Robotic laparoendoscopic single-site radical prostatectomy (R-LESS-RP) with daVinci Single-Site® platform. Concept and evolution of the technique following an IDEAL phase 1

To describe the evolution of robotic laparoendoscopic single-site radical prostatectomy (R-LESS-RP) performed with the daVinci Single-Site Platform® and a home-made multiport aimed to overcome classical drawbacks of LESS, still present with this platform. Between 09/2015 and 06/2017 12 patients underwent R-LESS RP for clinical localized prostate cancer. Following a "phase 1 (development-stage)" innovation, development, exploration, assessment, long-term study (IDEAL) framework, different solutions were drawn to overcome drawbacks of daVinci Single-Site Platform®, included 3 (A, B, and C) multi-ports developed and evaluated in term of advantages/drawbacks concerning ergonomy. The end points of this study were: feasibility, safety, efficacy, by reporting rational description of multiports configuration, demographics, perioperative variables, functional and oncological results. Semi-flexible robotic 5-mm needle-holder instead of Maryland forceps, 30° lenses up and barbed-suture allowed overcoming limits of robotic-platform. Multiport-C (GelPOINT Advanced-Access® and an extra 8-mm robotic trocar outside the multiport) showed the best compromise to ensure both surgeon and bed-side assistant to reproduce a standard robotic procedure. No conversion to either standard robotic or open technique or intraoperative complications occur in any case. Two patients experienced "high-grade" Clavien-Dindo complications. After 12.4 months follow-up, all patients were continent without any sign of biochemical relapse and among 5 preoperative potent patients submitted to nerve-sparing dissection, 4 reported good erectile-function. R-LESS-RP is feasible and safe in the hands of experienced minimally-invasive surgeons. Do date, we recommend a hybrid solution with a home-made multiport and use of an additional standard robotic trocar which allows the use endowrist® technology instruments.

Evaluation of the Role of Laparoendoscopic Single-Site Surgery vs Minilaparoscopy for Treatment of Upper Urinary Tract Pathologies: Prospective Randomized Comparative Study

OBJECTIVES

To present the first prospective randomized comparison between laparoendoscopic single-site surgery (LESS) and minilaparoscopy (ML) for treatment of upper urinary tract pathologies.

PATIENTS AND METHODS

Between January 2013 and June 2015, patients with different upper urinary pathologies were blindly randomized to both LESS and ML. All procedures were done by single experienced surgeon. Both cohorts were compared regarding demographic data, peri and postoperative characteristics, and visual analog pain scale (VAS). Cosmetic outcome was assessed after 12 months using patient scar assessment scale (PSAS) and observer scar assessment scale (OSAS).

RESULTS

Sixty patients were randomized into two equal groups with comparable demographic and preoperative characteristics. Indications included nephrectomy, pyeloplasty, cyst marsupialization, adrenalectomy, and repair of retrocaval ureter. Operative time was 167 ± 24 and 145 ± 39 minutes in LESS and ML groups, respectively (p = 0.09). Estimated blood loss was 59 ± 34 and 43 ± 42 mL in both groups, respectively (p = 0.2). VAS was 1.7 ± 0.6 and 2.8 ± 0.5 in both groups, respectively (p = 0.02). PSAS and OSAS were 5.9 ± 0.85 and 10.6 ± 1.98 vs 8.9 ± 0.9 and 13.5 ± 6.3 in both groups, respectively (p > 0.05). There were no intraoperative complications, conversions to open surgery, or conventional laparoscopy in both groups. Mean postoperative Diclofenac Na was 151.7 ± 35.6 and 169.7 ± 47.3 mg in both groups, respectively (p = 0.04). Postoperative complications rate and hospital stay were comparable between both groups.

CONCLUSION

Both LESS and ML have comparable operative time, blood loss, complication rate, and hospital stay in treatment of upper urinary tract pathologies. However, LESS is associated with less analgesic requirement and better cosmetic outcome.

Different approaches to the prostate: The upcoming role of a purpose-built single-port robotic system

With the aim of minimising the patient’s postoperative pain, expediting recovery and improving cosmesis, the idea of performing a laparoscopic procedure through a single abdominal incision was introduced. In the present report, we describe five different access routes to the prostate that may be at the surgeon’s disposal with the potential of decreasing patient’s perioperative morbidity. Robotic radical prostatectomy has been refined and became a standard of care in surgery for localised prostate cancer. The advent of single-port robotic surgery has prompted the re-discovery of different access routes to the prostate and ideally all of them are feasible. The potential for avoiding the abdominal cavity will decrease the surgical morbidity and minimise the surgical dissection. In the near future, each of the described approaches could be chosen on the basis of the patient’s preoperative comorbidities, body habitus, anatomy, and disease characteristics and location.

Laparoscopic single-incision triangulated umbilical surgery (SITUS) pyeloplasty: a description of the first 32 cases

INTRODUCTION AND OBJECTIVES

Transumbilical laparoendoscopic (LESS) procedures reduce access trauma. Laparoendocopic single-incision triangulated umbilical surgery (SITUS) utilizes straight instruments in a triangulated fashion, via three trocars placed through a single umbilical incision.

METHODS

Thirty-two consecutive patients underwent an SITUS pyeloplasty. Access is performed by incision of the umbilical fold by 3/4 of its circumference, a 5-mm camera port, and consequently, cranial and caudal 3 or 5 mm working trocars are placed at a distance of 3-6 cm, thus allowing triangulation. SITUS laparoscopy utilizes the standard straight instruments with a length of 43 cm.

RESULTS

All procedures were successfully performed and no conversion to open, or conventional laparoscopic approach was deemed necessary. Thirty patients underwent a dismembered and two a Fenger pyeloplasty. A crossing vessel was identified in 68.75% of the cases. The median laparoscopic and suturing times were 130 and 30 min, respectively; median blood loss was 50 ml. The median duration of hospitalization was 4 days. The visual analogue scores (VAS) reported were 1 on the first and 0 on the third postoperative day. The indwelling double-J or mono-J stents were removed after a median time of 5 weeks and 4 days, respectively. The overall success rate was 96.8%.

CONCLUSIONS

The SITUS technique for pyeloplasty is an attractive alternative to conventional laparoscopy and a viable competitor to LESS surgery. It combines the common principles of traditional laparoscopy, such as conventional instrumentation and triangulation, with the benefits of single-port surgery.

Unilateral Renal Tumor Cryoablation and Contralateral Radical Nephrectomy of Bilateral Renal Tumors by Transumbilical 3D Multichannel Laparoendoscopic Single-Site Surgery

Background: Unilateral renal tumor cryoablation and contralateral radical nephrectomy of bilateral renal tumors were performed by transumbilical three-dimensional (3D) multichannel laparoendoscopic single-site (LESS) surgery, in an attempt to verify the feasibility and safety of the procedure, sum up the operational experience, and evaluate the surgical outcome.

Case Presentation: This was a 47-year-old female patient with a body mass index of 27.34 kg/m² without backache, low back pain, hematuria, urinary urgency, frequent urination, dysuria, and other symptoms. Contrast-enhanced CT scan of the kidney on admission showed four masses in the left kidney and two masses in the right kidney. Preoperative serum creatinine (SCr) was 87 μmol/L. Operation was performed under general anesthesia by first laying the patient in a left lateral position. A 2-cm longitudinal transumbilical skin incision was made to expose the right kidney for complete dissection of the two tumors. First, puncture biopsy was performed, and then two freeze–thaw cryoablation cycles for the two tumors were performed. At last, the patient was laid in a right lateral position for radical nephrectomy of the left kidney. The operative duration, cryoablation time, and estimated blood loss were 200 minutes, 40 minutes, and 100 mL, respectively. Postoperative pathological examination revealed clear-cell renal cell carcinoma. The right glomerular filtration rate tested was 42.36 mL/minute and SCr was 131 μmol/L at day 5 after surgery. There was no evidence of contrast enhancement at the cryoablative region as shown by renal contrasted CT scan performed 4 days after surgery and renal contrasted MRI scan performed 6 weeks after surgery, indicating that there was no tumor remnant or recurrence.

Conclusion: Our preliminary experience shows that the treatment of bilateral renal tumors with unilateral renal tumor cryoablation and contralateral radical nephrectomy by transumbilical 3D LESS is safe, feasible, and effective. It may prove to be a viable option for patients with significant comorbidities and an insensitive treatment intention.

Single-Site Laparoscopy and Robotic Surgery in Pediatric Urology

PURPOSE OF REVIEW

In this review, we summarize research that has evaluated the role of laparoendoscopic single-site (LESS) and robotic surgery in pediatric urology, highlighting new and/or controversial ideas.

RECENT FINDINGS

The newest research developments over the last several years are studies that address generalizability of these techniques, ideal patient factors, extrapolation to more complex surgeries, and comparative studies to more traditional techniques to define the associated costs and benefits, as well as patient-centered outcomes. Specifically in the field of LESS, addressing the limitations of suboptimal vision, instrument crowding, and loss of triangulation have been a focus. The literature is now replete with new applications for robotic surgery as well as descriptions of the specific technical challenges inherent to pediatrics. Robotic surgery and LESS are areas of growth in pediatric urology that allow continual innovation and expansion of technology within a surgeon's armamentarium.

Quantifying the cognitive cost of laparo-endoscopic single-site surgeries: Gaze-based indices

BACKGROUND

Despite the growing interest concerning the laparo-endoscopic single-site surgery (LESS) procedure, LESS presents multiple difficulties and challenges that are likely to increase the surgeon's cognitive cost, in terms of both cognitive load and performance. Nevertheless, there is currently no objective index capable of assessing the surgeon cognitive cost while performing LESS. We assessed if gaze-based indices might offer unique and unbiased measures to quantify LESS complexity and its cognitive cost. We expect that the assessment of surgeon's cognitive cost to improve patient safety by measuring fitness-for-duty and reducing surgeons overload.

METHODS

Using a wearable eye tracker device, we measured gaze entropy and velocity of surgical trainees and attending surgeons during two surgical procedures (LESS vs. multiport laparoscopy surgery [MPS]). None of the participants had previous experience with LESS. They performed two exercises with different complexity levels (Low: Pattern Cut vs. High: Peg Transfer). We also collected performance and subjective data.

RESULTS

LESS caused higher cognitive demand than MPS, as indicated by increased gaze entropy in both surgical trainees and attending surgeons (exploration pattern became more random). Furthermore, gaze velocity was higher (exploration pattern became more rapid) for the LESS procedure independently of the surgeon's expertise. Perceived task complexity and laparoscopic accuracy confirmed gaze-based results.

CONCLUSION

Gaze-based indices have great potential as objective and non-intrusive measures to assess surgeons' cognitive cost and fitness-for-duty. Furthermore, gaze-based indices might play a relevant role in defining future guidelines on surgeons' examinations to mark their achievements during the entire training (e.g. analyzing surgical learning curves).

Factors influencing the operating time for single-port laparoscopic radical nephrectomy: focus on the anatomy and distribution of the renal artery and vein

Objective

It is considered that laparoscopic single-site surgery should be performed by specially trained surgeons because of the technical difficulty in using special instruments through limited access. We investigated suitable patients for single-port laparoscopic radical nephrectomy, focusing on the anatomy and distribution of the renal artery and vein.

Methods

This retrospective study was conducted in 52 consecutive patients who underwent single-port radical nephrectomy by the transperitoneal approach. In patients undergoing right nephrectomy, a 2-mm port was added for liver retraction. We retrospectively re-evaluated all of the recorded surgical videos and preoperative computed tomography images. The pneumoperitoneum time (PT) was used as an objective index of surgical difficulty.

Results

The PT was significantly shorter for right nephrectomy than left nephrectomy (94 vs. 123 min, P = 0.004). With left nephrectomy, dissection of the spleno-renal ligament to mobilize the spleen medially required additional time. Also, the left renal vein could only be divided after securing the adrenal, gonadal and lumbar veins. In patients whose renal artery was located cranial to the renal vein, PT tended to be longer than in the other patients (131 vs. 108 min, P = 0.070). In patients with a superior renal artery, the inferior renal vein invariably covered the artery and made it difficult to ligate the renal artery via the umbilical approach at the first procedure.

Conclusions

These findings indicate that patients undergoing right nephrectomy in whom the renal artery is not located cranial to the renal vein are suitable for single-port laparoscopic radical nephrectomy.

Three-flap umbilicoplasty: a novel and preliminary method of laparoendoscopic single-site transumbilical surgical approach for urachal remnants

PURPOSE

Symptomatic urachal remnants are rare benign anomalies affecting young adults. For these patients, both curative treatment and acceptable postoperative aesthetic outcomes are important. Here, we describe a novel transumbilical approach, using Y-shaped incisions and three-flap umbilicoplasty techniques, to improve repair and aesthetic outcomes.

MATERIALS AND METHODS

The clinical and perioperative data of 16 patients (11 men; median age, 25 years; range 16-46 years) who underwent LESS surgery and three-flap umbilicoplasty (LESS group) between December 2013 and March 2017 were analyzed. For comparison, the perioperative data of those who underwent conventional laparoscopic surgery (CL group) between May 2010 and November 2013 at the same institutions were investigated.

RESULTS

The median operative time of the LESS group was longer than that of the CL group (146.5 vs 107 min; p = 0.009). The estimated blood loss and postoperative hospital stay were not significantly different between the two groups. The two perioperative complications were injury to the transverse colon serosa and minor surgical site infection. Both complications were resolved with appropriate management.

CONCLUSIONS

This novel umbilical approach is useful for patients with symptomatic urachal remnants, with the reduction in port-site scarring resulting in good postoperative cosmesis.

Transumbilical laparoendoscopic single-site radical prostatectomy and cystectomy with the aid of a transurethral port: a feasibility study

OBJECTIVE

To describe the surgical technique and report early outcomes of transurethral assisted laparoendoscopic single-site (LESS) radical prostatectomy (RP) and LESS radical cystectomy (RC) in a single institution.

MATERIALS AND METHODS

Between December 2014 and March 2016, a total of 114 LESS RPs and RCs were performed, comprising 68 LESS RPs, 38 LESS RCs with cutaneous ureterostomy (CU) and eight LESS RCs with orthotopic ileal neobladder (OIN). Access was achieved via a single-port, with four channels placed through a transumblical incision. After the apex of prostate was separated from the urethra, a self-developed port ('Zhu's port') was inserted through the urethra to facilitate resection of prostate and urethrovesical anastomosis. The peri-operative and postoperative data were collected and analysed retrospectively. Patients were followed up postoperatively for evidence of long-term side effects.

RESULTS

All the procedures were completed successfully. No conversion to conventional laparoscopic surgery was necessary. For LESS RP, the average operating time was 152 min. Estimated blood loss was 117 mL. The mean hospital stay was 16.4 days after surgery. For LESS RC with CU and LESS RC with OIN, the mean operating times were 215 and 328 min, mean estimated blood loss was 175 and 252 mL, and mean hospital stay was 9.4 and 18.2 days, respectively. Six patients required blood transfusion (5.26%). Intra-operative complications occurred in two patients (1.75%), and postoperative complications in nine (7.89%). Fourteen out of 68 (20.6%) patients who underwent LESS RP had positive surgical margins. Follow-up ranged from 10 to 30.6 months. In the prostate cancer cases, good urinary control was observed in 35.3%, 97.1% and 100% of patients at 1, 6 and 12 months after the operation, respectively, while biochemical recurrence was observed in 11.8% patients. In the bladder cancer cases, two patients had local recurrence and two patients had distant metastasis.

CONCLUSION

Our results showed that LESS RP and LESS RC are feasible and safe with the aid of a transurethral port. Operating through the transurethral port might overcome the challenges posed by the single-port laparoscopic approach.

Laparoendoscopic single-site surgery for the treatment of different urological pathologies: Defining the learning curve of an experienced laparoscopist

Objectives

To define the learning curve of laparoendoscopic single-site surgery (LESS) of an experienced laparoscopist.

Patients and methods

Patients who had LESS, since its implementation in December 2009 until December 2014, were retrospectively analysed. Procedures were divided into groups of 10 and scored according to the European Scoring System for Laparoscopic Operations in Urology. Different LESS indications were done by one experienced laparoscopist. Technical feasibility, surgical safety, outcome, as well as the number of patients required to achieve professional competence were assessed.

Results

In all, 179 patients were included, with mean (SD) age of 36.3 (17.5) years and 25.4% of the patients had had previous surgeries. Upper urinary tract procedures were done in 65.9% of patients and 54.7% of the procedures were extirpative. Both transperitoneal and retroperitoneal LESS were performed in 92.8% and 7.2% of the patients, respectively. The intraoperative and postoperative complication rates were 2.2% and 5.6% (Clavien–Dindo Grade II 3.9% and IIIa 1.7%), respectively. In all, 75% of intraoperative complications and all conversions were reported during the first 30 LESS procedures; despite the significantly higher difficulty score in the subsequent LESS procedures. One 5-mm extra port, conversion to conventional laparoscopy and open surgery was reported in 14%, 1.7%, and 1.1% of the cases, respectively. At mean (SD) follow-up of 39.7 (11.4) months, all the patients that underwent reconstructive LESS procedures but one were successful.

Conclusion

In experienced hands, at least 30 LESS procedures are required to achieve professional competence. Although difficult, both conversion and complication rates of LESS are low in experienced hands.

Kinematic and ergonomic assessment of laparoendoscopic single-site surgical instruments during simulator training tasks

While laparoendoscopic single-site surgery (LESS) appears to be feasible and safe, instrument triangulation, tissue handling, and other bimanual tasks are difficult even for experienced surgeons. Novel technologies emerged to overcome LESS' procedural and ergonomic difficulties of "tunnel vision" and "instrument clashing." Surgeon kinematics, self-reported workload and upper body discomfort were used to compare straight, bent and two articulating instruments while performing two basic surgical tasks in a LESS simulator. All instruments resulted in bilateral elevation and rotation of the shoulders, excessive forearm motion and flexion and ulnar deviation of wrists. Surgeons' adopted non-neutral upper extremity postures and performed excessive joint excursions to compensate for reduced freedom of movement at the single insertion site and to operate the instrument mechanisms. LESS' cosmetic benefits continue to impact laparoscopic surgery and by enabling performance through improved instruments, ergonomic improvement for LESS can reduce negative impact on surgeon well-being and patient safety.

Comparative study of hybrid laparoendoscopic single-site (LESS) partial nephrectomy and conventional multiport laparoscopy

OBJECTIVE

To investigate the surgical and oncological outcomes of hybrid laparoendoscopic single-site (LESS) in partial nephrectomy with reusable components compared with multiport laparoscopy.

MATERIAL AND METHOD

Hybrid LESS technique with auxiliary 3.5mm trocar (n=20) was compared with conventional multiport laparoscopy (n=26) by a prospective, paired, nonrandomized, and comparative study in partially nephrectomized patients.

RESULTS

Follow-up average was 31±18.6 months. In one case, LESS was converted to laparoscopy. No differences were found regarding age, sex, body mass index, laterality, localization, tumor size or use of double J stent. Dominance of Loop-I (P=0.09) and benign histology (P=0.05) were observed in the LESS group. Neither there were differences regarding operating time, ischemia time, use of hemostatic materials, estimated blood loss, postoperative hemoglobin levels, transfusion or other complications. In any case, to extend the skin incision for specimen extraction was not necessary. Drainage time (P=0.006) and hospital stay (P=0.003) were better in LESS patients. Concerning complications, no significant differences were observed according Clavien-Dindo scale. In laparoscopic group one patient died of pulmonary embolism after hospital discharge. No positive margins were observed in any case. During follow-up neither tumor recurrence nor disease progression were observed.

CONCLUSIONS

Regarding surgical outcomes, partial nephrectomy by LESS technique does not imply improvements, excepting shorter hospital stay, probably due to accurate surgical hemostasis and/or selection of cases. No surgical and oncological risks are involved, as well as no improvement in ischemia time, blood loss or transfusion rate. We find no significant difference in cosmetic outcomes.

Laparoendoscopic single-site surgery versus conventional laparoscopy for hysterectomy: a systematic review and meta-analysis

Purpose

To assess the safety and effectiveness of LESS compared to conventional hysterectomy.

Methods

The systematic review and meta-analysis was performed according to the MOOSE guideline, and quality of evidence was assessed using GRADE. Different databases were searched up to 4th of August 2016. Randomized controlled trials and cohort studies comparing LESS to the conventional laparoscopic hysterectomy were considered for inclusion.

Results

Of the 668 unique articles, 23 were found relevant. We investigated safety by analyzing the complication rate and found no significant differences between both groups [OR 0.94 (0.61, 1.44), I² = 19%]. We assessed effectiveness by analyzing conversion risk, postoperative pain, and patient satisfaction. For conversion rates to laparotomy, no differences were identified [OR 1.60 (0.40, 6.38), I² = 45%]. In 3.5% of the cases in the LESS group, an additional port was needed during LESS. For postoperative pain scores and patient satisfaction, some of the included studies reported favorable results for LESS, but the clinical relevance was non-significant. Concerning secondary outcomes, only a difference in operative time was found in favor of the conventional group [MD 11.3 min (5.45–17.17), I² = 89%]. The quality of evidence for our primary outcomes was low or very low due to the study designs and lack of power for the specified outcomes. Therefore, caution is urged when interpreting the results.

Conclusion

The single-port technique for benign hysterectomy is feasible, safe, and equally effective compared to the conventional technique. No clinically relevant advantages were identified, and as no data on cost effectiveness are available, there are currently not enough valid arguments to broadly implement LESS for hysterectomy.

Electronic supplementary material

The online version of this article (doi:10.1007/s00404-017-4323-y) contains supplementary material, which is available to authorized users.

Laparoendoscopic single-site retroperitoneoscopic adrenalectomy: bilateral step-by-step technique

BACKGROUND

Laparoscopic adrenalectomy is the gold standard surgical approach for small benign adrenal tumors [1]. Several surgical approaches were developed in order to overcome the difficulty to access the adrenal glands, located in the upper retroperitoneum space [2-4]. Laparoendoscopic single-site posterior retroperitoneoscopic adrenalectomy (LESS-PRA) is an emerging technique that reduced the multiple trocar-related trauma and improved cosmetic outcomes while minimizing postoperative morbidity [5-8]. The aim of this study was to describe our step-by-step technique for LESS-PRA and to compare our perioperative outcomes with the conventional 3-port lateral retroperitoneoscopic adrenalectomy (LRA).

METHODS

A retrospective review was carried out from February 2008 to January 2016 that included 100 patients with adrenal tumors smaller than 4 cm. Study exclusion criteria were defined as tumor size greater than 4 cm, patients older than 80 years, and body mass index (BMI) greater than 40. A total of 20 patients underwent LESS-PRA and 80 patients underwent 3-port lateral retroperitoneoscopic laparoscopic adrenalectomy. Patient's demographic data and perioperative outcomes were compared and statistically analyzed. The cosmetic satisfaction was evaluated with a visual analog scale.

RESULTS

Estimated blood loss was higher in LRA (100 vs. 50 ml; p = 0.35). Operative time was longer in LESS-PRA than LRA (100.0 vs. 60 min; p < 0.001). Analgesic time necessary for LRA was longer than LESS-PRA (40 vs. 24 h; p < 0.001). Cosmetic satisfaction score was higher in LESS-PRA (9.5 vs. 8.6; p = 0.03). There were no significant differences in perioperative complications and length of hospital stay. No conversion to conventional laparoscopic or open surgery was necessary.

CONCLUSION

LESS-PRA presented comparable functional and perioperative outcomes to LRA for small adrenal tumors. Although LESS-PRA was associated with longer operative time, it provided inferior estimated blood loss, analgesic time, and improved cosmetic satisfaction.

Comparative study of multiport laparoscopy and umbilical laparoendoscopic single-site surgery with reusable platform for treating renal masses

INTRODUCTION

Umbilical laparoendoscopic single-site (LESS) surgery is an increasingly used modality for treating renal masses. We present a prospective comparison between LESS renal surgery and conventional laparoscopy.

MATERIAL AND METHOD

A comparative paired study was conducted that evaluated the surgical results and complications of patients with renal neoplasia treated with LESS surgery (n=49) or multiport laparoscopy (n=53). The LESS approach was performed with reusable material placed in the navel and double-rotation curved instruments. An additional 3.5-mm port was employed in 69.4% of the cases. We assessed demographic data, the type of technique (nephrectomy, partial nephrectomy and nephroureterectomy), surgical time, blood loss, haemoglobin, need for transfusion, number and severity of complications (Clavien-Dindo), hospital stay, histological data and prognosis.

RESULTS

There were no differences in follow-up, age, sex, body mass index, preoperative haemoglobin levels or type of surgery. Conversion occurred in 2 cases (1 in each group). The surgical time was equivalent (P=.6). Intraoperative transfusion (P=.03) and blood loss (P<.0001) was lower with LESS, postoperative haemoglobin levels were higher (P<.0001) and haemostatic agents were used more frequently (P<.0001). There were no differences in the number (P=.6) or severity (P=.47) of complications. The length of stay (P<.0001), the proportion of patients with drainage (P=.04) and the number of days with drainage (P=.0004) were lower in LESS. Twenty-five percent of the lesions operated on with LESS were benign, but the mean size was similar in the 2 groups (P=.5). Tumour recurrence and/or progression were more frequent in multiport laparoscopy (P=.0013).

CONCLUSIONS

Umbilical LESS surgery with reusable platform enables various surgical techniques to be performed when treating renal masses, with time consumption and safety comparable to conventional laparoscopy. The LESS approach is advantageous in terms of blood loss and hospital stay.

Landing Technique Improvements After an Aquatic-Based Neuromuscular Training Program in Physically Active Women

CONTEXT

Neuromuscular training programs (NTPs) improve landing technique and decrease vertical ground-reaction forces (VGRFs), resulting in injury-risk reduction. NTPs in an aquatic environment may elicit the same improvements as land-based programs with reduced joint stress.

OBJECTIVE

To examine the effects of an aquatic NTP on landing technique as measured by the Landing Error Scoring System (LESS) and VGRFs, immediately and 4 mo after the intervention.

DESIGN AND SETTING

Repeated measures, pool and laboratory.

PARTICIPANTS

Fifteen healthy, recreationally active women (age 21 ± 2 y, mass 62.02 ± 8.18 kg, height 164.74 ± 5.97 cm) who demonstrated poor landing technique (LESS-Real Time > 4).

INTERVENTIONS

All participants completed an aquatic NTP 3 times/wk for 6 wk.

MAIN OUTCOME MEASURES

Participants' landing technique was evaluated using a jump-landing task immediately before (PRE), immediately after (POST), and 4 mo after (RET) the intervention period. A single rater, blinded to time point, graded all videos using the LESS, which is a valid and reliable movement-screening tool. Peak VGRFs were measured during the stance phase of the jump-landing test. Repeated-measure analyses of variance with planned comparisons were performed to explore differences between time points.

RESULTS

LESS scores were lower at POST (4.46 ± 1.69 errors) and at RET (4.2 ± 1.72 errors) than at PRE (6.30 ± 1.78 errors) (P < .01). No significant differences were observed between POST and RET (P > .05). Participants also landed with significantly lower peak VGRFs (P < .01) from PRE (2.69 ± .72 N) to POST (2.23 ± .66 N).

CONCLUSIONS

The findings introduce evidence that an aquatic NTP improves landing technique and suggest that improvements are retained over time. These results show promise of using an aquatic NTP when there is a desire to reduce joint loading, such as early stages of rehabilitation, to improve biomechanics and reduce injury risk.

Towards autonomous motion control in minimally invasive robotic surgery

INTRODUCTION

While autonomous surgical robotic systems exist primarily at the research level, recently these systems have made a strong push into clinical settings. The autonomous or semi-autonomous control of surgical robotic platforms may offer significant improvements to a diverse field of surgical procedures, allowing for high precision, intelligent manipulation of these systems and opening the door to advanced minimally invasive surgical procedures not currently possible.

AREAS COVERED

This review highlights those experimental systems currently under development with a focus on in vivo modeling and control strategies designed specifically for the complex and dynamic surgical environment. Expert review: Novel methods for state estimation, system modeling and disturbance rejection, as applied to these devices, continues to improve the performance of these important surgical tools. Procedures such as Natural Orifice Transluminal Endoscopic Surgery and Laparo-Endoscopic Single Site surgery, as well as more conventional procedures such as Colonoscopy, serve to benefit tremendously from the development of these automated robotic systems, enabling surgeons to minimize tissue damage and shorten procedure times while avoiding the consequences of laparotomy.

Laparoendoscopic single-site surgery (LESS) for major urological procedures in the pediatric population: A systematic review

BACKGROUND

Improvements in laparoscopic surgery have led to the introduction of laparoendoscopic single-site surgery (LESS) as an alternative to conventional laparoscopy conferring a number of possible advantages. In this review, we aim to elucidate the aspects of LESS for major urological procedures in the pediatric population.

MATERIALS AND METHODS

An in-depth search of the literature was performed in the databases of PubMed and Scopus, for studies investigating the technical aspects and clinical outcomes of partial nephrectomies, nephrectomies, nephroureterectomies, varicocelectomies and pyeloplasties in children. Data on parameters such as operation time, instrumentation, perioperative complications, hospital stay and follow up period were collected and further analyzed cumulatively.

RESULTS

Twenty nine studies met the inclusion criteria incorporating 386 patients who underwent 401 procedures. There were no major intraoperative complications, with only 19 patients (4.73%) facing postoperative complications. No perioperative deaths were reported.

CONCLUSIONS

In the hands of experienced surgeons LESS seems a feasible, efficient and less invasive alternative to standard laparoscopy in the field of pediatric urology. There is an eminent need of well-designed randomized controlled trials comparing the two techniques.

The effectiveness of laparoendoscopic single-site surgery (LESS) compared with conventional laparoscopic surgery for ectopic pregnancy with hemoperitoneum

OBJECTIVE

The purpose of this study was to compare clinical outcomes of conventional laparoscopic surgery and laparoendoscopic single-site surgery (LESS) in the surgical treatment of tubal ectopic pregnancy.

MATERIAL AND METHODS

A total of 156 patients were diagnosed with ectopic pregnancies by ultrasonography and serum β-human chorionic gonadotrophin (β-hCG) levels at Pusan National University Yangsan Hospital from January 2009 through December 2013. We excluded 28 patients who only received medical treatment, 15 patients who underwent surgery by laparotomy for severe hypovolemic shock, and 30 patients who presented with less than 1 L of hemoperitoneum. Of the 83 patients with massive hemoperitoneum, 38 patients had LESS performed while the remaining 45 patients underwent conventional laparoscopic surgery.

RESULTS

In this study, there were no statistically significant differences in clinical outcomes in either surgical method except for operative time. Operative time of LESS was significantly shorter than conventional surgery for patients with more than 500 mL of hemoperitoneum.

CONCLUSION

LESS is a safe and feasible surgical approach in the treatment of tubal ectopic pregnancy. At the same time, LESS has been shown to be more effective than conventional laparoscopic surgery in handling massive hemoperitoneum of more than 1 L, which is a common complication of ectopic pregnancy.

Impact of novel techniques on minimally invasive adrenal surgery: trends and outcomes from a contemporary international large series in urology

OBJECTIVE

To evaluate contemporary international trends in the implementation of minimally invasive adrenalectomy and to assess contemporary outcomes of different minimally invasive techniques performed at urologic centers worldwide.

METHODS

A retrospective multinational multicenter study of patients who underwent minimally invasive adrenalectomy from 2008 to 2013 at 14 urology institutions worldwide was included in the analysis. Cases were categorized based on the minimally invasive adrenalectomy technique: conventional laparoscopy (CL), robot-assisted laparoscopy (RAL), laparoendoscopic single-site surgery (LESS), and mini-laparoscopy (ML). The rates of the four treatment modalities were determined according to the year of surgery, and a regression analysis was performed for trends in all surgical modalities.

RESULTS

Overall, a total of 737 adrenalectomies were performed across participating institutions and included in this analysis: 337 CL (46 % of cases), 57 ML (8 %), 263 LESS (36 %), and 80 RA (11 %). Overall, 204 (28 %) operations were performed with a retroperitoneal approach. The overall number of adrenalectomies increased from 2008 to 2013 (p = 0.05). A transperitoneal approach was preferred in all but the ML group (p < 0.001). European centers mostly adopted CL and ML techniques, whereas those from Asia and South America reported the highest rate in LESS procedures, and RAL was adopted to larger extent in the USA. LESS had the fastest increase in utilization at 6 %/year. The rate of RAL procedures increased at slower rates (2.2 %/year), similar to ML (1.7 %/year). Limitations of this study are the retrospective design and the lack of a cost analysis.

CONCLUSIONS

Several minimally invasive surgical techniques for the management of adrenal masses are successfully implemented in urology institutions worldwide. CL and LESS seem to represent the most commonly adopted techniques, whereas ML and RAL are growing at a slower rate. All the MIS techniques can be safely and effectively performed for a variety of adrenal disease.

Paratubal Borderline Malignancy: A Case of a 17-Year-Old Adolescent Female Treated with Laparo-Endoscopic Single-Site Surgery and a Review of the Literature

BACKGROUND

Although paratubal cysts are common, borderline paratubal cysts are extremely rare. We describe the case of a large borderline paratubal cyst in a 17-year-old adolescent female treated with laparo-endoscopic single-site surgery (LESS), and review the literature.

CASE

A 17-year-old female was referred due to a large right adnexal cyst on pelvic sonogram. A CT scan showed a 19-cm cystic lesion with enhancing papillary projection along the wall. Laparo-endoscopic single-site surgery confirmed a large cystic mass that originated from the right salpinx. Right salpingectomy and right ovarian wedge resection were performed, and intraoperative frozen section analysis was conducted. The result of the frozen section analysis and final pathologic review indicated that the cyst was a serous papillary-type borderline tumor in a paratubal cyst.

SUMMARY AND CONCLUSION

To the best of our knowledge, this is the first case report of a BPC treated with LESS. We suggest that minimally invasive, fertility-preserving surgery should be considered as a standard treatment of borderline paratubal cysts if patients desire future fertility.

Laparoscopic Single Site Surgery for Repair of Retrocaval Ureter in a Morbidly Obese Patient

This is to describe a case of a morbidly obese (BMI = 40) female with retrocaval ureter treated with laparoendoscopic single-site surgery. A JJ stent was positioned. A 2 cm umbilical access was created. A single port platform was positioned. The entire ureter was mobilized posterior to the vena cava and transected where the dilated portion ended. The distal ureter was repositioned lateral to the inferior vena cava. Anastomosis was done. A 3 mm trocar was used to assist suturing. At 4-month follow-up, CT revealed no evidence of obstruction of the right kidney and the patient was symptomless. Although challenging, in a morbidly obese patient, LESS repair for retrocaval ureter is feasible.

Heller myotomy with esophageal diverticulectomy: an operation in need of improvement

BACKGROUND

This study was undertaken to evaluate the outcomes after laparoscopic Heller myotomy with anterior fundoplication and diverticulectomy for patients with achalasia and esophageal diverticula.

METHODS

634 patients undergoing laparoscopic Heller myotomy and anterior fundoplication from 1992 to 2015 are prospectively followed up; patients were stratified for those undergoing concomitant diverticulectomy. Patients graded symptom frequency and severity before and after myotomy, using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Median data are presented (mean ± SD).

RESULTS

Forty-four patients, age 70 years (65 ± 14.2), underwent laparoscopic Heller myotomy, anterior fundoplication, and diverticulectomy. Operative time was 182 min (183 ± 54.6). Fifty percentage of patients had a postoperative complication: Most notable were leaks at the diverticulectomy site (n = 8) and pulmonary complications (n = 11; 10 effusion, 1 empyema). Length of stay (LOS) was 3 days (5 ± 8.3). All leaks occurred after discharge and resolved without sequelae using transthoracic catheter drainage and parenteral nutrition; two patients received endoscopic esophageal stents. Median follow-up is 39 months. Symptoms amelioration was significant postoperatively, including severity of dysphagia [6 (6 ± 3.9) to 2(4 ± 3.6)]. Seventy-six percentage of patients rated their symptoms at last follow-up as satisfying/very satisfying. Seventy-seven percentage of patients had symptoms once per week or less. Eighty-one percentage would have the operation again knowing what they know now.

CONCLUSIONS

Laparoscopic Heller myotomy, anterior fundoplication, and diverticulectomy well palliate the symptoms of achalasia with accompanying esophageal diverticulum. The operations are generally longer than those without diverticulectomy and are accompanied by a relatively longer LOS. Complications are relatively frequent and severe (e.g., leaks and pneumonia). In particular, leaks at the diverticulectomy site are unpredictable, occur after discharge, and remain vexing. Nevertheless, for this advanced form of achalasia, long-term symptom relief and patient satisfaction are high after anterior fundoplication with concomitant diverticulectomy. New and innovative techniques are needed to decrease the frequency of leaks at the diverticulectomy site.