We made selleckchem use of a single flexible/curved laparoscopic grasper to overcome parallel placement and recreate triangulation. Flexible and/or articulating instruments, which allow for intracorporeal triangulation, have been proposed as solutions to this problem [16]. However, bulk and technical challenge remain major obstacles in using articulating instruments at this stage of development [17]. Instrument crowding arises from a limitation in working space, as multiple instruments compete for the same space at the fulcrum of the entry port. This can result in hand collisions externally and difficulty with instrument tip manipulation internally [10, 15]. We attempted to maximize working space by holding the scope at a fixed distance away from the operating field.

At this distance, we were able to achieve a fine balance between preventing the scope from interfering with the other operating instruments and yet not compromise on the field of vision. The problem is further aggravated by the surgeon’s need to change the instruments multiple times during the surgery such as alternating the grasper with the bipolar. Perhaps the use of a single grasping diathermy would be useful in such circumstances, for example, Ligasure, PK knife, and so forth. Other multifunctional devices capable of grasping, dissecting, coagulating, and cutting can also overcome the limitations imposed by the reduced number of ports [16]. In the multi-institutional evaluation of LESS in gynaecology by Fader et al., multifunctional instruments (including the 5mm Ligasure Advance (Covidien) or the Harmonic scalpel (Ethicon Endosurgery)) were utilized in all cases [4].

Further attempts have been made to perform LESS surgery via the da Vinci surgical system robotic platform [18�C20]. Instruments with handles that can be articulated away from the port [15], or with varying lengths and streamlined profiles can also help avoid external hand collisions [10, 21, 22]. The limitation of lower excursion degrees among instruments in the abdominal cavity due to the loss of triangulation and instrument crowding was further hampered by the large size of the ovarian tumour. We worked around the constraints by shifting the traction maneuver from an orthogonal axis to a parallel one. Partially compromised view arising from inline viewing, associated with single port surgery [10, 15], was observed during the operation.

Depth perception was lost as the camera lined up with the shaft of the working instrument Brefeldin_A [10]. Recent improvements of technologies such as flexible tip scopes (Olympus Endoeye) can minimize this restriction and emulate the stereoscopic vision offered by standard laparoscopic techniques [15]. This is achieved by a lower profile camera system such as the Olympus Endoeye, in which the video laparoscope is integrated with a coaxial light cable in line with the shaft of the telescope [17].