in the last decade , laparoscopy has become the standard treatment for many gynecological conditions . today , laparoscopy is hailed as the standard approach in the surgical treatment of benign adnexal pathology . attempts to minimize access - related injuries and complications resulted in development of single port laparoscopic surgery ( spls ) , which , because of the decreased number of ports used , may be the next generation of minimally invasive surgery . the advantages of single - port surgery have been reported to include reduced perioperative morbidity , a quicker recovery time because of less postoperative pain , less blood loss , fewer complications , and certainly superior cosmetic results . a number of reports have reported on the success of performing adnexectomy using spls . yet moreover , difficult convergence of operating instruments and competition for operating space outside the abdomen during the spls makes the procedure demanding , especially when one uses conventional instruments . herein , we describe a minimally invasive technique for spls for the treatment of a 10 cm ovarian cyst , which reduces the technical difficulties involved in such surgery . a 27-year - old single nulliparous lady ( body mass index = 17.5 ) presented with a 3-day history of left iliac fossa and suprapubic pain which progressively got worse despite analgesia . the pain score of 8/10 upon presentation . abdominal examination revealed a normal - sized uterus with tenderness over the left iliac fossa and suprapubic region with no signs of peritonism . abdominal ultrasonography revealed a left ovarian cyst measuring approximately 8  5 cm ( suggestive of endometrioma ) without septae or echogenicity or any surface excrescences . preoperative ca-125 levels were elevated at 73.7 u / ml but other ovarian tumor markers were within normal limit . patient was positioned in the lithotomy with lloyd - davies position and was cleaned , draped , and catheterised . the surgical instruments used during the surgery were x - cone single port system [ figure 1 ] , a rigid 30 , 5-mm diameter , 45-cm long laparoscope in combination with , a rigid prebent atraumatic grasping forceps , a straight reddick grasping forceps [ figure 2 ] and a standard straight robi kelly bipolar . x - cone single port system is a reusable , low - cost single site trocar with four integrated access ports ( x - cone ; karl storz , tuttlingen , germany ) . x - cone is reusable , low - cost single site trocar with multiple ports rigid prebent atraumatic grasping forceps a 1.5 cm vertical incision was made at the umbilicus . laparoscopy revealed a normal - sized uterus with right ovarian endometriotic cyst measuring approximately 10 cm in diameter [ figure 3 ] with filmy adhesions between the cyst and ovarian fossa . as there were only minimal adhesions around the ovarian cyst , a decision was made to proceed with spls . a straight reddick grasper and a prebent 5-mm atraumatic grasper were inserted into the remaining two ports [ figure 4 ] . combined use of prebent and straight forceps through x - cone single port system vertical incision was made over the cyst and the incision was widened using laparoscopic scissor . the overlying ovarian tissue was teased away and the plane between the cyst and ovarian tissue dissected using reddick straight forceps . cyst was punctured under direct vision and its content was aspirated with a suction - irrigation device with minimal spillage as the incision edge was held up by the prebent atraumatic grasping forceps . cyst wall was then peeled off from the ovarian tissue using both the prebent and straight forceps in a  to - fro  manner along the z - axis : the prebent forcep pushed the top part of the cyst wall distally and the straight forcep pulled the inferior part proximally thus providing traction and counter - traction to facilitate stripping of the cyst . x - cone port placement was successful in creating pneumoperitoneum with no - minimal air leak . no vascular or visceral injuries or intraoperative port site bleeding occurred . after surgery , there was no wound hematoma , wound infection , or delayed bleeding . patients conveyed high satisfaction toward cosmetic result and postoperative pain control with a satisfaction score of 9 on a scale of 1 - 10 upon follow - up 2 months later [ figure 5 ] . ( a ) umbilical scar immediately after the surgery and ( b ) 8-week after the surgery benign lesions are usually unilateral , cystic , mobile and smooth , without ascites , and are frequently found in younger age groups . although , we noticed that in this patient , there is an elevated ca-125 , we feel that it is related to the endometriosis pathology . we used x - cone system ( karl storz ) , a new single port trocar device that allows simultaneous passage of various laparoscopic instruments through one small opening and also has the advantage of being reusable thereby reducing overall surgical cost . we advocate the use of a 5-mm , 30 long 45-cm telescope which helped to achieve both adequate visualization and to avoid a clashing of the operating instruments and the optic outside the abdomen . the use of rigid prebent instruments is crucial to widen the surgeon 's movements outside of the abdominal cavity , avoiding crossing between the instruments and the camera , and to allow lateral movements inside the abdomen . the highlight of our technique was the combined use of prebent instrument and standard straight instrument to provide traction - countertraction during cyst wall peeling in a  to - fro  manner along the z - axis which is parallel to the instrument axis unlike the standard laparoscopic traction . the advantage of this technique is that since both instruments are working together parallel to each other in the z - axis , crossing and collision between instruments outside the abdomen could be minimized . concerning the postoperative outcome , our patient was very happy with the cosmetic of her scar rating her satisfaction level at 9 out of 10 in a 1 - 10 scale . in addition , a single minimal incision of the peritoneum could suggest a shorter recovery , as observed in our patient . spls is an innovative approach that is rapidly gaining recognition around the world . in this study , using the described technique , we support the use of spls in laparoscopic cystectomy for ovarian cysts up to 10 cm .
we describe a technique for the treatment of large benign ovarian cysts by single port laparoscopic surgery via the umbilical approach . 
 x - cone single port system ( karl storz ) was employed in this surgery . 
 prebent atraumatic grasping forceps were used in conjunction with the straight laparoscopic instruments . 
 we propose using a  to - fro  peeling technique in the z - axis in spls cystectomy . 
 combined use of prebent and straight laparoscopic instruments enables the cystectomy to be performed in the z - axis , thereby avoiding instruments crossing and hands collision outside the abdomen . the proposed technique proved to be feasible , easy to employ , and safe in spls cystectomy , with the additional benefit of superior cosmetic outcome .