**3.1 GelPOINT advanced access platform by applied Medical**

The GelPOINT system is a gel topped port combined with Alexis wound retractor technology. The Alexis wound retractor provides 360 degree

**5**

[33, 34].

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

retraction of the port site; the rounded retraction allows for better instrument triangulation. Trocars supplied with the device are introduced through the GelSeal cap and may be arranged in any formation. The trocars accommodate instrument diameters from 5 to 12 mm. The device can be used in incisions ranging from 1.5 cm to 7 cm in length. The GelSeal cap has a diameter of 10 cm. The cap can be removed from the Alexis retractor for specimen retrieval

The GelPOINT Mini uses the same GelSeal and Alexis retractor technology but with a smaller footprint. This system accommodates incisions up to 4 cm. Triangulation is reduced further with the GelPOINT Mini system, limiting its util-

The SILS port by Medtronic consists of a blue colored foam, soft, flexible port that maintains pneumoperitoneum by conforming to the body wall. The outer diameter is 49 mm and the inner diameter is 29 mm. The port has an insufflation valve and three instrument placement channels. Three variations of the SILS port are available and can accommodate a range of instrument diameter from 5 mm to

Advanced Surgical Concepts offers three single incision laparoscopy platforms. All three variations are composed of an outer ring connected to an inner ring by a clear retracting sleeve. The distal ring is placed into the abdominal cavity with an introducer which punctures the abdominal wall. After the introducer is removed, the outer ring is passed over the retracting sleeve until it creates a seal. Because of its self adjusting retraction sleeve, this port can be used in abdominal walls up to 10 cm in thickness. The fixed ports are angled in order to minimize instrument crowding. The 10 mm and 15 mm ports are equipped with lip seal valves that allow for the introduction and removal of smaller diameter instruments without losing pneumo-

One model, the Triport+, contains four instrument ports (three 5 mm and one 10 mm) and two insufflation valves, while Triport15 contains three instrument ports (two 5 mm and one 15 mm) and two insufflation valves. Optimal incision length is between 12 mm and 25 mm. QuadPort contains five instrument ports (two 5 mm, one 10 mm, one 12 mm and one 15 mm) and two insufflation valves. It

The Anchorport system uses a set of unique self-adjusting, self-anchoring trocars [38]. The 5 mm trocar is available in three lengths: 75 mm, 100 mm, 135 mm. It has a clear bladeless optical tip for direct entry and a pistol-like grip handle. The distal portion of the cannula system adjusts to the patient's abdominal wall thickness with its accordion-like design, which anchors to the body wall for security. The AnchorPort design allows a minimum amount of the cannula tip inside the abdomen; this assists with laparoscopic instrument range of motion and widening instrument angles inside the abdomen. AnchorPort is uniquely designed for single incision laparoscopy; a single skin incision is made and then the trocars are introduced directly into the fascia, maintaining a bridge of tissue between each trocar

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

ity in more complex single incision laparoscopy [35].

**3.3 TriPort and QuadPort by advanced surgical concepts**

can be used with incisions 20 mm to 60 mm [37].

[33–35].

**3.2 SILS port by Medtronic**

15 mm [33, 34, 36].

peritoneum [33, 34, 37].

**3.4 AnchorPort by Conmed**

**Figure 3.** *(a) GelPOINT system, (b) SILS port, (c) TriPort15, (d) AnchorPort.* 

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

retraction of the port site; the rounded retraction allows for better instrument triangulation. Trocars supplied with the device are introduced through the GelSeal cap and may be arranged in any formation. The trocars accommodate instrument diameters from 5 to 12 mm. The device can be used in incisions ranging from 1.5 cm to 7 cm in length. The GelSeal cap has a diameter of 10 cm. The cap can be removed from the Alexis retractor for specimen retrieval [33–35].

The GelPOINT Mini uses the same GelSeal and Alexis retractor technology but with a smaller footprint. This system accommodates incisions up to 4 cm. Triangulation is reduced further with the GelPOINT Mini system, limiting its utility in more complex single incision laparoscopy [35].

#### **3.2 SILS port by Medtronic**

*Single Port Gynecologic Laparoscopic and Robotic-Assisted Surgery*

**3. Commercially available single incision access systems**

ments through one access point with a single, larger skin incision.

**3.1 GelPOINT advanced access platform by applied Medical**

have played a role in Bush's findings [32].

group [29].

would choose a Pfannenstiel incision while only 31% would choose multiport laparoscopic incisions, indicating that patient familiarity with the incision type may

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

A variety of access systems are available for single incision laparoscopic surgery [33, 34] (**Figure 3a-d**). Surgeon preference and comfort level is key when choosing laparoscopic entry. SILS ports were designed to allow the passage of many instru-

The GelPOINT system is a gel topped port combined with Alexis wound

retractor technology. The Alexis wound retractor provides 360 degree

**4**

**Figure 3.**

*(a) GelPOINT system, (b) SILS port, (c) TriPort15, (d) AnchorPort.* 

The SILS port by Medtronic consists of a blue colored foam, soft, flexible port that maintains pneumoperitoneum by conforming to the body wall. The outer diameter is 49 mm and the inner diameter is 29 mm. The port has an insufflation valve and three instrument placement channels. Three variations of the SILS port are available and can accommodate a range of instrument diameter from 5 mm to 15 mm [33, 34, 36].

#### **3.3 TriPort and QuadPort by advanced surgical concepts**

Advanced Surgical Concepts offers three single incision laparoscopy platforms. All three variations are composed of an outer ring connected to an inner ring by a clear retracting sleeve. The distal ring is placed into the abdominal cavity with an introducer which punctures the abdominal wall. After the introducer is removed, the outer ring is passed over the retracting sleeve until it creates a seal. Because of its self adjusting retraction sleeve, this port can be used in abdominal walls up to 10 cm in thickness. The fixed ports are angled in order to minimize instrument crowding. The 10 mm and 15 mm ports are equipped with lip seal valves that allow for the introduction and removal of smaller diameter instruments without losing pneumoperitoneum [33, 34, 37].

One model, the Triport+, contains four instrument ports (three 5 mm and one 10 mm) and two insufflation valves, while Triport15 contains three instrument ports (two 5 mm and one 15 mm) and two insufflation valves. Optimal incision length is between 12 mm and 25 mm. QuadPort contains five instrument ports (two 5 mm, one 10 mm, one 12 mm and one 15 mm) and two insufflation valves. It can be used with incisions 20 mm to 60 mm [37].

### **3.4 AnchorPort by Conmed**

The Anchorport system uses a set of unique self-adjusting, self-anchoring trocars [38]. The 5 mm trocar is available in three lengths: 75 mm, 100 mm, 135 mm. It has a clear bladeless optical tip for direct entry and a pistol-like grip handle. The distal portion of the cannula system adjusts to the patient's abdominal wall thickness with its accordion-like design, which anchors to the body wall for security. The AnchorPort design allows a minimum amount of the cannula tip inside the abdomen; this assists with laparoscopic instrument range of motion and widening instrument angles inside the abdomen. AnchorPort is uniquely designed for single incision laparoscopy; a single skin incision is made and then the trocars are introduced directly into the fascia, maintaining a bridge of tissue between each trocar [33, 34].

## **4. Accessory products**

#### **4.1 Laparoscopes**

Traditional lens-based laparoscopes have a rigid shaft and utilize two dimensional views. Laparoscope diameters vary from <1 mm to 15 mm, with the most commonly used diameters being 5 and 10 mm. Classically, laparoscopes utilize charge coupled device (CCD) sensors, in which higher resolution is obtained with larger diameters. In SILS, a smaller diameter, such as 5 mm or less, is often preferred at the expense of resolution in order to maintain maneuverability of surgical instruments [39].

Though flexible tip endoscopy was developed as early as the 1950s, it wasn't until the 2000s that flexible tip laparoscopes with adequate imaging capabilities were developed. The EndoEye Flex video laparoscope with "chip on the tip" design was developed in 2005 by Olympus. It has a deflectable tip that can rotate up to 100 degrees. The latest model allows for high definition video in a 5 mm diameter scope by utilizing complementary metal-oxide semiconductor (CMOS) technology as opposed to CCD. It is also the first autoclavable articulating videoscope, as other designs require chemical sterilization. Stryker has also developed articulating 5 and 10 mm videoscopes, however at the time of this manuscript, the Ideal Eyes HD Articulating Laparoscope does not appear to be available in the current Stryker product catalog. Flexible tip laparoscopes have demonstrated shorter operating times for single incision cholecystectomy, but have not yet been evaluated for gynecologic SILS [39].

Lens angles of rigid laparoscopes can vary. Zero degree scopes are most commonly utilized by gynecologic surgeons in multiport laparoscopy. Angled scopes, however, can be very useful in SILS gynecology by moving the imaging plane out of the line of the operating plane in order to reduce instrument collision. Thirty degree laparoscopes are most commonly used, although 45 degree and 70 degree options are available as well. Variable view laparoscopes developed by Karl Storz allow the surgeon to adjust the lens angle between 0 and 90 degrees without removing the scope from the trocar.

An in-line light cord adapter and low profile camera head are two updates that reduce tangling of cords and instrument collision. Use of a longer laparoscope, as those used in bariatric surgery, may also improve mobility. Future laparoscopes may be cordless and wireless [40].

#### **4.2 Instruments**

Traditional laparoscopic instruments are rigid with an average length of 33 cm. Some instruments allow for rotation of the tip while others are fixed. Prebent instruments have been utilized by other specialties in the past but have not been widely utilized in gynecologic SILS [33, 34].

Articulating instruments have been pivotal in improving triangulation constraints of SILS while also increasing the surgeon's range of motion (**Figure 4a** and **b**). Companies including Medtronic, BD and others manufacture articulating grasping instruments. There are currently 2 articulating 5 mm bipolar instruments on the market. Ethicon's Enseal G2 provides bipolar sealing of vessels up to 7 mm in diameter with 110 degrees of articulation and 360 degree rotation. The Caiman 5 Vessel Sealer by Aesculap offers 80 degrees of articulation, a 26.5 mm sealing length and 23.5 mm cutting length [41, 42].

The ArtiSential line of wristed instruments with 360 degree of freedom was registered with the FDA in 2019. They have yet to be described in single incision gynecology but offer similar range of motion as robotic instruments and may have utility in SILS procedures.

**7**

**Figure 4.**

*Articulating Bipolar Vessel Sealers. (a) Enseal G2, (b) Calman 5.* 

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

In instances where wider triangulation is necessary, mini laparoscopic instruments can be introduced away from the single incision port site. Many companies promote miniature laparoscopic instruments with diameters 3 mm and under. Some of the smallest diameter instruments are manufactured by Teleflex, which produces instruments with only a 2.4 mm shaft. The instrument is introduced directly through the skin using an integrated needle tip, which eliminates the need for a skin incision or trocar. The product line offers 2 handpieces, 4 types of graspers and 4

The magnetically anchored and guidance system (MAGS) was first described in 2007. This device utilizes magnetic coupling of an external handpiece and an internal instrument or camera. The internal components are inserted through a single incision and paired to their external components via magnetic attraction across the

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

monopolar electrosurgical tools.

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

In instances where wider triangulation is necessary, mini laparoscopic instruments can be introduced away from the single incision port site. Many companies promote miniature laparoscopic instruments with diameters 3 mm and under. Some of the smallest diameter instruments are manufactured by Teleflex, which produces instruments with only a 2.4 mm shaft. The instrument is introduced directly through the skin using an integrated needle tip, which eliminates the need for a skin incision or trocar. The product line offers 2 handpieces, 4 types of graspers and 4 monopolar electrosurgical tools.

The magnetically anchored and guidance system (MAGS) was first described in 2007. This device utilizes magnetic coupling of an external handpiece and an internal instrument or camera. The internal components are inserted through a single incision and paired to their external components via magnetic attraction across the

**Figure 4.** *Articulating Bipolar Vessel Sealers. (a) Enseal G2, (b) Calman 5.* 

*Single Port Gynecologic Laparoscopic and Robotic-Assisted Surgery*

Traditional lens-based laparoscopes have a rigid shaft and utilize two dimensional views. Laparoscope diameters vary from <1 mm to 15 mm, with the most commonly used diameters being 5 and 10 mm. Classically, laparoscopes utilize charge coupled device (CCD) sensors, in which higher resolution is obtained with larger diameters. In SILS, a smaller diameter, such as 5 mm or less, is often preferred at the expense of resolution in order to maintain maneuverability of surgical instruments [39]. Though flexible tip endoscopy was developed as early as the 1950s, it wasn't until the 2000s that flexible tip laparoscopes with adequate imaging capabilities were developed. The EndoEye Flex video laparoscope with "chip on the tip" design was developed in 2005 by Olympus. It has a deflectable tip that can rotate up to 100 degrees. The latest model allows for high definition video in a 5 mm diameter scope by utilizing complementary metal-oxide semiconductor (CMOS) technology as opposed to CCD. It is also the first autoclavable articulating videoscope, as other designs require chemical sterilization. Stryker has also developed articulating 5 and 10 mm videoscopes, however at the time of this manuscript, the Ideal Eyes HD Articulating Laparoscope does not appear to be available in the current Stryker product catalog. Flexible tip laparoscopes have demonstrated shorter operating times for single incision cholecystectomy, but have not yet been evaluated for gynecologic SILS [39]. Lens angles of rigid laparoscopes can vary. Zero degree scopes are most commonly utilized by gynecologic surgeons in multiport laparoscopy. Angled scopes, however, can be very useful in SILS gynecology by moving the imaging plane out of the line of the operating plane in order to reduce instrument collision. Thirty degree laparoscopes are most commonly used, although 45 degree and 70 degree options are available as well. Variable view laparoscopes developed by Karl Storz allow the surgeon to adjust the lens angle between 0 and 90 degrees without removing the

An in-line light cord adapter and low profile camera head are two updates that reduce tangling of cords and instrument collision. Use of a longer laparoscope, as those used in bariatric surgery, may also improve mobility. Future laparoscopes may

Traditional laparoscopic instruments are rigid with an average length of 33 cm.

Some instruments allow for rotation of the tip while others are fixed. Prebent instruments have been utilized by other specialties in the past but have not been

Articulating instruments have been pivotal in improving triangulation constraints of SILS while also increasing the surgeon's range of motion (**Figure 4a** and **b**). Companies including Medtronic, BD and others manufacture articulating grasping instruments. There are currently 2 articulating 5 mm bipolar instruments on the market. Ethicon's Enseal G2 provides bipolar sealing of vessels up to 7 mm in diameter with 110 degrees of articulation and 360 degree rotation. The Caiman 5 Vessel Sealer by Aesculap offers 80 degrees of articulation, a 26.5 mm sealing length

The ArtiSential line of wristed instruments with 360 degree of freedom was registered with the FDA in 2019. They have yet to be described in single incision gynecology but offer similar range of motion as robotic instruments and may have

**4. Accessory products**

**4.1 Laparoscopes**

scope from the trocar.

**4.2 Instruments**

be cordless and wireless [40].

widely utilized in gynecologic SILS [33, 34].

and 23.5 mm cutting length [41, 42].

utility in SILS procedures.

**6**

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

#### **4.3 Smoke evacuation systems**

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 decreased life expectancy [44].

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

### **5. Surgical techniques**

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 complex SILS cases as well.

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

**9**

**Author details**

M. Luann Racher\* and Ann Marie Mercier

provided the original work is properly cited.

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

Sciences, Little Rock, AR, USA

Department of Obstetrics and Gynecology, University of Arkansas for Medical

© 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,

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

straightened to pass through smaller trocars. Choice of suture is based upon surgeon preference as the suture is removed after the procedure is completed. As long as care is taken to avoid vascular structures, the uterus and adnexa can be retracted with puppet sutures. Large bowel should only be retracted by suturing through the epiploica. Small bowel should not be retracted in this manner due to risk of injury.

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

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

straightened to pass through smaller trocars. Choice of suture is based upon surgeon preference as the suture is removed after the procedure is completed. As long as care is taken to avoid vascular structures, the uterus and adnexa can be retracted with puppet sutures. Large bowel should only be retracted by suturing through the epiploica. Small bowel should not be retracted in this manner due to risk of injury.
