In general, reduction of laparoscopic port size is associated wit

In general, reduction of laparoscopic port size is associated with limited trauma on the abdominal wall. Smaller incisions result in decreased incisional pain and reduced risk of complications such as port-site bleeding, infection, and herniation. Moreover, minimal scarring allows better cosmetic results [73]. On the other hand, narrow operative field, lower image quality due to lack of definition and reduced light transmission [16, 74], and blurred vision with the use of electrocautery [75] are almost unanimously reported to be the ��Achilles’ heel�� of this technique and cause more stress for the surgeon especially when using 3mm scopes.

The use of modern 5mm optics with high-definition cameras and powerful light sources is much more comfortable in performing advanced laparoscopic procedures, though a 3mm optic inserted through an ancillary port may be useful if the 5mm port is to be used for a larger instrument such as the clip applier. As for smaller instruments, they may show a weaker grasping capability and a lack of tensile strength due to increased flexibility, particularly in the presence of fibrosis or inflammation. Manipulation of tiny laparoscopic instruments may result in an increased risk of tissue damage during dissection [16, 74, 76�C79]. Apart from these precautions, moving from standard laparoscopic technique to needlescopic colorectal resections is not to be considered as approaching a new technique but simply an adaptation of a well-established practice and does not require a long learning curve.

None of the steps of the operation has shown difficulties resulting from the use of miniaturized instruments. A good exposition of the surgical field has been always achieved during vessel ligation and viscera dissection, transection, and anastomosis. Building on the experience gained from needlescopic procedures such as cholecystectomy and appendectomy, we decided not to give up the greater definition provided by 5mm scopes, since the 3mm optics are still less performant for more advanced and complex procedures. The 3mm grasper has been shown to provide good traction, also during gentle dissection. We used a simple trick to overcome its aforementioned limits: a wad of gauze held within the jaws of the instrument itself was used for lifting and retracting viscera in order to increase its strength and decrease the risk of injury of other organs.

One aspect that has been reconsidered performing needlescopic colorectal surgery is the position of trocars: we thought it would be logical to incorporate the only 12mm port that must necessarily be placed for the introduction of Dacomitinib the stapler in the minilaparotomy which is generally a transverse suprapubic incision; we therefore started introducing the stapler from a suprapubic port not only for low rectal resection but also to transect the upper rectum and transverse colon.

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