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 Chia-Da Lin Chia-Chang Wu
Yao-Chou Tsai Stephen Shei-Dei Yang

Received: 16 March 2009 / Accepted: 20 June 2009

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 retractor 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, 48 (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 devicesR-portTM (Advanced
Surgical Concepts, Dublin, Ireland) and Uni-XTM (Pnavel

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Systems, Morganville, NJ, USA)to allow the introduction of several laparoscopic instruments through one
abdominal skin and fascial incision. However, both specialized ports are not available in Taiwan. Therefore, we
developed a homemade transumbilical port involving the
use of existing instrumentation and handy materials; we
report the preliminary experience of applying this technique in LESS.

Materials and methods

Subjects
From December 2008, we have used this technique for the
access of 14 urologic LESS procedures, including nephrectomy, pyeloplasty, and uretero-ureterostomy on porcine
laboratory and cadaveric human cases. After the successful
experience in simulation surgery, 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. 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.

Fig. 1 External views of the

homemade single-port
transumbilical access for LESS
varicocelectomy (step by step).
A Alexis wound retractor was
placed through an
infraumbilical transverse
incision. B Pair of sterile
surgical gloves was snapped
onto the external ring. 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. D Two
5-mm additional operating ports
were placed in triangulation for
subsequent procedure

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Surgical technique
A 1.5-cm umbilical skin incision was made and carried
down into the peritoneum. An Alexis wound retractor (Xsmall, Applied Medical, Rancho Santa Margarita, CA, USA)
was placed in position through the incision with the bottom
ring (green) inside the abdomen (Fig. 1A). A pair of sterile
surgical gloves was snapped onto the external ring (white),
and the upper half parts (including the five fingers) of the
gloves were ligated and truncated (Fig. 1B). A 5- or 10-mm
laparoscopic standard trocar was then inserted through the
gloves and secured by a pursestring suture around the trocar
(Fig. 1C). After pneumoperitoneum was established, a 5- or
10-mm laparoscope was inserted to inspect the peritoneal
cavity. Two (5/5-mm, 5/10-mm, or 5/12-mm) or three (5/5/
5-mm) additional operating ports were placed depending
on the procedures (Fig. 1D). RoticulatorTM articulating
instruments (Covidien Ltd, Norwalk, CT, USA) and standard laparoscopic instruments were used for subsequent
manipulation. A variety of LESS procedures were performed in standard fashions. After the operations were
completed, the Alexis wound retractor was removed and
the umbilical fascia was closed with 2-0 Vicryl suture. The
umbilical skin was approximated using 4-0 Monocryl running suture.

Surg Endosc

Results
All procedures were completed without any intraoperative
or postoperative complications. This alternative technique
of creating a transumbilical single-port access was successful in all cases. The time to achieve the transumbilical
port ready for subsequent LESS was short (range, 48
(median, 6) minutes). All procedures were performed with
instruments inserted through this port without the need for
any extraumbilical incisions or conversion to standard
laparoscopic surgery. The total operative time was between
60 and 190 minutes. No port-related complications (such as
wound infection, skin maceration, or ventral hernia) were
reported. The cosmetic results were excellent (Fig. 2).

Discussion
Wheeless and Thompson first published the technique of
laparoscopic tubal ligation in 1969 [1]. Through a 1-cm
curved infraumbilical incision, a laparoscope with a parallel offset eyepiece and a working channel was introduced
through a standard laparoscopic trocar after pneumoperitoneum was established. Similar settings have been
reported for hysterectomy with bilateral salpingo-oophorectomy (BSO), appendectomy, cholecystectomy, and right
hemicolectomy [26]. Because only one laparoscopic
instrument was used to manipulate, additional assistance
from outside, such as concomitant transvaginal cannula
or percutaneous anchoring stitches, may be needed to
provide the countertraction and better exposure. Thus, the
above settings were not feasible for complex laparoscopic
procedures that require intracorporeal suturing and knot
tying.

Fig. 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).
Piskun and Rajpal first used this method for laparoscopic
cholecystectomy [7]. 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]. Raman et al. performed three
nephrectomies through a single umbilical incision with
three adjacent conventional trocars as well (one at 12 mm,
two at 5 mm) [9]. However, several fascial punctures may
lead to skin maceration and fascial tear, and further complicate wound healing.
Recently, two commercialized single-port accesses
designed specifically for LESS have been reported.
R-portTM is a multichannel access that allows multiple
instruments to pass through one incision simultaneously,
without compromising the pneumoperitoneum. It consists
of one 12-mm and two 5-mm lumens for laparoscope and
working instruments. Reported LESS procedures using
R-portTM include cholecystectomy, sigmoidectomy, and
nephrectomy [1014]. Another option, the Uni-XTM system, consists of an inverted, cone-shaped, plastic outer unit
converging on three separate 5-mm inlets. The Uni-XTM
system has been applied for cholecystectomy, TAPP
inguinal hernia repair, varicocelectomy in children, and
abdominal sacrocolpopexy [1517]. To date, both specialized ports are not available in Taiwan.
Our homemade transumbilical port has some merits.
First, it is more cost-effective than current port entry systems. The use of disposable instruments increases the cost
of laparoscopic procedures. Because the majority of these
expendables are not covered by medical insurance in Taiwan, the patients have to bear the charges of surgery
themselves. Our port consists of existing instrumentation
and handy materials and costs approximately US$150. The
choices of trocar size (3- to 12-mm) and arrangement (3 to
4 trocars or more) of our technique are more flexible than
that of current commercialized techniques. Consequently, a
variety of instruments (3- to 12-mm) can be used to
facilitate the procedures. We can design optimal trocar
placement preoperatively or replace the smaller trocar to
larger one for unexpected occurrence intraoperatively, as in
standard laparoscopic surgery. In addition, the use of
wound retractor increases the size of incision, which makes
introducing several instruments simultaneously much easier. It also protects wounds from fascial tear or skin maceration and avoids port-site metastasis while performing
oncologic LESS procedures. The incision was approximated readily. By using the larger trocar (10- or 12-mm),
mesh or needle is delivered into the abdomen without
difficulty. Lastly, no significant gas leakage was noted
during the surgery, even in procedures with longer operative time.

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Conclusions
This homemade transumbilical single-port access offers a
simple, reliable, flexible, and cost-effective approach to
perform LESS. It provides a good operative field without
significant gas leakage to interfere with the procedures
intraoperatively. This technique may be an alternative for
current specialized port systems.

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