Over recent decades, the evolution of laparoscopic techniques has transformed much of the traditional surgery. Compared to an open approach, minimally invasive techniques have proven effective in reducing surgical trauma, thereby improving patient recovery and length of hospital stay [1
]. Benefits of improved postoperative pain and cosmesis are now well established for many operations [3
However, the true birth of laparoscopy can be dated to over 100 years ago when George Kelling from Dresden, Germany, introduced a cystoscope into the peritoneal cavity of a living dog and insufflated air to enhance the view [3
]. Surgery of the gallbladder has tremendously evolved over the last century. Carl Langenbuch performed the first successful cholecystectomy on a 43-year-old man with symptomatic cholelithiasis in 1882 [7
]. More than a century later (in 1985), German surgeon Eric Mühe [8
] applied the technique of laparoscopy to remove a gallbladder using a modified laparoscope, called the galloscope. It was soon thereafter (1987) that the advent of the computer chip television camera allowed Phillipe Mouret to perform the first video-laparoscopic cholecystectomy [9
Today, laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common laparoscopic surgical procedure in the world. Numerous reports have provided overwhelming evidence that laparoscopy provides better cosmetic results, less postoperative pain, and shorter recovery time when compared with open cholecystectomy [7
]. However, the quest to develop even more minimally invasive surgical techniques in order to enhance the advantages of laparoscopy remains robust. This quest has led surgeons to seek to minimize the number and the size of incisions, or in the case of natural orifice transluminal endoscopic surgery (NOTES), eliminate skin incision(s) altogether. The hope of these more minimally invasive procedures is that they will also lead to minimal or no postprocedural pain while improving cost-effectiveness and patient safety.
Although totally incisionless surgery remains an impossible idea at present, NOTES, initially performed in animal models, [10
] is now a clinically relevant idea with anecdotal procedures having been performed on human subjects worldwide. Reddy and Rao [11
] are credited with performing the first transgastric appendectomy in a human without an external incision, and Marescaux et al. [12
] performed the first cholecystectomy via a natural orifice. As a bridge between traditional laparoscopy and NOTES, recent focus has been on the development of single-incision laparoscopic surgery (SILS) to further minimize the invasiveness of laparoscopy by reducing the number of incisions, and hopefully the pain and complication(s) associated with them. SILS was described as early as 1992 by Pelosi and Pelosi [13
] who performed a single-puncture laparoscopic appendectomy and in 1997 by Navarra et al. [14
] who performed a laparoscopic cholecystectomy via two transumbilical trocars and three transabdominal gallbladder stay sutures. These innovations, either exclusively or in a hybridized fashion, have now been applied to a wide variety of surgical procedures.
Technological improvements have led to a progressive contraction in the size and number of operating ports; hence, reducing abdominal wall trauma and providing further benefits for the patients [15
]. The switch from four to single incision has constantly shown better outcomes in terms of postoperative pain and cosmetic results [16
], and may reduce the risk of trocar-site-related complications such as incision hernia or infections.
Single-port laparoscopic surgery is increasingly being performed today. It is deemed a safe and effective procedure, but has not yet passed the acid test because of operative difficulties, partly due to the lack of adapted instruments [19
]. Since operating instruments come from a single port, there is a lack of triangulation with repeated conflicts between operating instruments as well as a lack of proprioception due to the crossing of instruments with difficult exposure of organs and structures [20
]. Surgeons have to get used to these new surgical constraints and may be starting a new learning curve.
Unlike NOTES, to date, no consensus terminology has emerged for this technique of minimally invasive surgery. Many terminologies, seemingly centered on the type of acronym they will create, have been used rather than a description of the access technique and exposure methods [21
]. One of the early nomenclatures to gain popularity was single-port access (SPA) surgery.
Manufacturers of instruments have also adopted nomenclature of their own. Covidien Inc. has termed this new technique as single-incision laparoscopic surgery (SILS), whereas Ethicon EndoSurgery Inc. has proposed the nomenclature of single-site laparoscopy (SSL) [21
Some of the nomenclature is based on the site of access such as one-port umbilical surgery (OPUS) or transumbilical endoscopic surgery (TUES), embryonic NOTES (eNOTES), and natural orifice transumbilical surgery (NOTUS). Other nomenclature suggested include single laparoscopic port procedure (SLAPP), single-port laparoscopic surgery (SPLS), single-port laparoscopy (SPL), single laparoscopic incision transabdominal (SLIT) surgery [21
A recent symposium, convened to arrive at a consensus regarding the single-port concept, has suggested the name laparoendoscopic single-site surgery (LESS) [22
]. Another nomenclature that implies facility with the technique is single-incision multiple-port laparoscopic surgery (SIMPLE). Regardless of the final nomenclature that emerges there is a current lack of consensus about the nomenclature for this evolving technique.
Single-incision laparoscopic surgery can be broadly classified into three types based on the method of access:
- Single-incision single-port surgery
- Single-incision multiple-port surgery
- Single-incision direct access surgery