**Author details**

*Single Port Gynecologic Laparoscopic and Robotic-Assisted Surgery*

surgery, but has not yet been seen in gynecologic surgery [43].

**4.3 Smoke evacuation systems**

decreased life expectancy [44].

small as 0.01 microns [33, 34, 44].

**5. Surgical techniques**

complex SILS cases as well.

abdominal wall, up to a maximal thickness of 10 cm. The internal components can then be arranged in an ergonomic configuration by moving the external components along the abdominal wall. MAGS has been utilized in urology and thoracic

The dangers of surgical smoke to the surgical team are well documented. Electrocauterization instruments, lasers, and ultrasonic scalpels all release particulate matter (PM) into the ambient air during both open and laparoscopic surgery. Particles 10 microns or smaller can be inhaled. Studies evaluating the long term effects specific to surgical smoke are insufficient; however the PM found in surgical smoke is associated with coronary artery disease, congestive heart failure, asthma, and chronic obstructive pulmonary disease. Deposits of PM have been found in remote organs, including the brain, and may be associated with increased oxidative stress and systemic inflammation. Long term exposure may be associated with

During laparoscopy, surgical smoke also impairs visualization. As simply venting the plume into the ambient air is ill advised, smoke evacuation systems are crucial in providing adequate visualization of structures. Dozens of smoke evacuation systems have been marketed for laparoscopic procedures. ConMed's Airseal, released in 2007, is uniquely beneficial to gynecologic SILS. The Airseal system maintains the pneumoperitoneum, provides constant smoke evacuation and allows valve free port access. The high pressure nozzles of the port's cannula direct recirculated CO2 gas down into the trocar in order to maintain pressure which creates a horizontal gas barrier across the cannula. Thus, introduction of a smaller caliber instrument or even 2 instruments through a single trocar does not result in loss of pneumoperitoneum. AirSeal has 3 operational modes: AirSeal Mode, Smoke Evacuation Mode, and Standard Insufflation Mode. The system filters particles as

Although traditionally, the least experienced member of the surgical team is often tasked with uterine manipulation, expert uterine manipulation is often key in gynecologic SILS. Introduction of multiple instruments through a single port site reduces mobility, and manipulation of the uterus can enhance or replace retraction usually done through the abdominal wall. Retroversion of the uterus allows access to the vesicouterine space. Anteversion of the uterus exposes the rectouterine space. Rotational uterine manipulation, rather than straight lateral displacement of the uterus, provides better access to the adnexa of surgical interest. The uterus can also be pushed cephalad to displace the ureters laterally or pulled caudad to access the fundus of a larger uterus. Creation of a posterior colpotomy during a non-hysterectomy SILS procedure can provide a second point of access for instrumentation, passing suture or removing specimens. Vaginal natural orifice transluminal endoscopic surgery (vNOTES), which utilizes the vaginal as the sole entry point for endoscopic surgery, is discussed in a separate chapter. The techniques described for vNOTES may be employed in

Temporary sutures can be used to provide retraction during SILS procedures. This technique is often called "puppeteering" [1]. Straight needles are useful in that they can be passed through a trocar or inserted directly through the abdominal wall. Curved needles may be introduced through larger caliber trocars or partially

**8**

M. Luann Racher\* and Ann Marie Mercier Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA

\*Address all correspondence to: mlracher@uams.edu

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
