laparoscopic liver resection has gained increased acceptance as an alternative to liver resections by laparotomy , even for malignant tumors . in our department , liver resections have been done by the laparoscopic approach for more than a decade , and our series for both benign and malignant liver tumors comprises one of the largest single centre experiences published [ 1 , 2 ] . in this paper , we describe a patient with a single , synchronous liver metastasis from a colorectal adenocarcinoma operated by a single - port laparoscopic access through the stoma site of at time of reversal of the diversion loop ileostomy . the patient was a 79-year - old man with concomitant pre - dialytic kidney failure who was initially operated for two synchronous adenocarcinomas of which one was located in the ascending colon and the other at the rectosigmoid junction . the primary operation was done by the laparoscopic approach with a right - sided hemicolectomy and a separate low anterior total mesorectal resection of the rectum . there were no locoregional lymph node metastases detected in any of the resected primary tumor specimens , and the patient did not receive adjuvant chemotherapy , in accordance with norwegian national guidelines for colorectal cancer . a small , synchronous liver metastasis was detected at time of colorectal surgery , classifying the patient with stage iv disease . the 15  mm tumor was located subcapsular in segment 5 on the posterior aspect of the liver immediately lateral to the gallbladder ( figure 1 ) . the patient was referred to our hospital for liver resection 6 months after surgery for the primary tumors . the liver resection was planned as a combined procedure in combination with reversal of the loop ileostomy . a small bowel resection was necessary , and an end - to - end anastomosis was made . after completion of the anastomosis , a laparo - endoscopic single - site ( less ) tri - port trocar ( olympus ) was introduced through the stoma site . a percutaneous suture was introduced in the epigastrium and secured in the fissure between segments 3 and 4 in order to retract the liver upwards for proper visualisation of the tumor . a 5  mm deflectable - tip endoeye camera ( olympus ) was used for visualization as were specially designed curved instruments to obtain adequate exposure and triangulation . the resection margins were determined by intraoperative ultrasonography ( aloca , wallingford , ct ) , the liver capsula was divided by an ultrasonic cutting and coagulation device ( sonosurg , olympus ) , and the liver parenchyma was divided by the ligasure ( covidien ) bipolar tissue sealing device as previously described . the stoma aperture was closed with two separate layers of fascia suture and the skin was closed by a continous pursestring suture ( figure 2(b ) ) . no surgical complications occurred but due to a misfortunate postoperative fluid overload in combination with the patients pre - existing kidney failure , he developed a moderate pulmonary oedema which was resolved in two days with temporary respiratory support . he was discharged to his local hospital on the 5th postoperative day and went home seven days after surgery in good condition . the patient has been observed with repeated ct scans for 6 months without any evidence of tumor recurrence . laparoscopic liver resection has proven safe and feasible and can be performed according to established oncological principles in institutions with experience in both hepatobiliary and advanced laparoscopic surgery . the minimally invasive approach has several documented advantages such as fast recovery and cosmetic superiority and may even have some immunological benefits in malignant disease . the development of modern surgical tools has enabled us to perform these resections with minimal bleeding and excellent visual control . our recently published series of laparoscopic liver resection has shown that such resections can be performed with excellent perioperative results and oncological outcome compared to traditional , open surgery . the search for even less invasive methods the last few years has led to the development of natural orifice transluminal endoscopic surgery ( notes ) techniques as well as the development of equipment enabling surgery through single incisions . several companies now deliver specially designed products for such procedures . to date , a wide variety of single incision surgical procedures have been reported , including cholecystectomy , appendectomy , adrenalectomy , splenectomy , and colectomy . liver resections by the single incision have been scarely reported and certainly not as a simultaneous procedure through a bowel stoma site following reversal of a loop enterostomy . it is obvious that not all metastatic lesions of the liver are suitable for this technique . in our experience , the preferred lesions would be superficially located on the anterior aspect of the liver . such lesions will not demand extensive triangulation ,   major mobilization , or retraction of the remnant liver . the technique is also suitable for smaller anatomical resections such as resection of segment 2/3 as suggested in a recent publication .   the ideal timing from resection of a synchronous liver metastasis from a colorectal carcinoma is not known . neo - adjuvant or adjuvant chemotherapy is gaining acceptance as standard of care in many institutions , and recently published data indicates increased long - term survival and longer disease - free survival following this approach [ 5 , 6 ] . in the present case report , a neoadjuvant chemotherapy algorithm had not been implemented in our institution , but the patient 's age and pre - existing renal failure would in any case have contraindicated chemotherapy . although simultaneous surgery for a primary colorectal adenocarcinoma and combined liver surgery may be considered safe in selected cases , many centers still choose a two - stage procedure . in patients with high risk of anastomosis complications , which may be the case in some low anterior resections for rectal cancer , one may consider performing a laparoscopic liver resection prior to resection of the primary tumor in order to prevent delay in the treatment of liver metastases . however , the optimal strategy for resectable synchronous metastases from colorectal cancer is still not well defined . if a two - stage procedure is selected and a loop ileostomy has been established during the primary surgery , the single - port access for liver resection could be of particular interest in selected patients in centers with experience in laparoscopic liver resection , to minimize the surgical trauma to the abdominal wall . the position of an ileostoma in the right lower quadrant provides excellent visualisation of the anterior aspect of segments 4b , 5 , 8 and the lower lateral parts of segment 6 , and the distance from the stoma site to these segments facilitates adequate working conditions with available single - port equipment . in this case , the patient was fully mobilized on the day of his surgery and was scheduled for dismissal on the second postoperative day . before discharge , however , he suffered a respiratory complication . his pre - existing kidney failure was most likely underestimated , and due to a relatively low urine output he was given excess crystalloids without proper concomitant administration of diuretics . after proper treatment for the subsequent , transient pulmonary edema , his recovery went uneventful . we believe that the respiratory complication was related to his underlying renal condition and not to the surgical technique . further studies are needed in order to determine this method 's potential position among other minimally invasive liver resection techniques .
minimally invasive surgical techniques for liver tumors are gaining 
                               increased acceptance as an alternative to traditional resections by 
                               laparotomy . in this article we describe a laparoscopic liver resection 
                               of a metastatic lesion in a patient primarily operated for colorectal 
                               cancer . 
 the resection was conducted as a single port procedure through 
                               the stoma aperture at time of reversal of the diversion ileostomy . 
 sigle incision liver resections may be less traumatic than 
                               conventional laparoscopy and could be applied in selected patients 
                               with both benign and malignant liver tumors .