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The authors are thankful for the opportunity to address the comments made by Dr. Fazio and by Dr. Bergamaschi regarding our manuscript entitled ‘‘Single Incision Laparoscopic Colorectal Surgery: A Single Surgeon Experience of 102 Consecutive Cases.’’ The authors greatly appreciate both the insightful comments offered by Dr. Vic Fazio as well as his understanding that single-incision laparoscopic colorectal surgery is in its infancy. We also agree that benefits and outcomes will prove to be at least equivalent and likely superior to traditional laparoscopy, as its superiority to hand-assist surgery has been shown by others [1]. We are now indeed in the process of defining patient selection, disease processes, and limitations of a single-port technique. Further work is in process and results are forthcoming. As far as Dr. Bergamaschi’s comments, we agree that institutional review board (IRB) approval should be mandatory for such studies and greatly appreciate Dr. Bergamaschi’s acknowledgement that this was indeed the case in our study as we consider it routine. We also agree that there is a need for innovation in surgery and that this must be implemented in accordance with the rules of evidence. However, we cannot agree with his statement that laparoendoscopic single-site surgery (LESS) is neither technically simple nor random. Given the tremendous advances in new technology (Olympus endo-eye flexible tip 5-mm camera and 5-mm energy devices to name a couple), we are now able to perform even complex abdominal operations in an even less invasive fashion. In fact, the ergonomic challenges and time constraints of traditional laparoscopy are often greatly improved with a single-port technique. LESS is nothing more than grouping the ports together and operating through a single incision. Having performed well over 1,000 laparoscopic colorectal procedures primarily through a three-port technique popularized in the United States by John Marks, MD, the transition to single-incision surgery is quite simple. This has become our routine access as it is essentially a three-trocar technique with the grouping of the ports at a single-site. The authors also agree with Dr. Bergamaschi that the goal for innovative advances in surgery should be the improvement of patient benefit as that was the sole purpose of this study while better defining the patient selection, disease processes, and optimal technique. With regard to the actual technique, single-incision laparoscopy is in its infancy while standardized techniques have not yet been defined. However, it remains a three-trocar laparoscopic procedure. As we are now quickly approaching our second 100 cases, much has been learned. With the ports arranged in a triangular configuration directed to the pathology, the camera is best placed through the apical port with a grasper in the surgeon’s right hand and the energy device in the left. The same surgical principles that pertain to open surgery and utilized for a traditional laparoscopic approach are strongly adhered to with this access technique. Again, this simplified approach is a traditional three-trocar technique with the ports bunched together and we feel that this is readily adoptable by surgeons with the appropriate skill set utilized for a traditional laparoscopic resection. To date, over 100 surgeons with advanced laparoscopic experience have been proctored and report an excellent adoption rate. While others have D. Geisler (&) T. Garrett Pittsburgh, PA, USA e-mail: dgeisler@ma.rr.com

techniques in coloproctology

Author’s reply to V. Fazio’s invited comment on “Single incision laparoscopic colorectal surgery: a single surgeon experience of 102 consecutive cases”