Single-incision laparoscopic gastric bypass for morbid obesity

Transumbilical Stapling Technic of OAGB

Single-port or single-incision laparoscopic surgery (SILS) is esteemed for its efficacy in achieving superior postoperative cosmetic outcomes compared to the conventional laparoscopic approach (Behnia-Willison et al. in Aust N Z J Obstet Gynaecol 52:366-370, 2012; Rogula et al. in Obes Surg 24:1102-1108, 2014; Pitot et al. in Surg Endosc 28:3007-3011, 2014). The introduction of SILS for bariatric procedures can be attributed to the pioneering work of Saber in 2008, who initially applied this technique to laparoscopic sleeve gastrectomy (SG), followed by its utilization in laparoscopic adjustable gastric banding (AGB) (Saber et al. in Obes Surg 18:1338-1342, 2008;Nguyen et al. in Obes Surg 18:1628-1631, 2008). The inaugural application of SILS in Roux-en-Y gastric bypass (RYGB) was documented in 2009, employing a plastic reconstruction methodology. Acknowledging the intricate nature of complex bariatric interventions, we previously detailed a modified SILS approach termed the transumbilical two-site (TUTS) technique for RYGB, which was established as a standard procedure in 2010 (Lee et al. in Surg Obes Relat Dis. 8:208-13, 2012). At that juncture, a solitary article surfaced in 2010 elucidating the dimensions of the small gastric pouch as a mere 8-9 cm, falling short of contemporary surgical requisites for optimal outcomes in one anastomosis gastric bypass (OAGB) (Tacchino et al. in Obes Surg 20:1154-1160, 2010). Notably, the TUTS technique, which was successfully implemented for RYGB, had hitherto not been extended to OAGB due to the complexities associated with creating a slender gastric tube spanning 25 cm. In a pioneering development this year, we have devised a novel strategy to surmount this challenge. The present study is designed to expound upon the transumbilical stapling technique tailored to the unique demands of OAGB.

Robotic "Double Loop" Roux-en-Y gastric bypass reduces the risk of postoperative internal hernias: a prospective observational study

Background

Internal herniation (IH) is a potentially serious complication after laparoscopic Roux-en-Y gastric bypass (RYGB). The aim of the study is to evaluate the incidence of IH after robot-assisted RYGB (RA-RYGB) performed with the “Double Loop” technique at our Institution.

Methods

Prospective cohort study of patients submitted to RA-RYGB with the “Double Loop” technique, with a minimum follow-up of 2 years. Patients with complaints of abdominal pain at clinical visits or entering the emergency department were evaluated. Primary outcome was the incidence of IH, defined as the presence of herniated bowel through a mesenteric defect, diagnosed at imaging or at surgical exploration.

Results

A total of 129 patients were included: 65 (50.4%) were primary procedures, while 64 (49.6%) were revisional operations after primary restrictive bariatric surgery. Mean age was 47.9 ± 10.2 years, mean weight, and body mass index were, respectively, 105.3 ± 22.6 kg and 39.7 ± 9.6 kg/m². Postoperative morbidity rate was 7.0%. Mean follow-up was 53.2 ± 22.6 (range 24–94) months. During the follow-up period, a total of 14 (10.8%) patients entered the emergency department: 1 patient had melena, 4 renal colic, 1 acute cholecystitis, 2 gynecologic pathologies, 2 anastomotic ulcers, 1 perforated gastric ulcer, 1 diverticulitis and 2 gastroenteritis. There were no diagnoses of IH. During the follow-up period, no patient experienced recurrence of symptoms.

Conclusions

In the present study, the robotic approach confirms the low complication rate and absence of IH after “Double Loop” RA-RYGB in a large case-series at a medium-term follow-up.

Standardization of Bariatric Metabolic Procedures: World Consensus Meeting Statement

BACKGROUND

Standardization of the key measurements of a procedure's finished anatomic configuration strengthens surgical practice, research, and patient outcomes. A consensus meeting was organized to define standard versions of 25 bariatric metabolic procedures.

METHODS

A panel of experts in bariatric metabolic surgery from multiple continents was invited to present technique descriptions and outcomes for 4 classic, or conventional, and 21 variant and emerging procedures. Expert panel and audience discussion was followed by electronic voting on proposed standard dimensions and volumes for each procedure's key anatomic alterations. Consensus was defined as ≥ 70% agreement.

RESULTS

The Bariatric Metabolic Surgery Standardization World Consensus Meeting (BMSS-WOCOM) was convened March 22-24, 2018, in New Delhi, India. Discussion confirmed heterogeneity in procedure measurements in the literature. A set of anatomic measurements to serve as the standard version of each procedure was proposed. After two voting rounds, 22/25 (88.0%) configurations posed for consideration as procedure standards achieved voting consensus by the expert panel, 1 did not attain consensus, and 2 were not voted on. All configurations were voted on by ≥ 50% of 50 expert panelists. The Consensus Statement was developed from scientific evidence collated from presenters' slides and a separate literature review, meeting video, and transcripts. Review and input was provided by consensus panel members.

CONCLUSIONS

Standard versions of the finished anatomic configurations of 22 surgical procedures were established by expert consensus. The BMSS process was undertaken as a first step in developing evidence-based standard bariatric metabolic surgical procedures with the aim of improving consistency in surgery, data collection, comparison of procedures, and outcome reporting.

Consecutive Versus Selective Primary and Revisional Single Incision Laparoscopic Bariatric Surgery: Personal Experience in 330 Cases

BACKGROUND

This paper aims to retrospectively evaluate the feasibility, safety, and standardization for both consecutive primary and revisional SILS bariatric surgeries, and to analyze incisional hernia's prevalence, technical improvements, and limiting factors.

METHODS

A retrospective database review was undertaken involving, in Part I (Belgium), 290 consecutive SILS, including 80.68% primary bariatric surgeries, and 19.32% revisional gastric bypass, followed in Part II (Lebanon), by 40 selective primary SILS. Training for and standardization of the trans-umbilical technique was done for the operating room team, and was executed in part II.

RESULTS

The procedure of single incision was successfully completed in all of the 330 cases part I & part II. There was a need for additional salvage for one or two trocars in respectively 3.1% and 2.75% of the cases. There were no deaths or conversions in either group. Early complications included one medically healed fistula after revisional GB, and two secondary gastric and intestinal perforation requiring reoperations. Late surgical complications were: "3 patients (1.03%) in Part I and 2 (5%) in Part II suffered occlusions, requiring laparoscopic mesenteric defect's closure on an internal herniation." Twelve patients (4.1%) from part I and 5 (12.5%) in part II suffered an incisional hernia.

CONCLUSION

Selective SILS, when standardized, tends to be superior to consecutive SILS in terms of overall morbidity, operative time, and need for additional salvage trocars. Cost effectiveness and higher midterm rate of umbilical port site incisional hernia should be weighed against the beneficial cosmetic effect for the patient.

LSG vs MGB-OAGB-3 Year Follow-up Data: a Randomised Control Trial

AIM

The objective of this study is to compare 3-year follow-up results of one anastomosis gastric bypass (MGB-OAGB) and laparoscopic sleeve gastrectomy (LSG) in terms of weight loss, complications, resolution of comorbidities and quality of life.

MATERIALS AND METHODS

A prospective randomised study of results between 100 LSG patients and 101 MGB-OAGB patients was done from 2012 to 2015. The results were compared regarding operative outcomes, percentage of excess weight loss (%EWL), complications, resolution of comorbidities and quality of life (BAROS score) at 3 years follow-up.

RESULTS

Follow-up was achieved in 93 MGB-OAGB vs 92 LSG patients for 3-year period. The average %EWL for MGB-OAGB vs LSG was 66.48 vs 61.15% at the end of 3 years respectively, which was statistically insignificant. Diabetes remission was seen in 89.13% of MGB-OAGB patients and 81.82% of LSG patients. Remission of hypertension was seen in 74% of MGB-OAGB patients and 72.22% of LSG patients. Bariatric analysis reporting and outcome system (BAROS) with comorbidity in LSG patients and MGB-OAGB patients was 6.03 and 6.96 respectively, whereas in patients without comorbidity, BAROS score was 3.86 in LSG group and 4.34 in MGB-OAGB group.

CONCLUSIONS

In our study, at 36 months follow up, there was no significant difference between LSG and MGB-OAGB in %EWL and remission of HTN. Type 2 diabetes mellitus (T2DM) remission rates were higher after MGB-OAGB as compared to LSG but the difference was statistically insignificant. MGB-OAGB patients with comorbidities have a better quality of life and BAROS score compared to LSG patients.

15-year experience of laparoscopic single anastomosis (mini-)gastric bypass: comparison with other bariatric procedures

BACKGROUND

Laparoscopic single anastomosis (mini-)gastric bypass (LSAGB) has been validated as a safe and effective treatment for morbid obesity. However, data of the long-term outcome remain lacking.

METHODS

Between October 2001 and December 2015, 1731 morbidly obese patients who received LSAGB as primary bariatric procedure at the Min-Sheng General Hospital were recruited. Surgical outcome, weight loss, resolution of comorbidities, and late complications were followed, then compared with groups of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). All data derived from a prospective bariatric database and a retrospective analysis were conducted.

RESULTS

The average patient age was 33.8 ± 10.4 years with a mean body mass index (BMI) of 40.4 ± 7.7 kg/m². Of them, 70.0% were female while 30.0% were male. Mean operating time, intraoperative blood, and hospital stay of LSAGB were 124.6 ± 38.8 min, 39.5 ± 38.7 ml, and 5.0 ± 4.1 days, respectively. The 30-day post-operative major complication occurred in 30 (1.7%) of LSAGB patients, 16 (2.0%) of LRYGB, and 15 (1.4%) of LSG patients. The follow-up rates at 1, 5, and 10 years were 89.3, 52.1, and 43.6%, respectively. At postoperative 1, 5, and 10 years, the mean percentage of weight loss (%WL) of LSAGB patients were 32.7, 32.2, and 29.1%, and mean BMI became 27, 26.9, and 27 kg/m², respectively. The LSAGB had a higher weight loss than LRYGB and LSG at 2-6 years after surgery. LSG had a lower remission rate in dyslipidemia comparing to LSAGB and LRYGB. The overall revision rate of LSAGB is 4.0% (70/1731) which was lower than the 5.1% in LRYGB and 5.2% in the LSG.

CONCLUSION

LSAGB is an effective procedure for treating morbid obesity and metabolic disorders, which results in sustained weight loss and a high resolution of comorbidities.

A 6-year experience with 1,054 mini-gastric bypasses-first study from Indian subcontinent

BACKGROUND

We started laparoscopic mini-gastric bypass (MGB) for the first time in India in February 2007 for its reported safety, efficacy, and easy reversibility.

METHODS

A retrospective review of prospectively maintained data of all 1,054 consecutive patients (342 men and 712 women) who underwent MGB at our institute from February 2007 to January 2013 was done.

RESULTS

Mean age was 38.4 years, preoperative mean weight was 128.5 kg, mean BMI was 43.2 kg/m(2), mean operating time was 52 ± 18.5 min, and mean hospital stay was 2.5 ± 1.3 days. There were 49 (4.6%) early minor complications, 14 (1.3%) major complications, and 2 leaks (0.2%). In late complications, one patient had low albumin and one had excess weight loss; MGB was easily reversed in both (0.2%). Marginal ulcers were noted in five patients (0.6%) during follow-up for symptomatic dyspepsia, and anemia was the most frequent late complication occurring in 68 patients (7.6%). Patient satisfaction was high, and mean excess weight loss was 84, 91, 88, 86, 87, and 85% at years 1 to 6, respectively.

CONCLUSION

This study confirms previous publications showing that MGB is quite safe, with a short hospital stay and low risk of complications. It results in effective and sustained weight loss with high resolution of comorbidities and complications that are easily managed.

Presentation and surgical management of leaks after mini-gastric bypass for morbid obesity

BACKGROUND

Few data exist about the characteristics and management of enteric leaks after mini-gastric bypass (MGB).

OBJECTIVES

We aimed to describe the incidence, presentation, and surgical management of enteric leaks in patients who underwent laparoscopic MGB for morbid obesity.

SETTING

Private practice.

METHODS

An 8-year, 9-month retrospective chart review was performed on patients who had enteric leak requiring reoperation after MGB at a single institution.

RESULTS

Thirty-five of 2321 patients were included. Ninety-seven percent had symptoms. Arterial hypertension and heavy smoking were predicting factors of leaks occurrence post-MGB (P<.01). Enteric leak was diagnosed by systematic upper gastrointestinal series in 4 pts (11.4%) and by computed tomography with oral water soluble contrast in 4 of 31 pts (13%). In the other 27 patients, diagnosis of the leak was made intraoperatively. Eleven patients (32%) had leak arising from the gastric stapler line (type 1), 4 (11%) from the gastrojejunal anastomosis (type 2), and 20 (57%) from undetermined origin. The most common presentation was intra-abdominal abscess in type 1 and leaks of undetermined origin and generalized peritonitis in type 2. One third of the patients who underwent reoperation developed well-drained chronic fistula into the irrigation-drainage system, with complete healing in all patients without any further procedure. The mean hospital stay was 19 days with no mortality reported.

CONCLUSION

Enteric leak leading to intra-abdominal sepsis post-MGB is rare (1.5%) An operative aggressive management based on clinical symptoms is the treatment of choice allowing no postoperative leak-related mortality and complete healing.

Pure transumbilical SILS gastric bypass with mechanical circular gastrojejunal anastomosis feasibility

BACKGROUND

Since Wittgrove introduced the laparoscopic version of the gastric bypass in 1994, the interest still remains in the decrease of the abdominal wall trauma in order to optimize the benefits of laparoscopy on postoperative pain, cosmesis, hospital stay, and convalescence in bariatric patients. This work is to report the feasibility of gastric bypass surgery by a pure transumbilical single-incision laparoscopic surgery (SILS) with a mechanical circular gastrojejunal anastomosis.

METHODS

Thirty-four patients (10 males and 24 females) were offered to receive gastric bypass with circular mechanical gastrojejunal anastomosis by Single Incision Laparoscopic Surgery (SILS) using pure transumbilical access. Anastomotic leak occurrence was the primary end-point. Patients demographics, operative time, additional trocarts, hemorrhage, intra abdominal abscess, length of post-operative stay, readmission, 30 days death, gastrojejunal anastomosis stricture, marginal ulcers, reflux complains, seromas, incisional hernias, and % excess BMI loss were also recorded in a prospective database.

RESULTS

Primary end-point showed no anastomotic leak occurrence during the hospital stay or during the first 30 post-operative days. SILS gastric bypass with a circular mechanical gastrojejunal anastomosis is feasible and seems to be safe.

Zero frequency of internal hernias after laparoscopic double loop gastric bypass without closure of mesenteric defects

PURPOSE

Laparoscopic Roux-en-Y gastric bypass is among the most effective surgical procedures for morbid obesity; however, one of its most common long-term complications is internal hernia. The purpose of this study was to evaluate the incidence of internal hernia in patients undergoing a new gastric bypass surgical technique known as "double loop" without closure of the mesenteric defects.

METHODS

We reviewed 44 patients with morbid obesity, who underwent laparoscopic double loop gastric bypass. There were 34 women and 10 men, followed up for a mean period of 18 ± 3 months, mainly by periodic medical examinations and blood tests.

RESULTS

The initial body mass index (BMI) was 44.23 ± 4.7 and the mean % excess weight (%EW) was 105.83 ± 24.41. After 18 postoperative months, the mean BMI was 29.68 ± 3.7 kg/m(2), representing a mean loss of 14.5 BMI units, with the mean % excess weight loss (%EWL) of 64.33 ± 13.47. No cases of internal hernia were recorded.

CONCLUSIONS

Laparoscopic double loop gastric bypass without closure of the mesenteric defects is a safe and feasible procedure. A longer observational follow-up and a large number of patients are required to confirm significant results.

Novel/experimental bariatric techniques

Due to the documented effects regarding durable and pronounced weight loss as well as improvement/resolution of obesity-associated morbidity, the number of bariatric surgical procedures performed has increased in an 'epidemiologic' fashion during the last decade. Most common/established procedures used today have well-documented effects but are all associated with technique-specific advantages as well as shortcomings. In particular, complications in the short as well as long term constitute a drive for continuous development of new techniques. A common feature of such new techniques is to reduce the degree of surgical trauma by being less invasive. Some of the new techniques used for bariatric treatment have been in clinical practice for a long time. However, due to the lack of controlled data with documentation of their efficacy and risk of complications, these are still to be considered as experimental. Other techniques are newly being introduced, and therefore data on their potential use for treatment of morbidly obese patients are limited. In this article, an overview of some of the most important of such new techniques is given. Some recently presented methodologies in which very sparse documentation is present, but which have been appreciated for being innovative and sometimes controversial, are also mentioned.

Initial experience of single-port surgery assisted by percutaneous instruments for gastric bypass: a combination of safety and minimally invasive surgery

BACKGROUND

We present here the first reported cases of patients undergoing gastric bypass with a hybrid technique that involves a new concept of percutaneous instruments and provides the advantages of minimally invasive single-port surgery while maintaining the triangulation, safety, and timing of operative procedures.

METHODS

This was a prospective pilot study of eight patients selected for gastric bypass between December 2011 and January 2012 and treated by a technique that combined single SSL port and percutaneous surgical set PPS. We performed hand-sewn gastrojejunostomy in all cases. We analyzed preliminary results at 1 month and focused on the feasibility of the technique, duration of surgery, perioperative complications, and cosmetic results. The Ethics Committee of our institution approved this study and we obtained the informed consent of each patient.

RESULTS

We completed the procedure successfully in all patients. No conversions to laparotomy or classic laparoscopy were required. The average time of surgery was 112 min (85-155). Length of hospital stay was 4 days (3-5). One patient was re-admitted on the seventh postoperative day for gastrointestinal bleeding from the gastrojejunostomy suture and treated by endoscopic clipping. Residual scars were less than 2 cm for the single midline port and 2 mm for the percutaneous instruments.

CONCLUSIONS

This new technique combines the advantages of single-port surgery with the safety of conventional laparoscopy by using percutaneous instruments and leaves minimal scarring. It is likely that the use of percutaneous instrumentation will become widespread in all areas of laparoscopic surgery.

Transumbilical laparoscopic Roux-en-Y gastric bypass with hand-sewn gastrojejunal anastomosis

Single-port laparoscopic surgery has undergone significant development over the past 5 years. Single port is used in various procedures, including bariatric surgery. The aim of this paper is to describe a surgical technique for gastric bypass with a transumbilical approach (transumbilical gastric bypass-TUGB) with hand-sewn gastrojejunostomy, in selected patients who may be benefited by a better cosmetic result. The procedure begins with a transumbilical vertical incision. We use the GelPOINT single-port device and a 5-mm assistant trocar in the left flank (in the first two cases, a 2-mm subxiphoid liver retractor was used). A gastric pouch is made and calibrated with a 36-Fr bougie. The gastrojejunal anastomosis is performed by hand-sewing in two layers. A Roux-en-Y with a biliary limb of 50 cm and an alimentary limb of 120 cm is performed with a stapler. Three women were subjected to TUGB. The women were aged 28, 31, and 42 years; they had body mass indexes of 40.3, 33, and 38.2; and the operating times were 150, 200, and 150 min, respectively. The first two women underwent a Roux-en-Y gastric bypass (RYGB), and the last woman underwent a RYGB with a resection of the stomach remnant. There were no conversions to open or multitrocar techniques. No complications or deaths occurred. The three patients were satisfied with the cosmetic result. The technique described for TUGB is a feasible procedure for surgeons who have previous experience with the transumbilical approach.

Totally stapled gastrojejunal anastomosis using hybrid NOTES: single 12-mm trocar approach in a porcine model

BACKGROUND

The aim of this study was to evaluate the feasibility of a totally stapled gastrojejunal anastomosis performed using one transabdominal 12-mm trocar and a gastroscope in a porcine model.

METHODS

The procedure was carried out on six domestic pigs weighing 45 kg using a hybrid technique with a gastroscope and a 12-mm Hasson trocar, positioned in the left hypochondrium. At the end of the procedure a mechanical circular 21-mm gastrojejunal anastomosis was performed by inserting the stapler through a small gastrotomy after enlarging the trocar incision.

RESULTS

In all six cases the procedure was completed through a single 3 cm abdominal incision and without complications. The mean operating time was 2 h, and endoscopic investigation showed that the anastomoses were intact, patent, and airtight.

CONCLUSIONS

Totally stapled gastrojejunal anastomosis using a hybrid NOTES-single 12-mm trocar approach is a feasible procedure in the porcine model. Further survival studies are warranted, particularly to evaluate the functional results of this procedure.

Future directions in bariatric surgery

Bariatric surgery is a field in rapid evolution, and the speed of this evolution has been accelerating over the last several decades. A thorough understanding of past developments is crucial to anticipating the future intelligently. The trends that have driven evolution historically often persist, and continue to be influential in the future. With this in mind, this article briefly outlines the historical and current trends in bariatric surgery, and follows the trajectory of these trends into the future to anticipate the technologies and techniques that will be most important to the field in the coming years.

[Single port access surgery in colorectal disease: preliminary results]

INTRODUCTION

The aim of this study is to evaluate the single port access technique in colorectal disease, as regards its suitability to oncological criteria, reliability, safety and reproducibility of the technique. A descriptive and prospective case study is performed describing the preliminary results of our series.

MATERIAL AND METHODS

We present a series of 24 patients with colorectal disease who underwent single port access surgery using a Gel point® device between June and December 2010. The operations performed were, 9 right hemicolectomies, 9 sigmoid resections, 4 high anterior resections, 1 left hemicolectomy due to a tumour of the splenic flexure, and 1 sub-total colectomy.

RESULTS

The mean surgical time for the right colon was 82.8 minutes (range 40-170), 122.1 minutes (range 75-200) for the left colon and rectum, and 270 minutes for the sub-total colectomy. The median number of ganglia resected was 22 (range: 3-27) for the right colon and 21 (range: 11-28) left colon/rectum. The mean length of the surgical specimen was 20.37 cm (range: 16.2 - 27.5) for the right colon, and 24.92 cm (range: 14.5 - 31) for the left colon/rectum. The median overall hospital stay was 6 days (range: 5-13). Morbidity was 8.3% (2 patients); one with an occlusion due to adhesions, and another with a leak in the anastomosis. There were no deaths.

CONCLUSIONS

The single port access technique is safe and reproducible, maintaining oncological criteria, for surgeons accustomed to colorectal surgery by conventional laparoscopy. A larger number of cases would be required to standardise the technique.

Single-incision laparoscopic bariatric surgery

BACKGROUND

Bariatric surgery has been established as the best option of treatment for morbid obesity. In recent years single-incision laparoscopic surgery (SILS) has emerged as another modality of carrying out the bariatric procedures. While SILS represents an advance, its application in morbid obesity at present is limited. In this article, we review the technique and results of SILS in bariatric surgery.

METHODS

The PubMed database was searched and totally 11 series reporting SILS in bariatric surgery were identified and analyzed. The case reports were excluded. Since 2008, 114 morbidly obese patients receiving SILS bariatric surgeries were reported.

RESULTS

The procedures performed included SILS gastric banding, sleeve gastrectomy and gastric bypass. No mortality was reported in the literatures. Sixteen patients (14.05%) needed an additional incision for a liver retractor, a trocar or for conversion. Only one complication of wound infection was reported in these series. All the surgeons reported that the patients were highly satisfied with the scar.

CONCLUSION

Because of abundant visceral and subcutaneous fat and multiple comorbidities in morbid obesity, it is more challenging for surgeons to perform the procedures with SILS. It is clear that extensive development of new instruments and technical aspects of these procedures as well as randomized studies to compare them with traditional laparoscopy are essential before these procedures can be utilized in day-to-day clinical practice.

Transvaginal-hybrid vs. single-port-access vs. 'conventional' laparoscopic cholecystectomy: a prospective observational study

PURPOSE

In the recent past, access to the peritoneal cavity has involved primarily 'natural orifice transluminal' and 'single-port access' techniques, which are based on laparoscopy. The most frequently performed procedure using these new developments is cholecystectomy. Few studies compare more than one 'new' method with the 'golden standard' of laparoscopic cholecystectomy. Here we present the results of the first prospective observational study comparing standard laparoscopic cholecystectomy with single-port cholecystectomy as well as transvaginal-hybrid cholecystectomy.

METHODS

Fifty-one patients were included in a prospective observational study (20 four-trocar laparoscopic, 15 transvaginal-hybrid, 16 single-port cholecystectomies). Endpoints of the study were operative time, length of hospital stay and postoperative level of pain (numeric analogue score, while coughing). Conversion rates and complications are reported as well.

RESULTS

Median operating times did not differ among all three access methods [55 (35-135) min vs. 65 (35-95) min vs. 68 (35-98) min]. Hospital stay was significantly shorter in the transvaginal-hybrid group [3 (3-12) days] and in the single-port group [3 (1-9) days], compared to the four-trocar laparoscopic group [4 (2-17) days]. Pain score was significantly diminished in the transvaginal-hybrid group during the early postoperative course.

CONCLUSIONS

Concerning the length of hospital stay, transvaginal-hybrid cholecystectomy and single-port cholecystectomy appear to be superior to 'conventional' laparoscopic cholecystectomy. Additionally, transvaginal-hybrid access is associated with significantly less pain in the early postoperative course.

Laparoendoscopic single-site surgery in gynecology: review of literature and available technology

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.