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Single Port (SILS/LESS/ENOTES) Laparoscopic colorectal resection

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LESS (LaparoEndoscopic Single Site) surgery “accelerates” recovery after colorectal resection?


K Gash, WM Chambers, GL Greenslade, AR Dixon

SPIRE Bristol Hospital, Durdham Down, Bristol, BS6 6UT & Frenchay Hospital, Bristol BS16 1LT


Key words: Laparoendoscopic Single Site Surgery (LESS), laparoscopic colorectal surgery, ERAS, SILS, LESS; NOTES, Day case surgery


Aims: We report our experience of using LESS in complex colorectal surgery.

Methods: 20 consecutive, un-selected patients underwent LESS colorectal surgery: retro-caecal appendicectomy, re-do ileocolic anstomosis, right hemicolectomy (3), extended right hemicolectomy, colectomy & ileo-rectal (3), panproctocolectomy (2), high anterior resection (2), low anterior resection - TME (3), Abdominoperineal excision rectum, restorative proctocolectomy/ileoanal pouch (2) and ileocolic resection using a single port, conventional instrumentation and TAP block analgesia. Nine had undergone previous surgery, eight had cancer, two complicated diverticulosis and six were immunosupressed.

Results: Umbilical, right and left iliac fossa LESS was performed using conventional instrumentation.  Operative time ranged between 23 - 240mins (median 110).  Normal diet was tolerated within 6hrs in 8, 12-16 hrs/overnight in 11. Postoperative morphine was required in only 4 patients.  There were five complications: hyperphosphataemia/hypocalcaemia, anastomotic bleed, ileus (2) and urine retention.  There was one conversion through lack of theatre time.  Discharge occurred between 8-384hrs (median 46hrs) of surgery; 8 patients were discharged within 24hrs.

Conclusion: LESS colorectal resection is feasible and safe when performed by an experienced laparoscopic surgeon, anaesthetist and theatre team.  LESS may have advantages over conventional laparoscopic surgery in terms of minimal pain, lower costs and faster recovery.   Improved cosmesis is an additional advantage


Although Jacobs reported the first laparoscopic right-hemicolectomy in 19901 the uptake of laparoscopic colorectal surgery (LCRS) in the UK has been slow2; only 8.2% of resections are laparoscopic3 and only 18% of ACPGBI members report having a laparoscopic practice approaching 50%2.  This poor uptake arose through concerns about oncological safety4-6 and the technically demanding learning curve7-9.  Large randomized trials (CLASICC10,COST11, Barcelona12), Cochrane13 reviews and meta-analysis14 have all concluded that LCRS is not only safe but is associated with better short-term outcomes and without a negative effect on long-term cancer survival.  NICE updated its guidance15 in-favor of NHS trusts and appropriately trained surgeons offering LCRS as an alternative to open surgery.

Whilst LCRS is by definition less invasive than open surgery, it still requires several incisions for port placement as well as an extraction site.  Each of these is painful, impacts on the final cosmetic appearance and has the potential for bleeding, interfascial haematoma formation, visceral injury, local nerve irritation and long-term incisional hernia development.  Cosmesis is increasingly demanded by increasingly discerning patients16.   Natural Orrifice Transluminal Endoscopic Surgery (NOTES) e.g., trans-vaginal cholecystectomy17 and nephrectomy (porcine model)18 is currently in evolution but is considered by enthusiasts, quite rightly in our opinion, as being the next surgical frontier.  NOTES however, usually require additional ports, particularly when using endoscopic staplers18.  The procedures are protracted and require expensive specialized equipment and last but not least extensive training.   NOTES colectomy as it currently stands probably has no clinical application.  A more practical alternative is a hybrid approach where-by the rectum is utilized for specimen extraction by way of the transanal endoscopic operation (TEO) device19.  

A more viable alternative to NOTES is LaparoEndoscopic Single Site (LESS) colectomy.  Other acronyms that have been used include single incision (SILSTM) and E(embryological)NOTES; single port laparoscopic surgery “SPLS” is probably more appropriate. These approaches all use multi-lumen ports sited through the umbilicus.  Flexible instrumentation is also promoted to obviate the need for triangulation, a fundamental component of laparoscopic surgery.  However, it must be remembered that conventional instrumentation was used in the first case series of SILSTM; 53 retroperitoneal adrenalectomies20!  LESS/SILS/ENOTES or “SPLS” has been reported for appendicectomy21, cholecystectomy22, nephrectomy23, pyelopasty24 and most recently right hemicolectomy25,26 .  Here we describe our experience of using LESS in our routine colorectal practice.








20 unselected, consecutive patients (12 women) aged 24-80yrs (median 45yrs) underwent LESS/SILSTM/SPLS colorectal surgery over a 16-week period in 2009 (table 1). Indications were cancer (8), ulcerative colitis (3), Crohn’s (4), complicated diverticulitis (2), slow transit constipation (3) and recurrent appendicitis.  Eight had undergone previous abdominal surgery: nephro-uretectomy, high anterior resection (3) and ileocolic resection; one an umbilical hernia repair.  Inflammatory bowel disease patients were all immuno-suppressed.

Patients were admitted 2hrs before surgery and given a phosphate enema and 400mls carbohydrate drink.  Each operation used either an ASC - Tri-port (Advanced Surgical Concepts, Bray, Ireland) or SILSTM Port (Covidien Healthcare, Gosport, UK 2 cases) and conventional instruments: Johan bowel grasper (Karl Storz, Slough, UK), Harmonic Scalpel and linear/circular staplers (Ethicon EndoSurgery, Bracknel, UK).  Cancer resections followed conventional oncological principles.  Peri and postoperative analgesia was provided by Diamorphine spinal anaesthesia (two cases) or a combination of transversus abdominals plane (TAP) blocks, short acting intra-operative opiods and post-operative intravenous paracetamol27.

The ASC-Triport (Advanced Surgical Concepts, Bray, Ireland) is a multichannel access system that allows the simultaneous passage of up to two 5mm and one 12mm laparoscopic instruments with separate ports for gas insufflation and plume extraction.  It is made up of two components, a retractor and a valve.  The retractor consists of one internal ring, two external rings and a “doubled over “ cylindrical plastic sleeve.  The valves are made of a thermoplastic elastomer that allows the passage of lubricated instruments.  The Triport is very easily deployed using a blunt introducer loaded with the internal ring and passed through a 15-20mm incision into the peritoneal cavity.  It is the size of this incision that determines the size of the instruments that can be passed through the port into the abdominal cavity.  The plastic sleeve is then pulled upwards, an action that pulls the internal ring snug up against the abdominal wall.  The external ring is then pushed against the abdominal wall; it is the tension between these rings that retracts the abdominal wall28.  The SILS™ (Covidien Healthcare, Gosport, UK) Port Multiple Instrument Access Port is a much simpler product through which can be placed three conventional ports 5mm or 12mm29. 

Ports were positioned as appropriate: umbilical (13), ileostomy site (5) and left-iliac fossa (2).  300 laparoscopes were used throughout: 5mm EndoEye video-laparoscope, (Olympus KeyMed, Southend-on-Sea, UK) in six, conventional 10mm (5), 10mm flexible High Definition EndoEye flexible tip (Olympus KeyMed, Southend-on-Sea, UK) and 5mm conventional (8). Close mesenteric dissection/division with greater ommentum preservation followed by a rectal TME was used for the proctocolectomies.  A TLC55 (Ethicon Endosurgery, Bracknel, UK) was used to divide the terminal ileum in the panproctocolectomy after removal of the Triport; the specimen was then delivered via an inter-sphincteric pelvic dissection.  An ATG45 (Ethicon Endosurgery, Bracknel, UK) - two anterior-posterior firings was used in the TME and IAP patients to divide the gut tube at the level of the pelvic floor.  20cm J pouches were constructed after removal of the specimen through the port site.  Dissection was pragmatic using a combination of cranial to caudal and lateral to medial dissection (and visa versa).  Ports were removed to allow specimen extraction, placement of a purse string/circular staple gun head before being replaced to allow restoration of bowel continuity. In the segmental resections, named vessels were divided at their origin using an ATW45 endostapler (Ethicon Endosurgery, Bracknell, UK) or where appropriate 5mm Hem-o-Loc clips (Teleflex medical, High Wycombe, UK).  The splenic flexure was mobilized in all left-sided resections.   The appendicectomy required mobilisation of the caecum and ascending colon.  No extra-umbilical skin incisions, holding sutures or drains were used.  Patients were encouraged to mobilize and were offered a normal diet as the time of day their surgery dictated. 














Nineteen of twenty procedures were successfully completed without the need for open conversion or any extra-port skin incision/auxiliary port insertion.  The one conversion was only made due to time constraints; facilitate delivery of the mobilized specimen and division of the ileocolic vessels.  All dissecting maneuvers were done using regular instrumentation inserted through the two types of port.  No intra-operative complications occurred.  Operative time was surprisingly quick (23-240mins): median 110mins.  TAP blocks augmented by parenteral paracetamol were sufficient for providing good post-operative analgesia in all but four patients who required a total of 8x10mg doses enteric morphine.  A patient who had undergone a previous laparoscopic anterior resection commented - “the pain was a 10th of what it was last time” - “I was ready to go to work by the third day”. 

Recovery was impressively quick with normal diet tolerated at between 4-6hrs post procedure in eight and 12, 14 and 16hrs (i.e., overnight) in the remaining 11 patients.  Complications comprised: urine retention, ileus (2), anastomotic bleed and ARF secondary to hypophosphatemia – hypercalcaemia; the latter a side effect of erroneously prescribed bowel prep.   All patients with planned stomas were changing their appliances under supervision within 18hrs of surgery.  The median hospital stay was 46hrs (8-384hrs).  There was one ward return with a low grade temperature.



Single-port trans-umbilical laparoscopic surgery was first used 10 years ago for appendicectomy30 and cholecystectomy31 and it was probably only through the technical limitations of the instrumentation at the time that it failed to gain momentum.  LESS/SILSTM has recently been re-visited with the express aims of potentially enhancing the cosmetic benefits and further reducing the morbidity of minimally invasive surgery.  Whilst the former is a laudable aim, we believe that the techniques greatest asset is its apparent “lack of pain” and the potential for an even faster recovery and earlier discharge.

Conventional laparoscopic surgery is based around the concept of triangulation of instruments and laparoscope.  Successful LESS/SILSTM as described in the literature is based on this same assertion and its achievement has required the development of articulating or pre-bent instrumentation introduced via a fixed and stable platform (a large caliber trocar) or alternatively small, adjacently placed trocars.   Instrument articulation allows intra-corporeal triangulation of parallel instruments.  Unlike conventional laparoscopic surgery, optimal instrument utilisation in LESS/SILSTM demands that the operating surgeon makes greater use of his/hers none dominant hand.  It is also mandatory to have an expertise in directing, using and interpreting the image produced by a 300 laparoscope and total concentration.  Whilst not absolutely essential, a 5mm end-on light source video-laparoscope reduces clutter and instrument collision.  It is these differences and the tendency for instrument collision that makes this technique inherently difficult to learn and by definition, teach.  A final consideration is the need for quality 5mm laparoscopes and light cables; less than perfect optics makes this approach potentially dangerous.

That said we were very surprised at the ease and speed at which we were able to perform what amounted to complex laparoscopic interventions.  This ease of adaption probably relates to the experience of the senior author in performing pragmatic three-port complex laparoscopic surgery and not relying on an assistant to provide traction.  Gravity and natural tissue planes providing counter traction to a highly active none-dominant hand and a relatively “still” operating-dominant right hand using an energy source or scissors.  It is unnecessary to use a series of trans-parietal sutures25 to provide retraction.  The ability to operate with the none dominant hand is also essential.  This coupled with exclusive use of a 300 laparoscope and a highly motivated “camera operator” who intuitively co-ordinates himself or herself with the surgeon as well as providing, in conjunction with the anaesthetist positive encouragement throughout.   We consider it important to keep the laparoscope in a relatively fixed position just inside the abdominal cavity - if it is too far in it will restrict the operating instrumentation.  In our limited experience our preferred option was the 5mm video-laparoscope or the flexible 10mm high definition scope.  Nether the less, instrument collision still remains a challenge.  It is also necessary to periodically rotate either port and swap operating hands to optimize the placement and use of the instrumentation.  It was also useful if the camera operator stood/sat on the side opposite to the surgeon. 

Each port has drawbacks. The ASC-Triport (Advanced Surgical Concepts, Bray, Ireland) requires that the instruments are lubricated to allow easier passage through the elastomer valve; laparoscope are best lubricated using lens cleaning/anti fog solutions whilst water soluble gel is adequate for the operating instruments.  The extreme instrument torque leads to a rate of attrition with the valve such that a replacement port was required on three occasions. The SILS™ (Covidien Healthcare, Gosport, UK) Port Multiple Instrument Access Port is harder to insert, requires a larger incision in the abdominal wall and this results in substantially more peri-umbilical bruising.  In elderly patients undergoing long procedures there is the potential for this pressure to cause underlying superficial skin necrosis.  The individual SILSTM ports also tend to fill with droplets of blood, which makes cleaning the lens very difficult.  The large valve of the 12mm port is far too bulky and this causes instrument collision and reduced mobility.  No doubt Ethicon Endo-Surgery (Cincinati, Ohio, USA) will develop a “SPLS” port using valve technology soon.

Although this early limited experience of LESS/SILSTM is promising, experienced laparoscopic skills are both mandatory and essential for its safe and effective completion.  Evolving articulating instrumentation which offer surgeons seven degrees of freedom all within the control of one hand32 and the newer deflectable tip laparoscopes advocated for LESS/SILSTM implementation requires considerable training and practice, and it is our view that for the former this is probably best gained by repeated visits to an animal and then cadaveric lab.

An alternative to LESS/SILSTM is a NOTES hybrid using conventional operating ports; the specimen is extracted via the rectal lumen using a trans-anal endoscopic operation device (TEO).  This novel technique is said to be only applicable to patients with small recto-sigmoid tumours (<4cm).  Whilst the surgery itself can be completed in good time (approximately 2hrs), recovery is far from “accelerated”; a highly selected series of 10 patients still reported a median hospital stay of one week (range 4-18 days).  Elimination of complications relating to the mini extraction site through the abdominal wall, will by definition expose the patient to all the potential complications of this hybrid approach e.g., rectal perforation.  Surprisingly, the hybrid approach does not eliminate pain; median reported pain score was 2 (range 2-3).  This and our experience would suggest that it is the trauma of the ports (insertion, repeated movement of the fulcrum and closure) that is responsible for the majority of postoperative pain.

Single-port laparoscopic surgery “SPLS” in the hands of an experienced laparoscopic surgeon allows for all the common complex colorectal operations to be performed entirely through the patient’s umbilicus or chosen stoma site.  In doing so, it enables an essentially scarless and an almost painless procedure with the potential for an impressively quick recovery and almost certain psychological benefit.  Unlike others26, 32, we see no reason why LESS/SILSTM can’t be applied to cancer resections, provided that is, the surgeon carries out the exact same dissection as they would in either an open or conventional laparoscopic resection.  For small lesions and benign disease a transverse umbilical incision is probably appropriate.  For larger sized tumours and bulky specimens we would continue to advocate a longitudinal umbilical incision that can be extended as appropriate27. 

The observation of a complete lack of shoulder tip pain when the TAP blocks were working would suggest that it is referred pain form parietal injury/irritation and not the CO2 insufflation and diaphragmatic irritation that is responsible for its development.  The appendicectomy patient had no shoulder pain until the TAP block started to wear off; prompt use of oral analgesia aborted the pain.  A further patient developed shoulder pain refractory to intravenous paracetamol at 14hrs when her spinal “wore off”.   A TAP block eliminated the pain within 10 minutes.  The patient was later discharged home that same day.  We have observed this exact same phenomenon in patients who have had “conventional” three port laparoscopic surgery. This is potentially a very important observation and if substantiated will almost certainly reduce the need for overnight admission for pain control and so allow for higher rates of day case laparoscopic cholecystectomy. 

We are encouraged to increase our clinical experience and continued investigation of this new and potentially fruitful technique, which in our experience is applicable to every-day colorectal practice.   The technique also puts into question the necessity of expensive and over elaborate34 multimodal rehabilitation following large bowel surgery.   Our surgical forefathers were correct – counsel the patients, get the surgery right, minimize the surgical and anaesthetic insults and accelerated recovery with early hospital discharge will follow.  If our experience were replicated on a national scale the potential saving for healthcare providers would be substantial.  A controlled clinical trial is in progress.


1. Jacobs M, Verdeja JC, Goldstein HS. Minimally invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc 1991;1:144-50.

2. Schwab KE, Dowson HM, Van Dellen J, Marks CG, Rockall TA. The Uptake of Laparoscopic Colorectal Surgery in Great Britain and Ireland: A questionnaire survey of consultant members of the ACPGBI.  Colorectal Dis 2009; 11: 318-322

3. NICE implementation uptake report: laparoscopic surgery for colorectal cancer.  NICE technology appraisal 105.

4. Akle CA. Early parietal recurrence of adenocarcinoma of the colon after laparoscopic colectomy. Port site metastasis after laparascopic colorectal surgery for cure of malignancy. Br J Surg 1996;83:427.

5. Molenaar CBH, Bijnen AB, Ruiter AB.  Indications for laparoscopic colorectal surgery.  Results from the Medical Centre Alkmaar, The Netherlands.  SurgEndosc. 1998; 12: 42-5.

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8.. Choi DH, Jeong WK, Lim SW, Chung TS, Park JI, Lim SB, Choi HS, Nam BH, Chang HJ, Jeong SY. Learning curves for laparoscopic sigmoidectomy used to manage curable sigmoid colon cancer: single-institute, three-surgeon experience. Surg Endosc 2008.

9. Tekkis PP, Senagore AJ, Delaney CP.  Conversion rates in laparoscopic colorectal surgery.  A predictive model with 1253 patients.  Surg Endosc 2005; 19: 47-54.

10. Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AMH, Heath RM, Brown JM, MRC CLASICC trial group.  Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 2005;365:1718-26.

11. The Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer.  N Engl J Med 2004;350:2050-9.

12. Lacey AM, Garcia-Valdecasas JC, Delgado S et al., Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer; a randomized trial.  Lancet 2002; 359: 2224-2229.

14 Schwenk W, Haase O, Neudecker J, Muller JM.  Short term benefits for laparoscopic colorectal resection. Cochrane Database of Systematic Reviews 2008, Issue 3.

14. Bonjer HJ, Hop WC, Nelson H, Sargent DJ, Lacy AM, Castells A, Guillou PJ, Thorpe H, Brown J, Delgado S, Kuhrij E, Haglind E, Pahlman L. Laparoscopically assisted vs open colectomy for colon cancer: a meta-analysis. Arch Surg 2007;142:298-303.

15. National Institute for Health and Clinical Excellence (NICE).  Laparoscopic surgery for colorectal cancer.  London (UK): National Institute for `health and Clinical Excellence (NICE); 2006 Aug. 25 p. (Technology appraisal guidance; No. 105).

16. Dunker MS, Stiggelbout AM, van Hogezend RA, Ringers J, Griffioen G, Bemeiman WA.  Cosmesis and body image after laparoscopicaly-assisted and open ileocoloic resection for Crohn's disease.  Surg.Endosc 1998; 12: 1334-40.

17. Zorron R, Maggloni IC, Pombo L, Oliveira AL, Carvalho GL, Rigueiras M.  Notes transvaginal cholecystectomy: preliminary clinical application.  Surg.Endosc 2008; 22:542-7.

18. Clayman RV, Box GN, Abrahams JB et al., Rapid communication: transvaginal single-port NOTES nephrectomy: initial laboratory experience.  J.Endourol 2007; 21: 640-4.

19. Cheung HY, Leung AL, Chung CC, Ng DC, Li MK.  Endo-Laparoscopi Colectomy without mini-laparotomy for left sided colonic tumours,  World.J.Surg 2009 Apr 4 (Epub ahead of print).

20. Hirano D, Minei S, Yamaguchi K et al., Retroperitoneoscopic adrenalectomy for adrenal tumours via a single large port.  J.Endourol 2005; 19: 788-92.

21. Ates O, Hakguder G, Olgunner M, Akgur FM.  Single port laparoscopic appendicectomy conducted intracorporeally with the aid of a  transabdominal sling suture.  J.PaediatrSurg 2007; 42: 1071-4.

22. Podolsky ER, Rottman SJ, Poblete H, King SA, Curcillo PG.  Single Port Access (SPA)  Cholecystectomy: a completely transumbilical approach.  J.Laparoendosc Adv.Surg.Tech A.   2009 Mar 4. [Epub ahead of print].

23. Single port  transumbilical (E-NOTES) donor nephrectomy.  Gill IS, Canes D, Aron M, Haber GP, Goldfarb DA et al., J.Urol 2008; 180: 637-41.

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28. ASC-Triport.



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32. Autonomy™ Laparo-Angle™ Instruments from Cambridge Endo.

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We are grateful to Olympus KeyMed who provided the Triports, the EndoEye 5mm video-laparoscope and the 10mm deflectable tip HD laparoscope.  Covidien provided the SILSTM ports.  Further operative descriptions/digital images are available on .


















Table 1.  Demographic details of consecutive LESS cases



Age, sex, ASA

Previous surgery



& No. Nodes



Op Time mins

Time to discharge


40, M,


Right sided


Willms tumour

Retrocaecal Appendicectomy

Rec. Appendicitis x4



46, F,




Right hemicolectomy

T2, N0, M0 15; R0



68, F,


Lap Ant Resection

Extd. Right Hemicolectomy

T3, N0, M0 12; R0



43, F,



Panproctocolectomy & ileostomy

Ulcerative Colitis



78, F,


Open Anterior Resection

Colectomy & ileo-rectal

Slow Transit Constipation



44, F,


Drainage paracolic DD abscess

Anterior Resection

Diverticular Disease Stricture



26, M,



Proctocolectomy & ileo anal pouch

Ulcerative Colitis



42, M,



Low Ant Resection (TME) & ileostomy

T4, N1, M0

2/19; R0








Low Ant Resection (TME)

T3, N1, M0

14; R0




56, M,


Ileal Caecectomy Crohns (Right paramedian)

Adhesiolysis – Revision ileocoloic resection

Fistulating Crohns


16 days

34, F,


Laparoscopic Rectopexy for prolapse

Colectomy & ileo rectal

Slow Transit Constipation







Low Ant Resection (TME)

T2, N0, M0

14; R0







Abdominal Hysterectomy



T2, N0, M0

36; R0


9 days





Ant. Resection & partial cystectomy


Disease Colo

-Vesical Fistula








Excision Rectum

T3, N1, M0

17; Ro


6 days





Ileocolic resection








Proctocolectomy & ileo-anal pouch







Converted Lap.

Anterior Resection



Right Hemicolectomy

T2, N2, M0








Colectomy & ileo- rectal







Umbilical hernia repair

Right hemicolectomy





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