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Nicolay LI, Bowman RJ, Heldt JP, Jellison FC, Mehr N, Tenggardjaja C, Millard W, Koning JL, Baldwin DD. A prospective randomized comparison of traditional laparoendoscopic single-site surgery with needlescopic-assisted laparoscopic nephrectomy in the porcine model. J Endourol 2011; 25:1187-91. [PMID: 21631303 DOI: 10.1089/end.2010.0623] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE Laparoendoscopic single-site (LESS) surgery produces virtually no scar but is technically challenging because of the loss of triangulation. The objective of this study is to compare classic transumbilical LESS nephrectomy with needlescopic-assisted laparoscopy (NAL) surgery. In doing so, we evaluated whether the addition of a single 2-mm subcostal port could restore triangulation while not jeopardizing recovery or cosmetic outcome in the porcine model. MATERIALS AND METHODS Ten female farm pigs were randomized to laparoscopic nephrectomy with either LESS or NAL. In LESS, a TriPort was placed through a single 2.5-cm umbilical incision. In NAL, 5- and 10-mm ports were placed in the umbilicus and a 2-mm port was placed in the midclavicular line. Preoperative, perioperative, and postoperative parameters were compared. Variables were analyzed with the Wilcoxon signed-rank test and two-tailed Fisher exact test. Cosmesis was evaluated objectively using the Vancouver Scar Scale and subjectively by a blinded dermatologist. A cost analysis was performed. RESULTS Estimated blood loss was minimal in both groups (28.8 mL in LESS and 9.4 mL in NAL). Operative time was significantly shorter in NAL (103 vs 150 min; P<0.001). There was no difference in complications (2 vs 1; P=0.500), objective cosmesis (3.9 vs 3.8; P>0.2), or subjective cosmesis (2 vs 3; P=0.500). The NAL protocol had significantly lower disposable equipment costs ($363 vs $1696). CONCLUSIONS The addition of a 2-mm subcostal port and the restoration of triangulation in the NAL protocol enable shorter operative times, increased surgeon comfort, improved technical ease, and lower costs while maintaining the scarless cosmesis of the traditional LESS protocol.
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Affiliation(s)
- Lesli I Nicolay
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California 92354, USA
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152
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Canes D. Editorial comment. Urology 2011; 77:1369. [PMID: 21624597 DOI: 10.1016/j.urology.2010.10.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 10/07/2010] [Accepted: 10/11/2010] [Indexed: 11/24/2022]
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153
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Hansen EN, Muensterer OJ, Georgeson KE, Harmon CM. Single-incision pediatric endosurgery: lessons learned from our first 224 laparoendoscopic single-site procedures in children. Pediatr Surg Int 2011; 27:643-8. [PMID: 20859633 DOI: 10.1007/s00383-010-2735-x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2010] [Indexed: 02/06/2023]
Abstract
PURPOSE To identify technical difficulties during single-incision pediatric endoscopic surgery (SIPES) cases and to highlight solutions. MATERIALS AND METHODS After IRB approval, all SIPES cases were prospectively collected, and the surgeons involved were polled for technical difficulties encountered and their operative solutions. RESULTS Over a period of 13 months, 224 pediatric SIPES cases were performed in 223 pediatric patients (92 female, 131 male) aged 3 weeks to 19 years. Among these were 130 appendectomies, 32 pyloromyotomies, 32 cholecystectomies, 11 inguinal hernia repairs, 6 Nissen fundoplications and 4 laparoscopic-assisted endorectal pullthrough procedures. Eighteen procedures (8%) employed a primary extra-umbilical instrument in addition to the transumbilical trocar(s). Thirty procedures (13%) begun via a single-site technique required additional trocars for completion. None required laparotomy. Intraoperative complications are discussed. The main challenges of SIPES are: (1) variable umbilical anatomy, (2) large size of current proprietary multitrocar devices, (3) trocar crowding, (4) intra-abdominal exposure, (5) fewer degrees of freedom, (6) clashing instruments, (7) in-line endoscope viewing, and (8) limited number of working ports. We discuss coping strategies to address these issues. CONCLUSION Many of the drawbacks of SIPES can be overcome by specific techniques, which can make SIPES procedures more broadly feasible and applicable within pediatric endosurgery.
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Affiliation(s)
- Erik N Hansen
- Department of Pediatric Surgery, Vanderbilt University, Nashville, TN, USA
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154
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Do M, Liatsikos E, Beatty J, Haefner T, Dunn I, Kallidonis P, Stolzenburg JU. Laparoendoscopic single-site extraperitoneal inguinal hernia repair: initial experience in 10 patients. J Endourol 2011; 25:963-8. [PMID: 21542772 DOI: 10.1089/end.2010.0696] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND AND PURPOSE Recent technical advances and a trend toward laparoscopic single incision surgery have led us to explore the feasibility of laparoendoscopic single-site (LESS) hernia repair. PATIENTS AND METHODS We present our technique and initial experience with LESS extraperitoneal inguinal hernia repair in 10 consecutive men with unilateral inguinal hernias. Age range was 43.7 (28-64) years. Mean body mass index was 28 (range 24-30). Six were left inguinal hernias. There were six indirect and four direct hernias. Three patients had undergone previous open appendectomy. Incarcerated or bilateral hernias were excluded from our initial series. All cases were performed by three surgeons who were experienced in conventional totally extraperitoneal laparoscopic hernia repair as well as experienced in LESS. A literature review of current single-port inguinal hernia repair data is also presented. RESULTS The mean operative time was 53 minutes (range 45-65 min). The average length of skin incision was 2.8 cm (range 2.3-3.2 cm). No drain was necessary in any of the patients, while no recordable bleeding was observed. There were no intraoperative or immediate postoperative complications. Hospitalization period was 2 days for all patients. After a limited follow-up of 1 month, there have been no recurrences and no complaints of testicular pain. The results of the current series compare favorably with those found in a literature review. CONCLUSION LESS extraperitoneal inguinal hernia repair is both feasible and safe, although more technically demanding than its conventional laparoscopic counterpart. Although the cosmetic result with the former approach may prove superior, there are standing questions regarding the complications and long-term outcome. Randomized and if possible blinded trials that compare conventional and single-incision laparoscopic hernia repair may help to distinguish the most advantageous technique.
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Affiliation(s)
- Minh Do
- Department of Urology, University of Leipzig, Leipzig, Germany
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155
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White MA, Autorino R, Spana G, Laydner H, Hillyer SP, Khanna R, Yang B, Altunrende F, Isac W, Stein RJ, Haber GP, Kaouk JH. Robotic Laparoendoscopic Single-Site Radical Nephrectomy: Surgical Technique and Comparative Outcomes. Eur Urol 2011; 59:815-22. [DOI: 10.1016/j.eururo.2011.02.020] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 02/03/2011] [Indexed: 12/01/2022]
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156
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Salas N, Gorin MA, Gorbatiy V, Castle SM, Bird VG, Leveillee RJ. Laparoendoscopic Single Site Nephrectomy With the SPIDER Surgical System: Engineering Advancements Tested in a Porcine Model. J Endourol 2011; 25:739-42. [DOI: 10.1089/end.2010.0608] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Nelson Salas
- Joint Bioengineering and Endourology Developmental Surgical (JBEDS) Laboratory, Division of Endourology, Laparoscopy, and Minimally Invasive Surgery, Department of Urology, University of Miami Miller School of Medicine, Miami, Florida
- Department of Biomedical Engineering, University of Miami, Coral Gables, Florida
| | - Michael A. Gorin
- Joint Bioengineering and Endourology Developmental Surgical (JBEDS) Laboratory, Division of Endourology, Laparoscopy, and Minimally Invasive Surgery, Department of Urology, University of Miami Miller School of Medicine, Miami, Florida
| | - Vladislav Gorbatiy
- Joint Bioengineering and Endourology Developmental Surgical (JBEDS) Laboratory, Division of Endourology, Laparoscopy, and Minimally Invasive Surgery, Department of Urology, University of Miami Miller School of Medicine, Miami, Florida
| | - Scott M. Castle
- Joint Bioengineering and Endourology Developmental Surgical (JBEDS) Laboratory, Division of Endourology, Laparoscopy, and Minimally Invasive Surgery, Department of Urology, University of Miami Miller School of Medicine, Miami, Florida
| | - Vincent G. Bird
- Joint Bioengineering and Endourology Developmental Surgical (JBEDS) Laboratory, Division of Endourology, Laparoscopy, and Minimally Invasive Surgery, Department of Urology, University of Miami Miller School of Medicine, Miami, Florida
| | - Raymond J. Leveillee
- Joint Bioengineering and Endourology Developmental Surgical (JBEDS) Laboratory, Division of Endourology, Laparoscopy, and Minimally Invasive Surgery, Department of Urology, University of Miami Miller School of Medicine, Miami, Florida
- Department of Biomedical Engineering, University of Miami, Coral Gables, Florida
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Cox DR, Zeng W, Frisella MM, Brunt LM. Analysis of standard multiport versus single-site access for laparoscopic skills training. Surg Endosc 2011; 25:1238-44. [PMID: 20872019 PMCID: PMC4443802 DOI: 10.1007/s00464-010-1349-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2010] [Accepted: 08/17/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Single-site-access (SSA) laparoscopy is more challenging to perform than multiport (MP) laparoscopy. This study examined the effect of MP versus SSA skills training on laparoscopic performance using surgically naive medical students. METHODS For the study, 40 medical students at the end of their first year were randomized into two groups. Both groups were trained in four basic laparoscopic drills (peg, rope, bean drop, pattern cutting) using a standard MP setup (group 1) and an SSA approach (group 2). The time and number of repetitions required to attain proficiency were recorded. Each group then crossed over to the alternate approach and repeated the sequence. Data are presented as mean ± standard deviation, and statistical analysis was performed using the two-tailed, unpaired t test. RESULTS The total times required to attain proficiency for the SSA and MP approaches were not significantly different between the MP-trained group (234.0 ± 114.9 min) and the SSA-trained group (216.4 ± 106.5 min) (p = 0.67). The MP-trained group required less time to reach proficiency on the standard MP setup than the group using the SSA approach (119.1 ± 69.7 vs. 178.0 ± 93.4 min; p = 0.058) and significantly fewer repetitions (77.6 ± 42.6 vs. 118.8 ± 54.3; p = 0.027). The SSA-trained group required significantly less time to reach proficiency on the MP setup than the standard MP-trained group (38.4 ± 29.4 vs. 119.1 ± 69.7 min; p = 0.0013) and needed only a mean of 26.9 repetitions. When the standard MP trainees crossed over to the SSA setup, they required significantly less time to reach proficiency with the SSA approach than the SSA-trained group (114.8 ± 50.5 vs. 178.0 ± 93.4 min; p = 0.026) but required more repetitions than with the MP approach (86.2 ± 35.2 vs. 77.6 ± 42.6; nonsignificant difference). CONCLUSIONS Laparoscopic SSA skills training results in longer times and more repetitions to achieve proficiency than MP training, but the skills acquired transfer well to the MP approach.
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Affiliation(s)
- Daniel R Cox
- Department of Surgery and Institute for Minimally Invasive Surgery, Washington University School of Medicine, 660 S Euclid Avenue, Box 8109, St. Louis, MO 63110, USA
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158
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Alcaraz A, Musquera M, Peri L, Izquierdo L, García-Cruz E, Huguet J, Alvarez-Vijande R, Campistol JM, Oppenheimer F, Ribal MJ. Feasibility of transvaginal natural orifice transluminal endoscopic surgery-assisted living donor nephrectomy: is kidney vaginal delivery the approach of the future? Eur Urol 2011; 59:1019-25. [PMID: 21458151 DOI: 10.1016/j.eururo.2011.03.021] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Accepted: 03/15/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Natural orifice transluminal endoscopic surgery (NOTES) uses natural orifices to access the abdominal cavity. We adapted NOTES to perform transvaginal NOTES-assisted laparoscopic nephrectomy in living donors. OBJECTIVE To assess the feasibility and reproducibility of this procedure and compare it with conventional laparoscopic living donor nephrectomy (LLDN). DESIGN, SETTING, AND PARTICIPANTS From July 2009 to October 2010, 20 women underwent transvaginal NOTES-assisted living donor nephrectomy (LDN) in our centre. We compared the prospectively collected clinical data of each donor with those of a contemporaneous matched pair of conventional LLDNs (40 donors). SURGICAL PROCEDURE The procedure was performed using three abdominal trocars and one trocar through the vaginal wall. MEASUREMENTS Variables evaluated for donors were procedure length, blood loss, warm ischaemia time (WIT), complications, hospital stay, and first-month creatinine nadir. In the transvaginal LDN group, sexual function was assessed with the Female Sexual Function Index questionnaire before and after surgery. Variables evaluated for recipients were complications, graft function, and creatinine evolution. RESULTS AND LIMITATIONS The procedure was completed in all cases. Operative variables were similar for both groups except for WIT, which was longer in the transvaginal LDN group (p<0.001) without consequences for graft functioning. One transvaginal LDN case had postoperative bleeding requiring immediate open surgery. All transvaginal LDN donors reported unaltered sexual function after surgery and satisfaction with the results. All recipients had immediate urine output, and all had a functioning graft at last follow-up except for one recipient of the transvaginal LDN group who required transplantectomy. Despite promising results, randomised controlled studies with longer follow-up are warranted to further elucidate the potential of this novel technique. CONCLUSIONS Transvaginal NOTES-assisted LDN appears to be a feasible and reproducible surgical technique. The WIT was longer in the transvaginal group, and there was no effect on graft function after the short follow-up.
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Affiliation(s)
- Antonio Alcaraz
- Department of Urology, IDIBAPS, Hospital Clinic - Universitat de Barcelona, Barcelona, Spain.
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159
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Best SL, Donnally C, Mir SA, Tracy CR, Raman JD, Cadeddu JA. Complications during the initial experience with laparoendoscopic single-site pyeloplasty. BJU Int 2011; 108:1326-9. [DOI: 10.1111/j.1464-410x.2011.10078.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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160
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Abstract
In 2007, Rane presented the first single port nephrectomy for a small non-functioning kidney at the World Congress of Endourology. Since that time, the use of single port surgery for nephrectomy has expanded to include donor nephrectomy. Over the next two years the technique was adopted for many others types of nephrectomies to include donor nephrectomy. We present our technique for single port donor nephrectomy using the Gelpoint device. We have successfully performed this surgery in over 100 patients and add this experience to our experience of over 1000 laparoscopic nephrectomies. With the proper equipment and technique, single port donor nephrectomy can be performed safely and effectively in the majority of live donors. We have found that our operative times and most importantly our transplant outcomes have not changed significantly with the adoption of the single port donor nephrectomy. We believe that single port donor nephrectomy represents a step forward in the care of living donors.
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Affiliation(s)
- David B Leeser
- Surgery, Weill Cornell Medical College of Cornell University, USA.
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161
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Lee SW, Lee JY. Laparoendoscopic Single-Site Urological Surgery Using a Homemade Single Port Device: The First 70 Cases Performed at a Single Center by One Surgeon. J Endourol 2011; 25:257-64. [PMID: 21166578 DOI: 10.1089/end.2010.0445] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Seung Wook Lee
- Department of Urology, Eulji Hospital, Eulji University College of Medicine, Seoul, Korea
| | - Joo Yong Lee
- Department of Urology, Hanyang University College of Medicine, Seoul, Korea
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162
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Gettman MT, White WM, Aron M, Autorino R, Averch T, Box G, Cadeddu JA, Canes D, Cherullo E, Desai MM, Frank I, Gill IS, Gupta M, Haber GP, Humphreys MR, Irwin BH, Kaouk JH, Kavoussi LR, Landman J, Liatsikos EN, Lima E, Ponsky LE, Rane A, Ribal M, Rabenhalt R, Rao P, Richstone L, Sawyer MD, Sotelo R, Stolzenburg JU, Tracy CR, Stein RJ. Where Do We Really Stand With LESS and NOTES? Eur Urol 2011; 59:231-4. [PMID: 21122977 DOI: 10.1016/j.eururo.2010.11.016] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Accepted: 11/10/2010] [Indexed: 12/24/2022]
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163
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Stolzenburg JU, Do M, Haefner T, Dietel A, Kallidonis P, Kyriazis I, Beatty J, Liatsikos EN. Laparoendoscopic Single-Site Surgery Radical Nephrectomy. J Endourol 2011; 25:159-65. [DOI: 10.1089/end.2010.0673] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Minh Do
- Department of Urology, University of Leipzig, Leipzig, Germany
| | - Tim Haefner
- Department of Urology, University of Leipzig, Leipzig, Germany
| | - Anja Dietel
- Department of Urology, University of Leipzig, Leipzig, Germany
| | | | - Iason Kyriazis
- Department of Urology, University of Patras, Patras, Greece
| | - John Beatty
- Department of Urology, Northampton General Hospital, Northampton, United Kingdom
| | - Evangelos N. Liatsikos
- Department of Urology, University of Leipzig, Leipzig, Germany
- Department of Urology, University of Patras, Patras, Greece
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164
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Single-Site Laparoscopic Living Donor Nephrectomy Offers Comparable Perioperative Outcomes to Conventional Laparoscopic Living Donor Nephrectomy at a Higher Cost. Transplantation 2011; 91:e16-7. [DOI: 10.1097/tp.0b013e3181fecfe6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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165
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Robotic-assisted laparoscopic donor nephrectomies: early experience and review of the literature. J Robot Surg 2011; 5:115-20. [DOI: 10.1007/s11701-011-0245-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Accepted: 01/03/2011] [Indexed: 12/16/2022]
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166
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Rassweiler JJ. Is LESS/NOTES Really More? Eur Urol 2011; 59:46-8; discussion 48-50. [PMID: 20832932 DOI: 10.1016/j.eururo.2010.08.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 08/26/2010] [Indexed: 10/19/2022]
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167
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Geisler DP, Kirat HT, Remzi FH. Single-port laparoscopic total proctocolectomy with ileal pouch-anal anastomosis: initial operative experience. Surg Endosc 2011; 25:2175-8. [PMID: 21197548 DOI: 10.1007/s00464-010-1518-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Accepted: 07/13/2010] [Indexed: 01/13/2023]
Abstract
BACKGROUND Single-port laparoscopic surgery (SPLS) has been used in urologic, gynecologic, general, and colorectal surgery. We herein report our experience with the use of SPLS for total proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA). METHODS All patients who underwent a RP/IPAA using SPLS between June and September 2009 were identified from a prospectively maintained laparoscopic database. All procedures were performed with the use of a 5-mm Olympus EndoEye™ and traditional laparoscopic instruments via a SILS™ port placed at the planned ileostomy site. RESULTS There were five patients (3 male) included in the study. Median age was 43 years (range=13-47 years). Median body mass index was 20.66 kg/m2 (range=14.63-25.97 kg/m2). Diagnoses included ulcerative colitis (n=4) and familial adenomatous polyposis (n=1). Median ASA score was 2 (range=1-3). Median operative time was 153 min (range=132-278 min). Median estimated blood loss was 100 ml (range=50-200 ml). There were no conversions to either a conventional laparoscopic or an open procedure. Median time to return of bowel function was 2 days. Median length of stay was 4 days (range=3-6 days). Postoperative complications included two patients with partial small-bowel obstructions. Both resolved with conservative management. All patients had their ileostomies closed. CONCLUSION RP/IPAA using SPLS is a safe technique. Additional studies are needed to compare SPLS to conventional laparoscopy and open surgery with respect to operative times, convalescence, and outcomes.
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Affiliation(s)
- Daniel P Geisler
- Department of Colorectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, A30, Cleveland, OH 44195, USA
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168
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Fader AN, Levinson KL, Gunderson CC, Winder AD, Escobar PF. Laparoendoscopic single-site surgery in gynaecology: A new frontier in minimally invasive surgery. J Minim Access Surg 2011; 7:71-7. [PMID: 21197247 PMCID: PMC3002012 DOI: 10.4103/0972-9941.72387] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 09/06/2010] [Indexed: 12/16/2022] Open
Abstract
UNLABELLED REVIEW OBJECTIVE: To review the recent developments and published literature on laparoendoscopic single-site (LESS) surgery in gynaecology. RECENT FINDINGS Minimally invasive surgery has become a standard of care for the treatment of many benign and malignant gynaecological conditions. Recent advances in conventional laparoscopy and robotic-assisted surgery have favorably impacted the entire spectrum of gynaecological surgery. With the goal of improving morbidity and cosmesis, continued efforts towards refinement of laparoscopic techniques have lead to minimization of size and number of ports required for these procedures. LESS surgery is a recently proposed surgical term used to describe various techniques that aim at performing laparoscopic surgery through a single, small-skin incision concealed within the umbilicus. In the last 5 years, there has been a surge in the developments in surgical technology and techniques for LESS surgery, which have resulted in a significant increase in utilisation of LESS across many surgical subspecialties. Recently published outcomes data demonstrate feasibility, safety and reproducibility for LESS in gynaecology. The contemporary LESS literature, extent of gynaecological procedures utilising these techniques and limitations of current technology will be reviewed in this manuscript. CONCLUSIONS LESS surgery represents the newest frontier in minimally invasive surgery. Comparative data and prospective trials are necessary in order to determine the clinical impact of LESS in treatment of gynaecological conditions.
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Affiliation(s)
- Amanda Nickles Fader
- Divisions of Gynecologic Oncology, Greater Baltimore Medical Center and Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Kimberly L Levinson
- Divisions of Gynecologic Oncology, Greater Baltimore Medical Center and Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Camille C Gunderson
- Divisions of Gynecologic Oncology, Greater Baltimore Medical Center and Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Abigail D Winder
- Divisions of Gynecologic Oncology, Greater Baltimore Medical Center and Johns Hopkins Medical Institutions, Baltimore, MD, USA
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169
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Verhoest G, Patard JJ, Delreux A, Crepel M, Manunta A, Vincendeau S, Guille F, Bensalah K. La néphrectomie laparoscopique par accès ombilical unique : évolution ou révolution chirurgicale ? Prog Urol 2011; 21:29-33. [DOI: 10.1016/j.purol.2010.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Revised: 06/21/2010] [Accepted: 08/05/2010] [Indexed: 11/26/2022]
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170
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Stolzenburg JU, Do M, Kallidonis P, Dietel A, Oh MA, Till H, Liatsikos EN. Laparoendoscopic Single-Site Bladder Diverticulectomy: Technique and Initial Experience. J Endourol 2011; 25:85-90. [DOI: 10.1089/end.2010.0109] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | - Minh Do
- Department of Urology, University of Leipzig, Leipzig, Germany
| | | | - Anja Dietel
- Department of Urology, University of Leipzig, Leipzig, Germany
| | - Min-A Oh
- Department of Urology, University of Leipzig, Leipzig, Germany
| | - Holger Till
- Department of Paediatric Surgery, University of Leipzig, Leipzig, Germany
| | - Evangelos N. Liatsikos
- Department of Urology, University of Leipzig, Leipzig, Germany
- Department of Urology, University of Patras, Patras, Greece
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171
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Uppal S, Frumovitz M, Escobar P, Ramirez PT. Laparoendoscopic single-site surgery in gynecology: review of literature and available technology. J Minim Invasive Gynecol 2011; 18:12-23. [PMID: 20965792 PMCID: PMC4361065 DOI: 10.1016/j.jmig.2010.07.013] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 07/20/2010] [Accepted: 07/22/2010] [Indexed: 01/22/2023]
Abstract
The objective of this article was to review the published literature on laparoendoscopic single-site surgery (LESS) in gynecology and to present current advances in instruments used in LESS surgery. Inasmuch as LESS surgery is relatively new, the current literature on use of this technique in gynecology is somewhat limited. Sixteen articles were available for the literature review: 10 case series, 2 comparative studies, 3 case reports, and 1 surgical technique demonstration. In recent years, however, improvements in traditional laparoscopic techniques and availability of more advanced instruments has made single-incision laparoscopy more feasible and safer for the patient. There is increasing interest in LESS surgery both as an alternative to traditional laparoscopy and as an adjunct to robotic surgery when performing complicated procedures through a single incision. Although LESS surgery provides another option in the arena of minimally invasive gynecologic surgery, the ultimate role of this approach remains to be determined.
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Affiliation(s)
- Shitanshu Uppal
- Department of Obstetrics and Gynecology, Temple University Hospital, Philadelphia, Pennsylvania
| | - Michael Frumovitz
- Department of Gynecologic Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Pedro Escobar
- Department of Gynecologic Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Pedro T. Ramirez
- Department of Gynecologic Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
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Shi TP, Zhang X, Ma X, Li HZ, Zhu J, Wang BJ, Gao JP, Cai W, Dong J. Laparoendoscopic single-site retroperitoneoscopic adrenalectomy: a matched-pair comparison with the gold standard. Surg Endosc 2010; 25:2117-24. [PMID: 21170658 PMCID: PMC3116116 DOI: 10.1007/s00464-010-1506-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Accepted: 11/15/2010] [Indexed: 12/22/2022]
Abstract
Background Laparoscopic adrenalectomy has become the gold-standard for the surgical treatment of most adrenal lesions. This study evaluated the operative outcome of laparoendoscopic single-site (LESS) retroperitoneoscopic adrenalectomy (LESS-ARA) in comparison with the current standard operation procedure. Methods Between June and December 2009, 19 patients underwent LESS-ARA, and their outcomes were compared with a contemporary 1:2 matched-pair cohort of 38 patients who underwent standard ARA by the same surgeon. In LESS-ARA, a multichannel port was inserted through a 2.5- to 3.0-cm transverse skin incision below the tip of the 12th rib. The LESS-ARA procedure was performed using a 5-mm 30º laparoscopic camera and two standard laparoscopic instruments. The following parameters were compared between the two groups: demographics, details of the surgery, perioperative complications, postoperative visual analog pain scale score, analgesic requirement, and short-term measures of convalescence. Results The finding showed that LESS-ARA and standard ARA were comparable in terms of the estimated blood loss (30 vs 17.5 ml; p = 0.64), postoperative hospital stay (6 vs 6 days; p = 0.67), and postoperative complications (2 vs 3 patients; p = 1.00) for patients with similar baseline demographics and median tumor size (2.1 vs 3.0; p = 0.18) cm. The intraoperative hemodynamic values were similar in the two groups. The LESS-ARA group had a longer median operative time (55 vs 41.5 min; p = 0.0004), whereas the in-hospital use of analgesics was significantly less (5 vs 12 morphine equivalents; p = 0.03). Conclusions The LESS retroperitoneoscopic adrenalectomy approach is feasible and offers a superior cosmetic outcome and better pain control, with perioperative outcomes and short-term measures of convalescence similar to those of the standard approach, albeit with a longer operative time.
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Affiliation(s)
- Tao-ping Shi
- Department of Urology, Chinese People's Liberation Army General Hospital, Military Postgraduate Medical College, 28 Fuxing Road, Haidian District, 100853, Beijing, China
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Casanova N, Wolf JS. The alternative to laparoendoscopic single-site surgery: small strategic laparoscopic incision placement (SLIP) nephrectomy improves cosmesis without technical restrictions. J Endourol 2010; 25:265-70. [PMID: 21126191 DOI: 10.1089/end.2010.0340] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The latest attempt to improve the cosmesis of laparoscopic surgery is laparoendoscopic single-site surgery (LESS). We present our initial experience with an alternative procedure with similar cosmetic benefit but without technical limitations. METHODS Small strategic laparoscopic incision placement (SLIP) nephrectomy is performed transperitoneally, generally using three 5-mm ports (one in the umbilicus) and one 12-mm port placed below the pubic hairline, such that only two 5-mm scars are visible without close inspection. We assessed our first 21 procedures, which included all but five of the standard transperitoneal nephrectomies by a single surgeon from June 2008 through July 2009. These were matched 1:2 (exactly by gender and American Society of Anesthesiology score, and then closest in age and body mass index) from 96 patients undergoing similar standard transperitoneal laparoscopic procedures from 2005 through 2008. RESULTS The SLIP and control groups were well matched, with mean age and body mass index differing by only 3.6 years and 1.1, respectively. Of the SLIP patients, 34% were obese or morbidly obese, and a trainee was the primary surgeon in 81% of cases. Mean operative time was 23 minutes longer in the SLIP cases. There was no difference between groups in estimated blood loss, complication rate, or convalescence. CONCLUSIONS Like LESS, SLIP nephrectomy provides improved cosmesis. Unlike LESS, it is only slightly more difficult to perform than standard laparoscopic nephrectomy and can be performed in technically challenging cases (obesity, large specimen, etc). Similar to the literature on LESS, there is no convalescence benefit to SLIP nephrectomy; the advantage over standard laparoscopy is purely cosmetic.
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Affiliation(s)
- Nina Casanova
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan, USA
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Hagen ME, Pugin F, Bucher P, Fasel J, Markar S, Morel P. Robotic kidney implantation for kidney transplantation: initial experience. J Robot Surg 2010; 4:271-6. [PMID: 27627957 DOI: 10.1007/s11701-010-0221-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 10/03/2010] [Indexed: 10/18/2022]
Abstract
Despite improvements in minimally invasive techniques over recent decades, kidney implantation into the iliac fossa has remained a domain of open surgery. However, it was hypothesized that it would be feasible to perform robotic transplant kidney implantation as a means of reducing surgical trauma. Two robotic kidney transplantations into the iliac fossa were attempted in human cadavers. In the first cadaver, a 5 cm incision was placed in the right lower abdomen, the peritoneum was mobilized in a cranial direction, the iliac vessels were identified, and the kidney placed in the pre-peritoneal space. The incision was sealed with a gel port through which the Vinci(©) Surgical System was installed. In the second cadaver, a robotic kidney implantation with robotically sutured vascular and ureteric anastomoses was performed trans-abdominally. Open incision, identification, placement of gel port, and robotic docking were feasible. Robotic performance of vascular anastomosis was not possible in the first cadaver because of advanced decay and excess fat in the surgical field. Robotic kidney positioning was feasible and anastomoses were performed successfully in the second cadaver within 35, 25, and 20 min (arterial, venous, and ureteric, respectively). Robotic kidney transplantation seems feasible in human cadavers if tissue condition is suitable, but is very technically challenging. Because of the delicacy of anatomical structures, the cadaveric model with the risk of advanced decay and the absence of circulation sets limits on the exploration of this complex procedure. Hence, further research and animal work in this area is critical to improve understanding of the benefits and limitations of robotic kidney implantation.
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Affiliation(s)
- Monika E Hagen
- Division of Digestive Surgery, University Hospital Geneva, 24 Rue Micheli-du-Crest, 1211, Geneva, Switzerland.
| | - Francois Pugin
- Division of Digestive Surgery, University Hospital Geneva, 24 Rue Micheli-du-Crest, 1211, Geneva, Switzerland
| | - Pascal Bucher
- Division of Digestive Surgery, University Hospital Geneva, 24 Rue Micheli-du-Crest, 1211, Geneva, Switzerland
| | - Jean Fasel
- Division of Anatomy, University of Geneva, Geneva, Switzerland
| | - Sheraz Markar
- General Surgery Department, University College London Hospital, London, UK
| | - Philippe Morel
- Division of Digestive Surgery, University Hospital Geneva, 24 Rue Micheli-du-Crest, 1211, Geneva, Switzerland
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Tugcu V, Ilbey YO, Mutlu B, Tasci AI. Laparoendoscopic single-site surgery versus standard laparoscopic simple nephrectomy: a prospective randomized study. J Endourol 2010; 24:1315-20. [PMID: 20626273 DOI: 10.1089/end.2010.0048] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND PURPOSE Laparoendoscopic single-site surgery (LESS), an attempt to further enhance the cosmetic benefits of minimally invasive surgery while minimizing the potential morbidity associated with multiple incisions, has been developed recently. Our aim was to compare LESS simple nephrectomy (LESS-SN) and conventional transperitoneal laparoscopic simple nephrectomy (CTL-SN). PATIENTS AND METHODS In this randomized study that was conducted between December 2008 and September 2009, 27 patients who needed simple nephrectomy were randomized to either LESS-SN or CTL-SN. All procedures in both groups were performed by the first author, who is experienced in laparoscopic surgery. Patient characteristics, perioperative details, and time to return to work were recorded. Postoperative evaluation of pain and use of analgesic medication were recorded. RESULTS There was no difference in median operative time (117.5 vs 114 min, P = 0.52), blood loss (50.71 vs 47.15 mL, P = 0.60), transfusion rates (0% for both), and hospitalization time (2.07 vs 2.11 days, P = 0.74) between the LESS-SN and CTL-SN groups. Time to return to normal activities was shorter in the LESS-SN group compared with the CTL-SN group (10.7 vs 13.5 days, P = 0.001). Both the visual analogue scale and the postoperative use of analgesics were significantly lower during postoperative days 1, 2, and 3 in patients who underwent LESS-SN, compared with patients who underwent CTL-SN. There were no intraoperative or postoperative complications in both groups. Compared with CTL-SN, LESS-SN was more expensive, but all patients undergoing LESS-SN were very pleased with the cosmetic outcome (no visible scars). CONCLUSION The early experience described in this study suggests that LESS-SN is a safe and effective alternative to CTL-SN that provides surgeons with a minimally invasive surgical option and the ability to hide the surgical incision within the umbilicus; however, a larger series is necessary to confirm these findings and to determine if there are any benefits in pain, recovery, or cosmesis.
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Affiliation(s)
- Volkan Tugcu
- Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
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176
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Laparoendoscopic Single Site Live Donor Nephrectomy: Initial Experience. J Urol 2010; 184:2049-53. [DOI: 10.1016/j.juro.2010.06.138] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Indexed: 12/16/2022]
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Laparoendoscopic single-site surgery (LESS) in gynecology: a multi-institutional evaluation. Am J Obstet Gynecol 2010; 203:501.e1-6. [PMID: 20663487 DOI: 10.1016/j.ajog.2010.06.028] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Revised: 05/04/2010] [Accepted: 06/14/2010] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The study objectives were to determine the surgical outcomes of a large series of gynecology patients treated with laparoendoscopic single-site surgery (LESS). STUDY DESIGN This was a retrospective, multi-institutional analysis of gynecology patients treated with LESS in 2009. Patients underwent surgery via a single 1.5- to 2.5-cm umbilical incision with a multichannel single port. RESULTS A total of 74 women underwent LESS. Procedures were performed for benign pelvic masses (n = 39), endometrial hyperplasia (n = 9), endometrial (n = 15) and ovarian (n = 6) cancers, and nongynecologic malignancies (n = 5). Median patient age and body mass index were 47 years and 28, respectively. A Pearson product-moment correlation coefficient was computed and demonstrated a significant linear relationship between the operating time and number of cases for cancer staging (r = -0.71; n = 26; P < .001) and nonstaging (r = -0.78; n = 48; P < .002) procedures. Perioperative complications were low (3%). CONCLUSION LESS is feasible, safe, and reproducible in gynecology patients with benign and cancerous conditions. Operative times are reasonable and can be decreased with experience.
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Pfluke JM, Parker M, Stauffer JA, Paetau AA, Bowers SP, Asbun HJ, Smith CD. Laparoscopic surgery performed through a single incision: a systematic review of the current literature. J Am Coll Surg 2010; 212:113-8. [PMID: 21036069 DOI: 10.1016/j.jamcollsurg.2010.09.008] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Accepted: 09/09/2010] [Indexed: 10/18/2022]
Affiliation(s)
- Jason M Pfluke
- Department of Surgery, Mayo Clinic Florida, Jacksonville, FL 32224, USA
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Haber GP, White MA, Autorino R, Escobar PF, Kroh MD, Chalikonda S, Khanna R, Forest S, Yang B, Altunrende F, Stein RJ, Kaouk JH. Novel robotic da Vinci instruments for laparoendoscopic single-site surgery. Urology 2010; 76:1279-82. [PMID: 20980046 DOI: 10.1016/j.urology.2010.06.070] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Revised: 06/04/2010] [Accepted: 06/08/2010] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To describe novel robotic laparoendoscopic single-site surgery (R-LESS) instruments, and present the initial laboratory experience in urology. METHODS The VeSPA surgical instruments (Intuitive Surgical, Sunnyvale, CA) were designed to be used with the DaVinci Si surgical system. A multichannel port and curved cannulae were inserted through a single 3.5-cm umbilical incision. The port allowed 1 scope, 2 robotic instruments, and a 5- to 12-mm assistant instrument. Four pyeloplasties (right 2, left 2), 4 partial nephrectomies (right 2, left 2), and 8 nephrectomies (right 4, left 4) were performed in 4 female farm pigs (mean weight, 34.5 kg). Technical feasibility and efficiency were assessed in addition to perioperative outcomes. RESULTS All 16 R-LESS procedures were performed successfully without the addition of laparoscopic ports or open conversion. Mean total operative time was 110 minutes (range, 82-127), and mean blood loss was 20 mL (range, 10-100). Mean warm ischemia time for partial nephrectomy was 14.8 minutes (range, 12-20). There were no intraoperative complications. No robotic system failures occurred, and robotic instrument clashing was found to be minimal. One needle driver malfunctioned and assistant movement was limited. CONCLUSIONS R-LESS kidney surgery using the VeSPA instruments is feasible and efficient in the porcine model. The system offers a wide range of motion, instrument and scope stability, improved ergonomics, and minimal instrument clashing. Although preliminary experience is encouraging, further refinements are expected to optimize urological applications of this robotic technology.
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Affiliation(s)
- Georges-Pascal Haber
- Section of Laparoscopic and Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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180
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Khanna R, Autorino R, White MA, Laydner H, Forest S, Altunrende F, Yang B, Haber GP, Kaouk JH, Stein RJ. Laparoendoscopic single-site surgery: current clinical experience. BJU Int 2010; 106:897-902. [PMID: 20883241 DOI: 10.1111/j.1464-410x.2010.09666.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Rakesh Khanna
- Center for Advanced Laparoscopy and Robotics, Glickman Urological and Kidney Institute, Cleveland Clinic, OH, USA
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181
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Best SL, Tracy CR, Cadeddu JA. Laparoendoscopic single-site surgery and natural orifice transluminal endoscopic surgery: future perspectives. BJU Int 2010; 106:941-4. [PMID: 20883249 DOI: 10.1111/j.1464-410x.2010.09674.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hundreds of laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) cases have been reported in the literature across a broad span of urological procedures. Despite this, many hurdles to widespread adoption of these techniques exist, including technical challenges, such as decreased triangulation and unfamiliar viewing angles, and more philosophical issues, such as the necessity of demonstrating benefits of these techniques over conventional laparoscopy. Future research will seek to overcome these obstacles. This may be accomplished with further instrument development, including robotic instrumentation, as well as clinical studies evaluating outcomes of LESS/NOTES operations that may demonstrate advantages in these techniques.
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Affiliation(s)
- Sara L Best
- Department of Urology, University of Texas, Southwestern Medical Center, Dallas, USA
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182
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[Single-port in urology]. Prog Urol 2010; 20:609-15. [PMID: 20951928 DOI: 10.1016/j.purol.2010.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Revised: 05/25/2010] [Accepted: 06/09/2010] [Indexed: 11/23/2022]
Abstract
UNLABELLED Single-port transumbilical laparoscopy has emerged as an attempt to further enhance cosmetic benefits and reduce morbidity of minimally invasive surgery. Within a short span, several clinical reports have emerged in the urologic literature. As this field is poised to move forward, a complete understanding of its evolution and current status seems imperative. We have summarized and reviewed the history of Single-Port across surgical disciplines. This review emphasizes nomenclature, surgical technique, instrumentation, and perioperative outcomes. EVIDENCE ACQUISITION Using the National Library of Medicine database, the English language literature was reviewed for the past 40 years. Keyword searches included scarless, scar free, single-port/trocar/incision, laparoendoscopic single site surgery intraumbilical, and transumbilical. Within the bibliography of selected references, additional sources were retrieved. EVIDENCE SYNTHESIS The major findings and surgical techniques described in these papers, are summarized in a chronological and subject-grouped manner. CONCLUSIONS Single-port has made its initial forays into laparoscopic surgery. Ongoing refinement in technique and instrumentation is likely to expand its future role.
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Abstract
Since the introduction of laparoscopic surgery, the promise of lower postoperative morbidity and improved cosmesis has been achieved. LaparoEndoscopic Single Site (LESS) surgery potentially takes this further. Following the first human urological LESS report in 2007, numerous case series have emerged, as well as comparative studies comparing LESS with standard laparoscopy. Technological developments in instrumentation, access and optics devices are overcoming some of the challenges that are raised when operating through a single site. Further advances in the technique have included the incorporation of robotics (R-LESS), which exploit the ergonomic benefits of ex vivo robotic platforms in an attempt to further improve the implementation of LESS procedures. In the future, urologists may be able to benefit from in vivo micro-robots that will allow the manipulation of tissue from internal repositionable platforms. The use of magnetic anchoring and guidance systems (MAGS) might allow the external manoeuvring of intra-corporeal instruments to reduce clashing and facilitate triangulation. However, the final promise in minimally invasive surgery is natural orifice transluminal endoscopic surgery (NOTES), with its scarless technique. It remains to be seen whether NOTES, LESS, or any of these future developments will prove their clinical utility over standard laparoscopic methods.
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Affiliation(s)
- Harveer Dev
- LeFrak Center for Robotic Surgery & Institute for Prostate Cancer, James Buchanan Brady Foundation Department of Urology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
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Current Opinion in Urology. Current world literature. Curr Opin Urol 2010; 20:533-8. [PMID: 20940575 DOI: 10.1097/mou.0b013e32834028bc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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185
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White MA, Haber GP, Autorino R, Khanna R, Forest S, Yang B, Altunrende F, Stein RJ, Kaouk JH. Robotic Laparoendoscopic Single-Site Radical Prostatectomy: Technique and Early Outcomes. Eur Urol 2010; 58:544-50. [PMID: 20702030 DOI: 10.1016/j.eururo.2010.06.040] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Accepted: 06/29/2010] [Indexed: 10/19/2022]
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186
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Laparoscopic Living-Donor Nephrectomy: Is It Really Better? Eur Urol 2010; 58:510-1; discussion 512-3. [DOI: 10.1016/j.eururo.2010.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2010] [Accepted: 05/04/2010] [Indexed: 11/16/2022]
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187
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Greco F, Hoda MR, Fornara P. Reply from Authors re: Eric Lechevallier. Laparoscopic Living-Donor Nephrectomy: Is It Really Better? Eur Urol 2010;58:510–1. Eur Urol 2010. [DOI: 10.1016/j.eururo.2010.05.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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188
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Laparoscopy/New Technology. J Urol 2010. [DOI: 10.1016/j.juro.2010.06.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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189
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New trends in minimally invasive urological surgery: what is beyond the robot? World J Urol 2010; 31:505-13. [PMID: 20812015 DOI: 10.1007/s00345-010-0588-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Accepted: 08/03/2010] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To review the minimal-invasive development of surgical technique in urology focusing on nomenclature, history and outcomes of Laparo-Endoscopic Single-site Surgery (LESS), Natural Orifice Translumenal Endoscopic Surgery (NOTES) and Computer-Assisted Surgery (CAS). METHODS A comprehensive literature search was conducted in order to find article related to LESS, NOTES and CAS in urology. The most relevant papers over the last 10 years were selected in base to the experience from the panel of experts, journal, authorship and/or content. RESULTS Seven hundred and fifty manuscripts were found. Papers on LESS describe feasibility/safety in most of the procedures with a clinical experience of more than 300 cases and five compared results to standard laparoscopy without showing significant differences. NOTES accesses have been proved their feasibility/safety in experimental study. In human, the only procedures performed are on kidney and through a hybrid-Transvaginal route. New robots overcome the main drawbacks of the DaVinci® platform. The use of CAS is increasing its popularity in urology. CONCLUSIONS LESS has been applied in clinical practice, but only ongoing technical and instrumental refinement will define its future role and overall benefit. The transition to a clinical application of NOTES seems at present only possible with multiple NOTES access and transvaginal access. Robot and Soft Tissue Navigation appear to be important to improve surgical skills. We are already witness to the advantages offered by the former even if costs need to be redefined based on pending long-term results. The latter will probably upgrade the quality of surgery in a near future.
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Berkowitz JR, Allaf ME. Laparoendoscopic single-site surgery: complications and how to avoid them. BJU Int 2010; 106:903-7. [DOI: 10.1111/j.1464-410x.2010.09667.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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191
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Autorino R, Cadeddu JA, Desai MM, Gettman M, Gill IS, Kavoussi LR, Lima E, Montorsi F, Richstone L, Stolzenburg JU, Kaouk JH. Laparoendoscopic single-site and natural orifice transluminal endoscopic surgery in urology: a critical analysis of the literature. Eur Urol 2010; 59:26-45. [PMID: 20828918 DOI: 10.1016/j.eururo.2010.08.030] [Citation(s) in RCA: 187] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2010] [Accepted: 08/17/2010] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Riccardo Autorino
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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Ahmed K, Wang TT, Patel VM, Nagpal K, Clark J, Ali M, Deeba S, Ashrafian H, Darzi A, Athanasiou T, Paraskeva P. The role of single-incision laparoscopic surgery in abdominal and pelvic surgery: a systematic review. Surg Endosc 2010; 25:378-96. [PMID: 20623239 DOI: 10.1007/s00464-010-1208-6] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2009] [Accepted: 04/09/2010] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This review aimed to determine the role of single-incision laparoscopic surgery (SILS) in abdominal and pelvic operations. DATA SOURCES The Medline, EMBASE, and PsycINFO databases were systematically searched until October 2009 using "single-incision laparoscopic surgery" and related terms as keywords. References from retrieved articles were reviewed to broaden the search STUDY SELECTION The study included case reports, case series, and empirical studies that reported SILS in abdominal and pelvic operations. DATA EXTRACTION Number of patients, type of instruments, operative time, blood loss, conversion rate, length of hospital stay, length of follow-up evaluation, and complications were extracted from the reviewed items DATA SYNTHESIS The review included 102 studies classified as level 4 evidence. Most of these studies investigated SILS in cholecystectomy (n=34), appendectomy (n=24), and nephrectomy (n=17). For these procedures, operative time, hospital stay, and complications were comparable with those of conventional laparoscopy. Conversion to conventional laparoscopy was seldom performed in cholecystectomy (range, 0-24%) and more frequent in appendectomy (range, 0-41%) and nephrectomy (range, 0-33%). CONCLUSION The potential benefits of SILS include superior cosmesis and possibly shorter operative time, lower costs, and a shortened time to full physical recovery. Careful case selection and a low threshold of conversion to conventional laparoscopic surgery are essential. Multicenter, randomized, prospective studies are needed to compare short- and long-term outcome measures against those of conventional laparoscopic surgery.
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Affiliation(s)
- Kamran Ahmed
- Department of Biosurgery and Surgical Technology, Imperial College London, 10th Floor, QEQM Building, St Mary's Hospital Campus, Praed Street, London, W2 1NY, UK.
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Current world literature. Curr Opin Obstet Gynecol 2010; 22:354-9. [PMID: 20611001 DOI: 10.1097/gco.0b013e32833d582e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Santos BF, Enter D, Soper NJ, Hungness ES. Single-incision laparoscopic surgery (SILS™) versus standard laparoscopic surgery: a comparison of performance using a surgical simulator. Surg Endosc 2010; 25:483-90. [PMID: 20585958 DOI: 10.1007/s00464-010-1197-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Accepted: 06/14/2010] [Indexed: 12/21/2022]
Abstract
BACKGROUND Single-incision laparoscopic surgery (SILS™) is a potentially less invasive approach than standard laparoscopy (LAP). However, SILS™ may not allow the same level of manual dexterity and technical performance compared to LAP. We compared the performance of standardized tasks from the Fundamentals of Laparoscopic Surgery (FLS) program using either the LAP or the SILS™ technique. METHODS Medical students, surgical residents, and attending physicians were recruited and divided into inexperienced (IE), laparoscopy-experienced (LE), and SILS™-experienced (SE) groups. Each subject performed standardized tasks from FLS, including peg transfer, pattern cutting, placement of ligating loop, and intracorporeal suturing using a standard three-port FLS box-trainer with standard laparoscopic instruments. For SILS™, the subjects used an FLS box-trainer modified to accept a SILS Port™ with two working ports for instruments and one port for a 30° 5-mm laparoscope. SILS™ tasks were performed with instruments capable of unilateral articulation. SILS™ suturing was performed both with and without an articulating EndoStitch™ device. Task scores, including cumulative laparoscopic FLS score (LS) and cumulative SILS™ FLS score (SS), were calculated using standard time and accuracy metrics. RESULTS There were 27 participants in the study. SS was inferior to LS in all groups. LS increased with experience level, but was similar between LE and SE groups. SS increased with experience level and was different among all groups. SILS™ suturing using the articulating suturing device was superior to the use of a modified needle driver technique. CONCLUSIONS SILS™ is more technically challenging than standard laparoscopic surgery. Using currently available SILS™ platforms and instruments, even surgeons with SILS™ experience are unable to match their overall LAP performance. Specialized training curricula should be developed for inexperienced surgeons who wish to perform SILS™.
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Affiliation(s)
- Byron F Santos
- Department of Surgery, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 650, Chicago, IL 60611, USA
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Access for laparoendoscopic single site surgery. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2010; 2010:943091. [PMID: 20631903 PMCID: PMC2902049 DOI: 10.1155/2010/943091] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Accepted: 04/11/2010] [Indexed: 11/17/2022]
Abstract
Laparoscopic surgery is the standard of care for many abdominal and pelvic operations and is widely applied today. LESS (Laparo-Endoscopic Single Site) surgery, originally attempted in the 1990s, is an advanced minimally invasive approach that allows laparoscopic operations to be undertaken through a small (<15 mm) incision in the umbilicus, a preexisting scar. The presence of a preexisting scar allows LESS surgery to be essentially scarless, which is the key benefit to LESS operations. Herein, we review our experience with over 500 LESS operations and discuss the key techniques to establishing access to the peritoneal cavity. We review the options for obtaining access, available instrumentation, common challenges and solutions for access. We conclude that LESS surgery is safe and provides outcomes with superior cosmesis relative to conventional laparoscopy. LESS surgery should be embraced, as patient demand is rapidly increasing.
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Cindolo L, Gidaro S, Tamburro FR, Schips L. Reply to Riccardo Autorino, Robert J. Stein and Jihad H. Kaouk’s Letter to the Editor re: Luca Cindolo, Stefano Gidaro, Fabiola R. Tamburro, Luigi Schips. Laparo-Endoscopic Single-Site Left Transperitoneal Adrenalectomy. Eur Urol 2010;57:911–4. Eur Urol 2010. [DOI: 10.1016/j.eururo.2009.08.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Autorino R, Khanna R, White MA, Haber GP, Shah G, Kaouk JH, Stein RJ. Laparoendoscopic single-site repair of retrocaval ureter: first case report. Urology 2010; 76:1501-5. [PMID: 20381132 DOI: 10.1016/j.urology.2010.01.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Revised: 01/13/2010] [Accepted: 01/18/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE We describe a case of retrocaval ureter treated with laparoendoscopic single-site surgery (LESS). METHODS A 26-year-old female was referred to our institution with a history of intermittent right-sided flank pain. Radiological imaging demonstrated hydronephrosis, suggesting the presence of a retrocaval ureter. A LESS repair was planned. RESULTS Retrograde pyelogram confirmed a classic appearance for retrocaval ureter. A ureteral stent was positioned. The patient was placed in modified flank position. A 2-cm, completely concealed umbilical access was created, through which a single port access platform was positioned. An in-line endoscope was used for visualization. Articulating instruments were used during initial dissection. The entire ureter was mobilized posterior to the vena cava and transected at the caudal-most point where the dilated portion of the proximal ureter ended. The distal ureter was repositioned lateral to the inferior vena cava and spatulated laterally. The proximal ureter was spatulated medially. Two 4-0 Vicryl sutures were used for the ureteroureteral anastomosis. A separate 2-mm grasper placed in the right lower quadrant was used to assist with suture reconstruction. A drain was left through the umbilicus. Blood loss was minimal. Total operative time was 3 hours. The patient was discharged on postoperative day 2. At the 3-month follow-up, diuretic radionuclide scan revealed no evidence of obstruction of the right kidney and the patient was symptom-free. CONCLUSIONS Albeit challenging, LESS repair for retrocaval ureter is a feasible procedure that can be considered as a treatment option for this rare anatomic anomaly.
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Affiliation(s)
- Riccardo Autorino
- Center for Laparoscopy and Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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Chung MS, Kim SJ, Cho HJ, Ha US, Hong SH, Lee JY, Kim JC, Kim SW, Hwang TK. Hand-assisted laparoscopic right donor nephrectomy: safety and feasibility. Korean J Urol 2010; 51:34-9. [PMID: 20414408 PMCID: PMC2855464 DOI: 10.4111/kju.2010.51.1.34] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2009] [Accepted: 09/29/2009] [Indexed: 11/18/2022] Open
Abstract
Purpose We aimed to prove the safety and feasibility of right-sided hand-assisted laparoscopic donor nephrectomy (HALDN). Materials and Methods Between May 2006 and May 2009, 16 patients underwent right-sided HALDN at our institution. Of these patients, 15 showed significantly lower renal function in the right kidney than in the left one and 1 had a stone in the right kidney. When the right renal vein was divided, an EndoGIA stapling device was placed on the wall of the inferior vena cava to gain a maximal length of the vein. We evaluated intraoperative and postoperative parameters such as operative time, delivery time, warm ischemic time, estimated blood loss, intraoperative and postoperative complication rates, length of hospital stay, and serum creatinine levels of donors (at the time of discharge) and recipients (4 weeks postoperatively), comparing the right-sided HALDN group (our study) with a left-sided HALDN group (from a previously reported study). Results A total of 16 right-sided HALDNs were successfully performed without any complications or open conversion. All of the intraoperative and postoperative parameters were similar between the right-sided HALDN and left-sided HALDN groups. There were no technical problems in the recipients in the anastomosis of the renal vein, and the ureteral anastomoses were also successful. Conclusions Right-sided HALDN is safe and technically feasible in a donor, showing favorable graft outcomes. The results of our study suggest that right-sided HALDN may be preferable in patients with significantly lower renal function in the right kidney than in the left one.
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Affiliation(s)
- Moon-Soo Chung
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
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