Consensus statement on natural orifice transluminal endoscopic surgery and single-incision laparoscopic surgery: heralding a new era in urology?

Current status of laparoendoscopic single-site surgery in urology

PURPOSE

Laparoendoscopic single-site surgery (LESS) uses single incisions for the introduction of instruments through a specially designed multi-lumen single port (multi-port) for the performance of several urologic procedures.

METHODS

Literature review regarding the LESS approach took place on May 2009 and the experiences of our institutions were also included.

RESULTS

Almost all urologic intra-abdominal and pelvic procedures have been successfully and safely performed with the LESS approach. Nevertheless, current experience is limited and there are significant technical challenges to the performance of LESS techniques.

CONCLUSIONS

Wider adaptation of the approach requires refinement of LESS instrumentation to overcome the technical challenges of the approach. The improved outcome should also be documented with further clinical evaluation.

Current status of natural orifice trans-endoscopic surgery (NOTES) and laparoendoscopic single site surgery (LESS) in urologic surgery

Laparoendoscopic single site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) represent novel approaches in urological surgery. To perform a review of the literature in order describe the current status of LESS and NOTES in Urology. References for this manuscript were obtained by performing a review of the available literature in PubMed from 01-01-02 to 15-05-09. Search terms included single port, single site, NOTES, LESS and single incision. A total of 412 manuscripts were initially identified. Out of these, 64 manuscripts were selected based in their urological content. The manuscript features subheadings for experimental and clinical studies, as NOTES-LESS is a new surgical technique and its future evolution will probably rely in initial verified feasibility. A subheading for reviews presents information regarding common language and consensus for the techniques. The issue of complications published in clinical series and the future needs of NOTES-LESS, are also presented.

Laparoendoscopic single-site surgery in urology: worldwide multi-institutional analysis of 1076 cases

BACKGROUND

Laparoendoscopic single-site surgery (LESS) has gained popularity in urology over the last few years.

OBJECTIVE

To report a large multi-institutional worldwide series of LESS in urology.

DESIGN, SETTING, AND PARTICIPANTS

Consecutive cases of LESS done between August 2007 and November 2010 at 18 participating institutions were included in this retrospective analysis.

INTERVENTION

Each group performed a variety of LESS procedures according to its own protocols, entry criteria, and techniques.

MEASUREMENTS

Demographic data, main perioperative outcome parameters, and information related to the surgical technique were gathered and analyzed. Conversions to reduced-port laparoscopy, conventional laparoscopy, or open surgery were evaluated, as were intraoperative and postoperative complications.

RESULTS AND LIMITATIONS

Overall, 1076 patients were included in the analysis. The most common procedures were extirpative or ablative operations in the upper urinary tract. The da Vinci robot was used to operate on 143 patients (13%). A single-port technique was most commonly used and the umbilicus represented the most common access site. Overall, operative time was 160±93 min and estimated blood loss was 148±234 ml. Skin incision length at closure was 3.5±1.5 cm. Mean hospital stay was 3.6±2.7 d with a visual analog pain score at discharge of 1.5±1.4. An additional port was used in 23% of cases. The overall conversion rate was 20.8%; 15.8% of patients were converted to reduced-port laparoscopy, 4% to conventional laparoscopy/robotic surgery, and 1% to open surgery. The intraoperative complication rate was 3.3%. Postoperative complications, mostly low grade, were encountered in 9.5% of cases.

CONCLUSIONS

This study provides a global view of the evolution of LESS in the field of minimally invasive urologic surgery. A broad range of procedures have been effectively performed, primarily in the academic setting, within diverse health care systems around the world. Since LESS is performed by experienced laparoscopic surgeons, the risk of complications remains low when stringent patient-selection criteria are applied.

Laparoendoscopic single-site extraperitoneal aortic lymphadenectomy: first experience

OBJECTIVES

To report the first clinical experience with laparoendoscopic single-site (LESS) extraperitoneal aortic lymphadenectomy.

MATERIALS AND METHODS

A 33-year-old woman with biopsy proven locally advanced squamous cell carcinoma of the cervix was taken to the operating room for surgical staging. Preoperative imaging did not detect any aortic lymph node metastases. Informed consent for LESS extraperitoneal aortic lymphadenectomy was obtained. A 2 cm transverse incision was made on the left side midway between the iliac crest and inferior costal margin along the middle axillary line. The preperitoneal space was created and the Triport(TM) inserted. Using the Deflectable-Tip EndoEye(TM) laparoscope and two straight instruments, the aortic lymphadenectomy was performed as defined by the disease-specific oncologic principles.

RESULTS

The procedure was completed in 125 minutes. There were no intraoperative or postoperative complications, and the blood loss was minimal (10 mL). The patient was discharged home on postoperative day number 1. LESS extraperitoneal aortic lymphadenectomy yielded 10 lymph nodes. Microscopic metastatic squamous cell carcinoma was detected in 1 out of the 10 lymph nodes. Her treatment plan was modified to extend the field of radiation to include the paraaortic lymphatic basins.

CONCLUSIONS

LESS extraperitoneal aortic lymphadenectomy is feasible and safe, and provides a comprehensive assessment of aortic lymph nodes as defined by the disease-specific oncologic principles.

Natural Orifice Translumenal Endoscopic Surgery (NOTES) in urology

The concept of endoscopic surgery performed through natural orifices - Natural Orifice Translumenal Endoscopic Surgery (NOTES) - represents one of the most exciting ideas recently introduced in surgery. The use of natural orifice as a transluminal access to the peritoneal cavity has been shown to be effective and reproducible. After the introduction of the transgastric access (2004), the adaptation of the well-known transvaginal access, looking for ideal and more suitable entrance has led to the development of the transcolonic and transvescical ports. To date, the NOTES technique showed its full potential in experimental models, so as to allow the completion of most of the standard procedures performed in laparoscopic technique and thus opening the door to a new era, considered as "3rd generation surgery". However, only few experiences have been translated to humans and this concept is still at an early stage of experimental development. Many efforts are still needed to establish the standardization and validation of the techniques, the verification of safety and effectiveness. ?This article intends to photograph the actual role of NOTES, reviewing its history, analyzing the potential benefits and drawbacks, browsing and comparing the different transluminal routes, describing the equipment and platforms currently available, and finally to point out the state of the art of NOTES in the urological field.

A specialized course of basic skills training for single-port laparoscopic surgery

BACKGROUND

Single-port laparoscopy (SPL) requires specialized skills; however, there are currently no specialized training courses for SPL. The aim of this study is to present an effective specialized training course of basic skills for SPL.

METHODS

We designed a specialized training course for single-port laparoscopic basic skills. The study included 10 male urology residents. The trainees practiced the traditional training course for laparoscopy basic skills for 5 days. Basic skills were assessed on day 6 and a self-efficacy confidence index was measured. On day 7, all trainees performed a traditional laparoscopic nephrectomy and single-port laparoscopic nephrectomy. The participants were then randomized into 2 groups: 5 trainees performed the specialized training course and the other 5 trainees continued to practice the traditional training course. Both groups were trained for 5 days. After completion, the trainees were tested on completing a porcine single-port laparoscopic nephrectomy. Operative performance was measured by 2 experts who were blinded to which training the student had received, using an altered global rating. In addition, participants completed a general self-efficacy instrument after performing surgeries.

RESULTS

The overall operative performance score for single-port laparoscopic surgery was significantly better in the specialized training group. A significant difference in confidence index was seen between the traditional laparoscopy training and specialized single-port training groups (18.40 ± 2.70 vs 29.4 ± 3.51, respectively; P = .001.). Four relative instrument locations which avoided the problem of crowding were also noted in the specialized training group.

CONCLUSION

The specialized training course is effective for developing SPL skills.

Robotic natural orifice translumenal endoscopic surgery and laparoendoscopic single-site surgery: current status

PURPOSE OF REVIEW

To analyse the evidence supporting current and future application of robotic technology in natural orifice translumenal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS).

RECENT FINDINGS

Early clinical experience with the application of currently available da Vinci robotic system to LESS has been encouraging, as some of the constraints encountered during conventional LESS can be overcome. Robotic devices that are currently being developed for NOTES and LESS focus on improving either tissue manipulation capabilities for externally actuated robotic and flexible endoscopy systems or visualization for robots that are inserted completely into the peritoneal cavity.

SUMMARY

Robotic technology is rapidly evolving and is expected to drive several aspects of minimally invasive surgery forward in the near future with the ultimate goal of minimizing complications and improving outcomes.

Natural orifice transendoluminal surgery and laparoendoscopic single-site surgery: the future of laparoscopic radical prostatectomy

Techniques for minimally invasive radical prostatectomy (RP) have been carefully reviewed by surgical teams worldwide in order to identify possible weaknesses and facilitate further improvement in their overall performance. The initial plan of action has been to carefully study the best-practice techniques for open RP in order to reproduce and standardize performance from the laparoscopic perspective. Similar to open surgery, the learning curve of minimally invasive RP has been well documented in terms of objective evaluation of outcomes for cancer control and functional results. Natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have recently gained momentum as feasible techniques for minimal access urological surgery. NOTES–LESS drastically limit the surgeon’s ability to choose the site of entry for operative instruments; therefore, the advantages of NOTES–LESS are gained with the understanding that the surgical procedure is more technically challenging. There are several key elements in RP techniques (in particular, dorsal vein control, apex exposure and cavernosal nerve sparing) that can have significant implications on oncologic and functional results. These steps are hard to perform in a limited working field. LESS radical prostatectomy can clearly be facilitated by using robotic technology.

Laparoendoscopic single-site radical nephrectomy: a comparison with conventional laparoscopy

PURPOSE

To study the feasibility and safety of laparoendoscopic single-site (LESS) radical nephrectomy, we compared the operative results with conventional laparoscopic radical nephrectomy.

PATIENTS AND METHODS

Ten patients underwent LESS radical nephrectomy for renal tumors (group 1). Two types of single-port devices, a SILS port and a homemade single-port device that was made using a surgical glove and a wound retractor, were used through a 4-cm periumbilical incision. The operative results of LESS radical nephrectomy matched those of 12 patients who underwent conventional laparoscopic radical nephrectomy (group 2). For comparing the 2 groups, the Mann-Whitney U test and the Fisher exact test were used.

RESULTS

LESS surgeries were completed successfully, without conversion to conventional laparoscopic or open surgery. The patients' characteristics did not differ significantly between the two groups. The mean operative times in groups 1 and 2 were 127.7 ± 22.3 minutes and 126.1 ± 43.1 minutes, respectively (P = 0.235). The mean estimated blood loss was 185.7 ± 121.9 mL and 324.0 ± 187.0 mL, respectively (P = 0.65). The complication rates were 10% and 17%, respectively (P = 0.658). The mean times to postoperative initiation of ambulation and initiation of oral intake were not different in the two groups (1.1 vs 1.0 days, P = 0.269; 1.0 vs 1.0 day, P = 1.0). The mean lengths of hospital stay were 6.5 and 6.1 days (P = 0.435). The mean tumor sizes were 4.0 cm and 5.2 cm (P = 0.345).

CONCLUSIONS

LESS radical nephrectomy is technically feasible and comparable to conventional laparoscopy. Long-term follow-up and technical development, however, are needed for assessing the cancer-control effect and facilitating the minimal invasiveness of the surgery.

Female population perception of conventional laparoscopy, transumbilical LESS, and transvaginal NOTES for cholecystectomy

BACKGROUND

Recent population survey has shown a preference for transumbilical laparoendoscopic single-site surgery (U-LESS) compared with natural orifice transluminal endoscopic surgery (NOTES) for cholecystectomy, assuming similar surgical risk. This study was designed to evaluate the perception and preference of women regarding conventional laparoscopy, U-LESS, and transvaginal NOTES (TV-NOTES) with particular interest to access perception.

METHODS

An anonymous questionnaire on laparoscopic, U-LESS, and TV-NOTES cholecystectomy, without regards to risks or advantages, was given to female medical/paramedical staff (n=100), patients (n=100), and the general population (n=100). Women participants (median age, 35 (range, 16-79) years) were queried about preference, perception of the different accesses, and personal informations. Of the respondents, 54% had children, 79% had stable relationships, and 96% were sexually active (vaginal intercourse).

RESULTS

With similar operative risk, 87% preferred U-LESS, 4% TV-NOTES and 8% laparoscopy. LESS/NOTES choice was influenced by a desire of improved cosmetics (82%) and lower pain (44%). 96% had worries regarding transvaginal access, among them: dyspareunia (68%), decreased sensibility during intercourse (43%), refuse of short-term sexual abstinence (40%), and infertility (23%). Transumbilical access evocated worries in 35%: umbilical pain (19%), postoperative umbilical sensibility (15%), and incisional hernia (11%). Postoperative intercourse abstinence after TV-NOTES evocated worries in 76% (defined as 3 weeks in survey): feel less attractive (40%), less feminine (32%), tension with their intimate (35%), lover non-acceptation (20%), possible abortion of new relationship (26%), and feel less comfortable socially (16%).

CONCLUSIONS

The high acceptation rate for U-LESS approach compared with TV-NOTES may be related to fears regarding postoperative sexuality and fertility. The importance of temporary postoperative sexual abstinence (vaginal intercourse) is high and may be difficult to influence. Future research on TV-NOTES should focus on the access risk to be able to scientifically reassure our patients. For now, U-LESS seems to be favor compared with TV-NOTES for cholecystectomy in female patients.

[Transumbilical single-incision laparoscopic ureterolithotomy]

INTRODUCTION

laparoendoscopic single-site surgery (LESS) using transumbilical access and conventional laparoscopic instruments is a very attractive alternative to perform ureterolithotomy for ureteral stone with failed endourological management.

MATERIAL AND METHOD

a 29-year-old woman presented with chronic right lumbar pain and a 1.2 cm impacted calculus localized at transition of abdominal to pelvic ureter. Semi-rigid ureteroscopy had failed to fragment the stone and shockwave lithotripsy was not available. Double-J ureteral catheter had been inserted preoperatively. We performed a transumbilical single-incision laparoscopic ureterolithotomy. Three conventional trocars were inserted in a single semi-circular umbilical incision. Right colon was detached and the ureter was identified. Calculus was extracted and the ureteral incision was closed with intracorporal sutures.

RESULTS

ureterolithotomy was successfully completed, with all the operative steps performed transumbically. Operative time was 180 minutes. No single-port device or articulating and bent instruments were utilized. Estimated blood loss was less than 50 mL. No intraoperative, access-related and postoperative complications took place. The duration of hospitalization was 24 hours and scarless appearance was observed on postoperative day 15.

CONCLUSION

transumbilical single-incision laparoscopic ureterolithotomy is feasible and safe. This approach offers an inherent cosmetic advantage and few postoperative discomfort. Additional experience and continued investigation are warranted.

New trends in minimally invasive urological surgery

PURPOSE

The perceived benefits of minimally-invasive surgery include less postoperative pain, shorter hospitalization, reduced morbidity and better cosmesis while maintaining diagnostic accuracy and therapeutic outcome. We review the new trends in minimally-invasive urological surgery.

MATERIALS AND METHODS

We reviewed the English language literature using the National Library of Medicine database to identify the latest technological advances in minimally-invasive surgery with particular reference to urology.

RESULTS

Amongst other advances, studies incorporating needlescopic surgery, laparoendoscopic single-site surgery , magnetic anchoring and guidance systems, natural orifice transluminal endoscopic surgery and flexible robots were considered of interest. The results from initial animal and human studies are also outlined.

CONCLUSION

Minimally-invasive surgery continues to evolve to meet the demands of the operators and patients. Many novel technologies are still in the testing phase, whilst others have entered clinical practice. Further evaluation is required to confirm the safety and efficacy of these techniques and validate the published reports.

Laparoendoscopic single-site and natural orifice transluminal endoscopic surgery in urology: a critical analysis of the literature

CONTEXT

Natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have been developed to benefit patients by enabling surgeons to perform scarless surgery.

OBJECTIVE

To summarize and critically analyze the available evidence on the current status and future perspectives of LESS and NOTES in urology.

EVIDENCE ACQUISITION

A comprehensive electronic literature search was conducted in June 2010 using the Medline database to identify all publications relating to NOTES and LESS in urology.

EVIDENCE SYNTHESIS

In urology, NOTES has been completed experimentally via transgastric, transvaginal, transcolonic, and transvesical routes. Initial clinical experience has shown that NOTES urologic surgery using currently available instruments is indeed possible. Nevertheless, because of the immaturity of the instrumentation, early cases have demanded high technical virtuosity. LESS can safely and effectively be performed in a variety of urologic settings. As clinical experience increases, expanding indications are expected to be documented and the efficacy of the procedure to improve. So far, the quality of evidence of all available studies remains low, mostly being small case series or case-control studies from selected centers. Thus, the only objective benefit of LESS remains the improved cosmetic outcome. Prospective, randomized studies are largely awaited to determine which LESS procedures will be established and which are unlikely to stand the test of time. Technology advances hold promise to minimize the challenging technical nature of scarless surgery. In this respect, robotics is likely to drive a major paradigm shift in the development of LESS and NOTES.

CONCLUSIONS

NOTES is still an investigational approach in urology. LESS has proven to be immediately applicable in the clinical field, being safe and feasible in the hands of experienced laparoscopic surgeons. Development of instrumentation and application of robotic technology are expected to define the actual role of these techniques in minimally invasive urologic surgery.

Early experience of laparoendoscopic single-site nephroureterectomy for upper urinary tract tumors

Purpose

We evaluated the feasibility of a laparoendoscopic single-site (LESS) nephroureterectomy for an upper urinary tract tumor.

Materials and Methods

Between March 2009 and September 2009, 4 patients with upper urinary tract tumors underwent LESS nephroureterectomy. The mean age of the 2 female and 2 male patients was 69 years old, and their mean body mass index was 23.0. We used a homemade single-port device made with a surgical glove and a wound retractor, which were put into a 4 cm periumbilical incision. Operations with articulating and rigid laparoscopic instruments were performed transperitoneally. An open technique with a 4 cm additional midline incision and laparoscopic technique with an endoscopic stapler were used for the treatment of the distal ureter and bladder cuff.

Results

All cases were completed successfully, without conversion to conventional laparoscopy or open surgery. The mean operative time was 169.5 minutes. The mean estimated blood loss was 361.4 ml. One patient had transfusion and wound infection. The mean hospital stay was 7.8 days. The mean specimen weight and tumor size were 271.8 g and 2.9 cm. Pathologic results of all cases showed urothelial carcinoma with a negative surgical margin. Three patients were in stage T3N0M0 and 1 was in stage T2N0M0.

Conclusions

Our initial experience shows that LESS nephroureterectomy with a homemade single-port device is technically feasible. However, long term follow-up for the effect on cancer control and technical development for comfortable surgery are needed.

Population perception of surgical safety and body image trauma: a plea for scarless surgery?

BACKGROUND

Laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery (NOTES) are prospected as the future of minimally invasive surgery. While scarless surgery (NOTES and LESS) is gaining increasing popularity, perception of these approaches should be investigated.

METHODS

An anonymous questionnaire describing laparoscopy, LESS, and NOTES was given to medical staff (n=120), paramedical staff (n=100), surgical patients (n=100), and the general population (n=100). The survey participants (median age, 37 years; range, 18-81 years) were queried about their expectations for surgical treatment and their approach preference.

RESULTS

The first concern of the survey responders was the risk of surgical complications (92%). When asked about the respective importance of surgical safety, cure, and cosmetics, cure was placed first by 74%, safety by 33%, and cosmetics by 3%. These results were not influenced by sex, age, prior surgery or endoscopy, or education. When operative risk was similar, 90% of the participants preferred a scarless approach (75% preferred LESS and 15% preferred NOTES) to laparoscopy. The scarless approach preference was significantly higher among the younger participants (age<40 years; p=0.026), whereas sex showed no influence. The LESS preference was significantly higher among patients and the general population (86%) than among medical (67%) and paramedical (70%) staffs (p<0.001). A decreasing trend of preference for LESS and NOTES was observed with increased procedural risks.

CONCLUSION

Although cure and safety remain the main concern, the population has a favorable perception of scarless surgery, even in the case of increased procedural risk, with LESS favored over NOTES. Such a popular adoption of scarless surgery should warrant the promotion of further research, technological innovations, and the establishment of surgeon training to improve its safety.

The LESS (Laparo-Endoscopic Single-Site) Procedure in Urology. Technical and Clinical Aspects

Background

Minimally invasive urology is rapidly advancing, and single-site laparoscopic surgery is being explored clinically. Such laparoscopic procedures are technically challenging and require an experienced laparoscopic surgeon due to the lack of port placement triangulation and instrument clashing.

Methods

In the last years several surgeons all over the world have explored the feasibility and safety of LESS using several and different ports, approaches and devices. Hundereds of procedures have been described with overall favorauble intraoperative and postoperative outcomes.

Results

Our experience consists of more than 30 procedures successifully completed for adrenal, kidney disease and varicocele.

Conclusions

To date, LESS could be considered feasible and effective using currently available devices, however it is to be considered as an initial status technique requiring further confirmatory studies and advanced laparoscopic skills.

Single incision laparoscopic anterior resection for cancer using a 'QuadiPort Access System®'

BACKGROUND: Single incision laparoscopic surgery (SILS) is developing rapidly and different devices are already available. However there is limited data in the literature about single port laparoscopic colorectal surgery. AIMS: We report the first case of a single incision laparoscopic anterior resection for cancer using the device 'QuadiPort Access System?'. METHODS: A 66 year old female affected by adenocarcinoma of the rectosigmoid junction underwent a radical single incision laparoscopic anterior resection performed by an experienced laparoscopic team. RESULTS: The preoperative staging was T2N0M0. The total operative time was 135 min. Length of hospital stay was 6 days. The length of the specimen was 27 cm and 21 nodes were isolated. The pathological examination showed adenocarcinoma staged T3N2MX; G2. There was no postoperative morbidity and at the 6 month follow-up, the patient presented in well condition with no complications and free from cancer. CONCLUSION: Single incision laparoscopic anterior resection for locally advanced high rectal cancer seems to be feasible and the 'QuadiPort Access System?' seems to be a valid device. To evaluate outcomes and costeffectiveness of SILS versus the standard laparoscopic colorectal surgery multicenter prospective randomised trials are necessary and the 'QuadiPort Access System?' could prove to be the device of choice.

Transumbilical single incision laparoscopic sigmoidectomy for benign disease

BACKGROUND

Transumbilical single incision laparoscopic surgery (SILS) has made its initial forays into clinical minimally invasive surgery. SILS combines in part the cosmetic advantage and decrease parietal trauma of natural orifice surgery, but allow operative realization with standard and validated laparoscopic instruments. We report here the first clinical transumbilical SILS sigmoidectomy for benign disease.

METHOD

Preliminary experience with transumbilical single incision laparoscopic surgery (or embryonic natural orifice transluminal endoscopic surgery) sigmoidectomy in a female patient (34 years, BMI 22 kg/m(2)) with sigmoid stenosis caused by nodular endometriosis was reported. Transumbilical SILS treatment of pelvic endometriosis was performed during the same operation through cauterization.

RESULTS

Transumbilical single incision laparoscopic sigmoidectomy was feasible with conventional laparoscopic instruments. The combined uses of straight and articulated laparoscopic instruments allow the avoidance of transparietal sling suture for exposition. Operative time for sigmoidectomy and endometriosis therapy was 125 min. No intra-operative or postoperative complications were recorded. SILS achieved excellent cosmetic results and may be associated with accelerated recovery.

CONCLUSION

Transumbilical single incision laparoscopic sigmoidectomy is feasible by experienced laparoscopic surgeons using conventional laparoscopic instruments and staplers. The combined uses of strait and articulated instruments allow transumbilical SILS sigmoidectomy without the need for additional incision or transparietal sling suture. SILS sigmoidectomy may have the clinical advantage over NOTES of offering the safety of laparoscopic colectomy and the avoidance of vaginal access. It has to be determined if SILS offers benefit to the patient, except in cosmesis, compared with standard laparoscopic sigmoidectomy.

Supra-pubic single incision cholecystectomy

INTRODUCTION

Surgery is moving towards less invasive and cosmetically superior approaches such as single incision laparoscopy (SIL). While trans-umbilical SIL is gaining popularity, incisions may lead to post-operative deformations of the umbilicus and the possibility of an increased rate of incisional hernias. Access within the pubic hairline allows preservation of the umbilicus and results in a scar which is concealed within the pubic hair.

METHODS

Supra-pubic single incision cholecystectomy was performed in a 30-year-old patient with symptomatic gallstones. A 2.5-cm transverse incision was placed within the pubic hairline and a subcutaneous tunnel was formed. Three 5-mm ports were introduced into the tunnel and perforated the anterior rectus sheath superior to the skin incision. The surgical procedure was then undertaken with conventional laparoscopic instrumentation. The adjacent 5-mm incisions were merged for gallbladder removal. The entry site was closed under direct vision.

RESULTS

The above procedure was technically feasible and without complication. Operative time was 45 min, and the patient was discharged 5 h post-operatively.

CONCLUSIONS

Supra-pubic single incision laparoscopic cholecystectomy may offer a more cosmetically appealing result than standard umbilical access. The operation can be performed by surgeons skilled in single incision techniques with good result.

Laparoscopic transumbilical cholecystectomy: surgical technique

Even when conventional laparoscopic instrumentation was used, laparoscopic transumbilical cholecystectomy appeared to be a feasible alternative to conventional laparoscopic cholecystectomy.

Background:

Laparoscopic cholecystectomy is generally performed using 4 ports by transperitoneal access. Recent developments regarding laparoscopic surgery have been directed toward reducing the size or number of ports to achieve the goal of minimally invasive surgery, by minilaparoscopy, natural orifice access, and the transumbilical approach. The aim of this article is to describe our laparoscopic transumbilical cholecystectomy technique using conventional laparoscopic instruments and ports.

Methods:

The Veress needle was placed through the umbilicus, which allowed carbon dioxide inflow. A 5-mm trocar was placed in the periumbilical site for the laparoscope followed by the placement of 2 additional 5-mm periumbilical trocars. The entire procedure was performed using conventional laparoscopic instruments. At the end of the surgery, trocars were removed, and all 3 periumbilical skin incisions were united for specimen retrieval.

Results:

Five transumbilical cholecystectomies were performed following this technique. The mean BMI was 26.6 kg/m². The mean operative time and blood loss were 46.2 minutes and 55 mL, respectively. No intraoperative complications occurred. Analgesia was performed using dipyrone (1g IV q6h) and ketoprofen (100 mg IV q12 h). Time to first oral intake was 8 hours. Mean hospital stay was 19.2 hours.

Conclusion:

Laparoscopic transumbilical cholecystectomy seems to be feasible even using conventional laparoscopic instruments and can be considered a potential alternative for traditional laparoscopic cholecystectomy.

Treatment of bladder diverticula, impaired detrusor contractility, and low bladder compliance

Bladder diverticula are common enough to be encountered by most urologists in practice but are reported less frequently in the literature than they were 50 years ago. Some patients can be managed nonoperatively, whereas others will need surgical intervention consisting of bladder outlet reduction and possibly removal of the diverticulum itself. In addition to the decision to operate, the timing of each intervention deserves careful consideration. Cystoscopy, computed tomography with contrast, urodynamic studies, cytology, and voiding cystourethrography play important roles in informing the clinician. Many new techniques for treatment of the bladder outlet and the diverticulum are available, such as laparoscopy and robotic surgery.

Single-port access laparoscopic radical left colectomy in humans

BACKGROUND

Transumbilical single-port access (SPA) surgery is a rapidly evolving field that combines in part the cosmetic advantage of natural orifice transluminal endoscopic surgery (NOTES) with the ability to perform the operation with standard laparoscopic instruments. We report our experience with the first transumbilical single-port access radical left colectomy conforming to surgical oncologic principle and minimally invasive colectomy technique.

METHODS

Umbilical single-port access (embryonic natural orifice transluminal endoscopic surgery) left colectomy was performed in a patient with sigmoid colon adenocarcinoma in situ. During the same procedure, a single-port access cholecystectomy was performed for chronic cholecystitis.

RESULTS

Transumbilical single-port access radical left colectomy was feasible with conventional laparoscopic instruments. A 39-cm pathologic specimen with sufficient surgical margins and lymph nodes (34) was resected. Final diagnosis revealed an adenocarcinoma in situ. Operative time for left colectomy and cholecystectomy was 213 minutes. No intraoperative or postoperative complications were recorded.

CONCLUSION

Single-port access radical left colectomy is feasible when performed by experienced laparoscopic surgeons. Carcinologic surgical principles can be respected using this colectomy technique. Single-port access left colectomy may have a clinical advantage over natural orifice transluminal endoscopic surgery in offering the safety of laparoscopic colectomy. It has yet to be determined whether or not this approach would offer patient benefits, except in cosmesis, compared with standard laparoscopic left colectomy.

Single-port cholecystectomy with the TransEnterix SPIDER: simple and safe

Introduction

Single-port or single-incision cholecystectomy with current rigid laparoscopic devices is limited by in-line visualization, restricting the ability to approach the surgical site with proper angles and instrumentation. A single-port access system with articulating arms and strong instrumentation should minimize these issues. The TransEnterix system may facilitate safe and straightforward single-port surgery.

Methods

The TransEnterix single-port surgery system was used in both survival and nonsurvival porcine laparoscopic cholecystectomies under animal use committee approval. Nonsurvival procedures compared four standard laparoscopic with four single-port cholecystectomies from a histologic perspective. Five single-port swine laparoscopic cholecystectomy procedures were completed in sterile conditions, and all animals survived for 1 week postoperatively. Standard surgical clips were used for both cystic duct and artery ligation. At sacrifice, both gross and microscopic histology were obtained for assessment of surgical complications.

Results

All cholecystectomies were successfully completed with the TransEnterix single-port system. Operative time for the survival procedures averaged 39.4 (range 18–66) min. Histology of the acute specimens showed less inflammation at the single-port site compared with the trocar sites from the standard cholecystectomy. At sacrifice, no complications were identified.

Conclusions

The TransEnterix system is safe and straightforward for completing single-port cholecystectomy in this limited porcine series. Port site inflammation is reduced compared with standard laparoscopic trocars.

Pure natural orifice translumenal endoscopic surgery partial cystectomy: intravesical transurethral and extravesical transgastric techniques in a porcine model

OBJECTIVES

To describe 2 pure natural orifice translumenal endoscopic surgery (NOTES) techniques for partial cystectomy in a porcine model. NOTES is a new minimally invasive modality for performing abdominal surgery without transcutaneous incision.

METHODS

Transurethral-A rigid cystoscope is inserted into the porcine bladder with CO(2) insufflation. With an endoscopic loop device and a grasping device, the targeted area of the bladder is manipulated into the loop. The bladder segment is excised with electrocautery. Transgastric-A gastrotomy is made with a dual channel endoscope in the porcine stomach. The endoscope is inserted and pneumoperitoneum is established by insufflation through a channel. After identifying bladder, 2 endoscopic loops are placed at the intended area of resection. An incision is made between the loops to excise the specimen. In both cases, full-thickness specimen is removed en bloc with the scope and the defect is reapproximated with endoscopic clips.

RESULTS

Transurethral and transgastric NOTES approaches were achieved using standard endoscopic equipment in a porcine model. Transurethral NOTES partial cystectomy was successful in acute (n = 2) and chronic (n = 2) models. The transgastric NOTES approach was successfully performed in an acute animal.

CONCLUSIONS

NOTES partial cystectomy could potentially reduce morbidity of conventional methods of partial cystectomy. Transurethral NOTES may be the least invasive method possible for partial cystectomy. Potential advantages of a transgastric NOTES approach include visualization of adjacent structures, access to sites difficult to reach transurethrally, and lymph node sampling. However, a gastrotomy could be a source of morbidity. Further investigation is required to assess safety, efficacy, and adequate bladder healing.

Laparo-endoscopic single-site left transperitoneal adrenalectomy

A 53-yr-old woman presented with abdominal pain. Ultrasonography, computed tomography, and an endocrinologic work-up revealed a 4-cm nonfunctional left adrenal mass. A TriPort laparoscopic adrenalectomy was performed. The TriPort was inserted through a 3-cm subcostal incision. Using 5-mm instruments, a left adrenalectomy was performed. The specimen was dissected (harmonic scalpel) and extracted through a 10-mm bag. A TriPort adrenalectomy was successfully completed in 240 min (blood loss: 20 ml). The postoperative period was uneventful (discharge within 3 d). In our opinion, the TriPort adrenalectomy is feasible and safe, with favourable perioperative and short-term outcomes and a delighted patient at the 8-mo follow-up.

Minimal contamination of the human peritoneum after transvesical incision

BACKGROUND AND PURPOSE

The recent literature has questioned the infectious risk of natural orifice translumenal endoscopic surgery (NOTES). The need for a clean portal of entry may be important to minimize peritoneal contamination after NOTES. Our study examines the resultant microbial contamination of the human peritoneum after transvesical incision and exposure of the abdomen to bladder contents during robot-assisted laparoscopic prostatectomy (RALP) to better understand the potential for infection in transvesical NOTES.

PATIENTS AND METHODS

Sixty consecutive men undergoing RALP for clinically localized prostate adenocarcinoma from January to May 2008 were prospectively studied as part of a database approved by an Institutional Review Board. The patient's preoperative urine microscopy values, complete blood cell count, and prostate-specific antigen (PSA) levels were recorded, along with the total length of time the cystotomy was open to the peritoneum. Intraoperative samplings of peritoneal fluid were collected before and after transvesical incision and sent for anaerobic, aerobic and fungal cultures.

RESULTS

Patients undergoing RALP had peritoneal exposure after transvesical incision for an average of 118 minutes. Five of 60 (8.3%) patients had evidence of novel aerobic bacterial contamination of the peritoneum after RALP. No patient had a positive anaerobic culture or fungal culture from the peritoneum. Preoperative serum leukocyte and PSA levels were elevated in patients with peritoneal contamination (P < 0.05). Remaining clinicopathologic features, total operative time, or open cystotomy time did not predict peritoneal contamination.

CONCLUSION

Prolonged peritoneal exposure to bladder contents demonstrates minimal contamination of the abdominal cavity and is without postoperative infectious significance. This study may overestimate bacterial contamination via the bladder during RALP, because the specific bacteria seen may have originated from the seminal or prostatic fluid during prostatectomy. Transvesical incision would effectively be a clean portal of entry for NOTES with its low rate of peritoneal contamination.