Single site laparoscopic surgery: An intermediate step toward no (visible) scar surgery or the next gold standard in minimally invasive surgery?

The history of modern and contemporary surgery is characterized by the constant quest for decreasingly invasive techniques, for less overall surgical trauma and more limited destruction of organs. The laparoscopic revolution that commenced in the late nineteen-eighties is the most striking evidence of this phenomenon. Technological progress is leading (might lead) gradually to operations in which the surgeon, instead of creating artificial openings in the body wall, reaches internal organs by means of the body’s natural orifices. A segment of this trend is the growth of single-access laparoscopic surgery (Figure 1). In July 2008 a white paper entitled “Consensus Statement of the Consortium for Laparo-Endoscopic Single-Site (LESS) Surgery” was submitted by a group of urologists, gynecologists, colorectal surgeons and general surgeons who had gathered for the occasion at the Cleveland Clinic. That was the start of the LESSCAR Consortium, an analog of the NOSCAR consortium created for the study, research, development and assessment of NOTES techniques (1). Until then, laparoscopic access via a single pathway to the peritoneal cavity had been performed mostly in specialized surgical facilities, and publication was sporadic, usually in the form of technical notes or case reports, without any tangible evidence concerning outcomes, potential benefits and possible drawbacks of the new methodology. The working environment of single-access laparoscopic surgery resembles that of a procedure developed by Gerhard Buess in the mid-nineteen-eighties: Transanal Endoscopic Microsurgery TEM (2). Two or three long instruments equipped with an optical system are inserted through a cannula specifically designed for this sort of surgery, possessing a diameter greater than that of common laparoscopic trocars. They are almost parallel. The space for maneuver is very cramped. Consequently single-access laparoscopic surgery can be particularly strenuous and sometimes demands great manual skill of the surgeon. However, these restrictions, albeit limiting, do not mean that single-access laparoscopic surgery must deal with every single issue typical of natural orifices transluminal endoscopic surgery (NOTES). Its conversion into standard laparoscopic surgery is extremely simple, requiring only the placement of additional cannulae through the abdominal wall without, however, causing unneeded injury to other organs. The ability to perform an operation leaving only virtually invisible scars (the sole incision is usually made at the navel, where our abdomen already bears such a scar) is likely to improve postoperative quality of life. Accordingly, this new approach enthralls its users, driving the technique to spread far and wide. The expansion of single-access laparoscopic techniques was matched by an exponential increase in the number of papers published on the subject, both in general surgery, as well as in urology and gynecology. The graph of Figure 2 shows growth in publications on the subject between 2008 and 2011, obtained by performing a PubMed search entering the following search terms (MeSH Medical Subject Headings): SPA – Single Port Access, SILS – Single Incision Laparoscopic Surgery, LESS – Laparoendoscopic Single-Site Surgery, One Port Laparoscopic, Single Port Laparoscopy. At the same time, responding to the need for medical evidence that this new