Nowadays, the use of minimally invasive surgery is widely accepted. NOTES (natural orifice translumenal endoscopic surgery) and SALS are at the cutting edge of these techniques. SALS has some significant advantages over NOTES, in particular its facilitation of the use of all common laparoscopic instruments such as laparoscopes, straight and articulating instruments, and the full range of commercially available energy-based dissecting devices [13]. The first report of single-access laparoscopic surgery was a right hemicolectomy in 2008 [14]. Recently, a report from Egi et al. [15] showed no difference in oncologic results between single-port laparoscopic techniques and conventional ones. However, the major problem from a surgical point of view is that the concept of “triangulation,” to which laparoscopic surgeons have grown accustomed to in terms of both the instruments and scope, is lacking [16]. Examples of this are the laparoscope’s view and articulating instruments. With regard to rectum surgery, the major technical problems are (1) the difficulty in obtaining TME and (2) the limitations of Endo staple instrument use in the pelvis.

A report from Leroy et al. [17] showed that laparoscopic surgery achieved good long-term oncologic results in TME. In single-access laparoscopic surgery, the first report from Hamzaoglu et al. [9] shows promising preliminary pathologic results in 4 cases of LAR with the introduction of a sutured sigmoid hung into the abdominal wall as a way of attaining adequate exposure for TME. In 2010, Uematsu et al. [18] reported a novel single-access port for use in a sigmoidectomy, and in 2011 there was a report of the use of a suspending bar to lift up the sigmoid for TME [10] with excellent pathologic results. Another 2 reports [11, 12] also showed good pathologic results (Table 4). Our study attempted to share our initial experience of performing single-port laparoscopic surgery of rectal cancer in which we achieved equally good pathologic results. From our results, we believe that (1) a bigger port was helpful in reducing instrument collision during operations and enlarged the working channel to manipulate operative field; (2) articulating instruments, especially Endo clinches or graspers, are useful as they help to maintain “triangulation”; (3) a flexible videolaparoscope is necessary or even essential because of its adjustable tip which helps to provide an adequate operative field in rectal dissection; and lastly (4) the reverse Trendelenburg position is useful in helping to pull the rectum in a cranial direction using the force of gravity. With regard to the pelvic diameter and the limited articulation of Endo linear staplers, we had only limited experience; however, Kim et al. [19] reported that the use of multiple stapler firings was a significant risk factor for anastomotic leakage, and they concluded that a reduction in the number of linear stapler firings is necessary to avoid anastomotic leakage after laparoscopic colorectal anastomosis with a double stapling technique. In the LAR case in our study, we used 2 laparoscopic staples to transect the rectum vertically, and we did not create a protective ileostomy.