**2. Use of single port abdominal laparoscopy in minor gynecologic surgery**

Female sterilization by tubal ligation was the first procedure performed by way of single incision laparoscopy in the late 1960s. Though gynecologists were the first surgeons to perform SILS, the technique was more readily adopted by urologists in the 1990s [1]. Now, more than 40 years since its development, single incision laparoscopy has become widespread in gynecologic surgery. Minor gynecologic procedures that have been performed by single incision include, but are not limited to: diagnostic laparoscopy, tubal sterilization (by both occlusion and partial or complete salpingectomy), management of ectopic pregnancy, ovarian cystectomy, oophorectomy, ovarian detorsion, oophoropexy and myomectomy. Adnexal surgeries, especially oophorectomy and ovarian cystectomy, are the most commonly performed minor gynecologic SILS procedures [2–4].

Single incision laparoscopy has a greater degree of difficulty than multiport laparoscopy, mainly due to reduction of triangulation (**Figure 1a**, **b**). In multi-port laparoscopy, ports may be placed in a triangular formation in Ref. to the target organ. Generally, the central optical trocar is placed 10-15 cm away from the target organ and accessory ports are placed laterally along an arc maintaining a similar distance from the target organ. Instruments are then commonly introduced at a 60 degree angle. A wide angle of manipulation, ideally between 45 and 75 degrees, results in the most efficient movements from the surgeon. Triangulation also allows for the appropriate traction and countertraction necessary to retract, dissect, ligate, and suture during a multiport laparoscopic procedure [5, 6].

With a narrow angle of triangulation, as in single incision laparoscopy, ergonomics become more limited. Surgical techniques, advanced uterine manipulation, articulating or prebent instruments, and angled or flexible laparoscopes can improve surgical constraints, but the degree of technical difficulty remains higher in single incision laparoscopy. Cross-triangulation, or the crossing of surgical instruments, may improve triangulation constraints [5, 6].

Most authors agree that between 5 and 30 cases are required to establish proficiency in single incision laparoscopy. A multicenter analysis revealed a linear improvement in both entry and operating times for SILS cases, with the most substantial decrease (9.2 min to 4.8 min for abdominal entry and 79.4 min to 56.8 min for total operating time) after increasing procedure volume from 10 to 20 cases [6].

Based on available data, outcomes of single incision laparoscopy for minor gynecologic procedures are similar to multiport laparoscopy [1, 2, 4–30].

Abdominal access is often obtained more quickly with single incision laparoscopy, with one study demonstrating a near 50% shorter entry time for SILS. Operating times for adnexal surgery by way of SILS may be increased when compared to multi-port procedures. A meta-analysis of 3 randomized control trials

**Figure 1.** *(a) Triangulation in multiport laparoscopy. (b) Loss of triangulation with single incision laparoscopy.* 

**3**

**Figure 2.**

*Fundamentals of the Currently Available Single Port Abdominal Laparoscopic Gynecologic…*

(RCT) published in 2013 demonstrated an increase in operating time of 6.9 minutes for adnexal surgery performed via SILS [8]. A 2017 meta-analysis of 5 RCT found similar increases in operating time [2]. However, subsequent studies not included in these meta-analyses have shown operating time for SILS is not significantly different when compared to multiport laparoscopy[9]. Surgeon proficiency greatly impacts operating time, and has been demonstrated to improve in a linear fashion [6]. Intraoperative complications, such as bowel or vascular injury, blood loss, or conversion to laparotomy are similar. In the 2013 meta-analysis, 2.78% of SILS were converted to multi-port laparoscopy and 0.11% were converted to laparotomy. Of the multi-port laparoscopies, 0.5% were converted to laparotomy. The authors did not distinguish between hysterectomy and adnexal procedures [8]. In the 2017 meta-analysis, no adnexal SILS cases were converted to laparotomy [2]. Decline in hemoglobin on postoperative day 1 was similar in nearly all studies and was found

Postoperative pain has been found to be comparable in most studies [8–30]. Some have demonstrated less immediate postoperative pain (in recovery and at 6 and 12 hours postoperatively) when a single incision surgical approach is used. Others have also noted less use of postoperative analgesia after SILS. Meta-analyses have demonstrated no significant difference in postoperative pain between the two procedures [2, 4, 9]; however, minor gynecologic surgery, especially adnexal procedures, is generally not associated with a high amount of postoperative pain. Length of hospital stay is comparable for both types of laparoscopy. Given that the length of the average hospital stay for minor gynecologic surgery is already short, significant improvement is difficult to demonstrate. Resumption of normal

Patient reported satisfaction with cosmetic results is most often higher with single incision laparoscopy, although some studies have reported no significant difference [8–30]. One analysis conducted by Bush et al. in 2011 revealed that when presented with three illustrations of the placement of port sites - traditional multiport placement, umbilical SILS, and robotic port placement - over 56% of the 241 female respondents preferred the traditional multiport trocar placement over the SILS (p = .007). Importantly, the illustration of single incision laparoscopy denoted a 2.5 cm umbilical incision that extended past the borders of the model's navel [31] (**Figure 2a**). Many SILS surgeons strive to keep umbilical incisions hidden within the borders of the umbilicus (**Figure 2b**). A similar study conducted in the 1990s prior to the rise in popularity of laparoscopic gynecology - showed 68% of women

*(a) Replication of incision used during Bush study – umbilical incision extends past the umbilicus. (b) Most single incision laparoscopic surgeons will confine the umbilical incision in the borders of the natural orifice.* 

*DOI: http://dx.doi.org/10.5772/intechopen.96953*

to be statistically similar in the 2016 meta-analysis [4].

postoperative activity is also similar [2, 4, 8].

#### *Fundamentals of the Currently Available Single Port Abdominal Laparoscopic Gynecologic… DOI: http://dx.doi.org/10.5772/intechopen.96953*

(RCT) published in 2013 demonstrated an increase in operating time of 6.9 minutes for adnexal surgery performed via SILS [8]. A 2017 meta-analysis of 5 RCT found similar increases in operating time [2]. However, subsequent studies not included in these meta-analyses have shown operating time for SILS is not significantly different when compared to multiport laparoscopy[9]. Surgeon proficiency greatly impacts operating time, and has been demonstrated to improve in a linear fashion [6].

Intraoperative complications, such as bowel or vascular injury, blood loss, or conversion to laparotomy are similar. In the 2013 meta-analysis, 2.78% of SILS were converted to multi-port laparoscopy and 0.11% were converted to laparotomy. Of the multi-port laparoscopies, 0.5% were converted to laparotomy. The authors did not distinguish between hysterectomy and adnexal procedures [8]. In the 2017 meta-analysis, no adnexal SILS cases were converted to laparotomy [2]. Decline in hemoglobin on postoperative day 1 was similar in nearly all studies and was found to be statistically similar in the 2016 meta-analysis [4].

Postoperative pain has been found to be comparable in most studies [8–30]. Some have demonstrated less immediate postoperative pain (in recovery and at 6 and 12 hours postoperatively) when a single incision surgical approach is used. Others have also noted less use of postoperative analgesia after SILS. Meta-analyses have demonstrated no significant difference in postoperative pain between the two procedures [2, 4, 9]; however, minor gynecologic surgery, especially adnexal procedures, is generally not associated with a high amount of postoperative pain.

Length of hospital stay is comparable for both types of laparoscopy. Given that the length of the average hospital stay for minor gynecologic surgery is already short, significant improvement is difficult to demonstrate. Resumption of normal postoperative activity is also similar [2, 4, 8].

Patient reported satisfaction with cosmetic results is most often higher with single incision laparoscopy, although some studies have reported no significant difference [8–30]. One analysis conducted by Bush et al. in 2011 revealed that when presented with three illustrations of the placement of port sites - traditional multiport placement, umbilical SILS, and robotic port placement - over 56% of the 241 female respondents preferred the traditional multiport trocar placement over the SILS (p = .007). Importantly, the illustration of single incision laparoscopy denoted a 2.5 cm umbilical incision that extended past the borders of the model's navel [31] (**Figure 2a**). Many SILS surgeons strive to keep umbilical incisions hidden within the borders of the umbilicus (**Figure 2b**). A similar study conducted in the 1990s prior to the rise in popularity of laparoscopic gynecology - showed 68% of women

#### **Figure 2.**

*(a) Replication of incision used during Bush study – umbilical incision extends past the umbilicus. (b) Most single incision laparoscopic surgeons will confine the umbilical incision in the borders of the natural orifice.* 

*Single Port Gynecologic Laparoscopic and Robotic-Assisted Surgery*

performed minor gynecologic SILS procedures [2–4].

and suture during a multiport laparoscopic procedure [5, 6].

instruments, may improve triangulation constraints [5, 6].

surgeons to perform SILS, the technique was more readily adopted by urologists in the 1990s [1]. Now, more than 40 years since its development, single incision laparoscopy has become widespread in gynecologic surgery. Minor gynecologic procedures that have been performed by single incision include, but are not limited to: diagnostic laparoscopy, tubal sterilization (by both occlusion and partial or complete salpingectomy), management of ectopic pregnancy, ovarian cystectomy, oophorectomy, ovarian detorsion, oophoropexy and myomectomy. Adnexal surgeries, especially oophorectomy and ovarian cystectomy, are the most commonly

Single incision laparoscopy has a greater degree of difficulty than multiport laparoscopy, mainly due to reduction of triangulation (**Figure 1a**, **b**). In multi-port laparoscopy, ports may be placed in a triangular formation in Ref. to the target organ. Generally, the central optical trocar is placed 10-15 cm away from the target organ and accessory ports are placed laterally along an arc maintaining a similar distance from the target organ. Instruments are then commonly introduced at a 60 degree angle. A wide angle of manipulation, ideally between 45 and 75 degrees, results in the most efficient movements from the surgeon. Triangulation also allows for the appropriate traction and countertraction necessary to retract, dissect, ligate,

With a narrow angle of triangulation, as in single incision laparoscopy, ergonomics become more limited. Surgical techniques, advanced uterine manipulation, articulating or prebent instruments, and angled or flexible laparoscopes can improve surgical constraints, but the degree of technical difficulty remains higher in single incision laparoscopy. Cross-triangulation, or the crossing of surgical

Most authors agree that between 5 and 30 cases are required to establish proficiency in single incision laparoscopy. A multicenter analysis revealed a linear improvement in both entry and operating times for SILS cases, with the most substantial decrease (9.2 min to 4.8 min for abdominal entry and 79.4 min to 56.8 min for total operating time) after increasing procedure volume from 10 to 20 cases [6]. Based on available data, outcomes of single incision laparoscopy for minor

gynecologic procedures are similar to multiport laparoscopy [1, 2, 4–30].

Abdominal access is often obtained more quickly with single incision laparoscopy, with one study demonstrating a near 50% shorter entry time for SILS. Operating times for adnexal surgery by way of SILS may be increased when compared to multi-port procedures. A meta-analysis of 3 randomized control trials

*(a) Triangulation in multiport laparoscopy. (b) Loss of triangulation with single incision laparoscopy.* 

**2**

**Figure 1.**

would choose a Pfannenstiel incision while only 31% would choose multiport laparoscopic incisions, indicating that patient familiarity with the incision type may have played a role in Bush's findings [32].

Data regarding outcomes for single incision non-adnexal surgery is less abundant than that for adnexal procedures. A single RCT with 66 participants undergoing laparoscopic myomectomy by either SILS or multi-port laparoscopy demonstrated no significant differences in surgical outcomes with the exception of more favorable cosmesis and better patient satisfaction in the SILS group [29].
