SALS provides the benefits of conventional laparoscopy while reducing the tissue trauma due to the reduction in size and number of ports used. The potential benefits of SALS include reduced postoperative pain, a shorter recovery period, lower morbidity, reduced cost, and superior cosmesis [1]. It also obviates trocar-related intra-abdominal injury and port site incisional hernia formation, and thus may ultimately prove superior. This approach is particularly compelling in cases where a 3 cm incision is required anyway for the purposes of specimen extraction or stoma formation and so this wound can be made at the commencement of the surgery and used as the sole site of transabdominal incision before being closed securely under direct vision at procedure end. The ability to focus local anaesthetic regimens towards one single wound is also intuitively advantageous over the more variable responses associated with broader regional techniques such as transversus abdominus preperitoneal plane (TAPPS) blocks.

To date, however, the published experience is limited with regard to followup beyond hospital discharge and lack of long-term clinical outcome data demonstrating superiority. Furthermore, many laparoscopic surgeons still raise concerns overthe ergonomics of the technique. This is because most believe that triangulation is necessary to create the traction and counter traction that permits efficient surgery by facilitating both dissection along normal anatomical planes and laparoscopic suturing. That is why great care is taken during multiport laparoscopic surgery to respect this physical principle by ensuring trocar placement permits ideal instrument axial alignment. In contrast, the principle of triangulation hardly exists in SALS making it somewhat challenging for the laparoscopic surgeon to achieve fluent two-handed choreography for instrument movement. Therefore, there has been great interest in modification of laparoscopic instruments by implementing angulated shafts, tip reticulation, and robotic platforms to compensate for the limits of constrained parallel access [7]. At present, therefore many surgeons perhaps consider SALS best as a needlessly expensive, difficult, and time-consuming variant of minimal access surgery.

In this pilot series, we have presented a cohort of consecutive, unselected patients requiring surgery for ileal disease where a SALS access device and technique was adopted that minimizes these disadvantages while preserving the advantages of the approach. The “surgical glove port” provides more flexibility and allows greater manoeuvrability than most of the commercially available ports. The proximity of instruments within the access device, which hinders ergonomics, tends to be less constraining as the glove can stretch to increase or decrease the distance between instruments allowing greater horizontal, vertical, and rotational freedom as well as facilitate enhanced abduction and adduction of instrument tips. Furthermore, the flush positioning of the ring construct minimises the fulcrum bulk around which the instruments pivot in contrast to the majority of commercially available single-port devices which enforce parallel positioning of instrument shafts at least throughout the cylindrical component of the device. The glove port device is always readily available, thereby relieving the pressure of both preoperative selection and economic considerations and therefore means the modality can be employed with sufficient spontaneity and regularity (including its use during multiport laparoscopic colorectal resections such as to recapture the specimen extraction site to restore pneumoperitoneum and maintain full-port capacity) to ensure pan-departmental expertise [6]. Additionally a coaxial light cable instead of the tangential light cable on the laparoscope helps to overcome instrument clashing. For the novice SALS surgeon, utilizing this approach for ileal disease represents an ideal opportunity to ascend their learning curve. It is always possible to convert a SALS procedure standard laparoscopy by adding more trocars to complete the procedure (still using the single incision to extract the specimen at the end of the operation) or to extend the existing incision to convert to an open approach at no disadvantage to the patient and without significant added cost for the healthcare provider. An additional economic advantage is that, as only trocar sleeves are used with the Glove port, there is a cost-saving compared to the standard multiport approach which needs trocars with bladed obturators.

Laparoscopy is now considered an acceptable approach for initial assessment and possible management of small bowel obstruction with a conversion to a midline laparotomy rate of 29% [8]. Meta-analysis comparing laparoscopic and open approaches for the management of small bowel Crohn’s disease has also demonstrated that laparoscopic surgery is associated with reduced wound infection, reduced length of stay, shorter time for recovery of enteric function, reduced reoperation rates for nondisease-related complications, and no difference in disease recurrence [9, 10]. Since the first report of SALS for the management of ileocolic Crohn’s disease [11], there has been a further of four case reports [12–15] and seven case series with the number of patients ranging from one to fourteen [2, 16–21] demonstrating this approach is safe, feasible, and maintains all the advantages of traditional multiport approaches. The data presented herein further supports SALS for the management of small bowel Crohn’s disease. Given the predominantly young age of patients presenting for surgery with Crohn’s disease and their concerns regarding cosmesis [22] as well their potential for needing further surgery (and so the preservation of uninjured abdominal wall should facilitate reoperation), SALS may represent the optimal minimally invasive approach in this setting.

Finally, to the authors’ knowledge, the usefulness and safety of this technique in the acute setting has been demonstrated for the first time. Patients presenting for urgent gastrointestinal operation have higher rates of infectious and other postoperative morbidity and greater wound complications both in the short and intermediate term [23]. If there is to be a category of patients in whom reducing the abdominal wound is important for reasons other than cosmesis, it is clearly this group of patients.

In conclusion, SALS for small bowel diseases is feasible and it can be performed without specialized instrumentation and at no extra cost. Further evaluation is required to optimise the technique; however, there are currently many available innovative, adapted techniques that can spur on the evolution of minimal access surgery by interested practitioners for the benefit of patients. While caution is needed to ensure judicious selection, ileal disease is often limited in its extent and most often specifically diagnosed by a preoperative CT. Moreover, the ileum tends to be mobile and therefore positionable both in terms of intraperitoneal quadrant and extraction via the access site.