425507

07Barendse et alSurgical Innovation 19(3)

SRI19310.1177/15533506114255

Surgical Innovation

Transanal Single Port Surgery:  Selecting a

19(3) 323­–326
© The Author(s) 2012
Reprints and permission:

Suitable Access Port in a Porcine Model sagepub.com/journalsPermissions.nav

DOI: 10.1177/1553350611425507
http://sri.sagepub.com

Renée M. Barendse, MD1,Tessa Verlaan, MD1,

Willem A.Bemelman, MD, PhD1, Paul Fockens, MD, PhD1,
Evelien Dekker, MD, PhD1, Joost Nonner, MD2, and
Eelco J. R. de Graaf, MD, PhD2

Abstract
Single port surgery of rectal tumors may be associated with a shorter learning curve and fewer costs than transanal
endoscopic microsurgery. The authors aimed to select the most optimal single access port for transanal employment.
Four single access ports (GelPOINT, TriPort, SSL Access System, and SILS) were tested in 2 pigs. Insertion feasibility
and intraoperative features of each port were assessed. A rectal excision was attempted using the most suitable port.
Insertion of GelPOINT was impossible. SILS and TriPort were easily inserted; however, insufficient stability demanded
manual fixation. CO2 leaked through the TriPort trocar ports. Insertion of the 2-cm SSL Access System retractor
was difficult, but pneumorectum and surgical circumstances were favorable. Single port transanal surgery may be a
promising alternative for transanal endoscopic microsurgery. The SSL Access System was found the most suitable for
this indication in a porcine model.

Keywords
SILS, single site surgery, colorectal surgery, interventional
endoscopy
Introduction
Transanal endoscopic microsurgery (TEM), first described
by Buess et al,1 has proven to be superior to conventional
transanal excision for the surgical treatment of rectal
lesions.1-3 It has been implemented as the standard
resection method of rectal adenomas and selected carci-
nomas by many surgical practices. Although TEM has
proven to be more cost-effective than total mesorectal
excision, acquisition of the specialized instrumentation is
expensive and a long learning curve is present even after
a multiple day workshop.4,5
Minimally invasive surgery is a burgeoning field in
which the rapid development of new instrumentation has
led to multiport devices, requiring only single incision.
These devices have already facilitated a broad spectrum
of abdominal procedures.6-8 Little evidence is available
on the utilization of single access ports for transanal
surgery. Conceptually, transanal use of these ports demands
different features to ensure safe and effective surgery.
Four case series report successful transanal use of a single
access port for the resection of rectal lesions in 1 to 6
patients.9-12 All authors have used the SILS port (Covidien,
Mansfield, MA) for their procedures. However, 3 other
kinds of disposable single access ports for laparoscopic
surgery are currently available.
The purpose of this study was to evaluate all available
disposable single access ports in a porcine model and to
select the most suitable port for a feasibility study in
human subjects.
Methods
Procedures were performed by a single surgeon, who is
extensively experienced with TEM (EdG). The rectums
of 2 female pigs in lithotomy position were prepared by
means of saline enemas under general anesthesia. Four
available single access ports were evaluated: GelPOINT
(Applied Medical, Rancho Santa Margarita, CA),
TriPort (Olympus, Center Valley, PA), SSL Access
1
Academic Medical Center, Amsterdam, Netherlands
2
IJsselland Hospital, Capelle aan den IJssel, Netherlands
Corresponding Author:
Renée M. Barendse, Department of Gastroenterology and Hepatology,
Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam,
Netherlands
Email: R.M.Barendse@amc.uva.nl
324 Surgical Innovation 19(3)

Table 1. Port Score Criteria With Regards to Ease of Insertion, Pneumorectum and Mucosal Exposure and Port Stability

Port insertion
 Feasible Yes No  
 Ease 1. Very difficult 2. Difficult despite prior 3. Fairly easy 4. Easy without 5. Very easy
despite prior instructions with prior prior without prior
instructions instructions instructions instructions
Intraoperative
 Pneumorectum/ 1. Pneumorectum 2. Pneumorectum 3. Sufficient 4. Sufficient 5. Sufficient
mucosal not achieved insufficient for safe pneumorectum; pneumorectum; pneumorectum
exposure rectal surgery CO2 leakage CO2 leakage of 12-15 mm
after instrument after Hg; no CO2
introduction instrument leakage
manipulation
Port stability 1. Surgery not 2. Surgery only possible 3. Surgery possible 4. Surgery 5. Maintains
possible with continuous without possible position despite
despite manual/suture additional without instrument
continuous fixation fixation; port additional manipulation
manual/suture dislocation fixation; port
fixation frequent dislocation
infrequent

Table 2.  Attributed Scores to Ports With Regards to Ease

of Insertion, Pneumorectum and Mucosal Exposure and Port
Stability

SSL Access
SILS TriPort GelPOINT System
Port insertion
 Feasible Yes Yes No Yes
 Ease 5 3 Not applicable 2
Intraoperative
 Pneumorectum/ 5 3 Not applicable 5
mucosal exposure
Port stability 2 2 Not applicable 5

System (Ethicon Endo-Surgery, Cincinnati, OH), and

SILS (Covidien, Mansfield, MA).
Transanal insertion of all ports was attempted in the
first pig to evaluate feasibility and ease of port insertion.
When inserted successfully, CO2 was insufflated to assess
the pneumorectum. If the mucosal exposure was consid-
ered sufficient for rectal surgery, a standard 30° laparo- Figure 1. Partial dislocation of the SILS port after insufflation
scope and 2 surgical instruments were inserted through and trocar introduction
the trocar ports and manipulated to assess maintenance of
the pneumorectum and stability of the port. Port features The pigs were sacrificed after termination of the
were scored independently by 5 researchers (RB, TV, procedure.
WB, JN, and EdG) according to the criteria summarized
in Table 1. Attributed scores were discussed until consen-
sus was reached. Results
The port with the best pneumorectum and best Feasibility and Ease of Port Insertion
stability was selected for a rectal excision in the second
pig. Approximately 10 cm proximal to the dentate line, The SILS, TriPort, GelPOINT, and SSL Access System
a full-thickness rectal wall excision with a diameter of 2 were successively inserted transanally in the first pig. The
cm was performed. Maneuvers required to remove the interior ring of the GelPOINT port was too large for intra-
specimen were then assessed. luminal expansion. Therefore, this port was judged not
Barendse et al 325
Figure 2. Pneumorectum with Triport after CO2 insufflation (A) and after instrument introduction (B)
Figure 3. Auto-fixation of the SSL Access System retractor
suitable for transanal employment. Insertion of the SILS
was the easiest, followed by TriPort and SSL Access
System (Table 2). For the SSL Access System, we only
had the small, 2-cm fixed-length retractor at our disposal,
and we hypothesized that the 4-cm retractor would fit better.
None of the ports caused mucosal damage.
Intraoperative Features
Manual fixation of the SILS port was necessary to
prevent partial dislocation after CO2 insufflation and
dislocation of the entire port intraluminally during
trocar introduction (Figure 1). With manual stabilization,
a good luminal overview was achieved. The TriPort
achieved a good mucosal exposure after CO2 insufflation.
However, CO2 leakage occurred through the trocar
ports after introduction of the laparoscope and instru-
ments (Figure 2), the flexibility of the port retractor
hampered a secure position of the interior ring behind
the anal sphincter, and manual fixation of the port was
required as well.
With the SSL Access System, despite a tedious
insertion, an excellent pneumorectum was created.
The fixed-length retractor enables a stable position of
the port; the interior membrane is held in place by the
internal anal sphincter and the exterior membrane by the
anal verge. (Figure 3) Insertion of the laparoscope and
instruments did not influence the position or stability
of the port and did not cause any CO2 leakage. After
these observations, we selected the SSL Access System
as the most optimal single-access port for transanal
employment.
Resection
In the second pig, a rectal excision was attempted with
the SSL Access System and conventional laparoscopic
instrumentation. The surgeon (EdG) was seated between
the pig’s hind legs; a surgical resident (JN) handled the
326 Surgical Innovation 19(3)
laparoscope and was standing to the left of the surgeon.
The seal cap of the port can be rotated 360°, allowing
quick reorientation of instrumentation throughout the
procedure without necessitating instrument exchanges.
Resection circumstances were comparable to TEM. The
port with the 2-cm retractor dislocated once during the
procedure. The detachable seal cap facilitated collection
of the resected specimen, without further disassembly of
the operating set-up.
Discussion
This study is a first step in assessing the feasibility of
transanal employment of single access ports for rectal
surgery. Not all the various single access ports currently
available seem suitable for transanal surgery. The limited
space of the rectal cavity and the features of the anal
sphincter in comparison with the abdominal wall neces-
sitate certain dimensions of the port retractor and orienta-
tion of the trocars. Fixation of the access port in the anal
canal may be more difficult than fixation in an abdominal
wall incision as the interior retractor membrane needs to
unfold within the rectum. Rectal shape varies with gen-
der and is subject to pelvic floor contractions.
Because the rectal cavity is limited in space and the rec-
tal wall itself is operated on, a stable pneumorectum is
highly important for safe surgery and proper appreciation
of the endoluminal image. We found that because of its
dimensions, the GelPOINT is not suitable for transanal
surgery. Because of limited stability, the SILS and TriPort
systems require manual fixation or supportive sutures, as
reported in previous case reports. Our experiences with
the SSL Access System, however, were encouraging. Once
inserted, an excellent pneumorectum was achieved and
the ability to rotate the seal cap facilitated easy instrument
reorientation. Although we encountered some difficulty
with insertion, we hypothesized that this was because of the
short retractor, to which we were limited during this study.
The longer retractor may not be associated with these diffi-
culties. Stability of the set-up was found to be excellent.
The surgical skills required for single access surgery
are comparable to those required for TEM, as working
angles and endoscopic suturing in both techniques are
similar. Transanal employment of single access ports
may be a promising alternative for TEM in rectal surgery.
If the effectiveness and safety of single port transanal
surgery are comparable to TEM, this technique may
compete with TEM and may be associated with fewer
costs. Few others have reported promising clinical results
in small case series of patients operated with the SILS. In
our opinion, the SSL Access System is more appropriate
for transanal surgery. Feasibility in humans should be
investigated. Prospective case series are needed to show
the effectiveness and safety of this operating set-up.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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