Overview of single-port laparoscopic surgery for colorectal cancers: past, present, and the future

Abstract

Single-port laparoscopic surgery (SPLS) is implemented through a tailored minimal single incision through which a number of laparoscopic instruments access. Introduction of operation-customized port system, utilization of a camera without a separate external light, and instruments with different lengths has brought the favorable environment for SPLS. However, performing SPLS still creates several hardships compared to multiport laparoscopic surgery; a single-port system inevitably leads to clashing of surgical instruments due to crowding. To overcome such difficulties, investigators has developed novel concepts and maneuvers, including the concept of inverse triangulation and the maneuvers of pivoting, spreading out dissection, hanging suture, and transluminal traction. The final destination of SPLS is expected to be a completely seamless operation, maximizing the minimal invasiveness. Specimen extraction through the umbilicus can undermine cosmesis by inducing a larger incision. Therefore, hybrid laparoscopic technique, which combined laparoscopic surgical technique with natural orifice specimen extraction (NOSE)--i.e., transvaginal or transanal route-, has been developed. SPLS and NOSE seemed to be the best combination in pursuit of minimal invasiveness. In the near future, robotic SPLS with natural orifice transluminal endoscopic surgery's way of specimen extraction seems to be pursued. It is expected to provide a completely or nearly complete seamless operation regardless of location of the lesion in the abdomen.

Keywords: Colectomy; Colorectal neoplasms; Laparoscopy; Natural orifice endoscopic surgery; Single-port laparoscopic surgery.

Figure 1

Ports designed for single-port laparoscopic surgery. A: Materials for making homemade glove port (two-piece, terminal type); B: OCTO port (Dalim medical Co., South Korea) (two-piece, terminal type); C: Single incision laparoscopic surgery port (Covidien, United States) (one-piece, preoccupied type); D: Commercial glove port (Sejong medical Co., South Korea) (one-piece, terminal type).

Figure 2

Concept of triangulation vs inverse triangulation. Triangulation in multiport laparoscopic surgery allows traction on tissues to improve dissection along anatomical planes (A). In inverse triangulation of single-port laparoscopic surgery, the two instrumental ends do not encounter, but assist each other by creating tension (B). Therefore, the operation is carried out with the two instruments crossed-over.

Figure 3

Hanging suture. To facilitate operative field during total mesorectal excision, the uterus in female (A) or the peritoneal fold in male (B) were elevated by placing an intracorporeal stitch through the low abdominal wall.

Figure 4

Transluminal traction. A PPH (procedure for Prolapsed and Hemorrhoid Endo-Surgery, Ethicon, United States) was utilized to support the colorectum during dissection and to facilitate dissection by shifting the colorectum’s location as well.

Figure 5

Laparoscopic instrument holder. An installation of a laparoscopic instrument holder in operation bed (A). Application of a laparoscopic instrument holder during single-port laparoscopic surgery (B).

Figure 6

Umbilicus-sparing single-port laparoscopic surgery. After making a incision for single-port to the predetermined enterostomy site (A), a single-port was inserted (B), and operation was accomplished through the enterostomy site (C). Postoperatively, no scar, except for enterostomy, remained (D).