**Abstract**

Single site laparoscopy, while in its infancy, is being explored for potential areas of application within the realm of gynecology. Gynecologic Oncology is a field with high potential benefit from the single site technique. It boasts many practical and theoretical surgical improvements, such as facilitated specimen removal, which are elaborated further in this chapter. While much more research is needed, there are exciting and uniquely useful utilities of Laparo-endoscopic Single-site Surgery (LESS) in gynecology oncology.

**Keywords:** Gynecology Oncology, minimally invasive surgery, cancer, mini-laparotomy, surgical staging

## **1. Introduction**

Historically, gynecologic oncology has been dominated by laparotomy for peritoneal access, and this has carried partially even into the era of minimally invasive surgery [1]. There were good reasons for initial concern regarding laparoscopy, including port site metastasis, intact specimen removal, and technical complications of staging. Many would credit the hallmark LAP2 trial [2] with forever changing the face of gynecologic oncology, as it was the first high powered study to demonstrate laparoscopy to be comparable to laparotomy in gynecologic oncology procedures. This, combined with the already known advantages of minimally invasive surgery over classic laparotomy, launched the advent of laparoscopy in gynecologic oncology, in the opinion of many. The advantages were seen initially in the treatment of uterine cancer [3]. Many feel the extrapolation of this data was the impetus that eventually led to the saturation of minimally invasive surgery in the treatment of all other gynecologic malignant processes. With decreased length of stay, lower hernia rates, improved cosmesis, and lower infection rate, laparoscopy quickly became the preferred surgical methodology across gynecologic oncology. Gynecologic oncology has since contributed countless minimally invasive techniques since the LAP2 trial. Most notably, gynecologic oncologists were among the first to utilize and publish on single site laparoscopy [4–7].

Single site laparoscopic surgery provides many of the same potential improvements in cosmesis as benign gynecology, but also may hold the critical benefit of facilitated intact specimen extraction [8]. Removal of the intact specimen is generally a critical aspect of oncologic surgery, as attempting to avoid tumor spillage into body cavities is a critical concept in the treatment of malignancy [9]. This fulfills

#### **Figure 1.**

*(A) Completion of Salpingectomy vNTOES single site (B) Single site vNOTES visualization of the ureter. (C) Large adnexal mass liberated during laparoscopic single site surgery. (D) Uterine artery ligation and cauterization during vNOTES.*

what many authors refer to as the so-called "Goldilocks" concept of specimen removal [10], allowing the surgical oncologist to laparoscopically remove larger organ systems, a feat which which would have required laparotomy previously. Multiple methods of large specimen extraction in standard laparoscopy have been described, ranging from mini-laparotomy [11, 12] and nonstandard incisions [13], to incisional extension. While useful techniques, these are less studied in malignant processes and their long term sequelae are less elucidated. Therein, many would consider that Laparoendoscopic Single-site Surgery (LESS) techniques have great merit and promise in Gynecologic Oncology (**Figure 1**).
