• Nezar A. Almahfooz Faruk Medical City (FMC), Sulaimani, Kurdistan Region, Iraq.



Single Incision laparoscopic Surgery, SILS, Single Incision Multi-port Laparoscopic Surgery



Single incision laparoscopic surgery (SILS) is a natural evolution of minimally invasive surgery (MIS) era.The advent of SILS was in the field of gynecology 1969. The first published report in general surgery appeared in 1992 with appendectomies. The first report of SILS cholecystectomy came in 1997 in a letter to the editor in the British Journal of Surgery by Navarra.Curcillo et al., developed Single Port Access (SPA™) surgery in April 2007 as a novel and innovative platform of minimal access surgery. Saber et al. reported the first series of single-incision laparoscopic SG in 7 patients in 2008. SILS recently becoming an interest of both patients and minimally invasive surgeons. Purposes were esthetic (scarless surgery), minimize parietal trauma, less pain and fast patient postoperative recovery. Despite these advantages, there is a concerned report of complications. Aiming to overcome the SILS complications, this novel technique; Single Incision Multiport Laparoscopic Surgery SIMPLS innovated in Iraq.


To introduce SIMPLS (Single Incision Multiport Laparoscopic Surgery) as a novel technique in Iraq and assess safety, cost, aesthetic and any associated complications. To evaluate its use in some advanced laparoscopic procedures.

Materials and Methods

SIMPLS is a single surgeon prospective study conducted from Aug. 2009- Dec. 2016, in four hospitals in Iraq with the same laparoscopic platforms. Technique tested in different laparoscopic operative procedures on 129 different cases.


Cholecystectomy (n=76), sleeve gastrectomy (n=20), appendectomy (n=9), diagnostic laparoscopy (n=8), hydatid cystectomy liver (n=4), fundoplication (n=4), ovarian cystectomy (n=3), renal cystectomy (n=3), combined sleeve gastrectomy and hiatal hernia repair (n=1), and small bowel tumor(n=1). Time spend initiating ports ranging from 9-12 minutes. No much difficulty or struggle faced using standard laparoscopy instruments. Time spend in procedures noticed to be acceptable and less than SILS. P value couldn’t see any significant difference with SILS. No conversion was reported till today. The cosmetic outcome found to be extremely acceptable by patients.Specific complications and difficulties, one case difficult intra-corporal liver retraction, gall bladder retraction in a severely inflamed gall bladder, bleeding at (angle of His),hematoma and ecchymosis, no port incision infection, and no incisional hernia. 


SIMPLS technique is introduced by the author as a novel procedure in IRAQ 2009. Similar technique started few years before in some countries in the word. Benefits of the procedure: technically feasible, reproducible for expert devoted surgeons, shorter time ports initiation, excellent esthetic results, lowest cost, not associated with incisional hernia. I advise wider practice, more trials to confirm these findings and I suggest it for interested experienced minimally invasive surgeons.


Maryam N Saidy, Michele Tessier, Deron Tessier, Single-Incision Laparoscopic Surgery—Hype or Reality: A Historical Control Study. Perm J. 2012 Winter; 16(1): 47–50. DOI:

Prashanth P Rao, Pradeep P Rao, and Sonali Bhagwat1. Single-incision laparoscopic surgery – status and controversies. J Minim Access Surg. 2011 Jan-Mar; 7(1): 6–16. DOI:

Thompson B, Wheeless RC. Outpatient sterilization by laparoscopy. A report of 666 patients. Obstet Gynecol. 1971 Dec;38(6):912–5.

Pelosi MA, Pelosi MA., Laparoscopic appendectomy using a single umbilical puncture (minilaparoscopy) J Reprod Med. 1992 Jul;37(7):588–94. [PubMed].

Curcillo PG 2nd1, King SA, Podolsky ER, Rottman SJ. Single Port Access (SPA™) Minimal Access Surgery Through a Single Incision. Surg Technol Int. 2009 Apr; 18:19

Saber, A.A., Elgamal, M.H., Itawi, E.A., and Rao, A.J. Single incision laparoscopic sleeve gastrectomy (SILS): a novel technique. Obes Surg. 2008; 18: 1338–1342 DOI:

Wheeless CR. A rapid, inexpensive and effective method of surgical sterilization by laparoscopy. J Reprod Med. 1969;3(5):65–9.

Gaillard M, Tranchart H, Lainas P, Ferretti S, Perlemuter G, Dagher I.Single-port laparoscopic sleeve gastrectomy as a routine procedure in 1000 patients.Surg Obes Relat Dis. 2016 Aug;12(7):1270-1277. DOI:

Buckley FP d, Vassaur HE, Jupiter DC, Crosby JH, Wheeless CJ, Vassaur JL. Influencing factors for port-site hernias after single-incision laparoscopy. Hernia. 2016 Oct;20(5):729-33. Epub 2016 Jul 14.

Yao D, Wu S, Li Y, Chen Y, Yu X, Han J. Transumbilical single-incision laparoscopic distal pancreatectomy: preliminary experience and comparison to conventional multi-port laparoscopic surgery. BMC Surg. 2014 Dec 10; 14:105. DOI:

Rajkumar JS, Syed A, Anirudh JR, Kishor CM, Ganesh D. Single-Incision Multi-Port Appendectomy for a Patient with Situs Inversus Totalis: First case report. Sultan Qaboos Univ Med J. 2016 May;16(2): e242-5. DOI:

Liang ZW, Cheng Y, Jiang ZS, Liu HY, Gao Y, Pan MX. Transumbilical single-incision endoscopic splenectomy: report of ten cases. World J Gastroenterol. 2014 Jan . 7;20(1):258-63. DOI:

Petrotos AC, Molinelli BM. Single-incision multiport laparoendoscopic (SIMPLE) surgery: early evaluation of SIMPLE cholecystectomy in a community setting. Surg Endosc. 2009 Nov;23(11):2631-4.

Schoenthaler M, Avcil T, Sevcenco S, Nagele U, Hermann TE, Kuehhas FE, Shariat SF, Frankenschmidt A, Wetterauer U, Miernik A. Single-Incision Transumbilical Surgery (SITUS) versus Single-Port Laparoscopic Surgery and conventional laparoscopic surgery: a prospective randomized comparative study of performance with novices in a dry laboratory. World J Urol. 2015 Jan;33(1):51-7. DOI:

Chih-Kun Huang & Jui-Chi Tsai & Chi-Hsien Lo & Jer-Yiing Houng & Yaw-Sen Chen & Shu-Ching Chi & Po-Huang Lee. Preliminary Surgical Results of Single-Incision Transumbilical Laparoscopic Bariatric Surgery, OBES SURG (2011) 21:391–396 DOI:

Nguyen NT1, Hinojosa MW, Smith BR, Reavis KM. Single laparoscopic incision transabdominal (SLIT) surgery-adjustable gastric banding: a novel minimally invasive surgical approach. Obes Surg. 2008 Dec;18(12):1628-31. doi: 10.1007/s11695-008-9705-6. Epub 2008 Oct 2. DOI:

Parveen Bhatia, Vinay Sabharwal,1 Sudhir Kalhan,2 Suviraj John,2 Jagpreet S. Deed,3 and Mukund Khetan2. Single-incision multi-port laparoscopic appendectomy: How I do it J Minim Access Surg. 2011 Jan-Mar; 7(1): 28–32. DOI:

Chinnusamy P, Ahluwalia JS, Palanisamy S, Seshiyer RP.Single incision multi-trocar hepatic cyst excision with partial splenectomy.J Minim Access Surg. 2013 Apr;9(2):91-4

Evans L, Manley K. Is There a Cosmetic Advantage to Single-Incision Laparoscopic Surgical Techniques Over Standard Laparoscopic Surgery? A Systematic Review and Meta-analysis. Surg Laparosc Endosc Percutan Tech. 2016 Jun;26(3):177-82. DOI:

Aly OE, Black DH, Rehman H, Ahmed I. Single incision laparoscopic appendicectomy versus conventional three-port laparoscopic appendicectomy: A systematic review and meta-analysis. Int J Surg. 2016 Nov; 35:120-128. doi: 10.1016/j.ijsu.2016.09.087. Epub 2016 Oct 2. DOI:

Palanivelu Chinnusamy, Jasmeet Singh Ahluwalia, Senthilnathan Palanisamy, and Rajan Pidigu Seshiyer. Single incision multi-trocar hepatic cyst excision with partial splenectomy. J Minim Access Surg. 2013 Apr-Jun; 9(2): 91–94. DOI:

Buckley FP 3rd1, Vassaur HE, Jupiter DC, Crosby JH, Wheeless CJ,Vassaur JL4. Influencing factors for port-site hernias after single-incision laparoscopy.Hernia. 2016 Oct;20(5):729-33. DOI:

Buckley FP 3rd, Vassaur H, Monsivais S, Jupiter D, Watson R, Eckford J.Single-incision laparoscopic appendectomy versus traditional three-port laparoscopic appendectomy: an analysis of outcomes at a single institution.Surg Endosc. 2014 Feb;28(2):626-30. DOI:

Lee DY, Rehmani SS, Guend H, Park K, Ross RE, Alkhalifa M, McGinty JJ, Teixeira JA.The incidence of trocar-site hernia in minimally invasive bariatric surgery: a comparison of multi versus single-port laparoscopy. Surg Endosc. 2013 Apr;27(4):1287-91. DOI:

Zanghì G, Leanza V, Vecchio R, Malaguarnera M, Romano G, Rinzivillo NM, Catania V, Basile F G Chir. Single-Incision Laparoscopic Cholecystectomy: our experience and review of literature.2015 Nov-Dec;36(6):243-6. DOI:

Banujan Balachandran, MS1, Taha Mustafa, MD1, Theadore A Hufford, MD1, Kunal Kochar, MD1, Leela M Prasad, MD1, Suela Sulo, PhD3, Joubin Khorsand, MD2. A comparative study of outcomes between single-site robotic and multi-port laparoscopic cholecystectomy: An experience from a tertiary care center.

Athanassios C. PetrotosBruce M. Molinelli. Single-incision multiport laparoendoscopic (SIMPLE) surgery: early evaluation of SIMPLE cholecystectomy in a community setting. Surg Endosc (2009) 23: 2631. DOI:

White MA, Haber GP, Kaouk JH. Robotic single-site surgery. Curr Opin Urol. 2010; 20:86–91. DOI:



How to Cite

Almahfooz N. SINGLE INCISION MULTI-PORT LAPAROSCOPIC SURGERY (SIMPLS), A NOVEL TECHNIQUE IN IRAQ. JSMC [Internet]. 2017 Nov. 1 [cited 2024 Jul. 12];7(3):231-9. Available from:

Similar Articles

1-10 of 176

You may also start an advanced similarity search for this article.