to optimize the benefits of minimally invasive procedures , surgeons have attempted to reduce the overall abdominal wall trauma by decreasing either the size of the ports or the number of trocars . in these efforts
, transumbilical single - port surgery uses an umbilical single incision technique to access the peritoneal cavity and target organs . owing to the nature of umbilicus , single - port laparoscopy through the umbilicus offers an exciting opportunity to perform laparoscopic surgery with no visible scar . however , transumbilical single - port laparoscopy is not a new concept in gynecologic surgery [ 15 ] . in 1969 ,
wheeless and thompson first published the technique and the results of a large series of laparoscopic tubal ligations using single - trocar laparoscopy .
later , wheeless reported a large series of one - incision tubal ligation . additionally , in 1991 , the first laparoscopic total abdominal hysterectomy with bilateral salpingooophorectomy ( bso ) using only a single incision was reported by pelosi and pelosi iii .
one year later , four supracervical hysterectomies with bso for benign uterine disease were reported by the same authors [ 15 ] .
although single - port surgery enhances cosmetic benefits and reduces postoperative pain and morbidity , use of this technique was not widespread due to technical difficulties .
however , with advances in instrumental and surgical skills , the technical difficulties associated with this surgical procedure have been overcome considerably [ 615 ] .
particularly , single - port surgery is ideal for laparoscopic - assisted vaginal hysterectomy ( lavh ) because the vagina of woman can be considered as an additional route for surgery ; thus , uterine manipulators can be applied through the vagina [ 1117 ] . unlike uterine repair following myomectomy or bowel reanastomosis after bowel resection
this is because the vaginal stump can be repaired not by laparoscopy , but through the vagina . in this study
, we report our initial 100 cases observations of spa - lavh ( with or without bilateral salpingooophrectomy ( bso ) ) using a homemade , single - port , three - channel system .
a retrospective medical records review was performed for the initial 100 patients who underwent spa - lavh at eun hospital . between march 2010 and september 2011 ,
100 patients had undergone spa - lavh for nonmalignant gynecological diseases , including uterine leiomyoma ( 25 cases ) , adenomyosis ( 19 cases ) , adenomyosis coexisting leiomyoma ( 41 cases ) , preinvasive lesion of cervix coexisting adenomyosis or leiomyoma ( 7 cases ) , ovarian huge cyst ( 5 cases ) , endometrial hyperplasia ( 2 cases ) , and tuboovarian abscess ( 1 case ) . past abdominopelvic surgery , body mass index ( bmi ) , and the size of the uterus were not considered as exclusion criteria .
the following parameters were determined in the present observational study : age , parity , bmi , surgical history , indication for surgery , operative time ( from incision to final umbilical closure ) , largest dimension of the uterus , weight of the extirpated uterus ( as pathology report ) , hemoglobin change ( from before surgery to postoperative day 1 ) , and perioperative and postoperative complications .
we used homemade , single - port , three - channel system using the alexis wound retractor ( applied medical , rancho santa margarita , ca , usa ) , surgical glove , two 10  mm trocars , and one 5  mm trocar [ 7 , 16 , 17 ] .
after partial eversion of the umbilicus , a curved semilunar skin incision was performed at the hidden lateral aspect of the umbilical crater .
the incision was c - shaped and followed the natural curve of the inferior lateral aspect of the umbilical crater near the base .
after skin incision , a rectus fasciotomy and peritoneal incision were performed by direct cut - down technique .
an approximately 1.5 2  cm - sized skin incision was sufficient to install the three - channel , single - port system , because of the elasticity of the skin and the tissue beneath it , which can be dissected as long as required [ 16 , 17 ] .
as shown in figure 1(a ) , the fascial edges were tagged with suture for traction prior to port system installation ; this was useful for fascial closure at the end of the procedure .
the alexis wound retractor consists of a proximal ring , distal ring , and connecting retractable sleeve .
as shown in figure 1(a ) , the distal ring was loaded within the intraperitoneal space and tightly turned inside out of the proximal ring ( rolled up manner ) , creating an effective seal and a wider opening of the single - port incision by connecting retractable sleeve between the distal and proximal rings .
once fixed in the opening site , it laterally retracted the sides of the wound opening .
subsequently , as shown in figure 1 , a sterile surgical glove was placed over the proximal ring and fixed tightly to prevent leakage of carbon dioxide gas .
three trocars were inserted through the surgical glove with cut edges of the distal fingertips and tied with an elastic string .
the elastic nature of the glove enabled to achieve an airtight seal , which maintained the pneumoperitoneum .
the multiple truncated fingers of the glove functioned as a multiport for surgical instruments [ 16 , 17 ] .
a limited range of motion was closely related to the bulkiest portion of the trocar head and instrumental grip ( external handle ) extracorporeally overlapping . as shown in figure 1(b ) , the length of the instruments was the same , but the lengths of the truncated glove digits varied . however , varying the height of the trocar head may minimize clashing of the bulkiest portion of the trocar head and instrumental grip ( the external handle ) extracorporeally overlapping .
all the surgical procedures were performed as a standard lavh ( with or without bso ) technique using conventional nonarticulated rigid laparoscopic instruments and the ligasure system ( valleylab , boulder , co , usa ) . as has been established earlier , exploration of pelvis , coagulation and cut of ligaments and vessel above the uterine vessel , and bladder mobilization were undertaken in laparoscopic phase .
ligation of uterine vessel , cardinal and uterosacral ligament , extirpation of uterus , and vaginal stump closure were undertaken in the vaginal phase .
all procedures were successfully completed through the single - port system and vagina without the need for extraumbilical puncture or conversion to laparotomy .
as shown in table 1 , the mean  standard deviation ( sd ) of patient age , parity , and bmi was 48.2  6.5  years , 2.3  1.0 , 25.4  3.3  kg / m , respectively .
thirty - three patients had a past history of abdominopelvic surgery , such as a caesarean section , laparoscopic tubal ligation , appendectomy , ovarian cystectomy , or salpingooophrectomy . among these patients , six had a history of caesarean sections , five had a history of repeat caesarean sections , and five had a history of three caesarean sections .
seven patients needed 2 - 3 units of packed red blood cell transfusion due to chronic anemia or intraoperative hemorrhage .
the mean  sd of time to installation of the transumbilical single - port system was 7.3    1.5  min .
the mean  sd of total operative time , largest dimension of the uterus , and weight of the uterus were 73.1  24.6  min , 10.5    2.1  cm , and 300.8  192.5  gram , respectively .
the operative time between laparoscopic phase and vaginal phase was similar but depended on pelvic pathology .
the median decline in the hemoglobin level from before surgery to postoperative day 1 was 1.8  0.9  g / dl .
bladder injury occurred in one patient who had a history of three caesarean sections but was repaired through intraoperative laparoscopic suture .
the postoperative course was uneventful in most patients , but three had a transient paralytic ileus , and five had pelvic hematoma , all of whom recovered following conservative managements .
no port - related complications were noted , and the cosmetic results and patient satisfaction were excellent .
spa - lavh is a technically safe and feasible procedure , and the homemade single - port system offers reliable and cost - effective access for single - port surgery .
as mentioned earlier , lavh is most ideal for single - port surgery because the vagina of woman can be considered as an additional route for surgery ; thus , uterine manipulators can be applied through the vagina . unlike uterine repair after myomectomy
this is because the vaginal stump can be repaired not by laparoscopy , but through the vagina .
thus , spa - lavh is safe , and the procedure can be learned by skillful surgeons over a short period of time , because a considerable portion of the procedure can be performed through the vagina .
the homemade three - channel , single - port system using a surgical glove and an alexis wound retractor offers reliable , flexible , and cost - effective access for single - port procedures , and the system can be applicable in nonarticulated , rigid , conventional laparoscopic instruments [ 16 , 17 ] . limitations of single - port surgery include the loss of instrumental triangulation , reduced operative working space , reduced laparoscopic visualization , and instrumental crowding and clashing .
these limitations act as hurdles for some reconstructive procedures , such as repair after myomectomy .
however , the reconstructive procedure can be performed with instrumental advancement , such as the use of articulated instruments [ 615 ] .
our observations show that a history of abdominopelvic surgery is not a contraindication for single - port surgery ; however , central obesity is problematic to secure a route for the single - port system through a small intraumbilical incision .
procedural difficulties resulting from previous abdominopelvic surgery are not because of the single - port surgery itself , but owing to abdominopelvic conditions [ 10 , 1517 ] .
a linear correlation existed between the operation time and an extirpated uterine weight of > 400  g , because more time was needed for uterine fragmentation for extirpation through the vagina ; however , no linear correlation existed between the operation time and a uterus weight of < 400  g. for pelvic adhesion , such as in previous pelvic surgery or endometriosis , additional operation time is required for adhesiolysis .
it is not a case - control study , and pain score , hospital stay , cost effectiveness , and return to work were not considered because of the retrospective nature of the study .
additional clinical data and long - term followup may be needed to address port - related complications .
 
 objectives . to present our initial experiences with laparoscopically assisted vaginal hysterectomy performed using homemade transumbilical single - port system . materials and methods . 
 we reviewed the medical records of one hundred patients who underwent single - port access laparoscopically assisted vaginal hysterectomy ( spa - lavh ) . 
 spa - lavh was performed with homemade single port system and conventional rigid laparoscopic instruments . 
 results . 
 all procedures were successfully completed through the single - port system and vagina without need for extraumbilical puncture or conversion to laparotomy . 
 the median patient age was 48.2  6.5 years . 
 thirty - three patients had history of past abdominopelvic surgery . the median total operative time , 
 largest dimension of the uterus , and weight of the uterus were 73.1  24.6  min , 10.5  2.1  cm , and 300.8  192.5  gram , respectively . 
 the median decline in the hemoglobin from before surgery to postoperative day 1 was 1.8  0.9  g / dl . 
 bladder injury in occurred one patient who was repaired through intraoperative laparoscopic suture . 
 the postoperative course was uneventful in most patients except for three who had a transient paralytic ileus , five who had pelvic hematoma , but they were recovered following conservative managements . 
 no port - related complications were noted , and the cosmetic results were excellent . 
 conclusions . 
 spa - lavh is technically safe procedure , and the homemade single - port system offers reliable access for single - port surgery . 
1. Introduction
2. Materials and Methods
3. Results
4. Conclusion
5. Discussion