**Abstract**

This chapter describes the necessary steps to perform single port laparoscopic hysterectomy. This surgical approach is an innovative method to offer all of the benefits of multi-port laparoscopy through one single incision usually in and around the umbilicus. Using core surgical principles and instruments available for single port surgery external triangulation and full range of motion can be maintained to achieve the required internal manipulation of instruments and tissue dissection. All single port surgeries require a specialized port used along with an angled or flexible laparoscope for visualization. Traditional laparoscopic instruments may be used for the surgical dissection and completion of the procedure.

**Keywords:** single port, laparoscopic surgery, LESS, single site surgery

### **1. Introduction**

Laparoscopic hysterectomy was first described in 1989 and, with its superior surgical results and outcome metrics compared to the abdominal route, the number of laparoscopic hysterectomies has increased significantly over the past three decades [1–3]. Additionally, investments in product development over the last thirty years has further supported adoption of the procedure and the birth of the field of minimally invasive surgery in general. In gynecology, acceptance of the technique in all surgical subspecialties has further helped drive the increased procedure volume even when dealing with complex pathology. The improvements in surgical outcomes over the abdominal route demonstrated with all forms of laparoscopic surgery or, any minimally invasive approach, has led to further innovation in the minimally invasive field and the birth of single port access surgery (SPA). Single port surgery was developed in an effort to further decrease the invasiveness of the procedure and maximize the benefits of laparoscopy [4, 5].

Single port access surgery, as its name implies, is a route of laparoscopic surgery that involves performing the entire procedure through one incision and one port (as opposed to the usual 3–5), usually at the umbilicus, that is generally 2–3 cm in length [6]. This route of surgery goes by many names including SPA, laparoendoscopic single-site surgery (LESS), single-site laparoscopic (SSL), single-port laparoscopy (SPLS), and single incision laparoscopic surgery (SILS) amongst others, with SILS and LESS the two most common nomenclatures used [7]. However, all of the above names are acceptable and indicate the identical surgical procedure. The first single port laparoscopic hysterectomy was described in 1991, but did not gain initial acceptance likely due to both the steep learning curve required and the lack of appropriate instrumentation available at the time. The route did not begin to gain popularity until general surgery began publishing about SILS cholecystectomies and appendectomies in the mid-2000s [4, 5]. The main advantage to single port hysterectomy over the traditional laparoscopic approach is cosmetic, as the incision needed can often be well hidden in the umbilicus [6, 8]. There is also evidence that this route may reduce pain and result in a faster recovery for the patient [6, 8]. These improved outcomes must be balanced with the potential disadvantages of single port compared to multi-port laparoscopy, resulting from the technical challenges of the procedure. Having all the instruments passing through the same port site can certainly make the procedure more challenging due to instrument crowding, limits on visualization, and loss of triangulation [6, 8]. There is also some concern that the larger incision required may be more at risk for wound complications and hernias [6, 8]. However, with appropriate instrumentation and surgical technique these limitations can managed and overcome. Here we will review the key principles, strategies, and available instrumentation that can help mitigate the challenges of single port hysterectomy, as well as, discuss the clinical outcomes data comparing single port hysterectomy to multi-port hysterectomy.
