SILS: Technical aspects & feasibility - Leblanc et al
SINGLE INCISION LAPAROSCOPIC COLECTOMY: TECHNICAL ASPECTS,
FEASIBILITY AND EXPECTED BENEFITS
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: email@example.com
Review of the Literature
Authors’ email addresses:
- Fabien Leblanc: Fabienfirstname.lastname@example.org
- Bradley J. Champagne: email@example.com
- Knut M. Augestad: firstname.lastname@example.org
- Sharon L. Stein: email@example.com
- Eric Marderstein: firstname.lastname@example.org
- Harry L. Jr. Reynolds: email@example.com
- Conor P. Delaney: firstname.lastname@example.org
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.
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, ClinicalTrials.gov, 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).
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).
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).
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 . 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
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% . 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) . 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
. 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 . 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 . 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
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
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.
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incision laparoscopic sigmoid colon resections without visible scar: A novel
technique. Colorectal Dis 2009 in press.
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utilization associated with laparoscopic and open colectomy using a large national
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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
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Figure 1. Single incision laparoscopic colorectal surgery: studies selection.
Relevant studies identified and
screened for selection
n = 131
Studies selected for more
n = 14
Studies selected in
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.
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
Series 7 (6M - 1F) (60 – 83) (22 – 28) 4 cancers
1 left flexure
Original 3 (2M - 1F) (74 – 82) ns 1 cancer
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 /
Brunner  None 3 trocars (5, 5, 5) Rigid / Straight 5 30° AR – ST / ns
Remzi  Triport (5, 5, 5) None Flexible 5 (incorporated light source) ns Curved / Curved
Rieger  None 3 trocars (12, 5, 5) ns / ns 10 30° ST / AR
Merchant  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  Triport (10, 5, 5) None Rigid / Angular 10 0° AR / AR
Rigid / ns 3 0°
Ostrowitz  Triport (12, 8, 8)
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.
ns Grasping Lateral to medial
ns Grasping Medial to lateral Stapled Intracorporeal
Medial to lateral
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.
Medial to lateral
Medial to lateral
Scissors / Hook
Electrothermal ns Intracorporeal
enema per ano
IL magnetic anvil
Lateral to medial
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  Right 35 35 115 ns ns 4
Leroy  Sigmoid 20 20 90 40 ns 4
Brunner  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  Right 40 40 132 ns 22 4
Right 40 ns 158 ns ns 3
Right 2.5 ns 166 ns ns 4
Rieger  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.