Single port access sleeve is reasonable if done without any violation of basic principles.

Dear Sir,

This is a letter in response to the letter by Mittermair.[1] Laparoscopic sleeve gastrectomy is now well-accepted to be a primary procedure of choice, for the treatment of Obesity with enough and more evidence.[2-6] There has been an extensive debate on the various technical aspects of performing a sleeve-like distance from the pylorus, size of the bougie, staple size, requirement of reinforcements, and the like. This is evident from the Third International summit on sleeve gastrectomy held recently.[7] However, one standard step that has been accepted by all the surgeons who had participated is that > 90% of the fundus has to be resected with the specimen. For this to be performed, adequate fundal mobilisation, by releasing the anterior and posterior attachments, along with skeletonising the left crus has to be done. As noted in the letter,[1] it is stated that liver retraction may not be necessary in single incision sleeve gastrectomy. This may hold good for small livers. Moreover, even in cases of small livers, without adequate retraction, the anterior fundal attachments may not be released adequately, due to compromised vision. This same difficulty may present during application of the final staplers, where positioning it in relation to the cardio-oesophageal junction and adequate exclusion of the fundus may be troublesome.

This is significant as no one ever does a conventional 5-port sleeve gastrectomy without liver retraction. Even if anyone intends to operate a sleeve gastrectomy or any other single incision laparoscopic surgery by the single-port access technique, the basic principles must not be compromised. For liver retraction we prefer the liver suspension technique, as described by Huang et al.[8] The other alternative will be suspending the liver - using a stitch on the right crus and suspending the liver from outside.

Single-incision surgery may even be rephrased as reduced port surgery, and to make this retraction simple, one may use 2.3 mm graspers or even needlescopes. At the end, cosmesis must not compromise quality.