The incidence of incisional cellulitis or wound infection with LESS appears to be at least comparable to that of conventional laparoscopy. In a large multi-institutional series of women undergoing LESS for a gynecologic procedure, 5.2 % of women developed umbilical cellulitis. None of these patients required readmission or an additional procedure to manage this minor complication, and obesity was found to be significantly associated with umbilical morbidity (Gunderson et al. 2012). However, some reports have actually concluded lower rates of infection with LESS. In a prospective randomized trial of 108 women undergoing hysterectomy via LESS or conventional total laparoscopic hysterectomy (TLH), Li et al. reported a 1.9 % infection rate with LESS versus 8.9 % with TLH (p = 0.03) (Li et al. 2012).

Concern rightfully exists regarding the occult bacteria that the umbilicus may harbor, even after a sterilizing prep is applied. The American College of Obstetricians and Gynecologists does not routinely recommend antibiotic prophylaxis for adnexal surgery without hysterectomy (ACOG 2009). However, we propose consideration of antibiotic use with any LESS procedure in concordance with the individual’s umbilical anatomy, planned procedure, and underlying comorbidities.

Given the larger size of the umbilical incision required for LESS as compared to conventional laparoscopy, there is a theoretically increased risk of umbilical hernia formation. Furthermore, it is well understood that the incidence of hernia formation correlates with incision size, complexity and length of procedure, and underlying comorbidities (Kadar et al. 1993; Boike et al. 1995). However, the available data encompassing LESS in gynecology actually suggests a comparable rate of hernia formation to that of conventional laparoscopy. In a series of 211 women undergoing LESS for a variety of gynecologic procedures, Gunderson et al. noted a 2.4 % incidence of umbilical hernia formation when utilizing a 1.5–2.5 cm umbilical incision (Gunderson et al. 2012). It should be noted that the authors of this study used a meticulous incisional closure technique to reapproximate the fascia in a “mass closure” fashion and reattach the fascia to the umbilical stalk. Prospective studies are warranted to further validate these findings.

Advocates of the LESS approach deem that the single umbilical incision is cosmetically preferable to the multiple smaller incisions associated with conventional laparoscopy. The single central incision is relatively “scarless” as it may be easily concealed within the umbilicus. Several years ago, it was proposed that this predilection was purely surgeon speculation and was not based on objective information regarding actual patient preferences (Ramirez 2009). However, data have subsequently emerged which dispute this claim. Park et al. surveyed patients undergoing urologic surgery and found that they favored the cosmetic outcomes of LESS as compared to conventional laparoscopy or laparotomy (Park et al. 2011). This validation has also been recognized within the gynecologic surgery literature. Higher patient satisfaction scores were reported with LESS hysterectomy as compared to TLH (Li et al. 2012). Additionally, a recent randomized controlled trial noted a statistically significant higher rate of satisfaction by both the patient and the surgeon with the cosmetic result of LESS for benign adnexal surgery as compared to conventional laparoscopy. The improved satisfaction scores were noted both upon discharge from the hospital and 30 days postoperatively (Fagotti et al. 2011).