I believe that single-incision laparoscopic hysterectomy is easiest when articulating instruments and a flexible-tip scope are used, although some surgeons are using higher-angled scopes (30 or 45 degrees) and prototype instruments that are angled rather than having the capability to articulate. (An array of bent laparoscopic instrumentation should be commercially available early this year.)
The goal, of course, is to avoid the crowding or clashing of instruments—commonly called “sword fighting”—that can come with inserting several instruments through a single port and at a single trajectory. As with any laparoscopic surgery, one needs appropriate triangulation in order to have enough intracorporeal working space with access to the tissue.
I have used a specialized 5-mm Olympus flexible scope with a reticulating camera tip. With its hysteroscopelike controls, the instrument can flex to angles greater than 90 degrees in any direction. By flexing the camera tip, I can increase my working space and deflect the camera out of the operative field to prevent my hands and instruments from clashing.
To effectively use an articulating instrument such as a grasper, I find it is best to work “across” the patient. For work on the right side, this means inserting the articulating instrument through the left cannula on the port. The instrument will cross the pelvis and articulate back toward the midline. The straight vessel-sealing device is then placed through the remaining cannula.
A wider array of articulating laparoscopes and instruments should soon be available. Most, if not all, major manufacturers of laparoscopic equipment now have divisions on single-incision laparoscopy. (In December, the Millennium Research Group, a medical technology market research group, predicted that more than 20% of all laparoscopic procedures will be done through a single-port approach by 2014.)
Four companies currently market multichannel ports that can be inserted into the base of the umbilicus. The differences in the ports are subtle, and one's choice is a matter of personal preference.
The two Food and Drug Administration–approved multichannel ports that are most commonly used today are the SILS port by Covidien, and the TriPort now distributed by Olympus. Each consists of a retractor component that is placed through the fascia and individual valves or ports where laparoscopic instruments and scopes can be inserted simultaneously. Each of these multichannel ports has three inlet ports—one that holds a 12-mm instrument and two for 5-mm instruments.
Like the other instrumentation available for single-incision laparoscopy, the multichannel ports are in their infancy. All are in their first generation and are being revised by their manufacturers. The first of the second-generation ports should become available early this year.
Technique and Surgical Pearls
Overall, there is not much difference between the LESS approach and conventional laparoscopy, and the new approach should be performed in a manner that is similar to the conventional laparoscopic technique with which one is most familiar.
Entering the abdomen is performed in the traditional open laparoscopy technique described by Hassan. Although standard single-channel ports generally require a 5- to 10-mm incision (or a 15-mmincision for the Hassan entry technique), the multichannel ports used for single-incision laparoscopy require a slightly larger incision. I generally recommend a 20- to 25-mm incision.
In patients with a deeper umbilicus, I make a midline incision through the base of the umbilicus. In thinner patients with a flat umbilicus, I use a semicircular incision around the base of the umbilicus. In either case, making the incision in keeping with the natural folds of the umbilicus enables one to minimize or eliminate any visible scar in the abdomen.
With the TriPort, the inner ring is loaded into the transducer, and inserted into the fascial incision by advancing a lever with one's thumb. The plastic is repeatedly pulled up and the ring is advanced until it is firmly in place against the patient's abdomen. The port is then clamped into place so that it sits snugly against the inner abdominal peritoneum.
In obese patients, I recommend suturing the peritoneum to the fascia to prevent the inner ring from slipping into the preperitoneal space as the case progresses.
In patients for whom I use a semicircular incision, the fascial opening can be extended bilaterally to facilitate easy placement of either the SILS port or the TriPort by using S hooks to expand the incision.
To insert the SILS port, the port is grasped with a Kelly clamp and placed into the fascia so that it sits flat on the abdominal surface with the inner ring inside the peritoneal cavity. Individual cannulas are then placed in the holes of the SILS port.