to the multiport laparoscopic platform.
Single‐incision and single‐port surgery can be achieved using an operating laparoscope but is more commonly performed with commercially available single‐port devices.
Articulating instruments can be used to offset the limitations on triangulation that are inherent to the approach, although the use of rigid instrumentation is also possible.
Within veterinary medicine, this platform has expanded beyond the abdominal cavity to also include surgery within the thoracic and retroperitoneal spaces.
Single‐incision, single‐port, and laparoendoscopic single‐site surgery have secured a comfortable niche within veterinary minimally invasive surgery. Reducing invasiveness while maintaining the safety and efficacy of operative procedures should be our top priority as veterinary surgeons.
Surgery is forever evolving. As new evidence emerges on how to treat disease, the methods by which we apply this new knowledge to daily patient care are constantly refined. Within the past century, arguably one of the most important advancements to occur within the surgery is the development of laparoscopy. This approach has completely revolutionized modern surgical practices, significantly changing the surgical way of thinking, operative techniques, and all other aspects of modern surgical care [1]. Laparoscopy gained acceptance among surgeons and patients alike because of its unquestionable advantages, which include smaller incisions, reduced postoperative pain, shorter hospital stays, and faster return to everyday living compared with the traditional open approach [2]. After the laparoscopic revolution occurred in humans during the 1980s, it was not long before diseases once commonly addressed through open surgery began to be performed by laparoscopic means. The tremendous advantages and benefits of laparoscopy witnessed in human health care impacted companion animal health as well, eventually changing the way many common operative procedures could be performed in veterinary surgery. To date, veterinary surgeons now have the ability to use a minimally invasive approach for almost every type of intrathoracic and intra‐abdominal procedure offered in canine and feline surgery.
Another revolution in the field of laparoscopic surgery has occurred with striking technical advancements leading to the development of even less invasive operative procedures in both humans and animals. The journey to make minimally invasive techniques even less invasive has generated a drive within the surgical community to explore novel ways of achieving this paradigm [3]. New approaches to minimally invasive abdominal entry have included decreasing the overall number of trocars–cannula assemblies placed through the abdominal wall and attempting to eliminate them completely by using a natural orifice. These concepts have led to the birth of several new minimally invasive access platforms, with the most notable being single‐port style surgery. For the purpose of this chapter, and to be consistent with previous veterinary literature, we will use the term single‐port surgery to broadly encompass the single‐incision and single‐port style of laparoscopic approaches. Additionally, the concept of reduced port surgery will also be briefly discussed as a segue and bridge for reducing the overall number of ports it pert when discussing this platform in veterinary medicine.
Of note, the specific terminology for describing the various approaches and surgical procedures completed through a single laparoscopic incision or single port has varied. This confusion has led to a great deal of debate among a number of the leading human laparoscopic surgeons as to what proper nomenclature and terminology should be used for the literature. An international consortium of experts within human laparoscopy elected to attempt to utilize the term Laparoendoscopic Single‐Site Surgery (LESS) [4]. This was done to standardize the field and promote a more rapid dissemination of the associated research. However, that term is still not entirely accepted and continues to be a confusing topic. Additional terminology and acronyms are described in Table 6.1.
Table 6.1 Acronyms used in text.
| Acronym | Full procedure name |
|---|---|
| LESS | Laparoendoscopic single‐site surgery |
| NOTES | Natural orifice transluminal endoscopic surgery |
| SPA | Single‐port access |
| SILS | Single‐incision laparoscopic surgery |
| SILAIS | Single‐incision laparoscopic‐assisted intestinal surgery |
| SPAGO | Single‐port access gastropexy and ovariectomy |
| SPLC | Single‐incision laparoscopic cryptorchidectomy |
Interestingly, natural orifice transluminal endoscopic surgery (NOTES) has remained in its experimental stages and continues to suffer from numerous hurdles preventing its broad implementation. Single‐incision, single‐port, and reduced port laparoscopic surgery has emerged as the more acceptable choice for most surgeons [5]. The acceptance of these newer platforms, unlike NOTES, remains within the comfort zone of most surgeons because the instrumentation and techniques are similar to those used in standard laparoscopy [6].
Whereas conventional laparoscopy requires multiple, individually spaced incisions to accommodate ports ranging from 5 to 10 mm in length, the single‐incision and single‐port platform differs from this by placing all instruments through one single (1.5–3 cm) incision into the abdomen. In humans, at present, procedures such as single‐port cholecystectomy and hemicolectomy are gaining significant popularity.
Additionally, the development of the reduced‐port surgery concept has evolved as the middle ground between true multiport laparoscopy and single port. Reduced port surgery is gradual, step‐wise, incremental reduction of ports/incisions for a given procedure to reduces overall invasiveness. An example is going from 4 to 5 port cholecystectomy to a two‐port procedure. This reduced port platform is positioning itself to potentially replace conventional dogmatic style of multiport laparoscopic procedures by achieving reduced postoperative pain and optimized cosmetic results compared with the multiport procedure [7, 8].
Development of a New Platform
The early history of single‐port style laparoscopic surgery may date back to its early use in laparoscopic gynecologic surgery when Wheeless and Thompson described more than 1000 tubal ligations using a single puncture laparoscope with an offset eye piece [9]. However, purists within the contemporary single‐port arena argue that operative laparoscopy differs significantly from modern‐day single‐port surgery, and the origins of the single‐port surgical revolution were developed more recently. The first use of separate instruments and ports through a single incision was initially described in 1997 by Navarra et al., when they published their “one wound cholecystectomy” using two transumbilical trocars [10]. At that time, single‐port surgery seemed as if it was not ready to emerge as a viable access platform for the mainstream and even Navarra himself questioned the validity of that approach in terms of its safety, efficacy, and operative time. It was not until 2007, when Curcillo revisited Navarra's work and described a stepwise approach for the reduction of port sites and consolidation of trocars, resulting in one umbilical incision for laparoscopic cholecystectomy named single‐port access (SPA) [11]. Since 2007, a massive emergence of single‐port procedures has been successfully adapted to many common multiport laparoscopic abdominal procedures in both children and adults with the ultimate goal of reducing overall surgical invasiveness. The single‐port platform evolved rapidly with the objectives of minimizing overall surgical trauma, reducing postoperative pain, shortening convalescence, and improving cosmesis [11]. In humans, it is speculated that the potential advantages that single‐port surgery has over conventional