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SILS: Technical aspects & feasibility - Leblanc et al

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F. Leblanc, M.D., B. J. Champagne M.D., K. M. Augestad, M.D., M.D., S. L. Stein, 

M.D., E. Marderstein, M.D., H. L. Jr. Reynolds, M.D., C. P. Delaney, M.D., Ph. D.. 


Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, 

Ohio 44106, USA 


Correspondence to: Professor C. P. Delaney, M.D., Ph.D.,  Division of Colorectal 

Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, 

Ohio 44106-5047, USA. Email: 


Review of the Literature 


Authors’ email addresses: 

- Fabien Leblanc: 

- Bradley J. Champagne: 

- Knut M. Augestad: 

- Sharon L. Stein: 

- Eric Marderstein: 

- Harry L. Jr. Reynolds: 

- Conor P. Delaney:



Background: This review studied technical aspects and feasibility of single incision 

laparoscopic colectomy (SILC). 

Methods: Bibliographic Search was carried out up to October 2009 including original 

articles, case reports, and technical notes. Assessed criteria were techniques, operative 

time, scar length, conversion, complications, and hospitalization duration.  

Results: The review analyzed seventeen SILC by seven surgical teams. A single port 

system was used by four teams. No team used the same laparoscope. Two teams used two 

laparoscopes. All teams used curved instruments. SILC time was 116 ± 34 min.  Final 

scar was longer than port incision (31 ± 7 vs. 24 ± 8 mm; P = 0.036). No conversion was 

reported. The only complication was a bacteremia. Hospitalization was 5 ± 2 days.  

Conclusion: SILC is feasible. A single incision around the umbilical scar represents 

cosmetic progress. Comparative studies are needed to assess potential abdominal wall 

and recovery benefits to justify the increased cost of SILC. 


Key Words: single-port, single-incision, laparoscopy, colorectal surgery 









Most surgeons are now convinced of the benefits of the laparoscopic approach in 

colorectal surgery [1-4]. While the advantages of laparoscopic surgery include shorter 

postoperative stay, early return of bowel function, and decreased complications, the 

disadvantages of multi-port laparoscopic colectomy technique, include three to five port 

sites in the abdomen an additional incision to remove the specimen.  

The excitement to develop new techniques, to improve cosmesis and hasten recovery, 

have given rise to the natural orifice transluminal endoscopic surgery (NOTES), and 

more recently to single incision laparoscopic surgery (SILS). The initial applications of 

SILS in gastrointestinal surgery were appendicectomy and cholecystectomy [5, 6]. The 

guiding principle is operating through a single transumbilical incision, and removing the 

colonic specimen by the same small incision [7-9]. Compared to classic laparoscopic 

colectomy, the potential advantages of the SILS are believed to be reduction in cutaneous 

and parietal trauma, decreased postoperative pain, improved cosmesis, and shorter 

recovery, hopefully without additional cost [10, 11].  

The aim of this review was to analyze the current literature on single incision 

laparoscopic colectomy (SILC) including safety, techniques and feasibility, and to assess 

the potential benefits of this new technique.  







Articles Identification 

Databases consulted to carry out the search for relevant articles were Medline, The 

Cochrane Database of Systematic Reviews and Controlled Trials Register, The York 

Centre for Reviews and Dissemination,, and The National Research 

Register of the National Health Service. Relevant articles and websites related to the 

study topic were also reviewed. The search was conducted without language restriction 

from January 2005 to October 2009 (inclusive). The search keywords used were: triport 

system, single-port laparoscopic surgery, single incision laparoscopic surgery (SILS), 

embryonic natural orifice transumbilical endoscopic surgery (E-NOTES), 

laparoendoscopic single-site surgery (LESS). 


Articles Selection 

Original articles, case reports, and technical notes, about colorectal surgery were on 

adult patients were included. Editorials, abstracts, letters, experimental studies (cadaver, 

animal) were excluded. 


Studies Abstraction - Synthesis 

Data were extracted by the same surgeon reviewer (FL) experienced in laparoscopic 

colorectal surgery. Expected assessment criteria were: preoperative bowel preparation, 

surgical material, operative technique, operative time, conversion, incision length, 

complications, and hospitalization duration. Parametric data were expressed as mean  

SD and compared using the Mann Whitney U test. P < 0.05 was considered as 












Studies Selection and Characteristics 

The primary search identified 131 potentially relevant studies (Fig. 1). Adjusting to 

selected criteria, 122 studies were excluded. Nine studies, meeting all the inclusion 

criteria and representing the experience of 7 surgical teams, were analyzed. These 

included 5 technical notes, 2 case-series, and 2 original articles, permitting the analysis of 

17 cases of single incision laparoscopic colectomies: 11 right and 6 left colectomies to 

treat benign (n = 3), and malignant or potential malignant (n = 12) diseases (Table 1).  


Bowel preparation  

A preoperative bowel preparation was reported in 3 studies and not specified in 6 

studies (Tables 3, 4). A bowel preparation was performed in a single study for a sigmoid 

colectomy during which a preoperative sigmoidoscopy was performed (Table 4).  


Surgical material and operative techniques  

Four surgical teams used a single port system, and three teams used trocars inserted 

directly through the skin incision (Table 2, Fig. 2). One surgical team initially used 

trocars (2 first cases), then modified the technique to a single port system because of a 

pneumoperitoneum leak around trocars [Ostrowitz]. A variety of laparoscopes sizes, tips, 

and angulations were used. Three teams used a curved laparoscope (angular or flexible), 

four teams selected a 30° laparoscope, and two teams used two different diameter 

laparoscopes interchangeably (Table 2). All teams selected curved laparoscopic 

instruments. One team used robotic-assistance. 

To insert the port system, the skin incision measured 24 ± 8 mm long in average (n = 

16) (Table 5). Mesentery and colon were exposed using graspers (n = 17), transparietal 

stitches (n = 5), and a sigmoidoscope with a magnetic anvil (n = 1) (Table 3, 4). Both 

medial to lateral and lateral to medial approaches were used. The ligation of the vessels 

was performed electrothermally in seven studies, and tied or stapled in two studies. An 

ileotransverse anastomosis was stapled extracorporeally in four studies, and 

intracorporeally in one study (Table 3).  


Operative results 

Surgery was performed for a variety of benign and malignant diseases (Table 1). 

Mean final scar length was 31 ± 7 mm (n = 11) and was significantly higher than the 

initial skin incision (P = 0.036) (Table 5). Mean SILC time was 116 ± 34 min (n = 16). 

No conversion to straight, hand-assisted laparoscopy or laparotomy was reported. Mean 

specimen length was 30 ± 10 cm (n = 6). Proximal and distal colonic margins were 

described in two cases for malignancy and were noted to be > 10 cm [8, 13]. Mean 

number of removed lymph nodes for malignant and potential malignant diseases was 17 

± 8 (n = 9). No intraoperative complication and only one postoperative complication, an 

enterobacter bacteremia on a dialyzed patient, were reported. Mean hospitalization 

duration was 5 ± 2 days (n = 9).  






To date, only single case reports and small case series were available evaluating the 

success of Single Incision Laparoscopic Colectomy. Although multiple names have been 

used, Single Incision Laparoscopic Surgery appears to be the most accurate term to 

describe the variety of techniques utilized. This review of nine articles analyzes the 

technical aspects and operative results of SILS for colectomy. It combines data from 

seven different laparoscopic surgery teams. The data reviewed in this study suggest the 

safety and feasibility of SILC. The mean operative time in our analysis was 116 minutes. 

This compares favorably with mean published operative time of 178 minutes for a 

multiport laparoscopic colectomy in a multicenter trial of 872 patients [16]. That suggests 

that SILC may be as fast as multiport laparoscopic colectomy, albeit in selected cases 

performed by selected surgeons, with reporting bias for successful cases using a new 


The number of examined nodes and the colonic specimen length to treat malignant or 

potential malignant tumors appears oncologically satisfactory. Nonetheless, data were 

inadequate about the colonic margins and the surgical quality of colonic resection to 

validate the oncologic feasibility of SILC.  

Potential advantages of SILC over multiport laparoscopic colectomy include a single 

small skin incision. The length of the skin incision is dictated in part by specimen size. 

Extraction difficulties may be encountered for large colonic tumors, or obese patients 

with thickened mesentery, omentum, or deep abdominal wall. In addition, when the colon 

is full of stool, it may be difficult to extract. A bowel preparation may reduce the colonic 

diameter and incision length in these cases. In this review, the size of the final skin 

incision was significantly longer that the initial incision, suggesting that analysis of the 

cosmetic benefits of the SILC should be based on final, rather than initial scar length and 

device diameter. A better indicator of postoperative cosmetic result might be a blinded 

assessment of the abdomen after recovery from SILC compared with the abdominal 

incisions after traditional laparoscopic colectomy. 

Theoretically, a single midline fascial incision minimizes trauma to the abdominal 

muscles, epigatric arteries, and parietal nerves created by placement of several trocars, 

potentially reducing postoperative wall pain. Data were not available to assess any 

analgesic advantage of SILC. No study included specifics on postoperative pain scores or 

analgesic requirements. 

Furthermore, a single incision may decrease postoperative hernia rate. Published data 

on port-site hernias after multiport laparoscopic surgery and intraoperative closure are 

low, with an estimate of 0.14% [17]. However, the data on extraction sites after 

laparoscopic colectomy demonstrated significantly higher rates. A prospective 

comparative study of 166 patients found a significantly higher rate hernia through the 

midline than other extractions sites (17% vs. 0%; P < 0.0002) [18]. The larger, single 

transumbilical fascial incision may increase the midline hernia rate. However a study will 

be necessary. To maintain cosmesis, SILS uses a midline transumbilical fascial incision. 

Thus, the incidence of incisional hernia could increase with SILS even if this approach 

avoids peripheral port-site hernias.  

The length of stay did not appear to be decreased using SILS technology. The 

duration of hospitalization after a multiport laparoscopic colectomy is estimated at 5 days 

[3]. In our review, the duration of hospitalization was also 5 days, not demonstrating any 

advantage of SILS on recovery. No data was available on return of bowel function. The 

Cost of SILS is also an issue in the current health care climate. The use of trocars through 

a gelport, multiple laparoscopes, curved instruments, and robotic-assistance, make it very 

difficult to demonstrate any cost benefit for this approach in comparison with standard 

multiport laparoscopic surgery. Only an improvement in recovery, hospital stay or 

complications would make SILS cost effective. 

SILS presents several disadvantages compared to multiport laparoscopic surgery. 

Externally, the handling of both straight instruments in parallel with the laparoscope 

through a small single incision decreases the freedom of motion for the surgeon and 

complicates the holding of the laparoscope for the assistant. To reduce the lines and cords 

that clutter the operative table, a small diameter laparoscope with an angular tip and an 

incorporated light source were used by several teams [7-9]. One surgical team proposed 

also to use three trocars through a gelport to increase the freedom of motion [14]. Inside 

the peritoneal cavity, lack of instrument triangulation increases the complexity of colonic 

exposure and dissection. To improve view and dissection, a 30° laparoscope and 

articulating or curved graspers and/or scissors were used by some authors. In our 

experience, we have found the best results and least technical difficulty with straight 

instruments. The use of trocars without a device exposes the surgeon to the loss of the 

pneumoperitoneum as was demonstrated in one study [11]. In case of intraoperative 

difficulties, SILS always offers the possibility to rapidly convert to multiport 

laparoscopic surgery, permitting the advantages of laparoscopic surgery to be preserved. 

Lastly, SILS presents challenge for teaching laparoscopy. The mechanics of the 

operation are best suited to a single operator and this may hinder the training of surgeons 

in SILS. The potential difficulty in training residents and surgeons in this advanced 

technique needs to be addressed. Despite published benefits of minimally invasive 

colectomy, a prolonged learning curve had led to low adoption rate. SILS, with its new 

technical and training challenges may not be accessible to most surgeons and most 

patients in the near future.  




















For experienced laparoscopic colorectal surgeons, single incision laparoscopic 

colectomy is safe, feasible although technically more difficult than straight multiport 

laparoscopic colectomy. SILC may present cosmetic advantages in comparison to the 

multiport laparoscopic colectomy. Nevertheless, to determine its benefits, larger 

comparative studies to multiport laparoscopic colectomy with cost analysis, oncologic 

outcomes, and long-term follow up will be necessary.  







1. Transatlantic Laparoscopically Assisted vs Open Colectomy Trials Study Group. 

Laparoscopically assisted vs open colectomy for colon cancer: a meta-analysis. Arch 

Surg 2007;142:298-303.  

2. Laurent C, Leblanc F, Wütrich P, Scheffler M, Rullier E. Laparoscopic versus open 

surgery for rectal cancer: long term oncologic results. Ann Surg 2009;250:54-61. 

3. Clinical Outcomes of Surgical Therapy Study Group. A comparison of 

laparoscopically-assisted and open surgery for colon cancer. N Eng J Med 


4. Laurent C, Leblanc F, Bretagnol F, Capdepont M, Rullier E. Long-term wound 

advantages of the laparoscopic approach in rectal cancer. Br J Surg 2008;95:903-8. 

5. Ates O, Hakgüder G, Olguner M, Akgür FM. Single-port laparoscopic appendectomy 

conducted intracorporeally with the aid of a transabdominal sling suture. J Pediatr 

Surg. 2007;42:1071-4. 

6. Gumbs AA, Milone L, Sinha P, Bessler M. Totally transumbilical laparoscopic 

cholecystectomy. J Gastrointest Surg. 2009;13:533-4. 

7. Remzi FH, Kirat HT, Kaouk JH, Geisler DP. Single-port laparoscopy in colorectal 

surgery. Colorectal Dis 2008;10:823-6. 

8. Bucher P, Pugin F, Morel P. Single port access laparoscopic right hemicolectomy. Int 

J Colorectal Dis 2008;23:1013-6. 

9. Leroy J, Cahill RA, Asakuma M, Dallemagne B, Marescaux J. Single-access 

laparoscopic sigmoidectomy as definitive surgical management of prior diverticulitis 

in a human patient. Arch Surg 2009;144:173-9. 

10. Rieger NA, Lam FF. Single-incision laparoscopically assisted colectomy using 

standard laparoscopic instrumentation. Surg Endosc 2009 in press. 

11. Ostrowitz MB, Eschete D, Zemon H, Denoto G. Robotic-assisted single-incision right 

colectomy: early experience. Int J Med Robot 2009 in press.  

12. Bucher P, Pugin F, Morel P. Transumbilical single incision laparoscopic 

sigmoidectomy for benign disease. Colorectal Dis 2009 in press. 

13. Bucher P, Pugin F, Morel P. Single-Port access laparoscopic radical left colectomy in 

Humans. Dis Colon Rectum 2009;52 :1797-1801. 

14. Merchant AM, Lin E. Single-incision laparoscopic right hemicolectomy for a colon 

mass. Dis Colon Rectum. 2009;52:1021-4. 

15. Brunner W, Schirnhofer J, Waldstein-Wartenberg N, Frass R, Weiss H. Single 

incision laparoscopic sigmoid colon resections without visible scar: A novel 

technique. Colorectal Dis 2009 in press. 

16. Delaney CP, Chang E, Senagore AJ, Broder M. Clinical outcomes and resource 

utilization associated with laparoscopic and open colectomy using a large national 

database. Ann Surg 2008;247:819-24. 

17. Hussain A, Mahmood H, Singhal T, Balakrishnan S, Nicholls J, El-Hasani S. Long- 

term study of port-site incisional hernia after laparoscopic procedures. JSLS 


18. Singh R, Omiccioli A, Hegge S, McKinley C. Does the extraction-site location in 

laparoscopic colorectal surgery have an impact on incisional hernia rates? Surg 

Endosc 2008;22:2596-600. 


Figure 1. Single incision laparoscopic colorectal surgery: studies selection.  

Relevant studies identified and 

screened for selection 

n = 131 


Studies selected for more 

detailed evaluation 

n = 14 


Studies selected in 

the review 

n = 9 


Exclusion criteria (n = 5) 

- Laparoscopic approach : 1 

- Minilaparotomy : 2 

- Pig model : 1 

- Organ : 1 


Excluded studies (n = 117) 

- Surgical specialty : 71  

- Organ : 46 




Figure 2. Single port Systems used in the studies selected. A: SILS Port (Covidien, Norwalk, Connecticut, USA); B: ASC Triport 

(Advanced Surgical Concepts, Wicklow, Ireland); C: Uni-X (Pnavel Systems, Morganville, New Jersey, USA); D: GelPort (Applied 

Medical, Rancho Santa Margarita, California, USA). 

A B C D 

Table 1. Review of single incision laparoscopic colorectal surgery: included studies. 



Article Cases 






Indication Colectomy 



Original 1 (F) 67 35 Polyp Right  



Case 1 (ns) 81 ns Polyp Right  



TN 1 (F) 34 22 EM Sigmoid  



TN 1 (M) 56 26 Polyp Left  



TN 1 (F) 40 21 DV Sigmoid 



TN ns ns ns ns Right  



TN 2 (F) 56 


ns DV 


2 sigmoid  



Series  7 (6M - 1F) (60 – 83) (22 – 28) 4 cancers 

2 Polyps 

6 right 

1 left flexure 



Original 3 (2M - 1F) (74 – 82) ns 1 cancer 

2 villous 

3 right 

TN: technical note; EM: endometriosis; DV: diverticulitis; ns: not specified. 


Table 2. Single incision laparoscopic colorectal surgery: material required. 

Study [ref] Port system Laparoscope Graspers / 


Single port 

(diameter, mm) 


(diameter, mm) 

Tip Diameter 



Brunner [15] None  3 trocars (5, 5, 5) Rigid / Straight 5 30° AR – ST / ns 

Remzi [7] Triport (5, 5, 5) None Flexible 5 (incorporated light source) ns Curved / Curved 

Rieger [10] None 3 trocars (12, 5, 5) ns / ns 10 30° ST / AR 

Merchant [14] Gelport  3 trocars (10, 5, 5) Rigid / Straight 5 30° AR / ns 

Bucher [8, 12, 


None 2 trocars (12, 5) Rigid / Angular 10 (6mm working channel) ns AR / ST 

Rigid / Straight 5 30° 

Leroy [9] Triport  (10, 5, 5) None Rigid / Angular 10 0° AR / AR 

Rigid / ns 3 0° 

Ostrowitz [11] Triport (12, 8, 8) 

Third case 

3 trocars (12, 8, 8) 

Two first cases 

ns/ns 12 ns AR# / ns 

AR: articulating; ST: straight; ns: not specified; #Robotic-assistance. 

Table 3. Techniques step by step of single incision laparoscopic right colectomy. 





Exposure Mesenteric 











ns Grasping Lateral to medial  


Electrothermal Extracorporeal  








ns Grasping Medial to lateral Stapled  Intracorporeal 








ns Grasping 



Medial to lateral 

Scissors/ Hook/ 


Knotting ns ns Extracorporeal  




None* Grasping Lateral to medial  




ns ns Extracorporeal  




ns Grasping# Medial to lateral 










#Robotic-assistance; *Preoperative coloscopic marking of the tumor; ns: not specified. 


Table 4. Techniques step by step of single incision laparoscopic sigmoid and left colectomies. 





Exposure Mesenteric 











ns Grasping  



Medial to lateral 


Electrothermal Extracorporeal 







[12, 13] 

ns# Grasping 



Medial to lateral 

Scissors / Hook 

Electrothermal ns Intracorporeal 






fiber-free diet  


 enema per ano 



IL magnetic anvil 

Lateral to medial 


Electrothermal Intracorporeal 








None# Grasping Lateral to medial 


Electrothermal ns ns Extracorporeal 


#Preoperative coloscopic marking of the tumor; IL: intraluminal; *Left flexure colectomy; ns: not specified.  

Table 5. Review of single incision laparoscopic colectomy: results. 

Study [ref] Colectomy Skin Incision length Time 












Remzi [7] Right 35 35 115 ns ns 4 

Leroy [9] Sigmoid  20 20 90 40 ns 4 

Brunner [15] Sigmoid 20 ns 110 22 ns 7 

Sigmoid 20 ns 180 18 ns 6 

Bucher [8, 12, 


Right ns 30 158 38 33 ns 

Sigmoid 20 ns 125 23 14 2 

left 20 ns ns 39 ns ns 

Ostrowitz [11] Right 40 40 132 ns 22 4 

Right 40 ns 158 ns ns 3 

Right 2.5 ns 166 ns ns 4 

Rieger [10] Right 25 35 100 ns 10 ns 

Right 25 35 90 ns 26 ns 

Right 25 25 75 ns 16 ns 

Right 25 45 115 ns 10 11 

Right 25 30 80 ns 7 ns 

Right 25 25 88 ns 21 ns 

LF 25 25 75 ns 12 ns 

LF: left flexure; ns: not specified.


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