a 28-year - old woman , with primary infertility of three years was referred for laparoscopic myomectomy with a history of severe dysmenorrhea and a diagnosis of posterolateral wall myoma . on pelvic examination ,
a palpable myoma was noted on the posterior uterine surface , and the uterus was felt to be approximately 10 gestational weeks in size .
a well - circumscribed mass measuring 5.16  6.0  4.25 cms was seen in the posterolateral fundus and was found to be impinging on the endometrial stripe .
the patient was given a choice between conventional laparoscopic myomectomy and the single incision approach .
a 2 cm vertical incision was made at the base of the umbilicus and peritoneal access was gained .
, norwalk , ct ) , [ figure 1 ] was inserted through the incision .
the device , made from an elastic polymer , was slightly hourglass shaped and could be deployed through 2 cm fascial incision .
it contained four openings : one for insufflation via a right - angled tube and three that could accommodate trocars 5 to 12 mm in size .
the compressibility of the elastic polymer allowed for the access ports to expand and form fit the space in which they resided , and the ports also passed through the working channels .
the sils tm port has the capacity of up to three laparoscopic instruments of 5 to 12 mm after careful survey of the abdomen and pelvis , dilute vasopressin , 20 u , in 100 ml of saline solution , was injected subserosally over the posterior myoma .
once the correct plane was entered , the myoma was dissected out of the uterus using a 5 mm myoma cork screw and blunt scissors .
using mostly blunt dissection , the enucleation of the myoma was done [ figure 2 and 3 ] .
hemostasis was ensured and a piece of adhesion barrier ( gynecare interceed ; ethicon inc . ,
west somerville , new jersey ) was then cut in half , introduced into the abdomen through one of the 5 mm trocars , and placed over the hysterotomy incision .
the myoma was then grasped with a 12 mm claw forceps and electric morcellation was done using rotocut g1 morcellator
morcellation ( rotacut ) the advantages obtained by electronic morcellation over manual morcellation from umbilical incision site are : 
 reduction in operative timedecreased risk of hernia formation due to absence of tearing or stretching of fascialower risk of injury to the surrounding tissues . 
 
reduction in operative time decreased risk of hernia formation due to absence of tearing or stretching of fascia lower risk of injury to the surrounding tissues .
as laparoscopic myomectomies are performed routinely in our center , rotocut is preferred over gynecare morcellex for its cost effectiveness and speed .
it is reusable and can be used indefinitely with periodic replacement of the cutting blade .
the fascia was closed with a running 0 polyglactin 910 ( vicryl , somerville , nj ) suture .
the skin was then approximated with a series of interrupted 3/0 monocryl sutures ( ethicon inc . ) .
ten milliliters of 0.5% bupivacaine hydrochloride ( sensorcaine ) were injected into the incision site , and dermabond adhesive ( ethicon inc . ) was applied . the total procedure time ( time from first incision to end of procedure , d and c )
single - incision surgery has been reported to offer patients improved cosmetic outcomes as compared to multiport laparoscopic surgery , and possibly less postoperative pain , although these potential benefits have yet to be demonstrated in a well - designed prospective trial .
a number of advantages have been proposed including cosmesis , less incisional pain , less blood loss , and the ability to convert to standard multiport laparoscopic surgery .
an additional morcellation port is avoided as specimen retrieval / morcellation can be done through the umbilical incision .
the primary limitations of sils are the restricted degrees of freedom of movement , lack of triangulation , the number of ports that that can be used , and the proximity of the instruments to each other during the operation  all of which increase the complexity and technical challenges of the operation .
many of these difficulties may be related to the technique of port placement and utilization during single incision laparoscopic surgery .
a number of methods have been described for port access to perform sils , including multiple fascial punctures through one skin incision and use of novel port access devices . to further overcome the technical challenges of sils ,
different instruments that provide angulations and small profile trocars , endostitch , are being developed .
the barbed suture greatly facilitates myometrial closure because there is no need to tie knots and there is no backsliding of the suture , which enables continuous wound closure with even distribution of tensile strength throughout the repair .
these benefits of barbed suture are especially valuable in single - incision surgery , because intracorporeal knot tying can be more challenging here than in the multiport approach .
currently , careful case selection is paramount , so that these procedures can be explored safely , with a low threshold to convert to standard laparoscopy , as indicated , for safety and quality of care .
the use of novel port access devices , articulated instruments , and endostitch self - retaining sutures , makes the procedure easier , with a potential for saving time .
 single port laparoscopic surgery ( spls ) , also called sils is the natural extension of multi - incisional laparoscopic surgery , in the quest for reduction of traumatic insult and residual scarring to the patient . today with the evolution of newer instruments , bidirectional self - retaining sutures , and surgical experience we are able to perform many surgeries in gynecology . 
INTRODUCTION
SURGICAL TECHNIQUE
DISCUSSION