Laparo-endoscopic single-site left transperitoneal adrenalectomy

Minimally invasive techniques in benign and malignant adrenal tumors

Minimally invasive adrenalectomy has become the main treatment modality for most adrenal lesions. Both laparoscopic transabdominal and retroperitoneoscopic approaches are safe and feasible options, each with respective advantages, including better surgical outcomes, fewer complications, and faster recovery over open adrenalectomy. While open surgery remains a valid modality in treatment of adrenocortical cancer in the presence of some findings such as invasion, robotic platforms, and minimally invasive surgery have gained popularity as technology continues to evolve. Organ preservation during adrenalectomy is feasible in some conditions to prevent adrenal insufficiency. Ablative technologies are increasingly utilized in benign and malignant tumors, including the adrenal gland, with various outcomes. A multidisciplinary team, an experienced surgeon, and a high-volume center are recommended for any surgical approaches and management of adrenal lesions. This review article evaluated recent findings and current evidence on minimally invasive adrenalectomy.

Comparison of Technical Details and Short-term Outcomes of Single-incision Versus Multiport Laparoscopic Adrenalectomy

To date, the single-incision laparoscopic surgery (SILS) technique has been applied to a wide range of general surgical procedures; however, there are still scant data and debates on adrenal procedures. The aim of this study was to compare surgical outcomes of single-incision versus laparoscopic multiport adrenalectomy. The patients were divided into 2 study groups on the basis of the surgical approach: SILS (group 1) and multiport laparoscopic surgery (group 2). Patient demographics and their perioperative and postoperative results were evaluated retrospectively from the medical records. A total of 80 patients were included in the study. There were 44 patients in group 1 and 36 patients in group 2. The average operative time, estimated blood loss, and tumor size were similar between the study groups. There were no mortalities in both groups and the mean duration of hospital stay was 3 days for both groups. Without using any single-incision access trocars and articulated instrumentation, we achieved the same surgical outcomes in our SILS adrenalectomy series compared with conventional multiport laparoscopy series in terms of postoperative short-term outcomes and cost-effectivity.

Robot-assisted laparoendoscopic single site adrenalectomy: A comparison of 3 different port platforms with 3 case reports

RATIONALE

Laparoscopic adrenalectomy is currently the standard of care for adrenal lesion. Minimal invasive laparoscopic surgery such as laparoendoscopic single site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) have been developed to improve cosmetic outcomes and reduce postoperative pain. However, there are still some problems related to instruments and port limitation during LESS surgery. Robot-assisted laparoscopic surgery may help to overcome these problems, and port platforms selection is an important issue.

PATIENT CONCERNS

Three cases received robot-assisted LESS adrenalectomy due to adrenal tumor were enrolled. Blood loss, hospital stay, and analgesia injection were compared.

DIAGNOSES

Preoperative evaluations were done in a usual manner. Benign tumors were suspect for two patients, while metastatic tumor could not be excluded for the other patient with prior malignancy history. The pathology reports were all benign adrenal cortical adenoma after operation.

INTERVENTIONS

Three different port platforms, Da Vinci Single-Site Surgical Platform, GelPOINT, and homemade glove port were used. Trans-peritoneal approach was used for two patients, while the other one received trans-retroperitoneal approach. The advantage and disadvantage of different port platforms were discussed.

OUTCOMES

All patients underwent the operation smoothly without major complications or conversion to open surgery. Blood loss amount was small, hospital stay was short, and only one patient received one single dose of opioid analgesia injection after the surgery.

LESSONS

The main problems of LESS are the loss of a working triangle and the limitations of the instruments. Robot-assisted LESS may help surgeons overcome part of these problems. Many different port platforms are available, and based on our initial experience, we believe that the GelPoint may be a more suitable platform, for it maintains the endo-wrist function of the Da Vinci instruments, and allows the surgeon to design the position of ports freely to minimize external and internal collision.

Outcomes of laparoscopic adrenalectomy Conventional technique versus laparo-endoscopic single-site surgery

OBJECTIVE

Perform a comparative analysis of the outcomes of conventional laparoscopic adrenalectomy (LC) and the newly introduced laparo-endoscopic single-site surgery (LESS) over ten years.

MATERIAL AND METHOD

We retrospectively reviewed the experience of a single surgeon from our medical centre with laparoscopic adrenalectomy, either through LC or LESS, with 75 patients between August 2005 and June 2015. Here we describe: age, sex, size, lateralization, preoperative diagnosis, total operating time, intraoperative bleeding, conversion to open surgery, mean hospital stay, intra- and postoperative complications and histopathology report. We used Fischer's and the Chi-squared tests to compare categorical data and Student's T-test for a comparison of the means with a normal distribution. Statistical significance was determined when p<0.05.

RESULTS

LC was performed in 51 patients, and LESS in 24 patients. No statistical significance was found for total operating time (LC: 103.9±13.21min vs. LESS: 101.46±13.65min; p=0.07), estimated bleeding (LC: 258.82±136.92cc vs. LESS: 131,25±36,74cc; p=0.46), intraoperative complications (5 cases in LC, none in LESS; p=0.47), nor for postoperative complications (two in LC vs. one in LESS; p=0.69), as catalogued according to the modified Clavien classification system. We detected a statistical significance difference in the comparisons of the mean hospital stay, which was reduced in LESS (LC: 3.55±0.69 days vs. LESS: 2.21±0.31 days; p=0.01).

CONCLUSIONS

Adrenalectomy with LC is the approach of choice for surgical treatment of adrenal pathologies. The LESS technique is safe, improves the cosmetic results, and does not increase mortality if performed by experienced teams.

An all-joint-control master device for single-port laparoscopic surgery robots

PURPOSE

Robots for single-port laparoscopic surgery (SPLS) typically have all of their joints located inside abdomen during surgery, whereas with the da Vinci system, only the tip part of the robot arm is inserted and manipulated. A typical master device that controls only the tip with six degrees of freedom (DOFs) is not suitable for use with SPLS robots because of safety concerns.

METHODS

We designed an ergonomic six-DOF master device that can control all of the joints of an SPLS robot. We matched each joint of the master, the slave, and the human arm to decouple all-joint motions of the slave robot. Counterbalance masses were used to reduce operator fatigue. Mapping factors were determined based on kinematic analysis and were used to achieve all-joint control with minimal error at the tip of the slave robot.

RESULTS

The proposed master device has two noteworthy features: efficient joint matching to the human arm to decouple each joint motion of the slave robot and accurate mapping factors, which can minimize the trajectory error of the tips between the master and the slave.

CONCLUSIONS

We confirmed that the operator can manipulate the slave robot intuitively with the master device and that both tips have similar trajectories with minimal error.

Laparoendoscopic single-site surgery adrenalectomy - own experience and matched case-control study with standard laparoscopic adrenalectomy

Introduction

At our institution, laparoendoscopic single-site surgery (LESS) has been established as a technique for laparoscopic nephrectomy since 2011, and since 2012 in selected cases for adrenalectomy (AE) as well.

Aim

To compare LESS AE with standard laparoscopic AE (SLAE).

Material and methods

Between 3/2012 and 7/2014, 35 adrenalectomies were performed. In 18 (51.4%), a LESS approach was chosen. Indications were strictly non-complicated cases (body mass index (BMI) < 34 kg/m², tumour ≤ 7 cm, non-malignant aetiology, no previous surgery). All LESS procedures were done by one surgeon. Standard equipment was a 10 mm rigid 0° camera, Triport+, one pre-bent grasper, and a sealing instrument. The approach was pararectal in all cases except one (transumbilical in a slim man). Three patients with LESS were excluded (2 partial AEs only, one adrenal cancer converted to SLAE and then to open surgery). These 15 LESS AE procedures were compared to 15 SLAEs with similar characteristics chosen among 54 SLAEs performed in the period 1/2008–2/2012.

Results

In 8 cases (53.3%) of LESS AE, a 3 mm port was added to elevate the liver/spleen. Mean parameters of LESS AE vs. SLAE (Wilcoxon test): maximal tumour diameter 43.7 mm vs. 36.1 mm (p = 0.28), time of surgery 63.3 min vs. 55.3 min (p = 0.22), blood loss 38.0 ml vs. 38.0 ml (p = 0.38), BMI 26.9 kg/m² vs. 28.5 kg/m² (p = 0.13), discharge from hospital 5.4 days vs. 3.9 days (p = 0.038). There were no complications in either group.

Conclusions

The LESS AE is feasible in selected cases, especially small left-sided tumours in thin patients with no history of previous abdominal operations, but requires an additional port in half of the cases.

Perioperative outcomes and cosmesis analysis of patients undergoing laparoendoscopic single-site adrenalectomy: a comparison of transumbilical, transperitoneal subcostal, and retroperitoneal subcostal approaches

OBJECTIVE

To compare the perioperative outcomes and cosmetic results for transumbilical (TU), transperitoneal subcostal (TS), and retroperitoneal subcostal (RS) laparoendoscopic single-site surgery (LESS) adrenalectomy (AD).

MATERIALS AND METHODS

An observational study was conducted of patients who were had undergone LESS-AD using a TU (n = 9), TS (n = 17), or RS (n = 16) approach. The perioperative outcomes and comprehensive cosmetic results were analyzed statistically.

RESULTS

The RS-LESS-AD patients were more likely to have an indication for surgery of a right adrenal mass (TU-LESS-AD 11.1% and TS-LESS-AD 5.9% vs RS-LESS-AD 43.8%, P = .016) or partial AD (0% vs 9% vs 87.5%, P < .001). The TU-LESS-AD procedures had a longer median operative time but significantly lower postoperative pain. The median cosmesis rating for the TU-LESS-AD, TS-LESS-AD, and RS-LESS-AD scar photographs was 10, 8, and 9, respectively (P = .010). Only the cosmesis ratings after the photograph viewing were statistically significant across the surgical approaches (9.5 vs 8 vs 9, P = .048). Assuming equivalent surgical complication risks across the approaches, the preference for future TU-LESS-AD, TS-LESS-AD, RS-LESS-AD was 86%, 6%, and 8%, respectively. As the theoretical risk of TU-LESS-AD increased, the preference for TU-LESS-AD decreased and the preference for TS-LESS-AD and RS-LESS-AD increased.

CONCLUSION

LESS-AD is an effective procedure with a high level of cosmesis using a TU, TS, or RS approach. The surgeon's background, patient characteristics, and cosmetic perception must be carefully considered as a part of the entire clinical picture so that LESS-AD can be used for patients who will derive the most benefit.

Laparoendoscopic single-site adrenalectomy versus conventional laparoscopic surgery: a systematic review and meta-analysis of observational studies

PURPOSE

To assess the surgical efficacy and potential advantages of laparoendoscopic single-site adrenalectomy (LESS-AD) compared with conventional laparoscopic adrenalectomy (CL-AD) based on published literature.

METHODS

An online systematic search in electronic databasesM including Pubmed, Embase, and the Cochrane Library, as well as manual bibliography searches were performed. All studies that compared LESS-AD with CL-AD were included. The outcome measures were the patient demographics, tumor size, blood loss, operative time, time to resumption of oral intake, hospital stay, postoperative pain, cosmesis satisfaction score, rates of complication, conversion, and transfusion. A meta-analysis of the results was conducted.

RESULTS

A total of 443 patients were included: 171 patients in the LESS-AD group and 272 patients in the CL-AD group (nine studies). There was no significant difference between the two groups in any of the demographic parameters expect for lesion size (age: P=0.24; sex: P=0.35; body mass index: P=0.79; laterality: P=0.76; size: P=0.002). There was no significant difference in estimated blood loss, time to oral intake resumption, and length of stay between the two groups. The LESS-AD patients had a significantly lower postoperative visual analog pain score compared with the CL-AD group, but a longer operative time was noted. Both groups had a comparable cosmetic satisfaction score. The two groups had a comparable rate of complication, conversion, and transfusion.

CONCLUSIONS

In early experience, LESS-AD appears to be a safe and feasible alternative to its conventional laparoscopic counterpart with decreased postoperative pain noted, albeit with a longer operative time. As a promising and emerging minimally invasive technique, however, the current evidence has not verified other potential advantages (ie, cosmesis, recovery time, convalescence, port-related complications, etc.) of LESS-AD.

Current status and future directions of robotic single-site surgery: a systematic review

CONTEXT

Despite the increasing interest in laparoendoscopic single-site surgery (LESS) worldwide, the actual role of this novel approach in the field of minimally invasive urologic surgery remains to be determined. It has been postulated that robotic technology could be applied to LESS to overcome the current constraints.

OBJECTIVE

To summarize and critically analyze the available evidence on the current status and future of robotic applications in single-site surgery.

EVIDENCE ACQUISITION

A systematic literature review was performed in April 2011 using PubMed and the Thomson-Reuters Web of Science. In the free-text protocol, the following terms were applied: robotic single site surgery, robotic single port surgery, robotic single incision surgery, and robotic laparoendoscopic single site surgery. Review articles, editorials, commentaries, and letters to the editor were included only if deemed to contain relevant information. In addition, cited references from the selected articles and from review articles retrieved in the search were assessed for significant manuscripts not previously included. The authors selected 55 articles according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria.

EVIDENCE SYNTHESIS

The volume of available clinical outcomes of robotic LESS (R-LESS) has considerably grown since the pioneering description of the first successful clinical series of single-port robotic procedures. So far, a cumulative number of roughly 150 robotic urologic LESS cases have been reported by different institutions across the globe with a variety of techniques and port configurations. The feasibility of robot-assisted single-incision colorectal procedures, as well as of many gynecologic procedures, has also been demonstrated. A novel set of single-site instruments specifically dedicated to LESS is now commercially available for use with the da Vinci Si surgical system, and both experimental and clinical use have been reported. However, the current robotic systems were specifically designed for LESS. The ideal robotic platform should have a low external profile, the possibility of being deployed through a single access site, and the possibility of restoring intra-abdominal triangulation while maintaining the maximum degree of freedom for precise maneuvers and strength for reliable traction. Several purpose-built robotic prototypes for single-port surgery are being tested.

CONCLUSIONS

Significant advances have been achieved in the field of R-LESS since the first reported clinical series in 2009. Given the several advantages offered by current the da Vinci system, it is likely that its adoption in this field will increase. The recent introduction of purpose-built instrumentation is likely to further foster the application of robotics to LESS. However, we are still far from the ideal robotic platform. Significant improvements are needed before this technique might reach widespread adoption beyond selected centers. Further advances in the field of robotic technology are expected to provide the optimal interface to facilitate LESS.

Current status of laparoendoscopic single-site surgery in urologic surgery

Since the introduction of laparoscopic surgery, the promise of lower postoperative morbidity and improved cosmesis has been achieved. Laparoendoscopic single-site surgery (LESS) 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. However, comparative series between conventional laparoscopy and LESS for different procedures suggest a non-inferiority of LESS over standard laparoscopy, but the only objective benefit remains an improved cosmetic outcome. Challenging ergonomics, instrument clashing, lack of true triangulation, and in-line vision are the main concerns with LESS surgery. Various new instruments have been designed, but only experienced laparoscopists and well-selected patients are pivotal for a successful LESS procedure. Robotic-assisted LESS procedures have been performed. The available robotic platform remains bulky, but development of instrumentation and application of robotic technology are expected to define the actual role of these techniques in minimally invasive urologic surgery.

Laparoendoscopic single site (LESS) splenectomy with a conventional laparoscope and instruments

LESS splenectomy appears to be a feasible procedure that can be performed safely and may have higher patient satisfaction that conventional laparoscopic splenectomy.

Background and Objectives:

We present 2 cases of laparoendoscopic single site surgery (LESS) splenectomy performed with a conventional laparoscope and instruments, and the use of a novel internal retraction device.

Methods:

One patient underwent LESS splenectomy for idiopathic thrombocytopenia purpura (ITP), and a pediatric patient with sickle cell disease underwent LESS splenectomy and cholecystectomy. In each case, a 2-cm vertical incision was made within the confines of the umbilical ring, and a SILS port (Covidien, Norwalk CT) inserted. A 5-mm, 30-degree laparoscope and standard 5-mm instruments were used. After isolation of the splenic hilum, one 5-mm trocar of the SILS port was upsized to 12mm, and a laparoscopic stapler was used to divide the splenic artery and vein. An internal retractor consisting of a laparoscopic bulldog clamp with a hook attachment was used to retract the gallbladder, and to secure the specimen retrieval bag during splenic extraction, which eliminated the need for a fourth trocar.

Results:

Total operative time was 160 minutes for the LESS splenectomy, and 216 minutes for the LESS splenectomy and cholecystectomy. Both procedures were successfully completed with conventional instrumentation and a SILS port, without the need for additional incisions or trocars. No complications occurred, and both patients had an uneventful recovery.

Conclusions:

LESS splenectomy is a feasible procedure that can be performed safely. Although articulating instruments and laparoscopes may offer advantages, they are not necessary for performing LESS splenectomy.

Single-incision laparoscopic adrenalectomy for primary aldosteronism: report of a case

We herein report the first case of a single-incision laparoscopic access (SILA) adrenalectomy in Japan. A 74-year-old woman who was a hepatitis B virus carrier was referred to our hospital because of an abnormal screening result during a routine health checkup. Abdominal computed tomography and an endocrinologic workup revealed a 2-cm left adrenal tumor with primary aldosteronism. We prioritized the safety of the SILA adrenalectomy by choosing a left lower abdominal approach. A SILS port was inserted through a 2.5-cm incision. An ultrasonic coagulator was the main tool used during the surgical procedure. The duration of the surgery was 105 min and the blood loss was 1 ml. This result was comparable to that of a conventional laparoscopic adrenalectomy. Based on our experience, an SILA adrenalectomy is thus considered to be feasible and safe, with better cosmetic results and a greater overall patient satisfaction than that of a conventional laparoscopic adrenalectomy. However, further studies will be necessary before the universal adoption of this new technique can be considered.

Urologic Laparoendoscopic Single-Site Surgery (LESS): current status

BACKGROUND

The evolution of minimally invasive surgery led to the development of laparo-endoscopic single-site surgery (LESS).

DISCUSSION

The feasibility of almost all types of urologic procedures has been shown. Comparative series between conventional laparoscopy and LESS for different kidney procedures suggest a non-inferiority of LESS over standard laparoscopy but the only objective benefit remains an improved cosmetic outcome. Challenging ergonomics, instruments clashing, lacks of true triangulation, in-line vision are the main concerns of LESS surgery. LESS pre-bent and articulating instruments have been designed but only experienced laparoscopists and well-selected patients are pivotal for a successful LESS procedure. Da Vinci® assisted LESS procedures have been performed. The available robotic platform remains bulky, but innovative instruments and platforms may facilitate the future unrestricted development of LESS.

CONCLUSIONS

A steep learning curve limits the application of LESS procedures to well trained and experienced surgeons. Nevertheless, the adoption of LESS principles and the clinical experience with LESS techniques have significantly grown in the past few years worldwide. Improvements in the instruments and platforms will expand the application of LESS surgery, allowing us to better assess its advantages and disadvantages compared to other minimally invasive procedures.

Single-incision laparoscopic adrenalectomy

BACKGROUND

The aim of this study was to compare outcome measures between conventional transabdominal laparoscopic adrenalectomy and single-incision laparoscopic adrenalectomy (SILA).

METHODS

Between January 2006 and April 2010, a total of 96 patients underwent laparoscopic adrenalectomy. Of these, 74 (77.1%) underwent conventional transabdominal laparoscopic adrenalectomy (group 1) and 22 (32.9%) underwent SILA (group 2). Age, sex ratio, tumor size, operating time, blood loss, postoperative visual analog pain scale (VAS) scores, and duration of hospitalization were compared between the two groups.

RESULTS

The mean ages of the patients in groups 1 and 2 were 43.4 ± 12.3 and 43.3 ± 10 years, respectively (P = 0.7). The female:male ratios in groups 1 and 2 were 1.6:1 and 4.5:1, respectively (P < 0.0001). The mean tumor size was significantly larger in group 1 than in group 2 (4.7 ± 1.5 vs. 3.34 ± 1.06 cm, respectively; P = 0.093). No significant difference was found between group 1 and group 2 with respect to the mean operating time (68.4 ± 20.8 vs. 63.9 ± 16.9 min, respectively; P = 0.36) or the level of intraoperative blood loss (38 ± 26.5 vs. 48.4 ± 62.4 ml, respectively; P = 0.26). The postoperative VAS score was significantly lower in group 2 than in group 1 (2.05 ± 0.57 and 3.28 ± 0.63, respectively; P < 0.0001). The length of hospital stay was significantly higher in group 1 than in group 2 (3.04 ± 1.2 and 2.45 ± 0.96 days, respectively; P = 0.04).

CONCLUSION

The findings of the present study suggest that SILA is as safe as conventional transabdominal laparoscopic adrenalectomy. Furthermore, SILA is associated with less pain and better cosmesis than the conventional laparoscopic procedure.

Pure SILS Floppy Nissen Fundoplication with Hiatal Repair: A Case Report

Background. Single-incision laparoscopic surgery has recently became popular on behalf of inventing less invasive procedures. In this paper, we present a case of Pure SILS Nissen Fundoplication. Patient and Methods. In February 2010 a 29-year old male patient with a 4 cm sliding hiatus hernia presenting with reflux symptoms had undergone a standard floppy Nissen Fundoplication with a hiatus repair via single 2 cm incision in umbilicus. Results. The procedure had obeyed the standard natural orifice surgery rules, and no needlescopic assistance for any stage of the operation was used so to be a pure single-incision procedure. The operation lasted for 120 minutes without any need of conversion, and the patient was discharged the following day of operation. Conclusion. In the recent time, hybrid single incision laparoscopy techniques have been defined with the use of extra-abdominal supplements for retraction of liver or stomach for Nissen procedure. In addition the main issue in single-incision upper GI and/or hiatus surgery is still the retraction of liver. We succeeded to retract the left lobe of liver through the incision and completed the operation without any need for supplemental access besides the umbilical incision till the end. SILS Hiatus Surgery can be safely and effectively done but the issue needs further clinical studies to state the efficacy when compared to standard laparoscopy.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

INTERVENTION

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

MEASUREMENTS

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

RESULTS AND LIMITATIONS

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

CONCLUSIONS

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

Laparoendoscopic Single-Site (LESS) Retroperitoneal Radical Nephrectomy in a Patient with Renal Cell Carcinoma Receiving Hemodialysis

We present here the patient undergoing laparoendoscopic single-site (LESS) retroperitoneal radical nephrectomy while receiving hemodialysis. An 81-year-old man under hemodialysis for 6 years was incidentally discovered to have two left renal masses with acquired cystic disease of the kidney (ACDK). A 4-cm flank incision for GelPort was made. Three trocars were inserted into the retroperitoneum through GelPort. After division of the renal vessels and ureter, the kidney was placed into the extraction bag and was retrieved through flank incision without any extra skin incision. There were no intraoperative and postoperative complications. This procedure offers an effective, minimally invasive therapeutic alternative to the standard laparoscopic technique in high-risk end-stage renal disease patients.

Left transperitoneal adrenalectomy with a laparoendoscopic single-site surgery combined technique: initial case reports

Laparoendoscopic single-site surgery (LESS) is a step toward the development of minimally invasive surgery. It is initially difficult for surgeons with limited experience to perform the surgery. We describe two cases of left adrenalectomy with a LESS combined with the addition of an accessory port. After a 2.5-cm skin incision was made at the level of the paraumbilicus to insert the primary 12-mm trocar for the laparoscope, a 5-mm nonbladed trocar was placed through the skin incision side-by-side with the primary trocar. A second 3-mm nonbladed trocar was then placed along the anterior axillary line; a multichannel trocar was not used as a single port. Both adrenalectomies were completed successfully. In patients with a minor adrenal tumor, a combined technique using LESS and an additional port is easier than LESS alone and may, therefore, be a bridge between the conventional laparoscopic approach and LESS.

Laparoendoscopic single site (LESS) adrenalectomy: technique and outcomes

PURPOSE

To describe the surgical technique, to analyze outcomes and to provide an overview of the current status of laparoendoscopic single site (LESS) adrenalectomy.

METHODS

A comprehensive PubMed search was performed for all relevant urological literature regarding LESS and adrenal surgery. In addition, experience gained at the authors' own institutions was considered. Clinical descriptive and comparative reports on LESS adrenal surgery procedures were analysed.

RESULTS

LESS adrenal surgery has been effectively performed for a number of indications. A wide variety of approaches (transperitoneal versus retroperitoneal, multichannel trocar versus multiple ports, trans- or extraumbilical) have been described. LESS adrenalectomy seems to be safe, taking more time than the standard laparoscopic counterpart but appears to offer the patient less postoperative discomfort. Technical difficulties of the procedure include the requirement of more time for adjustment of articulating instruments, longer 'one-handed' manipulation time, and a high peroperative tissue re-grasping rate.

CONCLUSIONS

The feasibility and safety of LESS adrenalectomy has been demonstrated. Only long-term follow-up outcomes will prove its benefits over conventional laparoscopy and define the role and the oncological safety of LESS adrenal surgery.

Laparoendoscopic single-site retroperitoneoscopic adrenalectomy: a matched-pair comparison with the gold standard

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.

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

CONTEXT

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

OBJECTIVE

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

Single-port laparoscopic surgery

Laparoscopic surgery performed through a single-incision is gaining popularity. The demand from the public for even less invasive procedures will motivate surgeons, industry, and academic centers to explore the possibilities and refine the technology. Although the idea seems quite attractive, there are several technological obstacles that are yet to be conquered by improved technology or additional training. The question of safety has yet to be answered and will require well-designed randomized control trials. Opponents to the approach argue that the size of the single incision (see Table 1) is frequently larger than all the standard laparoscopy incisions combined. On the other hand, proponents remember a similar argument from traditional open surgeons during the initial development of laparoscopy. That argument was quickly discredited when the immediate benefits oflaparoscopy were compared with patients undergoing surgery with small laparotomy incisions. During the development of a new technique, the learning curve exposes patients to risk and society to expense. LESS pioneers appear to have reached a level of comfort with technology and techniques that paves the way for scientific scrutiny. Perhaps, the surgical community will capitalize on this situation with randomized, controlled studies and sound evidence to support or refute the benefits of LESS. If we do not seize this opportunity, patient demand and industry's dual edge message of financial success versus fear of losing referrals will lead to a scenario similar to the development of laparoscopic cholecystectomy in the 1990s. Regardless of its future, the surgical community will still benefit from a renewed excitement as surgeons aim to continually reduce the amount of pain and trauma our patients must endure. In addition, technological advances on instrumentation will benefit the field of laparoscopy and improve patient care.