Single incision laparoscopic surgery for ileal J-pouch–anal anastomosis: a 15-year review of the literature

Evangelia Balla^a, Dimitrios Dimitroulis^b,c, Nikolaos Garmpis^b,c, Ilektra Kyrochristou^d, Nikolaos Nikiteas^b,c, Dimitrios Patsouras^b,c

General Hospital of Filiates, Thesprotia; Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Greece; Hellenic Minimally Invasive Surgery Study Group, National and Kapodistrian University of Athens, Medical School; General Hospital of Nikaia and Piraeus, Athens, Greece

^aDepartment of Surgery, General Hospital of Filiates, Thesprotia, Greece (Evangelia Balla); ^bSecond Department of Propaedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece (Dimitrios Dimitroulis, Nikolaos Garmpis, Nikolaos Nikiteas, Dimitrios Patsouras); ^cHellenic Minimally Invasive Surgery Study Group (MIRS), National and Kapodistrian University of Athens, Medical School, Athens, Greece (Dimitrios Dimitroulis, Nikolaos Garmpis, Nikolaos Nikiteas, Dimitrios Patsouras); ^dDepartment of Emergency Medicine, General Hospital of Nikaia and Piraeus, Athens (Ilektra Kyrochristou), Greece

Correspondence to: Evangelia Balla, Department of Surgery, General Hospital of Filiates, Thesprotia, Greece, e-mail: evaballa@hotmail.com

Received 6 August 2025; accepted 29 October 2025; published online 12 December 2025

DOI: https://doi.org/10.20524/aog.2026.1027

Abstract

Single-incision laparoscopic surgery (SILS) has emerged as a refinement of minimally invasive techniques, offering potential cosmetic and postoperative recovery benefits. This review aimed to evaluate the current evidence regarding the safety, feasibility, and outcomes of SILS for ileal J-pouch–anal anastomosis (IPAA). A structured literature search was performed in PubMed for studies published between January 2010 and January 2025, focusing on adult and pediatric patients undergoing restorative proctocolectomy with IPAA performed through a single incision. Twenty-two studies were identified, encompassing 182 procedures. The mean operative time ranged from 144-284 min. Reported conversion to multiport laparoscopy or open surgery occurred in 3.9% of cases, while the mean estimated blood loss varied from 27-136 mL. The median length of hospital stay was 4 days in most studies. Major postoperative complications (Clavien-Dindo grade ≥III) occurred in approximately 9% of patients, most commonly small-bowel obstruction or anastomotic leak. Cosmetic satisfaction and postoperative pain scores were generally favorable, although long-term functional outcomes were rarely reported. SILS-IPAA appears feasible and safe in selected patients, particularly when performed by experienced surgeons familiar with conventional laparoscopic restorative proctocolectomy. The current literature is heterogeneous and limited by small sample sizes and overlapping institutional data. Further comparative studies, especially in the context of robotic platforms, are needed to define the role of SILS in modern pouch surgery.

Keywords Single incision laparoscopic surgery, ileal J-pouch–anal anastomosis, ulcerative colitis, minimally invasive surgery, colorectal surgery

Ann Gastroenterol 2026; 39 (1): 1-10

Materials and methods

Study design

This work was conducted as a narrative systematic review of the literature, following the key principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework (Supplementary Table 1) [19]. The review aimed to summarize current evidence on SILS IPAA, focusing on feasibility, safety, perioperative outcomes and early functional results.

Search strategy

A systematic search was performed in the PubMed database for studies published between January 2010 and January 2025. The year 2010 was chosen as the lower limit because the earliest reports of SILS IPAA appeared at that time [20]. PubMed was selected for its comprehensive medical indexing and coverage of peer-reviewed surgical literature; pilot searches in other databases (Scopus, Embase) revealed no additional eligible studies [21].

The following keywords and Boolean operators were used: (“single incision laparoscopic” OR “single port laparoscopic” OR “SILS”) AND (“ileal pouch anal anastomosis” OR “J-pouch” OR “restorative proctocolectomy”). Reference lists of relevant articles and review papers were also screened manually to identify additional eligible studies.

Eligibility criteria

Studies were included if they: (a) reported patients undergoing restorative proctocolectomy with IPAA performed entirely through a single incision; (b) were published in English; and (c) reported at least 1 perioperative or postoperative outcome. Case reports, case series, retrospective cohort studies and prospective non-comparative studies were eligible. Reviews, editorials, and animal or cadaveric studies were excluded. Both adult and pediatric populations were eligible, and this inclusiveness is acknowledged in the Results and Limitations sections.

Study selection

Two reviewers independently screened titles and abstracts, followed by full-text assessment of potentially eligible articles. Disagreements were resolved by consensus. The selection process is summarized in Fig. 1 (PRISMA flow chart).

Figure 1 PRISMA flowchart From: Moher D. Liberati A, Tetzlaff J. Altman DG. The PRISMA Group (2009). Preferred Reporting /tems for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097. For more information, visit www.prisma-statement.org.

Data extraction

For each included study, data were extracted on patient demographics, underlying disease (UC, FAP, or other), operative technique, operative time, conversion rate, intraoperative blood loss, perioperative complications, and length of hospital stay. When reported, functional and quality-of-life outcomes were also recorded.

Primary and secondary outcomes

The primary outcomes were feasibility (completion rate, conversion), safety (complications), and operative characteristics (time, blood loss).

The secondary outcomes included early functional results (bowel frequency, continence, pouchitis incidence), and patient-reported measures such as pain or cosmetic satisfaction.

Data synthesis

In view of the substantial heterogeneity in study design, sample size and reporting, no quantitative meta-analysis was attempted. Results are summarized descriptively and, where appropriate, presented as ranges or medians.

Results

Study selection

The search identified 83 potentially relevant records. After title and abstract screening, 37 full-text articles were assessed, of which 22 met the eligibility criteria for inclusion (Fig. 1). These comprised 3 case reports, 13 retrospective case series, and 6 case-controlled studies, encompassing a total of 182 procedures [22-43].

Potential overlap of cohorts from the same institutions was noted and is acknowledged in the Limitations section. No randomised or comparative trials were identified.

Patient demographics

Across studies, the mean age ranged from 22-42 years [22-43]. Both adult and pediatric populations were represented; 5 studies specifically included patients under 18 years of age [22,35,36,38,39]. Overall, approximately 12% of reported patients were pediatric. The inclusion of mixed age groups was prespecified and is noted in the materials and methods.

The sex distribution was balanced (49% male overall). The mean body mass index, reported in 9 studies, ranged between 21.8 and 25.6 kg/m² [22,23,28-31,34,41,43].

Underlying disease

UC accounted for 89% of indications, while FAP represented the remainder [22-43]. One study also reported a single case of indeterminate colitis [43]. All preoperative data are summarized in Table 1.

Table 1 Preoperative data

Operative characteristics

All operations were completed through a single umbilical incision, typically using a multiport access device (e.g., SILS Port or TriPort). The mean operative time ranged from 144-284 min, based on data from 15 studies that provided explicit times [22-26,28-30,34-36,38,39,41,43].

Conversion to multiport laparoscopy or open surgery occurred in 3.9% of cases overall, most commonly because of dense pelvic adhesions or inadequate visualization [24,28,30].

Estimated intraoperative blood loss was low across all studies, varying from 27-136 mL [22-25,34,38,41,43]. All intraoperative variables are presented in Tables 2A,B.

Table 2A Intraoperative data

Table 2B Intraoperative data

Postoperative outcomes

Postoperative recovery was generally favorable. The median length of hospital stay was 4 days, reported as the most common median in 13 studies [22,23,25-30,34,36,38,39,41,43].

Overall morbidity ranged from 0-31%, while major complications (Clavien-Dindo ≥III) occurred in approximately 9% of patients. The most frequent complications were small-bowel obstruction (n=6), anastomotic leak (n=5), pelvic abscess (n=3), and wound infection (n=2) [23,29,34-36,38,39,41,43]. There were no reported deaths. The postoperative outcomes are summarized in Table 3.

Table 3 Postoperative data

Functional and cosmetic outcomes

Functional results were rarely reported. When available, the median bowel frequency ranged from 4-6 movements per day at 6-12 months postoperatively [29,35,38,43]. Continence outcomes were described as satisfactory in all studies.

Cosmetic satisfaction was consistently high, with most patients preferring the single-incision approach. Pain scores were also reported as lower than those in historical multiport cohorts, though no comparative data were available [43].

Discussion

This review summarizes the cumulative experience from SILS IPAA over the past 15 years. The collective evidence demonstrates that SILS IPAA is technically feasible and can be performed safely in carefully selected patients, provided that the operating surgeon has significant experience in both conventional laparoscopic and restorative proctocolectomy techniques.

The principal advantages proposed for SILS are better cosmetic results, potentially lower levels of postoperative pain, and faster recovery, all derived from minimizing parietal trauma [44-46]. These benefits have been well documented for other colorectal procedures, including colectomy and appendicectomy [47-49]. In the present review, most authors reported high cosmetic satisfaction and low pain scores; however, the lack of comparative trials limits definitive conclusions.

Technical considerations

SILS IPAA presents several challenges. The limited triangulation, instrument crowding, and reduced range of motion increase the technical complexity of dissection in the narrow pelvis [26]. Innovative access platforms, articulated instruments, and flexible endoscopes have been employed to overcome these constraints [22,33,41]. Some groups have also described the use of a transanal or additional suprapubic port to facilitate difficult cases [24,34-36,38,39,41,43].

In experienced hands, SILS IPAA can replicate the oncological and functional quality of standard laparoscopy. Operative times, although initially longer, have approached those of conventional multiport procedures as experience has accumulated [34,36,43]. The conversion rate of 3.9% observed across the included series is comparable to that of multiport laparoscopy [29,32,37].

Comparison with robotics and other minimally invasive approaches

Since the introduction of robotic platforms, the role of SILS in colorectal surgery has been re-evaluated. Robotic systems provide enhanced dexterity, depth perception and ergonomics, which directly address the technical limitations of SILS [50,51]. The robotic single-port platform now allows intracorporeal triangulation through a single incision, potentially offering a more ergonomic and reproducible approach to IPAA [52-54].

While the cosmetic advantages of SILS are undeniable, its learning curve and ergonomic limitations may hinder its widespread adoption, especially in the era of advanced robotic technology. Therefore, future research should compare SILS directly with both conventional laparoscopy and robotic approaches, focusing on patient-centered outcomes such as pain, recovery, and long-term pouch function.

Limitations

This review is subject to several limitations. First, the heterogeneity of available studies—ranging from isolated case reports to small retrospective series—precluded meta-analysis or statistical synthesis. Second, potential data duplication may exist, as some institutions published multiple reports that could include overlapping patients. To avoid inflating sample size, totals were not aggregated across possibly overlapping cohorts. Third, only PubMed was searched, which may have limited the retrieval of articles indexed exclusively elsewhere; however, preliminary searches confirmed that nearly all SILS IPAA reports were PubMed-listed. Fourth, both adult and pediatric patients were included, which introduces clinical variability. Finally, long-term functional and quality-of-life data were inconsistently reported, and outcomes beyond 1 year were rarely available. Despite these constraints, this review provides the most comprehensive overview to date of SILS IPAA and its evolution over the past decade and a half.

Concluding remarks

SILS IPAA is a technically demanding, yet feasible and safe alternative to conventional laparoscopy in experienced hands. Reported short-term outcomes, including conversion rate, morbidity, and recovery, are comparable to those of multiport approaches, with the additional advantages of improved cosmetic satisfaction and potentially reduced postoperative discomfort.

However, the available evidence is limited by small sample sizes, possible cohort overlaps, and heterogeneous reporting. Current data do not demonstrate the superiority of SILS over established minimally invasive techniques. In the context of rapid technological progress, particularly the advent of robotic single-port systems, the clinical relevance of conventional SILS may become increasingly selective.

Future studies should prioritize comparative analyses between SILS, multiport laparoscopy, and robotic platforms, focusing on patient-centered outcomes, such as postoperative pain, recovery trajectory, functional results, and quality of life, rather than large, randomised trials designed solely to compare SILS with traditional laparoscopy.

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Notes

Conflict of Interest: None