but for mid to low rectum procedures , such as total mesorectal excision , it can be technically complicated . only a few reports have been published about single - access laparoscopic low anterior resection [ 26 ] . the usual techniques used to maintain an adequate operative field for tme are lifting the rectum with a second forceps or suspending the rectum with transparietal sutures . in this study , however , we introduced a single - access technique for rectal surgery without the use of other instruments . the study took place from december , 2011 to december , 2012 in the tertiary care unit of rajavithi hospital . the inclusion criteria were ( 1 ) patients who had been diagnosed with cancer at the middle or low rectum or the anal canal and ( 2 ) patients who had rejected neoadjuvant chemotherapy . the exclusion criteria were ( 1 ) patients who were unfit for surgery ; ( 2 ) patients who did not attend for followup ; ( 3 ) patients for whom anesthesia was contraindicated ; and ( 4 ) patients with asymptomatic stage iv disease . all of the patients underwent bowel preparation 1 day preoperatively either with 4 litres of polyethylene glycol electrolyte solution or 90  ml of sodium phosphate solution depending on their comorbid disease . surgical procedures were performed through a 5 - 6  cm single umbilical incision using a single - access multiport device ( glove port - single port , nelis ltd . , gyeonggi - do , korea ) ( figure 1 ) that allows three additional trocars ( two 5  mm and one 1012  mm ) to be inserted and has a co2 connection for insufflations ( figure 1 ) . the camera was a flexible videolaparoscope ( olympus medical systems corp . , tokyo , japan ) . operations were performed using a surgical technique similar to the standard laparoscopic ( medial - to - lateral ) approach . the inferior mesenteric artery and the inferior mesenteric vein were both skeletonized and clipped by hem - o - lok ( teleflex medical , durham , nc , usa ) or liga clip ( johnson and johnson , new york , ny , usa ) and divided with scissors . then , we dissected downwards in a semicircular motion from the mesenteric window to the pelvis on the right side of the rectum . for posterior dissection , the rectum was grasped and pushed anteriorly using endo grasp forceps or a flexible endo clinch and dissection was performed from the promontory of the sacrum in a semicircular motion deep down to the coccyx . the descending colon was grasped by endo grasp forceps or flexible endo clinch and pulled anteromedially to clearly identify the lateral peritoneal attachment , and it was then severed by cauterization up to the splenic attachment ( figure 2 ) . at this point downward , medial traction was applied to the colon to expose the splenic attachment and then divided with cautery . the flexible tip videolaparoscope proved helpful for changing the angle and operative view in this phase . to facilitate the process of dissecting deep into the pelvis , we used the force of gravity by moving the patient into the reverse trendelenburg position , and we also utilised a port that allowed two endo grasps or endo clinches to push the rectum anteriorly . for anterior dissection , the peritoneal attachment was pulled up anteriorly , and the mobilized rectum was dissected ( figure 3 ) . in the low anterior resection , the rectum was transected using 2 endoscopic linear staplers ( endo gia , covidien plc , dublin , ireland ) . the position of the applied stapler is shown in figure 4 . due to limitations in endo stapler angulation and pelvis diameter resection was achieved following extracorporealization , and anastomosis was performed with the double stapling technique using a transanally inserted circular stapler ( cdh29 , ethicon endo - surgery inc . , a pelvic drainage tube was inserted at a new stab incision at the right lower quadrant under laparoscopic view . in the apr cases , we started the perineal resection phase after finishing the intraperitoneal phase using the standard ap resection technique . in our hospital , demographic data including patients ' age , gender , and body mass index ( bmi ) were tabulated together with their history of prior abdominal surgery . intraoperative parameters including operative time , estimated blood loss , and intraoperative complications were analyzed . pathologic characteristics such as depth invasion , lymph node retrieval , circumferential margin , distal margin , and mesorectal capsule status were reviewed , and postoperative outcomes including length of stay in hospital and complication rates were collected . between december , 2011 and december , 2012 , 10 patients ( 4 females and 6 males , mean age 69 years , range 5286 ) underwent sals for middle rectal , low rectal , and anal canal cancer . kg / m ) ( table 1 ) . in all cases , the patients ' consent for single - access laparoscopic surgery was obtained . the average intraoperative blood loss was 145  ml ( range 50300  ml ) . in the lar case , the anastomosis was 6  cm from the anal verge ( table 2 ) . intraoperatively , there were no complications , but postoperatively , there were 6 problems : 2 cases of lung atelectasis ; 2 instances of nonorganic cause delirium ; 1 case of thrombophlebitis on the forearm ; and 1 case of perineal wound infection . none of the patients developed neurogenic bladder ( table 3 ) , and none of the male patients developed any sexual disorders . postoperatively , all patients were oncologic stage ii or iii ( 4 patients were stage ii , and the other 6 were stage iii ) , and all patients received adjuvant chemoradiation therapy . surgical margins were negative in all patients , with a distal margin of at least 2  cm and circumferential margin of at least 2  mm in all cases ( figure 5 ) . and all patients were allowed oral fluid on the first postoperative day ; bowel movement median occurrence was on the third postoperative day ; free light diet was allowed on the subsequent day ; and patients were discharged when they were able to return to a regular diet with the exception of one patient who developed a perineal wound infection . nowadays , the use of minimally invasive surgery is widely accepted . notes ( natural orifice translumenal endoscopic surgery ) and sals are at the cutting edge of these techniques . sals has some significant advantages over notes , in particular its facilitation of the use of all common laparoscopic instruments such as laparoscopes , straight and articulating instruments , and the full range of commercially available energy - based dissecting devices . the first report of single - access laparoscopic surgery was a right hemicolectomy in 2008 . recently , a report from egi et al .   showed no difference in oncologic results between single - port laparoscopic techniques and conventional ones . however , the major problem from a surgical point of view is that the concept of  triangulation ,  to which laparoscopic surgeons have grown accustomed to in terms of both the instruments and scope , is lacking . examples of this are the laparoscope 's view and articulating instruments . with regard to rectum surgery , the major technical problems are ( 1 ) the difficulty in obtaining tme and ( 2 ) the limitations of endo staple instrument use in the pelvis . a report from leroy et al .   showed that laparoscopic surgery achieved good long - term oncologic results in tme . in single - access laparoscopic surgery , the first report from hamzaoglu et al . shows promising preliminary pathologic results in 4 cases of lar with the introduction of a sutured sigmoid hung into the abdominal wall as a way of attaining adequate exposure for tme . in 2010 , uematsu et al . reported a novel single - access port for use in a sigmoidectomy , and in 2011 there was a report of the use of a suspending bar to lift up the sigmoid for tme   with excellent pathologic results . another 2 reports [ 11 , 12 ] also showed good pathologic results ( table 4 ) . our study attempted to share our initial experience of performing single - port laparoscopic surgery of rectal cancer in which we achieved equally good pathologic results . from our results , we believe that ( 1 ) a bigger port was helpful in reducing instrument collision during operations and enlarged the working channel to manipulate operative field ; ( 2 ) articulating instruments , especially endo clinches or graspers , are useful as they help to maintain  triangulation  ; ( 3 ) a flexible videolaparoscope is necessary or even essential because of its adjustable tip which helps to provide an adequate operative field in rectal dissection ; and lastly ( 4 ) the reverse trendelenburg position is useful in helping to pull the rectum in a cranial direction using the force of gravity . with regard to the pelvic diameter and the limited articulation of endo linear staplers , we had only limited experience ; however , kim et al .   reported that the use of multiple stapler firings was a significant risk factor for anastomotic leakage , and they concluded that a reduction in the number of linear stapler firings is necessary to avoid anastomotic leakage after laparoscopic colorectal anastomosis with a double stapling technique . in the lar case in our study , we used 2 laparoscopic staples to transect the rectum vertically , and we did not create a protective ileostomy . the single - access laparoscopic technique is gaining favour with surgeons around the world with the evolution of minimally invasive techniques and instruments . our results show that the single - access technique for rectal surgery seems to be safe and effective with potentially reproducible oncologic results . in the future , randomized clinical trials should be carried out to confirm our preliminary results showing the benefits of single - access procedures .
introduction . single - access laparoscopic surgery ( sals ) has been successfully introduced for colectomy surgery ; however , for mid to low rectum procedures such as total mesorectal excision , it can be technically complicated . in this study , we introduced a single - access technique for rectum cancer operations without the use of other instruments . 
 aims . to show the short - term results of single - access laparoscopic rectal surgery in terms of pathologic results and immediate complications . settings and design . prospective study . 
 materials and methods . 
 we selected middle rectum to anal canal cancer patients to undergo single - access laparoscopic rectal resection for rectal cancer . 
 all patients had total mesorectal excisions . 
 an umbilical incision was made for the insertion of a single multichannel port , and a mesocolic window was created to identify the inferior mesenteric artery and vein . 
 total mesorectal excision was performed . 
 there were no perioperative complications . 
 the mean operative time was 269 minutes ; the median hospital stay was 7 days ; the mean wound size was 5.5  cm ; the median number of harvested lymph nodes was 15 ; and all patients had intact mesorectal capsules . statistical analysis used . 
 mean , minimum  maximum . conclusion . 
 single - access laparoscopic surgery for rectal cancer is feasible while oncologic principles and patient safety are maintained .