Selection of a Port for Use in Laparoendoscopic Single-siteSurgery

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

Objectives

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

Patients and methods

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

Results

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

Conclusion

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

Current status of robotic laparoendoscopic single-site partial nephrectomy

Robotic laparoendoscopic single-site partial nephrectomy is increasingly carried out in an attempt to improve the cosmetic outcome of minimally-invasive procedures. However, the actual role of this novel technique remains to be determined. The present article reviews evidence and examines updates of robotic laparoendoscopic single-site partial nephrectomy outcomes reported in more contemporary studies. A comprehensive online systematic search of PubMed, Scopus and Web of Science databases according to Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria recommendations was carried out in January 2014, identifying data from 2008 to 2014 regarding robotic laparoendoscopic single-site partial nephrectomy. The majority of medical evidence to date is based on case reports or retrospective studies. Current studies show that robotic laparoendoscopic single-site partial nephrectomy is a feasible procedure carried out in an acceptable length of operative time, and resulting in a desirable cosmetic outcome and less postoperative pain. However, comparable studies show that robotic laparoendoscopic single-site partial nephrectomy is inferior to the conventional approach, especially with regard to warm ischemia time. Furthermore, the numerous limitations that exist with the utilization of the current commercial single-site devices make robotic laparoendoscopic single-site PN more challenging and more complicated for surgeons compared with conventional procedures. Further significant improvements, along with more studies, are required in order to develop the ideal robotic laparoendoscopic single-site robotic platform and overcome the current limitations. For the time being, robotic laparoendoscopic single-site partial nephrectomy procedures could be applicable in patients with low tumor size and complexity, and should not be routinely applied in all cases.

Robotic laparoendoscopic single-site transumbilical partial nephrectomy: functional and oncologic outcomes at 2 years

OBJECTIVE

To assess the functional and oncologic outcomes of robotic laparoendoscopic single site surgery (LESS) partial nephrectomy with a minimum of 2-year follow-up.

MATERIALS AND METHODS

Thirty-nine consecutive patients who had undergone robotic LESS partial nephrectomy were identified with a minimum of 2-year follow-up. Perioperative data were recorded along with functional and oncologic outcomes. Patient's estimated glomerular filtration rate was determined using the Modification of Diet in Renal Disease formula. A univariate analysis was performed using independent samples t test. Data are presented as medians with interquartile range and counts or frequencies with percentages or proportion.

RESULTS

The median age was 51 (45, 59). The median resected tumor size was 3 cm (2, 3.7), and the median operative time was 185 minutes (135, 237). The median estimated blood loss was 150 mL (70, 150), and the median warm ischemia time was 25 minutes (17, 35). The estimated glomerular filtration rate did not change significantly at 24 month follow-up with a mean decrease of 6.4 mL/minute/1.73 m(2) (-7.5%, P = .22). Renal cell carcinoma was confirmed in 33 patients (85%) with tumor stage pT1a in 26 patients (78%). There was 1 patient with a positive surgical margin. At a median follow-up of 26 months (24, 32), there was no local recurrence and only 1 distant recurrence was detected.

CONCLUSION

This study appears to be the first to report on intermediate term functional and oncologic outcomes after robotic LESS partial nephrectomy. It has shown comparable results with other minimal invasive surgical options.

Comparison of laparoscopic skills performance between single-site access (SSA) devices and an independent-port SSA approach

BACKGROUND

This study compared the performance of validated laparoscopic tasks on four commercially available single-site-access (SSA) devices with the performance of those tasks on an independent-port (IP) SSA setup.

METHODS

A prospective, randomized comparison of laparoscopic skills performance on four access devices (ADs) (GelPOINT, SILS Port, SSL Access System, TriPort) and one IP-SSA setup was conducted. A laparoscopic trainer box was used to train 18 (2nd- to 4th-year) medical students, four surgical residents, and five attending surgeons to proficiency in multiport laparoscopy using four laparoscopic drills (i.e., peg transfer, bean drop, pattern cutting, extracorporeal suturing). Drills then were performed in random order on each IP-SSA and AD-SSA setup using straight laparoscopic instruments. Repetitions were timed and errors recorded. Data are presented as mean ± standard deviation. Statistical analysis was performed by two-way analysis of variance (ANOVA) with Tukey HSD post hoc tests.

RESULTS

The attending surgeons had significantly faster total task times than the residents or students (P < 0.001), but the difference between the residents and students was not significant. Pair-wise comparisons showed significantly faster total task times for the IP-SSA setup than for all four AD-SSAs within the student group only (P < 0.05). The total task times for the residents and attending surgeons showed a similar profile, but the differences were not significant. When the data for the three groups were combined, the total task time was less for the IP-SSA setup than for each of the four AD-SSA setups (P < 0.001). Similarly, the IP-SSA setup was significantly faster than three of the four AD-SSA setups for peg transfer, three of the four setups for pattern cutting, and two of the four setups for suturing. No significant differences in error rates between the IP-SSA and AD-SSA setups were detected.

CONCLUSIONS

Compared with an IP-SSA laparoscopic setup, AD-SSAs are associated with longer task performance times in a trainer box model, independently of the level of training. Task performance was similar across the different SSA devices.

Laparo-endoscopic single-site surgery: recent advances in urology

Significant advances have been achieved in the field of urologic laparo-endoscopic single-site surgery (LESS) since the first reported clinical series in 2007. The aim of the present review paper is to summarize and critically analyze the most recent advances in the field of urologic LESS. A literature review was performed using PubMed to retrieve publications related to LESS in urology over the last two years (from January 2011 to May 2012). In the free-text protocol, the following terms were applied: LESS; single port laparoscopy; single incision laparoscopy. Despite unsolved challenges, LESS can be regarded as an emerging trend in minimally invasive urologic surgery and it has significantly evolved, becoming a widely applicable technique in a relatively short time. Outcomes demonstrate that a broad range of procedures can be effectively and safely done, given a solid laparoscopic surgical background and stringent patient-selection criteria. The recent introduction of a purpose-built instrumentation is likely to further foster the application of robotics to LESS. Further improvements are needed before this technique might reach a widespread adoption. Future advances in the field of robotic technology are expected to overcome the current limitations of LESS.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

INTERVENTION

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

MEASUREMENTS

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

RESULTS AND LIMITATIONS

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

CONCLUSIONS

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