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Surg Endosc

DOI 10.1007/s00464-009-0620-2

TECHNIQUE

Homemade transumbilical port: an alternative access
for laparoendoscopic single-site surgery (LESS)
Huai-Ching Tai Æ Chia-Da Lin Æ Chia-Chang Wu Æ
Yao-Chou Tsai Æ Stephen Shei-Dei Yang

Received: 16 March 2009 / Accepted: 20 June 2009
Ó Springer Science+Business Media, LLC 2009

Abstract
Background Laparoendoscopic single-site surgery (LESS)
is a possible advancement for minimally invasive surgical
interventions. However, this technique requires a specialized
multichannel port for introducing laparoscope and instruments. We present our preliminary experience of using a
homemade transumbilical single-port access for performing
LESS.
Method An Alexis wound retractorÒ was placed through
the umbilical incision, and a pair of sterile surgical gloves
was then snapped onto it. Standard laparoscopic trocars
were inserted through the gloves after the upper half parts
of the gloves were truncated. Using this port and RoticulatorTM articulating instruments, we performed 14 urologic
LESS procedures on porcine laboratory and cadaveric
cases, and we performed 10 transabdominal pre-peritoneal
inguinal hernia repairs (TAPP), and 5 laparoscopic varicocelectomies on human cases, respectively. All procedures
were performed with instruments inserted through this port
without the need for any extraumbilical incisions or conversion to standard laparoscopic surgery.

H.-C. Tai  C.-D. Lin  Y.-C. Tsai (&)  S. S.-D. Yang
Division of Urology, Department of Surgery,
Buddhist Tzu Chi General Hospital, Taipei Branch, Taipei,
Taiwan
e-mail: tsai0523@ms29.url.com.tw
H.-C. Tai
Department of Urology, National Taiwan University Hospital,
Taipei, Taiwan
e-mail: taihuai48@hotmail.com
C.-C. Wu
Department of Urology, Taipei Medical University
Shuang-Ho Hospital, Taipei, Taiwan

Results All LESS procedures were successfully completed without any complications. The time to achieve
the transumbilical port ready for subsequent LESS was
short (range, 4–8 (median, 6) minutes). The total operative
time was between 60 and 190 minutes. No port-related
complications were noted, and the cosmetic results were
excellent.
Conclusions This homemade transumbilical port offers a
safe, reliable, flexible, and cost-effective access for LESS
procedures. This technique may be an alternative for current specialized port systems.
Keywords Laparoendoscopic single-site surgery 
Wound retractor  Port

Laparoscopic surgery has been a well-established alternative to open counterpart. Generally, it is associated with
excellent visualization, decreased blood loss, less postoperative pain, earlier convalescence, superior cosmesis, and
comparable oncologic outcomes. Efforts are continuing to
further reduce the morbidity and improve the cosmetic
outcome of laparoscopic surgery, including reduction of
the size and number of ports. This has led to the evolution
of a novel surgical approach, now collectively known as
laparoendoscopic single-site surgery (LESS), and encompasses recent terminology, including embryonic natural
orifice translumenal endoscopic surgery (E-NOTES), single-incision laparoscopic surgery (SILS), transumbilical
single-port surgery (TUSPS), and one-port umbilical surgery (OPUS).
Currently, LESS can be approached with a skin incision
with several fascial punctures or the use of two novel
multichannel single-port devices—R-portTM (Advanced
Surgical Concepts, Dublin, Ireland) and Uni-XTM (Pnavel

123

Rancho Santa Margarita. 1C). we have used this technique for the access of 14 urologic LESS procedures. Ten healthy men underwent transabdominal pre-peritoneal (TAPP) inguinal hernia repair and five underwent laparoscopic varicocelectomy performed by a single surgeon (YCT) at our institute. a 5. A 5. B Pair of sterile surgical gloves was snapped onto the external ring. RoticulatorTM articulating instruments (Covidien Ltd. and uretero-ureterostomy on porcine laboratory and cadaveric human cases. C The upper half parts of the gloves were truncated and a 5-mm laparoscopic standard trocar was inserted through the gloves and secured by a pursestring suture around the trocar.or 10-mm laparoscope was inserted to inspect the peritoneal cavity. After the operations were completed. Two (5/5-mm. However.5-cm umbilical skin incision was made and carried down into the peritoneum. pyeloplasty. the Alexis wound retractorÒ was removed and the umbilical fascia was closed with 2-0 Vicryl suture. we developed a homemade transumbilical port involving the use of existing instrumentation and handy materials. A pair of sterile surgical gloves was snapped onto the external ring (white). CT. 1D). Norwalk. 5/10-mm. including nephrectomy. A variety of LESS procedures were performed in standard fashions. Morganville. A Alexis wound retractorÒ was placed through an infraumbilical transverse incision. both specialized ports are not available in Taiwan. The umbilical skin was approximated using 4-0 Monocryl running suture. Applied Medical. and the upper half parts (including the five fingers) of the gloves were ligated and truncated (Fig. we report the preliminary experience of applying this technique in LESS.Surg Endosc Systems. 1A).or 10-mm laparoscopic standard trocar was then inserted through the gloves and secured by a pursestring suture around the trocar (Fig. Materials and methods Subjects From December 2008. Therefore. 1 External views of the homemade single-port transumbilical access for LESS varicocelectomy (step by step). An Alexis wound retractorÒ (Xsmall. NJ. CA. USA) and standard laparoscopic instruments were used for subsequent manipulation. we have transferred this technique to live human cases after obtaining institutional review board approval from the ethical committee of the hospital and informed patient consent. After the successful experience in simulation surgery. USA)—to allow the introduction of several laparoscopic instruments through one abdominal skin and fascial incision. After pneumoperitoneum was established. or 5/12-mm) or three (5/5/ 5-mm) additional operating ports were placed depending on the procedures (Fig. 1B). Fig. . D Two 5-mm additional operating ports were placed in triangulation for subsequent procedure 123 Surgical technique A 1. USA) was placed in position through the incision with the bottom ring (green) inside the abdomen (Fig.

123 . cone-shaped. Thus. two at 5 mm) [9]. 2 Postoperative photograph shows the umbilical incision after LESS varicocelectomy LESS also can be approached with a single skin incision with a common or several fascial punctures (fasciotomies). Discussion Wheeless and Thompson first published the technique of laparoscopic tubal ligation in 1969 [1]. We can design optimal trocar placement preoperatively or replace the smaller trocar to larger one for unexpected occurrence intraoperatively. sigmoidectomy.’’ such as concomitant transvaginal cannula or percutaneous anchoring stitches. which makes introducing several instruments simultaneously much easier.Surg Endosc Results All procedures were completed without any intraoperative or postoperative complications. several fascial punctures may lead to skin maceration and fascial tear. no significant gas leakage was noted during the surgery. and nephrectomy [10–14]. The incision was approximated readily. plastic outer unit converging on three separate 5-mm inlets. without compromising the pneumoperitoneum. Consequently. The cosmetic results were excellent (Fig. Similar settings have been reported for hysterectomy with bilateral salpingo-oophorectomy (BSO). Through a 1-cm curved infraumbilical incision. Raman et al. No port-related complications (such as wound infection. Because the majority of these expendables are not covered by medical insurance in Taiwan. Because only one laparoscopic instrument was used to manipulate. Reported LESS procedures using R-portTM include cholecystectomy. even in procedures with longer operative time. Lastly. First. consists of an inverted. the Uni-XTM system. may be needed to provide the countertraction and better exposure. Fig. the patients have to bear the charges of surgery themselves. the use of wound retractor increases the size of incision. Our port consists of existing instrumentation and handy materials and costs approximately US$150. TAPP inguinal hernia repair. Our homemade transumbilical port has some merits. and right hemicolectomy [2–6]. It also protects wounds from fascial tear or skin maceration and avoids port-site metastasis while performing oncologic LESS procedures. The Uni-XTM system has been applied for cholecystectomy. additional assistance from ‘‘outside. All procedures were performed with instruments inserted through this port without the need for any extraumbilical incisions or conversion to standard laparoscopic surgery. 4–8 (median. This alternative technique of creating a transumbilical single-port access was successful in all cases. However. skin maceration. two commercialized single-port accesses designed specifically for LESS have been reported. as in standard laparoscopic surgery. Another option. 2). By using the larger trocar (10. performed three nephrectomies through a single umbilical incision with three adjacent conventional trocars as well (one at 12 mm. The use of disposable instruments increases the cost of laparoscopic procedures. The time to achieve the transumbilical port ready for subsequent LESS was short (range. It consists of one 12-mm and two 5-mm lumens for laparoscope and working instruments. mesh or needle is delivered into the abdomen without difficulty. a laparoscope with a parallel offset eyepiece and a working channel was introduced through a standard laparoscopic trocar after pneumoperitoneum was established.to 12-mm) and arrangement (3 to 4 trocars or more) of our technique are more flexible than that of current commercialized techniques. the above settings were not feasible for complex laparoscopic procedures that require intracorporeal suturing and knot tying. and abdominal sacrocolpopexy [15–17]. cholecystectomy. The first laparoscopic adrenalectomy was performed in a similar manner: three 5-mm ports were placed through separate fascial entry points with a triangular arrangement [8]. it is more cost-effective than current port entry systems. both specialized ports are not available in Taiwan. Recently. or ventral hernia) were reported. The total operative time was between 60 and 190 minutes. and further complicate wound healing.or 12-mm). a variety of instruments (3. In addition. The choices of trocar size (3. Piskun and Rajpal first used this method for laparoscopic cholecystectomy [7]. To date. varicocelectomy in children. R-portTM is a multichannel access that allows multiple instruments to pass through one incision simultaneously.to 12-mm) can be used to facilitate the procedures. appendectomy. 6) minutes).

Saba SC. Buchs N. Rackley RR. Cadeddu JA (2007) Laboratory and clinical development of single keyhole umbilical nephrectomy. Bucher P. Bucher P. Rao P. Desai MM. Palmer JS (2008) Single-port laparoscopic surgery: initial experience in children for varicocelectomy. Leroy J. Ginsberg PC. Kaouk JH. Canes D. Pelosi MA III (1991) Laparoscopic hysterectomy with bilateral salpingo-oophorectomy using a single umbilical puncture. Kroh M. Harmon JD (2008) Single-port access adrenalectomy. J Laparoendosc Adv Surg Tech A 19:215–217 16. Stern JM. Desai MM (2008) Single port transumbilical (E-NOTES) donor nephrectomy. Review of 3600 cases. Haber GP. Moore C. Thompson BH (1973) Laparoscopic sterilization. Pugin F. N J Med 88:721–726 3. Ostermann S. Rosenblatt S (2009) Single-port. Aron M. Morel P (2009) Single-port access laparoscopic cholecystectomy (with video). and cost-effective approach to perform LESS. BJU Int 102:97–99 17. Pelosi MA. Rao P (2008) Single-port-access nephrectomy and other laparoscopic urologic procedures using a novel laparoscopic port (R-port). Kaouk JH. Kaouk JH. Haber GP. Desai MR. Canes D. Rane´ A. Urology 70:1039–1042 10. Desai MM. Morel P (2008) Single-port access laparoscopic right hemicolectomy. Pelosi MA III (1992) Laparoscopic appendectomy using a single umbilical puncture (minilaparoscopy). Olguner M. Gill IS (2009) Transumbilical single-port laparoscopic partial nephrectomy. J Endourol 22:1573–1576 9. Marescaux J (2009) Single-access laparoscopic sigmoidectomy as definitive surgical management of prior diverticulitis in a human patient. Langwieler TE.Surg Endosc Conclusions This homemade transumbilical single-port access offers a simple. Urology 72:260–263 14. Gill IS. Hakgu¨der G. References 1. Kaouk JH. J Reprod Med 37:588–594 4. Pugin F. Int J Colorectal Dis 23:1013–1016 7. It provides a good operative field without significant gas leakage to interfere with the procedures intraoperatively. Wheeless CR Jr. laparoscopic cholecystectomy and inguinal hernia repair: first clinical report of a new device. flexible. Gill IS (2008) Single-port laparoscopic surgery in urology: initial experience. BJU Int 103:516–521 13. Pelosi MA. Back M (2009) Single-port access in laparoscopic cholecystectomy. Castellucci SA. J Pediatr Surg 42:1071–1074 5. Raman JD. Bagrodia A. Arch Surg 144:173–179 12. Charara F. Asakuma M. Surg Endosc 23:1138–1141 11. Aron M. Goel RK. J Laparoendosc Adv Surg Tech A 9:361–364 123 8. Dallemagne B. Flechner S. World J Surg 33:1015–1019 6. Bensalah K. Obstet Gynecol 42:751–758 2. J Urol 180:637–641 15. Piskun G. Rajpal S (1999) Transumbilical laparoscopic cholecystectomy utilizes no incisions outside the umbilicus. Jaffe JS. Cahill RA. This technique may be an alternative for current specialized port systems. Aron M. Curcillo PG. Goldfarb DA. Nimmesgern T. Ates¸ O. Urology 71:3–6 . Akgu¨r FM (2007) Single-port laparoscopic appendectomy conducted intracorporeally with the aid of a transabdominal sling suture. Haber GP. reliable.