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Background: An important aspect of a new surgical technique is whether it can be performed by other surgeons in other institutions. The authors report the first 297 cases in a multi-institutional and multinational review of laparoscopic cholecystectomy performed via a single portal of entry.Methods: Data were collected retrospectively for the initial patients undergoing single-port cholecystectomy by 13 surgeons who performed these procedures in their institutions after training by the authors. The review included operative time, blood loss, incision length, length of hospital stay (LOS), necessary additional trocars, and other parameters important to cholecystectomy. A database of all the single-port-access (SPA) surgeries performed by the surgeons included demographic and procedural details, LOS, complications, and initial follow-up data.Results: To date, 297 single-port cholecystectomies have been performed for a variety of diagnoses, primarily cholelithiasis. The average operative time was 71 min, and the average LOS was 1-2 days. The average blood loss was minimal. The use of additional port sites outside the umbilicus occurred in 34 of the cases. Of the 35 intraoperative cholangiograms performed, 34 were successful. No significant complications occurred except for seromas and minor postoperative wound infections. These results are comparable with those for standard multiport cholecystectomy. In addition, no access site hernias (ASH) occurred.Conclusions: The findings demonstrate that SPA surgery is an alternative to multiport laparoscopy with fewer scars and better cosmesis. One factor affecting the rate for adoption of SPA surgery among other surgeons is the reproducibility of this new procedure. Although this study had insufficient data to determine fully the benefits of SPA surgery, the feasibility of this procedure with safe, acceptable results was demonstrated in this initial large series across multinational institutions. [ABSTRACT FROM AUTHOR]

Objective: To describe the Single port access (SPA) laparoscopic entry technique for canine ovariectomy (OVE), report complications, and outcomes., Study Design: Pilot study., Animals: Intact female dogs (n = 6)., Methods: With owner consent, 6 intact female dogs had SPA laparoscopic OVE. Data, including signalment, surgical time (from incision to completion of closure), size and location of port placement, need for conversion (both to standard multiport laparoscopy and laparotomy), as well as any intraoperative complications including blood loss or tissue injury were recorded., Results: Mean surgical time was 52.5 minutes (range, 45-60 minutes) and mean incision length, 1.8 cm (range, 1.5-2.0 cm). In an 18-kg mix breed dog (dog 3), a "single port rescue" was required and located on midline 2-cm caudal to the umbilicus. Close positioning of the trocars caused instrument interference, limited viewing, and prevented safe ligation of the ovarian vessels vein with a vessel-sealing device. OVE was successfully completed laparoscopically in all dogs., Conclusion: The SPA laparoscopic entry technique can be used in dogs, although instrument and camera interference can occur if trocar placement is too consolidated within the initial skin incision., (© Copyright 2012 by The American College of Veterinary Surgeons.)

Single-port surgery has seen almost as rapid an application as multiport laparoscopy during the early 1990s. Hopefully, we will learn from our predecessors to apply the dictums of safety and science as we move forward with this new technique to ensure adequate adoption and successful outcomes with limited errors and concerns along the way.

"Scarfree" surgery is a desired goal in the world of laparoscopy and interventional endoscopy. One possibility to achieve this goal is abdominal access via a natural orifice (natural orifice transluminal endoscopic surgery, NOTES); however, this procedure and its applications lack an appropriate platform. Further possibilities are reduced port techniques or single port access surgery, which result in minimal scarring. Development and continued growth in this area cover a broad spectrum. Although acceptance has been demonstrated, the technique must be adopted in a safe and effective manner and must be economically and ecologically safe. This article gives an overview of the development of the technique, the learning curve, and new applications for this new technique. An English full-text version of this article is available at SpringerLink as supplemental.

Background: Over the past 3 years, minimal-access surgery has seen movement toward single-port-access (SPA) surgery. Since its inception in the spring of 2007, a number of differing approaches and technologies for reduced-port surgery have become available to move the field toward "scarless" surgery. As with any advance, a cautious eye needs to observe changes with respect to the risks and benefits of new procedures or devices. Although the adoption of reduced-port techniques in cholecystectomy may move the field of surgery forward, there is a need to ensure that basic tenets of safety are not left behind. In cholecystectomy, one of the gold standards for safety is preservation of the critical view of safety during cystic duct dissection and transection., Methods: Early in the development of SPA surgery, a standardized procedure was sought that could be extended safely to laparoscopic surgeons. With this ideal in mind, the technique of SPA cholecystectomy was evaluated early. Deeming exposure to be critical, specifically the view of the cystic-to-common duct relationship beneath the liver, the authors aimed to evaluate whether this critical view of safety can be maintained during the procedure and before the cystic port is clipped and transected. To determine reproducibility, the authors did a simple comparison of their initial 10 two-instrument SPA cholecystectomies with their subsequent 10 three-instrument cholecystectomies by reviewing the videos of each case., Results: The authors' review confirmed that the critical view of safety was obtained in all the three-instrument cases but was difficult to obtain in the two-instrument procedures. In addition, they were able to demonstrate the critical angle of clip placement in all three-instrument cases., Conclusion: The authors present their initial results in an attempt to demonstrate that as new procedures develop, there is a need to ascertain their safety and adherence to underlying principles already established before advancing them further at the risk of compromise and complication.

There has been an emergence of reduced port techniques for laparoscopic surgery over the past three years. Although growing in presentations and papers, few scientific studies have yet to be published demonstrating benefits and risks of these techniques. In particular, very little is mentioned regarding the increased costs. This brings to the forefront the concept that the development of new surgical techniques should adhere to safe standards of surgery and undergo continued evaluation during development to ensure they maintain safety, and are able to be reproduced by our colleagues. Evaluation also needs to focus on costs, both economical and ecological. A review of our first three years experience of single port access surgery has been done. Costs in terms of both the potential economic and environmental impact have also been evaluated as compared with multiport procedures. In the first 36 months of this evolving technique, we were able to mimic multiport procedures with similar results. The costs of single port access are less than comparable multiport procedures, both in terms of dollars as well as medical waste. We are able to now offer "proof of concept" of a novel reduced port procedure from four important aspects in the development of new surgical techniques. We demonstrate comparable results in terms of outcomes and safety, improvement in financial and environmental costs, as well as showing initial success with training and application of the procedure by our colleagues.

Background: Laparoscopic ventral hernia repair has been demonstrated to be an acceptable and successful technique. Aside from similar, albeit fewer, complications compared to open hernia repair, the laparoscopic technique has the additional complication of port site hernia to its follow-up criteria. Our initial experience with reduced port surgery in hernias was described as a two-port one-stitch repair technique in 2002. We initially applied our Single Port Access (SPA) technique to ventral hernia repairs and reported it at the American Hernia Society meeting in 2008. Now we present the first 30 cases, some with 6-24-month follow-up., Methods: The charts of 30 patients undergoing surgery for primary and recurrent ventral hernias employing the SPA technique were reviewed. The SPA technique was applied through a 1.0-1.6-cm incision remote from and lateral to the hernia location in the abdominal wall. Polypropylene-based coated mesh and non-fascial fixation were used in all cases., Results: All procedures were completed via the SPA technique. Operative time, length of stay, and estimated blood loss were acceptable. The size of mesh placed ranged from 81 to 500 cm(2). Postoperative seromas were observed and all resolved spontaneously. There have been no wound infections or port site hernias during the 6-24-month follow-up period. There have been no recurrent hernias at the primary site., Conclusion: We have successfully demonstrated the applicability of Single Port Access surgery for ventral hernia repair. In our initial series we performed this procedure on smaller hernias but have now begun applying it to larger repairs.

Introduction: In April 2007, we performed our first single port access (SPA) surgical procedure. Beginning with simple procedures, we progressed to more complex procedures employing modifications of the initial technique., Methods: Maintaining our abdominal entry technique through a single incision, typically umbilical, we have now successfully performed cholecystectomies, colon resections, small bowel procedures, liver biopsy, splenectomy, adrenalectomy, and surgery of the gastroesophageal junction., Results: Two procedures have required additional port sites, none has employed transabdominal sutures, and <5% of all procedures have required articulation. Immediate follow-up demonstrates safe completion of multiple procedures with acceptable outcomes of blood loss and hospital stay. Although initial operative times are extended, a decrease is seen following a learning curve. At 2-year follow-up, two hernias developed at the extended incision for colon extraction., Discussion and Conclusion: With initial procedures performed in April 2007, we now report 24-month follow-up of a novel laparoscopic approach utilizing standard instrumentation. We demonstrate that SPA surgery is an alternative to multiport procedures with proposed initial benefits of decreased number of incisions and improved cosmesis for the patient. Long-term prospective randomized large case series will be necessary to assess pain, recovery, and hernia formation proving advantages, if any, over multiport laparoscopy.

Background: We have developed a single port access (SPA) surgical technique that allows for procedures to be done through a single umbilical port incision <20 mm in length. For a new approach to be universally beneficial, it needs to be easily learned and applied., Methods: Single port access abdominal procedures are performed through one umbilical incision where skin and soft tissue flaps are raised from the underlying fascia to allow insertion of up to 4 instruments. Fifty surgeons with varying degrees of laparoscopic training participated in SPA training programs at Drexel University to learn and apply the SPA technique through participation in an animate (porcine) laboratory., Results: All surgeons successfully performed the SPA access technique without difficulty and completed the cholecystectomy in <55 minutes (average, 42). Eight surgeons successfully performed placement of a cholangiogram catheter. All recognized the value of a formal training symposium to learn SPA techniques before performing SPA procedures in their practice., Conclusions: The SPA technique has been successfully shown to be an approach that is easily learned and accomplished. We believe this is a necessary and important bridge towards proficiency in performing SPA procedures in clinical patients.

Introduction: Over the last decade, laparoscopic splenectomy has become the standard of care for spleen removal. Elimination of a large incision and difficult exposure has decreased postoperative morbidity and length of stay. Single port access (SPA) surgery was developed as an alternative to traditional multiport laparoscopy, potentially exploiting the already proven benefits of minimally invasive surgery. We apply the SPA technique to splenectomy via a single umbilical incision., Methods: SPA splenectomy was performed in a 36-year-old male for staging. The single-port access technique was used to gain abdominal entry. Exposure, dissection, and removal were performed via a single incision within the umbilicus. The final incision was extended for removal of a complete specimen for pathologic evaluation., Results: Splenic mobilization and control of the short gastrics was successfully performed via a single umbilical incision. The final incision was extended inferiorly for en bloc organ removal. Follow-up at 18 months revealed a well-healed incision with no signs of hernia formation., Conclusions: The single-port access technique has been successfully applied to splenectomy as an available alternative to multiport laparoscopic splenectomy. Use of standard instrumentation and trocars maintains costs and familiarity of the procedure. Exposure, visualization, and dissection are the same as in standard laparoscopy. SPA surgery may be more ergonomically pleasing to the surgeon and offer patient benefits, such as faster recovery and decreased adhesion formation in the long term.

Introduction: Laparoscopy is a constantly evolving field of surgery. New technology, applications, and benefits prompt continual improvement. We have developed a Single Port Access (SPA) surgical technique that allows for the entire cholecystectomy to be performed through a single incision within the umbilicus while maintaining safe standard dissection and retraction techniques of currently performed multiport laparoscopic cholecystectomy., Methods: Fifteen consecutive patients underwent SPA cholecystectomy. Indications were cholelithiasis, cholecystitis, CBD stones, and biliary akinesia. The entire procedure was performed through a single umbilical incision measuring <1.8 cm within the umbilicus. Three trocars and a rigid grasper were inserted through separate fascial sites within the same skin incision. The cholecystectomy procedures are then performed in the standard fashion described in multi-port cholecystectomy., Results: Fifteen patients successfully underwent Single Port Access cholecystectomy. One patient required a second 5-mm port site secondary to difficulty with retraction of a large liver. Operative times averaged 107 minutes. Blood loss, patient recovery, and outcomes have been comparable to those of standard multi-port procedures. No umbilical hernias have been seen at 2 years of follow-up., Conclusion: We present the SPA cholecystectomy as an alternative to multi-port cholecystectomy. In the first 2 years, SPA surgery has evolved into a technique easily taught and performed without the restrictions of new equipment or added cost.

Background: Access procedures for alimentation have been performed both endoscopically and surgically. In those patients in whom endoscopic tubes cannot be placed, the minimally invasive approach is a viable alternative. To minimize incisions and their sequelae, we have developed a single port access (SPA) technique in which minimal access surgery can be done through one portal of entry, often the umbilicus., Methods: We have used the SPA technique to place gastric feeding tubes in patients who are not candidates for PEG tubes due to supraglottic stenosis. We reviewed our experience in the first five procedures we performed., Results: In all five patients a gastrostomy tube was placed laparoscopically via an umbilical incision and a left-upper-quadrant tube insertion point. Mean operative time was 44 min. All patients began tube feeds on postoperative day 1., Conclusion: We present the first series of five SPA gastric tube placements, offering a viable alternative to PEG or open placement.

We have seen substantial changes in minimally invasive surgery since its development in the early 1900s. Over the past 10 years, the addition of natural orifice transluminal endoscopic surgery and robotics has turned our attention to improved cosmesis and advancements in instrumentation. We have developed a new technique-single port access (SPA) surgery-and have applied it to the cholecystectomy. In this paper, we present and review the application of this access technique to the first 5 consecutive patients that underwent an SPA cholecystectomy. All 5 patients were female, with an average age of 45 years and an average weight of 172 pounds. Indications included biliary dyskinesia and symptomatic cholelithiasis. Average operative time was 121 minutes in these initial 5 cases. All but 1 patient was discharged in 24 hours. At 6 months, no umbilical hernias were observed. This new technique allows for a complete cholecystectomy to be performed entirely through the umbilicus without the need for additional retraction sites or transabdominal sutures. This procedure utilizes the same basic technique of the laparoscopic cholecystectomy already employed by general surgeons. Therefore, the SPA cholecystectomy can be readily learned and performed by many surgeons without the need for expensive or experimental equipment. Using a single portal of entry to the abdominal cavity, the umbilicus, cosmesis, and scar reduction is achieved.

The practice of surgical techniques is constantly improving and evolving. In the last two decades, minimally invasive surgery has gained widespread acceptance. Virtually all procedures can now be performed laparoscopically. This trend not only provides better cosmesis, but offers decreased recovery times as well. The initial trend from open to laparoscopic surgery was to use smaller incisions. The natural continuation of this is to now decrease the number of incisions necessary to perform minimal access surgery. To this end, the authors have seen a constantly evolving stream of technology and instrumentation in laparoscopy. New venues, such as robotics and Natural Orifice. Transluminal Endoscopic Surgery (NOTES), have developed as well. As part of this evolution, the authors developed Single Port Access (SPA™) surgery in April 2007 as a novel and innovative platform of minimal access surgery. Its acceptance through our training programs, as well as the subsequent development of modified Single Port techniques, demonstrates the potential to develop a new platform of minimal access surgery. The SPA™ technique is a method of abdominal entry for a wide spectrum of laparoscopic procedures performed by multiple surgical specialties. Using the access techniques we developed, the authors have performed nearly 200 general surgical and gynecologic procedures through a single incision, often <2 cm in length and hidden within the umbilicus. In addition, the development of SPA™ surgery has been focused on using current and standard instrumentation, as well as currently practiced surgical techniques already familiar to surgeons in standard multiport laparoscopy. The "Independence of Motion" attained in this access technique, without the need for any new access or operative devices, allows up to four instruments to be place through a single incision<2 cm in length. We have striven to maintain safety principles of multiport laparoscopy, as well, and have continued to improve the technique to increase the availability and broad application of SPA™ surgery. Out technique and its application, across a broad range of surgical procedures and surgical specialties, are presented herein.

Objective: To report the first single port access (SPA) adrenalectomy to minimize patient discomfort through a less invasive procedure., Methods/results: We performed the first SPA in a 63-year-old, otherwise healthy Caucasian female who had a 4.5-cm left adrenal mass that was incidentally discovered on computed tomography scan of the abdomen and pelvis. Through a 2-cm single longitudinal supraumbilical incision extended down to the abdominal fascia, three 5-mm ports were placed through separate facial entry points, to make a triangular port arrangement. The adrenal vein was identified and ligated using hemoclips. The remainder of the dissection was done using hemocoagulation. The adrenal gland was extracted via an EndoCatch bag device by removing one 5-mm port and upsizing to a 12-mm port., Conclusion: We report on the first SPA adrenalectomy. Although this technology is still in its infancy, the use of a single port for surgery provides a means to provide a potentially better patient outcome with a less invasive procedure.

Background: Neoadjuvant chemotherapy has become the standard treatment for stage III breast cancer. Gratifying results in these patients prompted this prospective, nonrandomized study of neoadjuvant chemotherapy in stage II breast cancer. This study presents our experience with neoadjuvant chemotherapy in 127 patients with stage II carcinoma of the breast., Study Design: Patients with stages IIA (T > 3.0 cm) and IIB carcinoma were considered for this study and underwent treatment with cyclic chemotherapy until a plateau of response was achieved. Responders underwent breast conservation or mastectomy according to conventional assessment. Chemotherapy was continued in the adjuvant setting. Survival data were compared with historic controls., Results: Between 1981 and 2001, 127 women between the ages of 22 and 80 years (mean age 52, median age 50), with stage II breast cancer were enrolled, with median followup of 60 months. One hundred twenty-two patients (96.1%) responded to chemotherapy. Of this group, 35 (29.2%) experienced complete pathologic responses or had only microscopic foci of disease after treatment. Sixty-two patients (52.5%) had negative lymph nodes at the time of the operation; 28 of these patients were previously considered N-1 clinically. Seventy-six patients (62%) underwent breast conservation. Overall survivals at 5 years for stage IIA and IIB disease were 94.7% and 88%, respectively. Disease-free survival at 5 years was 85.2% for stage IIA patients and 69.1% for stage IIB patients., Conclusions: Neoadjuvant chemotherapy can be effectively applied to patients with stage II disease, and breast conservation becomes feasible in the majority of patients. When compared with historic controls, the current study suggests a statistically significant overall survival advantage (p < 0.007) at 5 years.

Purpose: To determine the diagnostic performance of functional magnetic resonance cholangiography (fMRC) for the evaluation of anatomic and functional biliary disorders., Materials and Methods: At 1.5 T, 39 MR examinations with conventional MRC and mangafodipir trisodium-enhanced fMRC were retrospectively reviewed by three observers who recorded anatomic (duct dilation, stricture, filling defects) and functional (cholecystitis, obstruction) abnormalities in three modes: MRC alone, fMRC alone, and MRC and fMRC images together (combined-MRC). Performance was determined by comparing findings with each mode to findings of invasive cholangiography (IC) and surgery., Results: Among 75 biliary segments (correlated with IC), the sensitivity/specificity for diagnosing dilation (N = 41) with MRC was 95%/97%; with fMRC, 90%/100%; with combined-MRC, 100%/97%. For stricture (N = 7), the sensitivity/specificity of MRC was 86%/98%; of fMRC, 43%/100%; of combined-MRC, 86%/100%. For filling defects (N = 9), the sensitivity/specificity of MRC was 91%/98%; of fMRC, 82%/100%; of combined-MRC, 91%/100%. For diagnosing obstruction (N = 9), the sensitivity/specificity of MRC, fMRC, and combined-MRC were 89%/100%, 100%/100%, and 100%/100%, respectively. For surgically proven cholecystitis (N = 13), positive predictive values for diagnosing acute/chronic cholecystitis for MRC were 33%/40%; for fMRC, 100%/50%; for combined-MRC, 100%/50%., Conclusion: Although single-shot fast spin echo (SSFSE)-MRC is valuable, the addition of fMRC increased diagnostic performance for functional biliary disorders., (Copyright 2003 Wiley-Liss, Inc.)

We have constructed an automated, eight-cage indirect calorimeter (AIC) for the measurement of energy expenditure in rats. We compared the measurements of resting energy expenditure (REE) in rats during a 30-h fast obtained with the AIC with those obtained with a manual indirect calorimetry (MIC) system. There was both a high degree of correlation between the two techniques during the initial 18 h of the fast (r = 0.90, P < 0.05) and strong intertechnique agreement. REE (AIC) decreased during the final 12 h of the 30-h fast (79.6 +/- 2.7-72.0 +/- 4.4 kcal.kg-0.75.d-1 [mean +/- SD, P < 0.01]). REE (MIC) did not show a significant decrease during this part of the fast (79.7 +/- 2.6 - 75.2 +/- 4.7 kcal.kg-0.75.d-1 [P = NS]). During the final 12 h of the fast agreement between the two systems gradually dissipated and correlation was poor (r = 0.375, P < 0.05). The frequency of animal handling necessitated by MIC may have resulted in a stress-induced increase in metabolic work that would mask the animals' adaptive response to starvation. This investigation demonstrates the advantages of the AIC and calls into question the accuracy of manual methods under long-term starvation conditions.

Objective: To evaluate resting energy expenditure compared to predicted energy expenditure in patients with cervical or ovarian carcinoma who require specialized nutritional support., Design: Women with biopsy-proven cervical or ovarian carcinoma referred to the Nutrition Support Service were studied. Resting energy expenditure was measured by indirect calorimetry and compared to predicted energy expenditure (PEE) as determined by the Harris-Benedict equation for females., Results: Sixty one patients were studied. Patients with ovarian cancer (n = 31) had a significantly higher measured resting energy expenditure (% PEE) than patients with cervical cancer (109 +/- 18% vs. 98 +/- 16%, p < 0.02, respectively). This difference in measured resting energy expenditure between groups could not be explained by differences in the extent of disease, nutritional status, body temperature, or nutrient intake between groups. A greater proportion of patients with ovarian cancer were hypermetabolic (> 110% of predicted) in comparison to patients with cervical cancer (55% vs. 13%, p < 0.01, respectively). Measured resting energy expenditure varied between 53% and 157% of predicted for the entire population., Conclusion: Ovarian cancer patients are more hypermetabolic than cervical cancer patients. The Harris-Benedict equation for females is a unreliable estimate of caloric expenditure in patients with cervical or ovarian cancer receiving specialized nutritional support.

The most common surgical treatment for achalasia is a modified anterior extramucosal esophagomyotomy. Unfortunately, a poor outcome may result secondary to recurrent dysphagia or gastroesophageal reflux. The reported incidence of reflux is 4 to 50 per cent. Our treatment for achalasia is an esophagomyotomy carried onto the cardia combined with a partial gastric fundoplication. Of 22 patients who presented with achalasia and moderate to severe symptoms of dysphagia and odynophagia, 19 had this procedure performed. Of these 19 patients, only two required a second procedure (postoperative dilatation) for recurrent symptoms. All three patients who had a full fundoplication required further surgical correction. Although fundoplication has been condemned in the past as treatment of achalasia to avoid the postoperative outcome of reflux, we have been successful with a partial fundoplication added to the standard esophagomyotomy. Given the fine line that needs to be tread to prevent recurrent signs and symptoms of achalasia or reflux when performing esophagomyotomy, our procedure offers a viable alternative to transthoracic esophagomyotomy alone.