Objective. To report our experience treating adnexal masses using a combination of the SILS port and straight nonroticulating laparoscopic instruments. Study Design. This prospective feasibility study included 14 women with symptomatic and persistent adnexal masses. Removal of adnexal masses via single-incision laparoscopic surgery using a combination of the SILS port and straight nonroticulating laparoscopic instruments was performed. Results. All of the patients had symptomatic complex adnexal masses. Mean age of the patients was 38.4 years (range: 21–61 years) and mean duration of surgery was 71 min (range: 45–130 min). All surgeries were performed using nonroticulating straight laparoscopic instruments. Mean tumor diameter was 6 cm (range: 5–12 cm). All patient pathology reports were benign. None of the patients converted to laparotomy. All the patients were discharged on postoperative d1. Postoperatively, all the patients were satisfied with their incision and cosmetic results. Conclusion. All 14 patients were successfully treated using standard, straight nonroticulating laparoscopic instruments via the SILS port. This procedure can reduce the cost of treatment, which may eventually lead to more widespread use of the SILS port approach. Furthermore, concomitant surgical procedures are possible using this approach. However, properly designed comparative studies with single port and classic laparoscopic surgery are urgently needed.

Introduction. Single-access laparoscopic surgery (SALS) has been successfully introduced for colectomy surgery; however, for mid to low rectum procedures such as total mesorectal excision, it can be technically complicated. In this study, we introduced a single-access technique for rectum cancer operations without the use of other instruments. Aims. To show the short-term results of single-access laparoscopic rectal surgery in terms of pathologic results and immediate complications. Settings and Design. Prospective study. Materials and Methods. We selected middle rectum to anal canal cancer patients to undergo single-access laparoscopic rectal resection for rectal cancer. All patients had total mesorectal excisions. An umbilical incision was made for the insertion of a single multichannel port, and a mesocolic window was created to identify the inferior mesenteric artery and vein. Total mesorectal excision was performed. There were no perioperative complications. The mean operative time was 269 minutes; the median hospital stay was 7 days; the mean wound size was 5.5 cm; the median number of harvested lymph nodes was 15; and all patients had intact mesorectal capsules. Statistical Analysis Used. Mean, minimum–maximum. Conclusion. Single-access laparoscopic surgery for rectal cancer is feasible while oncologic principles and patient safety are maintained.

In the modern era of neurosurgery, the use of the operative microscope, rigid rod-lens endoscope, and neuronavigation has helped to overcome some of the previous limitations of surgery due to poor lighting and anatomic localization available to the surgeon. Over the last thirty years, the supraorbital craniotomy and subfrontal approach through an eyebrow incision have been developed and refined to play a legitimate role in the armamentarium of the modern skull base neurosurgeon. With careful patient selection, the supraorbital “keyhole” approach offers a less invasive but still efficacious approach to a number of lesions along the subfrontal corridor. Well over 1000 cases have been reported in the literature utilizing this approach establishing its safety and efficacy. This paper discusses the nuances of this approach, including the benefits and limitations of its use described through our technique, review of the literature, and case illustration.

Introduction. Though traditional microsurgical techniques are the gold standard for intraventricular tumor resection, the morbidity and invasiveness of microsurgical approaches to the ventricular system have galvanized interest in neuroendoscopic resection. We present a systematic review of the literature to provide a better understanding of the virtues and limitations of endoscopic tumor resection. Materials and Methods. 40 articles describing 668 endoscopic tumor resections were selected from the Pubmed database and reviewed. Results. Complete or near-complete resection was achieved in 75.0% of the patients. 9.9% of resected tumors recurred during the follow-up period, and procedure-related complications occurred in 20.8% of the procedures. Tumor size ≤ 2cm (P = 0.00146), the presence of a cystic tumor component (P < 0.0001), and the use of navigation or stereotactic tools during the procedure (P = 0.0003) were each independently associated with a greater likelihood of complete or near-complete tumor resection. Additionally, the complication rate was significantly higher for noncystic masses than for cystic ones (P < 0.0001). Discussion. Neuroendoscopic outcomes for intraventricular tumor resection are significantly better when performed on small, cystic tumors and when neural navigation or stereotaxy is used. Conclusion. Neuroendoscopic resection appears to be a safe and reliable treatment option for patients with intraventricular tumors of a particular morphology.

Minimally invasive techniques in neurosurgery evolved in two steps. Many minimally invasive concepts like neuronavigation, endoscopy, or frame based stereotaxy were developed by the pioneers of neurosurgery, but it took decades till further technical developments made the realization and broad clinical application of these early ideas safe and possible. This thesis will be demonstrated by giving examples of the evolution of four minimally invasive techiques: neuronavigation, transsphenoidal pituitary surgery, neuroendoscopy and stereotaxy. The reasons for their early failure and also the crucial steps for the rediscovery of these minimally invasive techniques will be analysed. In the 80th of the 20th century endoscopy became increasingly applied in different surgical fields. The abdominal surgeons coined as first for their endoscopic procedures the term minimally invasive surgery in contrast to open surgery. In neurrosurgery the term minimally invasive surgery stood not in opposiotion to open procedures but was understood as a general concept and philosophy using the modern technology such as neuronavigation, endoscopy and planing computer workstations with the aim to make the procedures less traumatic.

Lumbar stenosis is a well-defined pathologic condition with excellent surgical outcomes. Empiric evidence as well as randomized, prospective trials has demonstrated the superior efficacy of surgery compared to medical management for lumbar stenosis. Traditionally, lumbar stenosis is decompressed with open laminectomies. This involves removal of the spinous process, lamina, and the posterior musculoligamentous complex (posterior tension band). This approach provides excellent improvement in symptoms, but is also associated with potential postoperative spinal instability. This may result in subsequent need for spinal fusion. Advances in technology have enabled the application of minimally invasive spine surgery (MISS) as an acceptable alternative to open lumbar decompression. Recent studies have shown similar to improved perioperative outcomes when comparing MISS to open decompression for lumbar stenosis. A literature review of MISS for decompression of lumbar stenosis with tubular retractors was performed to evaluate the outcomes of this modern surgical technique. In addition, a discussion of the advantages and limitations of this technique is provided.

Introduction. Laparoscopic appendectomy (LA) has been performed in many approaches such as open, laparoscopic and recently Single Port Access (SPAA). In order to elucidate its potential advantages, we compared the two laparoscopic approaches. Methods. 87 patients were included in a multicentric study for suspected appendicitis in order to perform (SPAA) appendectomy or laparoscopic appendectomy (LA). All outcomes, including blood loss, operative time, complications, and length of stay and pain were recorded prospectively. Results. There were 46 patients in the SPAA group and 41 in the LAG with a mean operative time of 40,4 minutes in the SPAA group and 35,0 minutes in the LA group. Only one patient was converted to an open approach. We described only 2 complications. Pain was graded 2,8 in the SPAA group and 2,9 in the LA group, according to the AVS after 24 hours. Patients in the SPAA Group were more satisfied (7,5 versus 6,9) (P < 0.05). Same results were found for the cosmetic result (8,6 versus 7,4) (P < 0.05). Conclusion. Using the single port approach feasible and safe. The true benefit of the technique should be assessed by new randomised controlled trials.

During the last two decades laparoscopic surgery has become the standard care for the management of various emergent and elective surgical pathologies. Well-known advantages of laparoscopy include faster recovery, less postoperative pain, lower perioperative complications, and improved cosmesis. Recent development of laparoscopy was represented with introduction of the concept of scarless surgery using natural orifice transluminal endoscopic surgery (NOTES). Unfortunately, NOTES approach has not yet has been overcome and refused due to need for specialized instruments, learning curve, and prolonged surgery time. Single-port laparoscopic surgery (SPLS) is a rapidly evolving technique in the field of minimally invasive surgery. SPLS was initially described in 1992 for gynecologic surgery and in general surgery seven years later. The most commonly reported advantages of SPLS include improved cosmesis, lower morbidity associated with elimination of peripheral ports, shorter length of hospital stay, and potential for decreased incisional pain. Another advantage of this technique is the ability to convert to an alternate minimally invasive procedure such as multiport laparoscopy and avoid the need for an open procedure, therefore maintaining the patient benefits well associated with minimally invasive surgery. Development of innovative articulated or bent instruments, adjustments in laparoscopes, and developed special multilumen access devices allowed simultaneous multiple instruments insertion facilitated the acceptance of this technique. Increasing application of this modality has been described through case reports and case series proving it is a safe and feasible technique for the surgical treatment of benign and malignant diseases expanded within general, urological, gynecological, and pediatric surgery. Recent publications described using SILS for appendectomy, cholecystectomy, colectomy, adrenalectomy, splenectomy, bariatric surgery, hysterectomy, ovarian cystectomy, and hernias repair. The interest for the technique has gradually progressed toward assessing its efficacy compared with established techniques in minimally invasive surgery. Comparative studies with standard and hand-assisted laparoscopic surgery have shown that SPLS maintains the benefits of minimally invasive surgery. There are number of challenges associated with SPLS: special access ports, instrumentation, and surgical techniques. Many of healthcare manufacturers that designed and developed various access devices as SPLS port (Covidien, Mansfield, MA, USA), TriPort (Olympus, Wicklow, Ireland), AirSeal (SurgiQest, Inc., Orange, CT, USA), GelPoint (Applied Medical, Rancho Santa Margarita, CA, USA), Endocone (Karl Stortz GmbH & Co, KG, Tutlingen, Germany) have made single site surgery easier and more efficient. While there exists concern about the learning curve of the experimented surgeons who are used to perform a classic laparoscopic approach, current evidence suggests that this technique can safely be mastered in the hands of experienced laparoscopic surgeons. The technical challenges of SILS included limited triangulation and retraction due to confinement of the instrumentation to a single axis, requiring a greater level of surgical experience. A cross-hand technique, flexible tip scope, and articulated instruments have been developed to solve this problem. However, more surgeons reported effective using regular laparoscopic instruments for SPLS procedures. The concept of performing laparoscopic surgery through a single incision is gaining momentum among patients, surgeons, and industry alike. SPLS is a developing field and, to date, level I and II clinical data on the benefits of SILS are lacking. The various publications relating to the technique are mostly case reports or small series describing the feasibility and technical problems of operations. Most of them suggested that SPLS procedures are comparable to the standard laparoscopic surgery. Furthermore, increasing experience of SPLS will continue to innovate to further improve the ergonomics, feasibility, and range of the technique. This special issue included various reports about using SPLS approach in different surgical fields. Appendectomy is one of the most frequent urgent surgical procedures. Regarding the use of SPLS for appendectomy, a multicentric study comparing SPLS with standard laparoscopic surgery shows the feasibility and success of this technique extended to not only uncomplicated patients but also to complicated and obese patients. There was no difference shown in spite of surgery time, postoperative pain, and postoperative complications. Patients were satisfied with better cosmesis following SPLS appendectomy. In regards to biliary tract surgery, laparoscopic cholecystectomy still remains as the gold standard for the surgical removal of the gallbladder in the treatment of symptomatic cholelithiasis. The question is if SPLS cholecystectomy can replace traditional surgical approach. The cosmetic results offered by SPLS have resulted in improved patient satisfaction with the final incision versus the four scars created by the conventional laparoscopic approach. A thorough literature review, technical challenges and instrumentation, complications and outcomes of SPLS cholecystectomy are presented along the work in this special article. in authors' opinion SPLS cholecystectomy is long way off from replacing laparoscopic cholecystectomy due to increased rate of complications with longer operative time, lack of standardization and instrumentation, and needs an additional development. In the field of colon and rectal surgery, the feasibility and the safety of the SPLS colectomy are gaining acceptance for the treatment of colon diseases and colon cancer. This article not only presents the accepted and proposed advantages for this surgical technique but it also makes it clear to us that some disadvantages are yet to be conquered before the procedure can become the standard in minimally invasive colorectal surgery. The application of SPLS to a wide variety of procedures is explored during this special edition article as well. A literature review of the use of SPLS in patients with inflammatory bowel disease shows that in experienced hands the use of SPLS is feasible even in patients with complications when used in well-selected patients. The paper showed wide range of possible complications following single incision surgery for IBD and again absence of procedure standardization. Following experience in adult surgery pediatric surgeons became SILS in children for appendectomy, cholecystectomy, pyloromyotomy, splenectomy and nephrectomy. In this special edition, we present the evolution of SPLS since the original development until the application into the pediatric field and the benefits of these techniques. Even with the success that exists in pediatrics with the use of these minimally invasive techniques, great obstacles will need to be overcome in order to optimize the approach in children. Herein, we tried to show controversies in various aspects of single incision surgery. Patients and surgeons enthusiasm, technical progress, and prospective randomized control trials will show the future way and availability of this technique. We hope that you enjoy this special edition as much as we enjoyed working on it. Boris Kirshtein Eric M. Haas

Purpose. The relatively new and less-invasive therapeutic alternative “interspinous process decompression device (IPD)” is expected to result in improved symptoms of neurogenic intermittent claudication (NIC) caused by lumbar spinal stenosis. The aim of the study was to analyze IPD position particularly regarding damage originating from surgical implantation. Methods. Anatomic assessments were performed on a fresh human cadaver. For the anatomic examination, the lumbar spine was plastinated after implantation of the IPDs. After radiographic control, serial 4 mm thick sections of the block plastinate were cut in the sagittal (L1–L3) and horizontal (L3–L5) planes. The macroanatomical positioning of the implants was then analyzed. The insertion procedure caused only little injury to osteoligamentous or muscular structures. The supraspinous ligament was completely intact, and the interspinous ligaments were not torn as was initially presupposed. No osseous changes at the spinal processes were apparent. Contact of the IPD with the spinous processes was visible, so that sufficient biomechanical limitation of the spinal extension seems likely. Conclusions. Minimally invasive IPD implantation with accurate positioning in the anterior portion of the interspinous place is possible without severe surgical trauma.

Introduction. Single-incision laparoscopic surgery (SILS) is a virtually “scarless” technique. A retrospective analysis is performed to evaluate an initial experience of this surgical approach. Materials and Methods. From January 2010 to October 2011, SILS was considered as a minimally invasive approach to abdominal disease. The access was made by a standard wound protector and a size 6 glove. A series of little accesses were made on the tips of the glove-fingers to induce pneumoperitoneum and to create a working channel for the laparoscopic instruments. An analysis of costs of this technique was made too. Results. SILS was successfully completed with low cost in 34 patients: 20 appendectomy, 12 cholecystectomy, and 2 right colectomy were performed with a median operative time of 35, 45, and 67.5 minutes, respectively. In no patient any conversion to standard laparoscopy or to open surgery was needed. The postoperative course was uneventful in all patients. In right hemicolectomy, the oncological parameters were respected. Conclusions. In this paper the glove-port technique showed multiple advantages. The SILS is a feasible approach for some pathologies in selected patients. The glove-port is a simple, low-cost, reproducible, and sure method to perform SILS in a high-experienced laparoscopic surgical centre.