Hansen and colleagues emphasized the importance of using graspers of different lengths and upside-down grip of instruments to avoid instrument and hand clashing when working with straight conventional laparoscopic instruments [11]. Novel instruments with bent tips and roticulating mechanisms address, to some extent, this issue and have the benefit of avoiding selleck inhibitor in-line viewing and clashing of instruments [11, 19]. Unfortunately, the availability of these sophisticated instruments is restricted, its cost is high, and its applicability to young children is limited by their large size. Some surgeons routinely place a thin grasper (2mm Minilap Alligator-Stryker Endoscopy, San Jose, CA) through the same or a remote fascial incision to assist with retraction [20].

A group in Argentina designed laparoscopic magnetic graspers that allow organ retraction when coupled with external magnets during SILS [21]. These magnets effectively provide retraction and overcome the lack of adequate triangulation. Harmonic scalpel and LigaSure (Covidien Norwalk, CT, USA) are coagulation/cutting devices commonly used in SILS. These devices seem to simplify the dissection of tissues and reduce operative times when comparing SILS to conventional laparoscopy in adults [22]. SIL splenectomy utilizing a combination of harmonic scalpel and LigaSure was safely performed in children [23]. Finally, as laparoscopic instruments evolve, newly developed angled light cord extensions and extralong endoscopes (>50cm) allowed enhanced visualization and better maneuverability without interfering with the already hand-crowded single port [19].

3. SILS in Children SILS was introduced in children much later than in adults [4, 7, 24]. This delay may be due to the perception that the small scars left by pediatric laparoscopic instruments were acceptable. Most likely, use of SILS in children has been slower since the broad application of minimally invasive techniques in children, in general, has historically lagged behind those in adults. Moreover, there is a concern regarding the limited maneuverability of laparoscopic instruments in the small peritoneal cavity of children, which is already challenging even with multiple trocar laparoscopy. In spite of these uncertainties, pediatric surgeons considered performing more complex procedures with less invasive techniques.

Soon enough, single-port Drug_discovery gastrostomy proved to be a suitable technique in children [24]. Later, Rothenberg and colleagues validated the use of SILS in the pediatric patient describing their experience on laparoscopic cholecystectomy. Their technique used an operating laparoscope, through which a single working instrument could be introduced. Often, they had to insert an additional instrument through a separate incision and use transabdominal sutures to retract the gallbladder [25].