Applications of laparoscopic surgery in urology: impact on patient care

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.

Percutaneous Externally Assembled Laparoscopic vs Laparoendoscopic Single-Site Nephrectomy in a Porcine Model: A Prospective, Randomized, Blinded, Study

OBJECTIVE

To compare the outcomes between laparoendoscopic single-site (LESS) and a novel percutaneous externally assembled laparoscopic (PEAL) nephrectomy in an in vivo porcine model.

MATERIALS AND METHODS

Ten female farm pigs were randomized to LESS nephrectomy (5) or PEAL nephrectomy (5). Operative times, estimated blood loss, and intraoperative and postoperative complications were compared. The surgeons used a Likert scale to grade difficulty of peritoneal access, port placement, tool assembly, hilar dissection, closure, and overall difficulty of surgery. Scar assessment was performed by a blinded plastic surgeon using the Vancouver Scar Scale. Descriptive statistics were reported as median and range. The Mann-Whitney U test was used for continuous and ordinal variables. A p value <0.05 was considered significant.

RESULTS

Median operative time was significantly shorter in the PEAL group vs the LESS group (85 minutes vs 127 minutes, p = 0.03). Median Likert scores showed overall hilar dissection and nephrectomy to be significantly easier using PEAL compared with LESS (2 vs 9, p < 0.01 for both). The PEAL instruments left no visible scar at 5 feet in any animal, and only 1 out of 10 scars could be identified on physical examination.

CONCLUSIONS

The PEAL surgical paradigm demonstrates nearly scarless outcomes while providing shorter operative times and easier performance than LESS nephrectomy in a porcine model.

Percutaneous Externally Assembled Laparoscopic Instruments: Creation of a New Surgical Paradigm

OBJECTIVES

Laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) produce excellent cosmetic outcomes, but are technically challenging. The objective of this study was to test the functionality and feasibility of a novel minimally invasive surgical paradigm, which maintains triangulation but uses special externally assembled instruments to minimize the postoperative cosmetic impact.

METHODS

Percutaneous Externally Assembled Laparoscopic (PEAL) instruments have specialized 2.96-mm shafts with interchangeable 5-mm working tips that are assembled externally. First, 5-mm laparoscopic, PEAL, and 2-mm needlescopic instruments were tested to determine piercing force on fresh human cadaver organs. In a bench-top study, 20 subjects assembled and used PEAL instruments in five different skills tests that were also compared with the same tasks using conventional laparoscopic instruments. Finally, PEAL instrument functionality was tested in a four-porcine nephrectomy feasibility study.

RESULTS

PEAL (2.80 lbF) and 5-mm laparoscopic instruments (2.28 lbF) had a significantly higher mean organ piercing perforation force compared with needlescopic instruments (1.39 lbF, p < 0.05). Average assembly time of PEAL instruments was 31.08 seconds (range: 19.83-43.85). There were no significant differences in the amount of time needed for completion of the bench-top tasks between laparoscopic and PEAL instruments (p > 0.05 for all tasks). Four-porcine PEAL nephrectomies were completed with no complications and minimal blood loss (mean 7.5 mL). Mean operative time was 98.25 minutes (range 79-116).

CONCLUSION

PEAL tools are easily assembled, have similar safety and efficacy compared with standard laparoscopic tools, and are less likely to injure organs compared with needlescopic instruments. They function well during laparoscopic nephrectomy and may decrease the invasiveness of conventional laparoscopic instrumentation.

Single-port laparoscopic retroperitoneal surgery using a modified single-port device in urology

OBJECTIVES

To investigate the use of a flexible instrument platform in performing single-port laparoscopic retroperitoneal urologic surgeries and to verify the safety and feasibility of these surgeries.

METHODS

The homemade instrument platform consisted of two control loops and a powder-free surgical glove to form multichannels. 56 patients underwent this kind of single-port surgery for different urologic diseases, including radical nephrectomy in 31 patients, nephroureterectomy in 7 patients, partial nephrectomy in 8 patients, living donor nephrectomy in 4 patients, adrenalectomy in 3 patients, renal cyst surgery in 2 patients and ureterolithotomy in 1 patient.

RESULTS

All surgeries were completed successfully with no switch to conventional laparoscopic or open surgery. The mean hospital stay was 13.13 days (range 6-36). All patients were satisfied without major complications.

CONCLUSIONS

Retroperitoneal laparoendoscopic single-site surgery using our cost-effective homemade instrument platform appears to be a feasible and safe surgical strategy to perform retroperitoneal laparoscopic urologic surgery.

Ex-vivo training model for laparoendoscopic single-site surgery

BACKGROUND:

Laparoendoscopic single-site surgery (LESS) has recently been applied successfully in the performance of a host of surgical procedures. Preliminary consensus from the experts is that this mode of surgery is technically challenging and requires expertise. The transition from trainee to practicing surgeon, especially in complex procedures with challenging learning curves, takes time and mentor-guided nurturing. However, the trainee needs to use platforms of training to gain the skills that are deemed necessary for undertaking the live human case.

OBJECTIVE:

This article aims to demonstrate a step-by-step means of how to acquire the necessary instrumentation and build a training model for practicing steeplechase exercises in LESS for urological surgeons and trainees. The tool built as a result of this could set the platform for performance of basic and advanced skills uptake using conventional, bent and articulated instruments. A preliminary construct validity of the platform was conducted.

MATERIALS AND METHODS:

A box model was fitted with an R-Port^™ and camera. Articulated and conventional instruments were used to demonstrate basic exercises (e.g. glove pattern cutting, loop stacking and suturing) and advanced exercises (e.g. pyeloplasty). The validation included medical students (M), final year laparoscopic fellows (F) and experienced consultant laparoscopic surgeons (C) with at least 50 LESS cases experience in total, were tested on eight basic skill tasks (S) including manipulation of the flexible cystoscope (S1), hand eye coordination (S2), cutting with flexible scissors (S3), grasping with flexible needle holders (S4), two-handed maneuvers (S5), object translocation (S6), cross hand suturing with flexible instruments (S7) and conduction of an ex-vivo pyeloplasty.

RESULTS:

The successful application of the box model was demonstrated by trainee based exercises. The cost of the kit with circulated materials was less than £150 (Pounds Sterling). The noncamera handling skills (S2–S8) of the ex-vivo training model for LESS can distinguish between laparoscopically naïve fellows and experienced consultants in LESS. S4–S8 showed the highest level of construct validity, by accurately differentiating among the M, F and C groups.

CONCLUSION:

LESS requires a significant amount of skill and has an inherent steep learning curve. The ex-vivo model described provides a cost-effective means that a trainee or training unit can build for optimising preliminary skill acquisition in LESS for urological trainees. It has construct validity in several tasks. Such platform models should be tested further with an emphasis on rapid sequence uptake of optimal skills, prior to undertaking the live human case.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Urologic laparoendoscopic single-site surgery

Laparoendoscopic single-site surgery (LESS) probably represents the next evolutionary step in laparoscopic surgery. Although most urologic procedures are feasible by the LESS approach, significant challenges in terms of intraoperative ergonomics and requirement for laparoscopic skill are present. New, specially designed instruments and ports represent a solution for combating ergonomic problems during surgery. Documentation of the advantages of LESS over other approaches is currently lacking, as comparative clinical trials are scarce in the literature; in the absence of such information, the technique has been accepted at centers of laparoscopic expertise. Thus, further prospective randomized clinical trials are necessary to fully characterize the outcomes of LESS.

Laparoendoscopic single-site surgery in urology: where have we been and where are we heading?

One-port, single-incision laparoscopy is part of the natural development of minimally invasive surgery. Refinement and modification of laparoscopic instrumentation has resulted in a substantial increase in the use of laparoendoscopic single-site surgery (LESS) in urology over the past 2 years. Since the initial report of single-port nephrectomy in 2007, urologists have successfully performed various procedures with LESS, including partial nephrectomy, pyeloplasty, orchiectomy, orchiopexy, ureterolithotomy, sacrocolpopexy, renal biopsy, renal cryotherapy, and adrenalectomy. Further advancements in technology, such as magnetic anchoring and guidance systems, and robotic instrumentation, may allow broader application of this emerging surgical technique. Future research is required to determine the intraoperative and postoperative benefits of LESS in comparison with standard laparoscopy.

Devices for laparoendoscopic single-site surgery in urology

The quest to make minimally invasive techniques even more 'minimal' has generated a drive within the surgical community to explore novel ways of achieving this. This has led to surgeons attempting to either decrease the number of trocars placed through the abdominal wall or eliminate them completely. This led to the evolution of several approaches, including natural orifice translumenal endoscopic surgery (NOTES), single incision laparoscopic surgery (SILS), single port access surgery and one port umbilical surgery (OPUS) or E-NOTES. The most recent consensus on nomenclature involves the term laparoendoscopic single-site surgery (LESS). The transition from multiple port access surgery to single port access surgery represents a paradigm shift in reconstructive and extirpative surgery and is a testament to the recent advances in surgical technology. Successful LESS involves the use of articulating or bent instrumentation via a single large-caliber trocar or small, adjacent trocars. Advances in technology have led to the development of new laparoscopic access ports (R-Port and Quadriport by Advanced Surgical Concepts, Wicklow, Ireland; and Uni-X Single Port, PNavel Systems, Cleveland, OH, USA) capable of permitting several instruments to be inserted through multiple channels incorporated in, and as part of, a larger single port. The development of articulating and bent instrumentation permits triangulation intracorporeally despite the close proximity of several instruments via a single port. Currently, commercially available instruments can be broadly divided into articulating laparoscopic graspers and shears (Real Hand, Novare Surgical Systems, Cupertino, CA, USA; and Autonomy Laparo-angle, Cambridge Endo, Framingham, MA, USA), endoshears (Cambridge Endo), and laparoscopic needle drivers (Cambridge Endo). Despite the preliminary optimistic results in the outcomes of LESS, an experienced laparoscopic skill set is essential for the safe and effective completion of surgery.

Intact specimen extraction in laparoscopic nephrectomy procedures: Pfannenstiel versus expanded port site incisions

OBJECTIVES

Laparoscopic nephrectomy is considered the standard of care for most Stage T1 and T2 renal tumors. Most centers perform intact extraction rather than morcellation. The extraction incision location varies, with no consensus on the best site. We compared the operative and perioperative parameters after transperitoneal laparoscopic nephrectomy procedures with intact specimen extraction through a Pfannenstiel (PFN) or expanded port site (EPS) incision.

METHODS

The consecutive charts of 150 patients (March 2001 to October 2003) undergoing laparoscopic radical nephrectomy (LRN), laparoscopic nephroureterectomy, or laparoscopic donor nephrectomy with intact specimen extraction were reviewed. The specimens were extracted by way of a PFN or an EPS incision. Two analyses were completed. The first included only LRN, and the second included LRN, laparoscopic nephroureterectomy, and laparoscopic donor nephrectomy.

RESULTS

In the LRN-only analysis, the PFN group had a shorter hospital stay (2.84 versus 3.37 days, P <0.05). This group also used significantly less morphine (23.7 versus 47.3 mg, P <0.006). The PFN group in the second analysis also used less morphine (26.3 versus 51.1 mg, P <0.002). Four extraction site complications were found; 1 patient in the PFN group developed cellulitis, and 3 patients in the EPS group developed an incisional hernia.

CONCLUSIONS

This evidence suggests reduced morbidity with intact specimen extraction through a PFN incision compared with an EPS incision during laparoscopic nephrectomy procedures. Our practice has been modified on the basis of these data, and all specimens are now removed through a PFN incision when suitable. Urologists should consider PFN incisions for specimen extraction with laparoscopic nephrectomy procedures.

Synthetic Torso for Training in and Evaluation of Urologic Laparoscopic Skills

BACKGROUND

The expanding use of advanced minimally invasive surgical techniques demands more advanced training methods, objective measures of resident performance, and more realistic and anatomically correct training models.

MATERIALS AND METHODS

A new synthetic torso for urologic laparoscopy training was developed and assessed. The trainer, Lapman, was based on the Visible Human Model and has the exact shape of a human torso. The torso models the outer shape of the body and the abdominal and pulmonary cavities. Animal or synthetic models of the abdominal organs may be placed in the abdominal cavity. An abdominal wall provides access and seals the cavity and can be replaced after repeated punctures with laparoscopic instruments. The thoracic cavity connects to a pneumatic pump to simulate breathing. In order to render realistic mechanic properties, the torso is cast of materials with elastic properties similar to those of soft tissue and incorporates a synthetic skeleton. These similar mechanical properties and the thoracic insufflation create realistic ventilatory motion simulation.

RESULTS

Twenty-five individuals--medical students, residents, and attending urologists--participated in a study comparing Lapman with a standard training box. Lapman presented several advantages over the traditional training box, specifically with regard to internal and external views and the incorporation of a realistically shaped abdominal wall. A significant and recurrent theme was the value of the synthetic wall as a tool to gain a greater appreciation of the importance of port placement. Study participants at all levels of training appreciated that Lapman gives a more realistic approximation of the operative procedure.

CONCLUSIONS

The novelty of the trainer consists in its anatomic shape, realistic mechanical properties, and ventilatory simulation. This paper reports on its design, construction, and preliminary tests.

Videolaparoscopic orchiectomy and nephrectomy: training model in rats

OBJECTIVE

Videolaparoscopic surgery conducted on small animals has proved to be of great importance for the improvement of surgical skills. This is a report utilizing an experimental model for laparoscopic orchiectomy and nephrectomy in training courses for urologists.

MATERIAL AND METHODS

Of 350 American Wistar rats enrolled, 319 animals underwent laparoscopic orchiectomy and nephrectomy under intraperitoneal general anesthesia. Graspers, dissectors, and a 0-degree telescope were introduced into the peritoneal cavity by two trocars of 5 mm and one of 10 mm, respectively.

RESULTS

Of 350 rats enrolled, 15 (4.2%) died due to anesthetic complications and 16 (4.5%) due to cannibalism and stress during transport. A total of 319 rats were operated on, 178 underwent bilateral orchiectomy, two per model (356 operations), and in 141 animals one nephrectomy per model (141 operations) was performed. A total of 497 operations were performed involving 140 urologists. The animals were easy to handle providing adequate practice without the occurrence of any major intraperitoneal lesion and hemorrhage.

CONCLUSION

Nephrectomy and orchiectomy are feasible in rats, and this model can be utilized for training videolaparoscopic surgeries.