Early reports of SILS describe the placement of multiple ports through a single incision with additional retraction utilizing transabdominal sutures. Retraction of the appendix with transabdominal ��sling�� sutures through the mesoappendix is an example of a commonly used strategy in the early stages of SILS appendectomy despite [2]. More recently, innovative techniques evolved into more complex laparoscopic procedures including nephrectomy, splenectomy, adrenalectomy, and bowel resection with intracorporeal anastomosis [3�C6]. 2. Single-Incision and Single-Port Laparoscopy In the beginning of the SILS era, the lack of proper devices to gain access to the peritoneal cavity motivated surgeons to implement new techniques and to generate innovative ideas.

Home-made devices were initially used as an alternative to the currently available multichannel ports [7, 8]. An example of this was the use of a single-access device made of a surgical glove introduced through an umbilical incision; each finger of the glove was used to fit a separate laparoscopic instrument [9]. More recently, access to the abdomen was accomplished by introducing three 3�C5mm trocars through separate but contiguous incisions in the fascia under the same skin incision, a technique commonly used in small children (Figure 1). The separate fascial incisions are connected into a single incision at the end of the procedure to facilitate the extraction of the resected specimen. When the working space is limited, as is the case in neonates, accessory laparoscopic instruments are inserted directly through fascial stab wounds to avoid trocar crowding [10].

As expected, carbon dioxide leak can be significant with this technique [11]. Figure 1 Single-incision multiple-trocar technique. Three low-profile trocars are inserted through separate contiguous incisions in the fascia. A transabdominal suture used to retract the gallbladder fundus is shown in the RUQ. The increasing need for an optimal access platform in SILS led to the invention of a multichannel ��cannula�� by a group in Spain [12]. The idea of introducing multiple instruments through a single device or port was well received by surgeons making possible the development of sophisticated ports for laparoscopic and thoracoscopic procedures [13�C18].

Modern access ports can carry multiple trocars; these include the R-port, Uni-X Single Port, TriPort, and Quadport systems and allow the simultaneous introduction of multiple laparoscopic instruments and permit insufflation with an airtight seal. However, the large size of these devices (which may require a 2-3cm fascial incision) often precludes the use in small children. Despite the development of improved single-access ports, the need for instrument Entinostat triangulation remained a concern when using SILS.