space trocars for triangulation, thus allowing the creation of a small, solitary portal of entry into the abdomen. Laboratory and early clinical series showed the feasibility as well as safe and successful completion of SILS. Natural-orifice transluminal endoscopic surgery (NOTES) is another exciting development in minimally invasive urology, but existing flexible endoscopes and instruments are limited in providing a platform for this form of advanced surgery, resulting in the slow adoption of NOTES. Future work is needed to improve existing instrumentation, increase clinical experience, assess the benefits of both surgical approaches, and explore other potential applications for these novel techniques.



Open surgical approaches have historically been the reference standard therapy for managing benign and malignant internal diseases. Despite the development of open surgery, there is considerable morbidity and delayed convalescence after open surgical procedures. Since the first laparoscopic nephrectomy by Clayman et al. [1] in 1991, minimally invasive urological surgery has gained significant momentum. The advantages of laparoscopic surgery over open surgery are well established [2,3]. While the laparoscopic approach decreases surgical morbidity, it still requires three to four incisions each ≥1–2 cm long. In addition, each working port risks morbidity from bleeding, hernia and/or internal organ damage, and incrementally decreases cosmesis [4,5]. Cosmesis is particularly important in procedures on children, and is increasingly demanded by discerning adult patients [6]. In an effort to reduce these sequelae of laparoscopy, some groups have advocated specimen morcellation and transvaginal extraction of specimens [7,8], but both techniques are infrequently practised.



NOTES has been described as the next surgical frontier with the objective of incision-free abdominal surgery. NOTES approaches abdominal surgery through natural orifices (mouth, vagina and rectum) thus obviating external abdominal scars. Animal models have been used to show the potential applications of NOTES, including transgastric and transvesical peritoneoscopy, transvaginal tubal ligation, hysterectomy, and cholecystectomy [9,10]. Recently, two transvaginal cholecystectomies were described. The first was in New York, USA, in a 66-year-old patient [11], and the second in Strasbourg, France, in a 30-year-old patient [12]. Subsequent preliminary clinical series in human patients with transvaginal NOTES cholecystectomy similarly appear to be promising [13].

The first urological application of NOTES was by Gettman et al. [14] in 2002, who reported the successful completion of six laparoscopic transvaginal nephrectomies using conventional instrumentation in a porcine model. Notably, five nephrectomies still required the use of one conventional laparoscopic port. Further, the authors noted that limitations of standard laparoscopic and endourological instrumentation made the procedure ‘cumbersome and time-consuming’. A key requirement of NOTES surgery, as identified by the Natural Orifice Surgery Consortium for Advancement and Research, is a stable surgical platform to support and guide the flexible endoscope and instruments. Existing flexible endoscopes and instruments are limited in providing a platform for advanced surgery, resulting in this technique languishing for several years. More recently, Clayman et al. [15] reported their experience with single-port NOTES nephrectomy using a purpose-built multilumen transvaginal operating platform (TransPortTM Multi-Lumen Operating Platform, USGI Medical, San Clemente, CA, USA). This flexible device has four working channels and can be locked into position, thereby creating a rigid multitasking platform that allows two-handed tissue manipulation. However, notably, a 12-mm midline transabdominal port was still necessary to deploy an endoscopic stapler across the renal pedicle.

While appearing promising, potential drawbacks to NOTES nephrectomy are significant. The operative duration is significantly longer than conventional laparoscopy, specialized equipment is necessary, and the newer instrumentation and operative approach requires extensive training and experience.


Triangulation is one of the fundamental concepts of conventional laparoscopic surgery. Adequate external placing of trocars allows the intracorporeal spacing of instrumentation to facilitate traction and anatomical dissection. Further, triangulation minimizes collision or ‘sword fighting’ of laparoscopic instruments, both externally and internally. An alternative to conventional laparoscopy and NOTES is SILS, which uses articulating or bent instrumentation with specialized multilumen ports. Such instrumentation would obviate the need to space trocars for triangulation, allowing for the creation of a small, solitary portal of entry into the abdomen.


As the urological applications of SILS expand, various nomenclature and terminology have been used to describe similar surgical methods. Single-port access (SPA) broadly encompasses surgical laparoscopic techniques performed through one port, either via a transperitoneal or retroperitoneal approach. Indeed, the first series of single-port endoscopy was reported by Hirano et al. [16] in 2005, who used a 4-cm resectoscope tube to perform retroperitoneoscopic adrenalectomy in 53 patients. While no insufflation was used, the procedure otherwise deployed standard laparoscopic instrumentation. Thus, while the surgical technique was not truly laparoscopic, it did provide the platform for the development of SPA surgery. A variant of SPA surgery is one-port umbilical surgery (OPUS), which is a similar concept, although using a transumbilical port. This approach is transperitoneal and potentially affords maximal benefits of cosmesis, with the surgical incision hidden within the umbilicus. Finally, several groups have published single-access or ‘keyhole’ surgery which uses adjacent 5-mm trocars with skin incisions connected at the time of specimen extraction. This latter concept seeks to accomplish the same goal of single-port surgery without the incremental cost of multi-access port technology.


Successful SILS involves the use of articulating or bent instrumentation via a single large-calibre trocar or small, adjacent trocars. Advances in technology have led to the development of new laparoscopic access ports (R-Port, Advanced Surgical Concepts, Wicklow, Ireland; and Uni-X Single PortTM, PNavel Systems, Cleveland, Ohio, USA) capable of allowing several instruments to be inserted through different cannulae of a single port.

Articulating and bent instrumentation allows for triangulation intracorporeally despite trocars being adjacent to one another through the same skin incision. Currently, articulating laparoscopic graspers and shears (Real HandTM, Novare Surgical Systems, Cupertino, CA, USA; and Autonomy Laparo-angleTM, Cambridge Endo, Framingham, MA, USA), endoshears (Cambridge Endo), and laparoscopic needle drivers (Cambridge Endo) are commercially available for clinical use. Bent laparoscopic instrumentation is more cost-effective than articulating equipment, although the restriction on the degrees of freedom might result in more difficult in learning to use them. The optimum use of instrumentation requires crossing intracorporeally such that tissue manipulation, traction, and diathermy are performed with the contralateral hand compared with conventional laparoscopy. Such differences and collision of instrumentation creates an inherent difficulty in learning the techniques during initial procedures, although this is significantly easier than for NOTES.

Another important instrumentation component is the selection of an appropriate laparoscope to optimize visualization while minimizing collision with working instruments. Clearly, suboptimal visualization can result in the procedure failing to progress, while potentially increasing the surgical risk to patients. Anecdotally, in our experience, laparoscopes using right-angled light sources were problematic due to collision with working instruments. More recently, we have used a 45° 5-mm rigid laparoscope with an end light source (Karl Storz, Tuttlingen, Germany) or a 5-mm deflectable tip video laparoscope (Olympus, Orangeburg, NY, USA).



SILS has been reported for appendectomy [17] and cholecystectomy [18] since 1998, although the approach failed to gain momentum for several years, due to technical limitations with conventional instrumentation. The technical innovations described above have ushered a recent renaissance for SILS. Raman et al [19] recently reported their initial experience with SILS nephrectomy in a porcine model and in human subjects. In that series, SILS nephrectomy was successfully completed in all eight porcine renal units and in all three human subjects. The mean (range) operative duration for the porcine nephrectomies was 49 (20–85) min, with a mean blood loss of 20 (5–100) mL. The incision size was 3–5 cm. The mean operative duration for the human nephrectomies was 133 (90–160) min, the estimated blood loss 30 mL, and the kidneys were extracted through a solitary 2–4.5 cm peri-umbilical incision. There were no perioperative complications, and all three patients were discharged after 2 days.

Small clinical series have further supported the feasibility, safety and successful completion of SILS for urological disease. Rane et al. [20] reported five human cases (two simple nephrectomies, ureterolithotomy, orchidopexy, and orchidectomy) with successful surgical outcomes. Desai et al. [21] similarly reported on the successful completion of a single-port transumbilical nephrectomy and pyeloplasty. Other small series show similarly promising outcomes, with surgical procedures including nephrectomy, adrenalectomy, pyeloplasty, renal cryotherapy, and sacrocolpopexy (Raman JD and Cadeddu JA, Single incision (keyhole) umbilical urologic surgery: initial clinical experience, University of Texas, Southwestern Medical Center, unpublished data; Kaouk JH and Desai MM, single-port laparoscopic surgery in urology: initial experience, Cleveland Cleveland Clinic Foundation, unpublished data; Curcillo PG, single-port access adrenalectomy using the Starion TLS and the Endoeye Videoscope, Philadelphia, PA Hahnemann University Hospital, unpublished data).

Although the early experience of SILS is promising, an experienced laparoscopic skills are essential for the safe and effective completion of surgery. The articulating and bent instrumentation requires training and experience, which can be readily assimilated in an animal or ‘dry’ laboratory [19]. Further, in many instances, despite using articulating or bent graspers and either the 45° rigid endoscope or the deflectable tip laparoscope, instrument collision, both internally and externally, is a constant challenge. As such, coordination between the surgeon and the camera driver is essential. Notably, OPUS does readily permit the introduction of other transabdominal conventional laparoscopic ports to aid completion of the surgical procedure should there be an intraoperative complication or failure of progression.


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The attractiveness of SILS is multifaceted. First, it improves cosmesis by allowing a single incision which can readily be hidden (particularly for OPUS). Second, it is within a surgeon’s ‘comfort range’, as specimens are extracted via the abdominal wall, as opposed to removal through a hollow viscus as required by NOTES. This might be a significant consideration as this technology is translated to lower-volume surgeons in the community, where vaginal or gastric incisions might present complications [9]. Third, as shown by the operative duration, it is more rapidly learned than NOTES. This is attributable to instrumentation that is similar to conventional laparoscopic devices. Also, SILS provides a ‘familiar’ anatomical view of the kidney, which might be lost during the development of transvaginal, transgastric or transcolonic surgery. Finally, the ability to rapidly and readily convert SILS to a conventional laparoscopic procedure ensures the safety of the patient is preserved during the early surgical experience.


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Future work with SILS is multifaceted. One novel approach is the use of magnetic anchoring and guidance system (MAGS) technology that can be used to actively control an intra-abdominal camera and working instruments introduced through a single trocar. Park et al. [22] recently developed a novel adjunct laparoscopic system comprised of a moveable, ‘lockable’ platform that is positioned intra-abdominally and stabilized by an external permanent magnet on the abdominal skin. In fact, Zeltser et al. [23] subsequently described the first successful completion of two porcine nephrectomies via one 15-mm transumbilical trocar using a prototype MAGS camera and a magnetically anchored robotic arm cauterizer.

The development of MAGS technology and articulating/bent instrumentation is necessary to improve the ergonomics and visualization of SILS. Proponents of SILS suggest that in addition to benefits for cosmesis, there is the possibility of less associated perioperative pain and morbidity. Comparison of short-term measures of convalescence to that of NOTES and traditional laparoscopic surgery are needed to better address this issue. Finally, exploring other potential applications for SILS with the hopes of optimizing surgical, aesthetic and patient-orientated outcomes are necessary. Future endeavours might involve more complicated operative procedures, such as laparoscopic partial nephrectomy and prostatectomy.



SILS is feasible; using varied instrumentation and technology, several groups have reported the safe and successful completion in both a porcine model and in human patients. NOTES is still developing; future work will need to assess the benefits and explore other potential applications for these novel approaches.



None declared.



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In (X)Synergy( )PubMed (MEDLINE)( )CrossRefBy keywords[ ]minimally invasive surgery[ ]single-port access[ ]one-port umbilical surgery[ ]natural-orifice transluminal endoscopic surgeryBy author[ ]Jay D. Raman[ ]Jeffrey A. Cadeddu[ ]Pradeep Rao[ ]Abhay Rane[ ][          ][GO]

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