A novel modification of traditional 2-port laparoscopic surgery using a 5-mm flexible scope

In embryonic natural orifice transumbilical endoscopic surgery, more than 1 port is inserted through the umbilicus. In the present study, embryonic natural orifice transumbilical endoscopic surgery combined with a flexible scope was used to further improve gynecologic surgery. A surgical incision was made in the umbilical region to enter the abdominal cavity using the closed approach. A 12-mm port was placed at the umbilical incision, and the 5-mm flexible scope was inserted through the port. Another surgical port was then made in the left inguinal region for insertion of a 5-mm port while monitoring it with the flexible scope. The flexible scope was then inserted through the 5-mm inguinal port, and another 5-mm port was inserted caudal to the 12-mm port while monitoring the umbilical region with the flexible scope. The 12- and 5-mm ports were inserted through the same umbilical incision so that they were positioned vertically. The surgeon stood on the left side of the patient to manipulate the 12-mm umbilical port with the right hand and the 5-mm inguinal port with the left hand. An assistant surgeon inserted the flexible scope through the 5-mm umbilical port and manipulated it with the left hand to secure the view during surgery by appropriately adjusting the angle of the flexible scope. With the present technique, the flexible scope did not interfere with the forceps inside or outside of the body cavity because its angle could be freely set. Since March 2, 2009, we have performed 8 procedures using this surgical technique including 1 salpingectomy, 3 ovarian cystectomies, 2 total laparoscopic hysterectomies, 1 linear salpingostomy, and 1 total laparoscopic myomectomy. Intracorporeal suturing was performed in all cases but one because a suture needle could be easily inserted through the 12-mm port. Furthermore, total laparoscopic myomectomy could be completed using a 12-mm power mocellator inserted through the 12-mm port. The flexible scope and forceps did not hinder each other either inside or outside of the body cavity. Use of the flexible scope enables the conventional rigid straight forceps to be used in almost the same manner as with the conventional laparoscopic technique.