INTRODUCTIONRecently developed single-port laparoscopic surgery(SPLS) obtains better cosmesis.1 However, it entails alarge (up to 3.5 cm) umbilical fascial incision foraccommodating the operating-port. This may lead tosignificant wound-related morbidity and remarkably highincisional hernia rate (5.8%).2 Moreover, it adds to thesurgical expenses and needs expert handling.2,3 In thiscontext, we describe a simple technique of umbilicalaccess/porting in an attempt to improve the existingtechnology. The authors call it the Single-site Multi-portLaparoscopic Endo-surgery (SIMPLE) technique.

TECHNIQUEUnder general anaesthesia, the patient is positionedsupine. For right-sided pathologies, the surgeon standson the left of the patient (and vice versa). The camera-assistant stands on the left of the surgeon. The monitoris placed opposite the surgeon.

Pneumoperitoneum is created by inserting the Veressneedle at the umbilical ring (Figure 1A). The intra-

abdominal pressure is set at 12 - 16 mmHg. As againstthe SPLS, this technique defers large umbilical incisionand subsequent umbilical-flap elevation. Instead, threetrocars (one 10 mm and two 5 mm) are secured directlyat the umbilical mound via corresponding three smallcurvilinear skin-incisions (Figure 1B). The trocars aredirected in peculiar paths. Once in the subcutaneousspace, their tips are deviated outwards and forwards (byabout a centimetre at 45o angle to the skin) to puncturethe fascia and the peritoneum. Thus, these “lazy S” path-pattern help in distancing the trocars right from theirskin-entries till the tips of the inserted instruments. Thisarrangement is better conceptualized in the form of threeisosceles triangles placed one-in-another-the inner-mostformed by the skin-entries, the middle-one formed by thefascial-entries and the outer-most formed by the tips ofthe laparoscopic instruments (Figure 2). Moreover, thepneumoperitoneum stretches the umbilicus to augmentthis triangular arrangement. With the triangulationmaintained, the trocar-location can be rotated as per thesite/quadrant of the “target-organ”.

The tight surgeon-cameraman interface can beconsiderably eased as follows: Horizontal “dissociation”:1

The camera-trocar is kept maximally withdrawn and theworking-trocars are advanced further by 8 - 10 mm.2 Thecamera-assistant introduces his/her right hand fromunderneath the surgeon's left hand for holding thecamera (Figure 3). With this, the camera-assistant's lefthand manoeuvres the camera-cable comfortably.Vertical “dissociation”: The surgeon stands on a 0.5 feethigh wooden stool during the entire procedure.

The valves of the 5 mm trocars are kept facing awayfrom each other; one may be used for the CO2-inflow and the other for the surgical-smoke venting.

Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (3): 203-205 203

NEW TECHNIQUE

Single-site Multi-port Laparoscopic Endo-surgery: The SIMPLETechnique - A Useful Method of Purely Umbilical Porting that

Ensures Triangular Laparoscopic ErgonomicsPriyadarshan Anand Jategaonkar1 and Sudeep Pradeep Yadav2

ABSTRACTUmbilical single-port surgery is a recent development that produces better cosmesis and lesser pain. However, the steeplearning curve and the higher surgical expense have led to its rather sceptical acceptance. In this regard, a technique ishereby described in which three ports are directly inserted on the umbilical mound (without raising the umbilical-flap)through three small incisions to form an isosceles triangle. The respective fascial-entries are made farther away to achievesatisfactory inter trocar distance. This technique complies with the laparoscopic triangulation principles, likely to furtherreduce postoperative umbilical pain/morbidity, and achieve good umbilical aesthetics as the scars recede within theumbilicus. As only the routine laparoscopic instruments were utilized, it also has a potential to reduce the surgical cost.Therefore, the authors feel that this technique can be a valuable addition to the existing umbilical laparoscopic methods.

Key Words: Laparoscopic surgery. Trans-umbilical surgery. Triangular ergonomics.

1 Department of General and Minimal Access Surgery,Mahatma Gandhi Institute of Medical Sciences, Sevagram,Wardha- 442102, Maharashtra, India.

2 Department of Surgery, Jagjivan Ram Western RailwayHospital, Mumbai Central, Mumbai-400008, Maharashtra,India.

Correspondence: Dr. Priyadarshan Anand Jategaonkar, 201,Yamuna Apartment, Yashasvi Nagar, Balkum, Thane (W),Thane - 400 608, Maharashtra, India.E-mail: shekharsmitaj@yahoo.com

Received: May 22, 2013; Accepted: September 30, 2013.

Priyadarshan Anand Jategaonkar and Sudeep Pradeep Yadav

204 Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (3): 203-205

Furthermore, the occasional problem of sub-optimalextra-hepatic exposure during cholecystectomy issolved by grasping the fundus of the enlargedgallbladder by catgut-loop that, in turn, is held retractedby the standard port-closure needle inserted via per-abdominal 2 mm stab-incision. When required, 10 mmclip-applier may be used after interchanging the 10 mm

laparoscope by the 5 mm. Endobag is routinely used forthe specimen-extraction through the 10 mm port. We donot connect the mini-incisions for this purpose.

All three fascial punctures are meticulously closed underdirect vision using 3/0 polyglactic acid. The skin-incisions are closed by subcuticular sutures using 3/0mono-filament material to achieve excellent cosmeticresults (Figure 4).

DISCUSSIONNavarra has been credited for performing the first SPLScholecystectomy in the year 1997.4 Since then, as thecosmetic advantage of single incision was better appre-ciated, many authors have reported their experience invaried pathologies across the globe.1 Despite array ofport-systems available in the market,3 the SPLS isfraught with a rather sceptical acceptance. Apart fromthe expenses, this seems to be due to its two innateproblem-interfaces:

1. The surgeon-port interface: Triangular porting-ergonomics, the basis of any laparoscopic surgery, isdeficient.3 The specially-designed SPLS instrumentsrequire expertise for handling.3 They cause a chop-stickeffect (simulating the surgeon's crossed-hands in anopen surgery), are scarcely available and expensive.Moreover, smoke-venting system is lacking in the basicdesign of these ports.

2. Surgeon-camera man interface: Any un-obstructedhand-movement of either of them becomes ratherdifficult without frequent clashing. It also limits thecamera-person's ability to smoothly manoeuvre the 30o

camera-cable. Consequently, even the simple surgicaltasks turn difficult.

Thus, wider dissemination of the single-site surgery isfar from possible unless these shortcomings are tackled.However, the SIMPLE technique addresses many ofthese issues:

Apart from offering favourable ergonomics, the inner-triangle of the skin mini-incisions helps the future scars

Figure 1: Pneumoperitoneum creation and the umbilical mini-incisions. Notethat the Veress needle is inserted on the umbilical mound. Solid lines, skinincisions for the trocars; dotted lines, fascial trajectories of the trocars that is“off-line” with the respective skin-entries.

Figure 2: The port-paths. Note that the triangle of skin-entries < triangle offascial-entries < triangle of instruments-tips entries. While maintaining thetriangulation, this arrangement increases the inter-trocar distance right fromthe skin-incisions.

Figure 3: Port and hand positions. Note that the working-trocars are pushedin an extra 8-10 mm while the camera-trocar is withdrawn to its maximum.The camera-holder's hand comes from beneath the surgeon's. Valves ofthreaded plastic trocars are outwardly placed. Light and gas cables exitsuperiorly. Such an entire assembly follows basic principles of laparoscopicergonomics and allows rather free hand movements to the surgeon.

Figure 4: Postoperative scars. Note that the scars almost recede in theumbilicus.

to recede in the umbilicus (thus, achieving goodumbilical aesthetics) and the outer triangle formed by thefascial entry-points helps in trocar-spacing. Bypassingthe umbilical flap-raising potentially reduces the seromaformation. The often-frustrating problem of surgicalsmoke-venting is curbed in this technique. Peri-port gas-leak is reduced by precisely tailored skin-incisions andusing threaded trocars to seal-off the leaky gaps. Usageof the day-to-day laparoscopic instruments is likely toshorten the learning curve and reduce the surgical cost.Our learning curve cholecystectomy by this techniquewas 15 cases and for appendectomy were 10 cases.The port-closure needle mirrors the “dynamic” retractionas in the conventional laparoscopy. By enhancingthe exposure, it can reduce the rising bile-duct injuryrate (0.72%)5 for the SPLS. In contrast to SPLS, our all-small-incisions method that tends to minimize theaccess-trauma, the oblique port-paths and the promptfascial-closure of all the ports are likely to diminish theport-site hernia formation. Using this technique, we havesuccessfully performed cholecystectomy (>300 cases),appendectomy (>300 cases), peritoneal dialysiscatheter fixation (>50 cases), combined laparoscopicsurgery like appendectomy with cholecystectomy (12cases), ovarian cystectomy (18 cases) and diagnosticlaparoscopy (>200 cases) over last 4 years. From thisexperience, we have observed that, apart fromacceptable cosmetic results, postoperative incision-sitepain was remarkably less than the conventionallaparoscopy. Moreover, nobody has developed port-sitehernias till now.

However, this technique has certain limitations. There isa very bleak margin-of-error for strategic trocar-placement designed to avoid the trocar-clashing. Narrowslit-like umbilicus is challenging to access. Largespecimen-extraction becomes unfeasible withoutconnecting the mini-incisions.

In conclusion, the SIMPLE technique complies thebasic principles of laparoscopic triangulation and maybe considered as a valuable method of trans-umbilicalsurgery.

REFERENCES1. Pisanu A, Reccia I, Porceddu G, Uccheddu A. Meta-analysis of

prospective randomized studies comparing single-incisionlaparoscopic cholecystectomy (SILC) and conventionalmultiport laparoscopic cholecystectomy (CMLC). J GastrointestSurg 2012; 16:1790-801. Epub 2012 Jul 6.

2. Alptekin H, Yilmaz H, Acar F, Kafali ME, Sahin M. Incisionalhernia rate may increase after single-port cholecystectomy.J Laparoendosc Adv Surg Tech A 2012; 22:731-7.

3. Goel R, Lomanto D. Controversies in single-port laparoscopicsurgery. Surg Laparosc Endosc Percutan Tech 2012; 22:380-82.

4. Navarra G, Pozza E, Occhionorelli S, Carcoforo P, Donini I.One-wound laparoscopic cholecystectomy. Br J Surg 1997; 84:695.

5. Joseph M, Phillips MR, Farrell TM, Rupp CC. Single incisionlaparoscopic cholecystectomy is associated with a higher bileduct injury rate: a review and a word of caution. Ann Surg2012; 256:1-6.

The SIMPLE technique

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