Laparoendoscopic single site (LESS) splenectomy with a conventional laparoscope and instruments

Systematic review and meta-analysis of single-incision versus conventional multiport laparoscopic splenectomy

BACKGROUND

There is no consensus that single-incision laparoscopic surgery splenectomy (SILS-SP) is on a par with conventional multiport laparoscopic surgery splenectomy (CMLS-SP).

AIMS

The aim of this systematic review and meta-analysis was to assess feasibility and safety of SILS-SP when compared with CMLS-SP.

MATERIALS AND METHODS

Eligible articles were identified by searching several databases including PubMed, EMBASE, CNKI (China) and the Cochrane Library, up until February 2016. Studies were reviewed independently and rated by Newcastle-Ottawa Quality Assessment Scale. Evaluated outcomes were complications, operative time, post-operative hospital stay, blood loss, starting diet, post-operative pain scores, conversion and analgesic requirements.

RESULTS

Ten retrospective studies met the eligibility criteria. Overall, there was no significant difference between SILS-SP and CMLS-SP in complications, operative time, post-operative hospital stay, blood loss, starting diet, post-operative pain scores, conversion and analgesic requirements.

CONCLUSIONS

SILS-SP is feasible and safe in certain patients, with no obvious advantages over CMLS-SP. Therefore, it may be considered an alternative to CMLS-SP. We await high-quality, double-blind RCTs. These should include clear statements on standard scores of post-operative pain and cosmetic results, longer follow-up assessment and cost-benefit analysis.

Operative and Immediate Postoperative Differences Between Traditional Multiport and Reduced Port Laparoscopic Total Splenectomy in Pediatric Patients

BACKGROUND

Laparoscopy offers many benefits to splenectomy, such as reduced incisional pain and shortened hospital duration. The purpose of this study is to evaluate procedural and outcome differences between multiport (MP) and reduced port (RP) splenectomy when utilized to treat children.

PATIENTS AND METHODS

An institutional review board approved retrospective analysis of all consecutive laparoscopic total splenectomies performed at a single institution between January 2010 and October 2015 was conducted. We evaluated demographics, surgical technique, instance of conversion, operative duration, estimated blood loss, need for intraoperative blood transfusion, postoperative length of stay, time to full feeds, complications, and follow-up duration.

RESULTS

Over a 5-year period, 66 patients less than 20 years of age underwent laparoscopic total splenectomy. RP splenectomy was attempted in 14 patients. The remaining 52 were MP operations. Populations were comparable with regard to demographics. Preoperative splenic volumes (mL) were greater in the RP population (median [IQR]: 1377 [747-1508] versus 452 [242-710], P = .039). RP splenectomy demonstrated no difference compared to MP splenectomy in operative time (153 versus 138 minutes, P = .360), estimated blood loss (120 versus 154 mL, P = .634), or percent of cases requiring intraoperative blood transfusion (14 versus 23, P = .716). By the first postoperative day, 57% of RP and 17% of MP patients could be discharged (P = .005). Thirty-day readmission rates were similar, at 7% for RP and 8% for MP operations. Fever was the indication for all readmissions. Mean duration of follow-up is 28 months for MP and 13 months for RP cases.

CONCLUSION

A reduced number of ports can be safely utilized for total splenectomy in pediatric patients without increasing procedural duration or need for intraoperative blood transfusion. In addition, rate of discharge on the first postoperative day was significantly higher in the RP splenectomy group.

Single-incision laparoscopic splenectomy

Background and Objectives:

The single-incision approach in laparoscopic surgery is a relatively new concept. This systematic review of the literature was performed to appraise the existing clinical evidence concerning the use of the single-incision technique for spleen resection.

Methods:

We performed a systematic search of the PubMed and Scopus databases, and the studies retrieved were included in our review. The references of the included studies were also hand searched.

Results:

Thirty-one relevant studies were found in the field including 81 patients with an age range from 0.6 to 90 years and a body mass index range from 18 to 36.7 kg/m². Splenomegaly (44.6%), idiopathic thrombocytopenic purpura (31%), and immune thrombocytopenic purpura (6.8%) were the most common indications for the procedure. Concerning the applied port system, multiple single ports (5 to 12 mm) were used in 54.4% of patients, the SILS port (Covidien, Mansfield, Massachusetts) was used in 26.6%, the TriPort (Advanced Surgical Concepts, Wicklow, Ireland) was used in 7.6%, glove ports were used in 6.3%, and the GelPort (Applied Medical, Rancho Santa Margarita, California) was used in 5.1%. The median operative time was 125 minutes (range, 45–420 minutes), and the median quantity of blood loss was 50 mL (range, 10–450 mL). No conversion to open surgery and no transfusion were needed. The length of hospital stay was between 1 and 9 days. Low rates of complications and no patient deaths were found. The existing evidence on cosmesis is limited.

Conclusion:

Single-site/single-port laparoscopic surgery is a minimally invasive procedure that seems to be a challenging alternative in the management of spleen resection.

Single-site multiport combined splenectomy and cholecystectomy with conventional laparoscopic instruments: Case series and review of literature

INTRODUCTION

Conventional laparoscopic procedures have been used for splenic diseases and concomitant gallbladder stones, frequently in patients with hereditary spherocytosis since 1990's. The aim of this study is to evaluate the feasibility of single-site surgery with conventional instruments in combined procedures.

PRESENTATION OF CASE SERIES

Six consecutive patients who scheduled for combined cholecystectomy and splenectomy because of hereditary spherocytosis or autoimmune hemolytic anemia were included this study. Both procedures were performed via trans-umbilical single-site multiport approach using conventional instruments. All procedures completed successfully without conversion to open surgery or conventional laparoscopic surgery. An additional trocar was required for only one patient. The mean operation time was 190min (150-275min). The mean blood loss was 185ml (70-300ml). Median postoperative hospital stay was two days. No perioperative mortality or major complications occurred in our series. Recurrent anemia, hernia formation or wound infection was not observed during the follow-up period.

DISCUSSION

Nowadays, publications are arising about laparoscopic or single site surgery for combined diseases. Surgery for combined diseases has some difficulties owing to the placement of organs and position of the patient during laparoscopic surgery. Single site laparoscopic surgery has been proposed to have better cosmetic outcome, less postoperative pain, greater patient satisfaction and faster recovery compared to standard laparoscopy.

CONCLUSION

We consider that single-site multiport laparoscopic approach for combined splenectomy and cholecystectomy is a safe and feasible technique, after gaining enough experience on single site surgery.

REDUCE PORT LAPAROSCOPIC SPLENECTOMY FOR GIANT EPITELIAL CYST

BACKGROUND

Delaitre and Maignien performed the first successful laparoscopic splenectomy in 1991. After that, laparoscopic splenectomy has become one of the most frequently performed laparoscopic solid organ procedures.

AIM

To demonstrate the surgical techique of laparoscopic splenetomy with reduced portals.

METHODS

A reduce port laparoscopic splenectomy was performed by using a 10 mm and two 5 mm trocars. To entered the abdomen a trans-umbilical open technique was done and a 10 mm trocar was placed. A subcostal 5 mm trocar was placed under direct vision at the level of the anterior axillary line and another 5 mm port was inserted at the mid-epigastric region. Once it was completely dissected and freed from all of its attachments the hilum, splenic artery and vein, was clipped with hem-o-lock and divided with scissors. Then an endobag was used to retrieve the spleen after being morcellated trough the umbilical incision.

RESULTS

This technique was used in a 15 years old female with epigastric and left upper quadrant pain. An abdominal ultrasound demonstrated a giant cyst located in the spleen. Laboratory tests findings were normal. The CT scan was also done, and showed a giant cyst, which squeeze the stomach. The patient tolerated well the procedure, with an unremarkable postoperative. She was discharge home 72 h after the surgery.

CONCLUSION

The use of reduce port minimizes abdominal trauma and has the hypothetical advantages of shorter postoperative stay, greater pain control, and better cosmesis. Laparoscopic splenectomy for giant cysts by using reduce port trocars is safe and feasible and less invasive.

Single-Incision Laparoscopic Splenectomy Using the Suture Suspension Technique for Splenomegaly in Children with Hereditary Spherocytosis

BACKGROUND

With increasing laparoscopic surgery experience and improved new vessel-sealing equipment, single-incision laparoscopic surgery (SILS) for splenectomy has emerged as an alternative to multiport laparoscopy, but the application of SILS for splenomegaly is still challenging due to technical difficulties. The aim of this study was to describe the suture suspension technique contributing to SILS for hereditary spherocytosis (HS).

MATERIALS AND METHODS

A retrospective review was conducted to evaluate all SILS for splenomegaly performed by a single surgeon. On preoperative ultrasonography, the spleen size index ranged from 0.67 to 0.82. An umbilical incision was used for the placement of a multichannel single port. To provide excellent exposure of the splenic hilum, a needle with a 1-0 suture was percutaneously introduced from the left hypochondriac region and then penetrated out the anterior chest wall for suspending the enlarged spleen. Dissection was facilitated by the use of a 5-mm curved reusable grasper and a 5-mm Harmonic(®) scalpel (Ethicon Endo-Surgery, Cincinnati, OH), and the splenic vessels were ligated with 5-mm Weck(®) Hem-o-lok(®) clips (Teleflex(®), Morrisville, NC). The resected spleen was placed in an endosurgical bag, morcellated, and removed from the abdomen via the umbilical incision.

RESULTS

Nine children underwent SILS during the study period without conversion to open procedures or requiring additional ports. The suture suspension technique was successfully used and markedly improved the exposure of the splenic hilum. The operative time was 122.6 ± 31.2 minutes, and the extracted spleen weight was 562 ± 74.5 g (range, 420-1260 g). No intraoperative or postoperative complications were recorded. The umbilical incision healed well with a satisfactory cosmetic effect.

CONCLUSIONS

Our outcome shows the suture suspension enables safe and feasible usage of SILS for the management of splenomegaly in children with HS. More experience is needed to assess advantages and disadvantages compared with the standard laparoscopic approach.

Comparison of two minimal invasive techniques of splenectomy: Standard laparoscopy versus transumbilical multiport single-site laparoscopy with conventional instruments

BACKGROUND

Laparoendoscopic single-site (LESS) splenectomy which is performed on small number of patients, has been introduced with better cosmetic outcome, less postoperative pain, greater patient satisfaction and faster recovery compared to standard laparoscopy.

MATERIALS AND METHODS

Thirty six patients were included in the study comparing standard laparoscopic splenectomy (LS, 17 patients) transumbilical multiport splenectomy performed with conventional laparoscopic instruments (TUMP-LS, 19 patients). Two groups of patients were compared retrospectively by means of operation time, intra- and postoperative blood loss, perioperative complications, packed red cell and platelet requirements, lenght of hospitalization, pain scores and patient satisfaction.

RESULTS

There was no mortality in any of the groups, and no significant differences determined in operative time (P = 0,069), intraoperative blood loss (P = 0,641), patient satisfaction (P = 0,506), pain scores (P = 0,173) and the average length of hospital stay (P = 0,257). Umbilical incisions healed uneventfully and no hernia formation or wound infection was observed during follow-up period (2-34 months). There were no conversions to open surgery.

CONCLUSIONS

Transumbilical multiport splenectomy performed with the conventional laparoscopic instruments is feasible and could be a logical alternative to classical laparoscopic splenectomy by combining the advantages of single access techniques and standard laparoscopy.

Extraumbilical single-incision laparoscopic cholecystectomy with standard laparoscopic instruments

BACKGROUND AND AIM

Single-incision laparoscopic surgery is a rapidly progressing field as it combines some advantages such as cosmesis and less incisional pain. However, it also has some disadvantages such as limitation of movement and clashing of the hand instruments, which increase the complexity and technical challenges of the operation. In this study, we describe a pilot trial of single-incision laparoscopic cholecystectomy through a paramedian access site.

MATERIAL AND METHODS

A total of 25 patients underwent single-incision laparoscopic cholecystectomy with this method. Acute cases with empyema and patients with history of previous abdominal surgery were excluded. Single-incision is established on the right upper quadrant, right latero-superior of the umbilicus, so that trocar sites and projection of the gallbladder on the abdominal wall are on the same vertical line. Standard laparoscopic instruments were placed into the abdominal cavity providing triangulation. Once the laparoscope, grasper, and dissector are in place, the overall procedures are similar to the standard laparoscopic cholecystectomy.

RESULTS

Single-incision laparoscopic cholecystectomy through an extraumbilical access site was successfully completed in all 25 patients without conversion to open surgery. Additional skin incisions and trocar access were required only in two patients. The mean operative time was 39.3 min (range: 20-75 min). The mean body mass index was 27.2. Postoperative course was uneventful in all patients. The mean postoperative hospital stay was shorter than 24 h, and all patients were discharged at first day postoperatively. No postoperative complications including seroma, wound infection, and trocar-site hernia were observed at 6-month follow-up.

CONCLUSION

We described a new access site for single-incision laparoscopic cholecystectomy using standard laparoscopic instruments. We believe that this type of access site overcomes the technical difficulties of performing single-incision laparoscopic cholecystectomy, and it is a promising alternative method for the treatment of patients with symptomatic gallstone disease as a minimal invasive abdominal surgery.

Routine utilization of single-incision pediatric endosurgery (SIPES): a 5-year institutional experience

BACKGROUND

Single-incision pediatric endosurgery (SIPES) allows operation through one access site, eliminating the multiple sites traditionally used. There are few large series evaluating the versatility of SIPES. The purpose of this study is to review a 5-year single-institution experience with routine SIPES use.

PATIENTS AND METHODS

This is an Institutional Review Board-approved retrospective analysis of prospectively collected data. All SIPES cases from March 2009 to December 2013 were included. Our database contains demographics, procedure type, operative duration, estimated blood loss, instance of added ports or conversion to open, complications, and follow-up duration.

RESULTS

Of 1322 SIPES operations performed, most (82.1%) were appendectomies and cholecystectomies. Of 871 (66%) patients seen in follow-up, with a median duration of 26 days, 53 (6.1%) experienced postoperative complications. Forty-two cases (4.8%) were surgical-site infections, of which 4 required drainage. Less frequent complications that required operative intervention include recurrent inguinal hernia (n=4), umbilical hernia (n=3), intraabdominal abscess (n=1), bleeding (n=1), abdominal compartment syndrome (n=1), bowel obstruction (n=1), stitch granuloma (n=1), and persistent postoperative pain (n=1).

CONCLUSIONS

Operative times and complication rates are comparable to those in prior reported multiport laparoscopic series, allowing safe integration of SIPES into the routine of a surgical practice for most common procedures.

Minimally invasive surgery in the management of abdominal tumors in children

The application of minimally invasive surgical techniques to pediatric abdominal tumors is a controversial application towards the surgical management of childhood cancer. Although general pediatric surgeons practice minimally invasive surgery techniques in a vast array of abdominal cases, its role in pediatric oncology is still developing, with no consensus in North America about its use for pediatric solid abdominal tumors. The purposes of this article are to review the current literature about the use of minimally invasive surgery in pediatric abdominal oncology and to examine established indications, procedures and technologic advances.

Feasibility and safety of single-incision laparoscopic splenectomy: a systematic review

OBJECTIVE

The aim of this review was to evaluate the feasibility, safety, and potential benefits of single-incision laparoscopic splenectomy (SILS-Sp).

METHODS

We conducted a systemic review of literature between 2009 and 2012 to retrieve all relevant articles.

RESULTS

A total of 29 studies with 105 patients undergoing SILS-Sp were reviewed. Fifteen studies used a commercially available single-port device. The range of body mass index was 14.7-41.4 kg/m(2). Six studies described combined operations including cholecystectomy (n = 8), mesh-pexy (n = 1), and pericardial devascularizaion (n = 1). The ranges of operative times and estimated blood losses were 28-420 min and 0-350 mL, respectively. Of 105 patients, three patients (2.9%) required additional ports, two patients (1.9%) were converted to open, and three patients (2.9%) to conventional multiport laparoscopic splenectomy (overall conversion rate, 4.8%). Postoperative bleeding occurred in two patients (1.9%) who both required reoperation. Overall mortality was 0% (0/105). The length of postoperative stay varied across reports (1-11 d). Among four comparative studies, one showed greater estimated blood loss and lower numeric pain rating scale score in the SILS-Sp group than in the multiport laparoscopic splenectomy group (206.25 ± 142.45 versus 111.11 ± 99.58 mL) and (3.81 ± 0.91 versus 4.56 ± 1.29), respectively. Another comparative study showed that SILS-Sp was associated with a shorter operative time (92.5 versus 172 min; P = 0.003), lower conversion rate, equivalent length of hospital stay, reduced mortality, similar morbidity, and comparable postoperative narcotic requirements.

CONCLUSIONS

In early series of highly selected patients, SILS-Sp appears to be feasible and safe when performed by experienced laparoscopic surgeons. However, as an emerging operation, publication bias is a factor that should be considered before we can draw an objective conclusion.

First experience with single incision laparoscopic surgery in Slovakia: concomitant cholecystectomy and splenectomy in an 11-year-old girl with hereditary spherocytosis

AIMS

Hereditary spherocytosis is an autosomal dominant inheritance disorder of the red blood cell membrane characterized by the presence of spherical-shaped erythrocytes (spherocytes) in the peripheral blood. The main clinical features include haemolytic anemia, variable jaundice, splenomegaly and cholelithiasis caused by hyperbilirubinemia from erythrocyte hemolysis. Splenectomy does not solve the congenital genetic defect but it stops pathological hemolysis in the enlarged spleen. If gallstones are present, it is appropriate to perform cholecystectomy at the time of splenectomy, although the patient has symptoms of gall bladder disease. We present the case of single incision laparoscopic surgical (SILS) concomitant splenectomy and cholecystectomy performed with conventional laparoscopic instruments in an 11-year-old girl with the diagnosis of hereditary spherocytosis.

METHODS

A 2-3 cm umbilical incision was used for the placement of two 5 mm trocars and one 10 mm flexible videoscope. Conventional laparoscopic dissector, grasper, Ligasure, Harmonic Ace and hemoclips were the main tools during surgical procedure. We prefer Single Incision Laparoscopic Surgery Foam Port (Covidien) as the single umbilical device for introduction into the abdominal cavity. First, we performed cholecystectomy, then the gallbladder was put aside over the liver and after that we peformed splenectomy. To remove the detached spleen and gallbladder, a nylon extraction bag is introduced through one of the port sites. The spleen is than morcellated in the bag with forceps and removed in fragments. After that we removed them and the umbilical fascial incision was closed.

RESULT

Splenectomy is the only effective therapy for this disorder and often it is performed in combination with cholecystectomy. Conventional surgery requires a wide upper abdominal incision for correct exposure of the gallbladder and spleen. Our experience shows that SILS splenectomy and cholecystectomy is feasible even in young children and despite the small number of cases in the world, we consider the combined laparoscopic approach safe and effective for the treatment of hereditary spherocytosis.

CONCLUSION

According to actually published guidelines, the laparoscopic approach to concomitant splenectomy and cholecystectomy is recommended, but it depends on the availability of appropriately trained surgeons and suitable equipment.

Laparoscopic approach for isolated splenic metastasis: comprehensive literature review and report of 6 cases

BACKGROUND

Splenic metastases are extremely unusual. The aim of this paper is to review the world experience to date concerning to laparoscopic approach for splenic metastasis, and to report ours at the Hospital de Sant Pau.

METHODS

Literature review was carried out and relevant reports on laparoscopic approach to splenic metastasis were obtained. In addition, we reviewed our patient's database and retrieved the data of those who underwent laparoscopic splenectomy due to splenic involvement.

RESULTS

Electronic search yielded 8 relevant articles on open splenectomy and 7 articles on laparoscopic splenectomy for splenic metastasis. During the study period, 6 patients were operated on laparoscopically. Primary neoplasms were 3 melanomas, 2 colon carcinomas, and 1 malignant fibrous histiocytoma. None of the patients had surgical complications. Outcome ranged from 2-month to 11-year survival.

CONCLUSIONS

The laparoscopic approach for splenic metastasis is feasible. Of course, it must be individualized in each case.

Reduced port laparoscopic splenectomy using a newly developed multichannel port: a pilot study

BACKGROUND

The authors introduce the dual-incision laparoscopic splenectomy (DILS) technique using a specially designed multichannel trocar and report on the surgical outcomes and operative cost of DILS compared with conventional laparoscopic splenectomy (CLS).

MATERIAL AND METHODS

The medical records of 53 patients who underwent a laparoscopic splenectomy using CLS with four trocars and DILS at our institution were analyzed.

RESULTS

There was no statistical difference in operative time between the two groups and the intraoperative transfusion rate of red blood cell substitution was not different between the two groups. In terms of postoperative pain score, hospital stay, and overall complication rate, there were no differences between the two groups. Operative cost was significantly lower in the DILS group compared with the CLS group.

CONCLUSIONS

DILS is a feasible and cost-effective modality of reduced port surgery in laparoscopic splenectomy.

Anterior versus posterolateral approach for total laparoscopic splenectomy: a comparative study

OBJECTIVE

Although the anterior approach is normally used for elective laparoscopic splenectomy (LS), the posterolateral approach may be superior. We have retrospectively compared the effectiveness and safety of these approaches in patients with non-severe splenomegaly scheduled for elective total LS.

METHODS

Patients with surgical spleen disorders scheduled for elective LS between March 2005 and June 2011 underwent laparoscopic splenic mobilization via the posterolateral or anterior approach. Main outcome measures included operation time, intraoperative blood loss, frequency of postoperative pancreatic leakage, and length of hospital stay.

RESULTS

During the study period, 203 patients underwent LS, 58 (28.6%) via the posterolateral and 145 (71.4%) via the anterior approach. Three patients (1.5%) required conversion to laparotomy due to extensive perisplenic adhesions. The posterolateral approach was associated with significantly shorter operation time (65.0 ± 12.3 min vs. 95.0 ± 21.3 min, P < 0.01), reduced intraoperative blood loss (200.0 ± 23.4 mL vs. 350.0 ± 45.2 mL, P < 0.01), and shorter hospital stay (5.0 ± 2.0 d vs. 9.0 ± 3.0 d, P < 0.01) than the anterior approach. The frequency of pancreatic leakage was slightly lower in patients undergoing LS via the posterolateral than the anterior approach (0.0% vs. 3.4%, P > 0.05).

CONCLUSIONS

The posterolateral approach is more effective and safer than the anterior approach in patients without severe splenomegaly (< 30 cm).

Single incision versus reduced port splenectomy--searching for the best alternative to conventional laparoscopic splenectomy

BACKGROUND

Laparoscopic splenectomy (LS) is a well accepted approach for the treatment of multiple hematologic diseases. Single port access splenectomy (SPAS) emphasizes the concept of surgery through one small incision. The reduced port access splenectomy (RPAS) entails the use of fewer trocars of smaller sizes. The aim of this study was to compare the clinical outcomes after LS, SPAS, and RPAS, and to analyze the aesthetic result and patient satisfaction.

METHODS

We included patients who underwent LS (group 1, n = 15), SPAS (group 2, n = 8), and RPAS (group 3, n = 10) between June 2008 and February 2012, whose final spleen weight was less of 500 g. The outcome parameters analyzed were operative time, need of additional trocars, blood loss, blood transfusion, weight of the spleen, postoperative complications, and duration of hospital stay. To evaluate the cosmetic result, patients were asked to take the Body Image Questionnaire.

RESULTS

Patients in group 3 were younger than group 1. Operative time was significantly longer in group 2 compared to groups 1 and 3 (83 ± 19 vs. 131 ± 43 vs. 81 ± 22 min, p = 0.01). There was no need to convert to open surgery in any group, nor were there differences in intra- or postoperative outcome. There were no differences between the groups in relation to the analgesic requirements. Twenty-two out of the 33 patients answered the questionnaire. There was a significant advantage in group 2 and 3 in the body image index with respect to group 1. There were no differences between groups 2 and 3 (7.3 ± 2.8 vs. 5.8 ± 1.3 vs. 5.1 ± 0.4, p < 0.02).

CONCLUSIONS

RPAS is a good alternative to LS and SPAS. It improves the aesthetic results as compared to LS, whereas minimizes the technical challenges faced with SPAS.

Laparoscopic surgery of the spleen through single umbilical incision

Introduction

Single incision transumbilical laparoscopic procedures are the next step in development of minimally invasive surgery. Recent studies prove that the new technique can be a safe alternative to multiport laparoscopy; therefore it is becoming more and more popular.

Aim

We present our preliminary experience with single incision laparoscopy of the spleen.

Material and methods

We analyse a group of 9 patients (7 women and 2 men) in whom we attempted single incision laparoscopic surgery of the spleen.

Results

Single incision laparoscopy was successful in all patients – in 7 of them we performed splenectomy and in 2 unroofing of the splenic cyst. Additionally, in 3 patients we performed concomitant cholecystectomy. The operative technique was identical to multiport procedures. One patient required reoperation due to intra-abdominal bleeding from the wound on the first postoperative day. In one patient due to superficial injury of the stomach wall continuous suture was used to prevent perforation. In our opinion these complications are not the result of the new technique.

Conclusions

The described technique can become a safe alternative to multiport laparoscopy. It is a reasonable alternative in young patients to whom an excellent cosmetic effect is particularly important because until now it is the only documented advantage of this surgical technique.

Transabdominal wall deployment for instruments, lights, and micromotors using the concept of secured independent tools

Use of secured independent tools (SIT) is changing the laparoscopy paradigm, which involves the use of instruments inside the abdominal cavity that are operated via a port that is larger in diameter than the instrument itself. However, in SIT instead of ports we used filaments or cables. Here we describe a modified SIT for use in the introduction of sutures or cables inside the peritoneum. Cables or sutures are passed through a tunnel made by an intravenous catheter and then exteriorized via a 12-mm port for tying, plugging (attaching), or connecting to different types of devices such as an endoscopic bulldog, alligator clamps, lights, and micromotors. These devices are introduced inside the abdomen and remotely operated with cables or filaments. The use of SIT is not limited to laparoscopy; it was successfully used in clinical experiences of single-port and single-incision laparoscopy and could facilitate natural orifice surgery. The technique offers a good force for traction, retraction, and mobilization. In addition, it has transmission capabilities for cameras and may facilitate the placement of wired microrobotics.