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Zou X, Zhang G, Xie T, Yuan Y, Xiao R, Wu G, Wang X, Xu H, Liu F, Wu Y, Liao Y, Liu Q, Sun Y, Yang B, Wang L, Xu C, Gao X. Natural orifice transluminal endoscopic surgery in urology: The Chinese experience. Asian J Urol 2019; 7:1-9. [PMID: 31970065 PMCID: PMC6962750 DOI: 10.1016/j.ajur.2019.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 09/21/2018] [Accepted: 12/26/2018] [Indexed: 12/21/2022] Open
Abstract
Objective To describe the Chinese experience of natural orifice transluminal endoscopic surgery (NOTES) in urology. Methods From December 2008 to May 2017, 35 animal experiments and 305 clinical surgeries of NOTES or natural orifices specimen extractions (NOSE) were performed in China. The animal experiments included five kidney biopsies, 24 nephrectomies and six partial nephrectomies. The clinical surgeries included 12 transvaginal NOSE (TV-NOSE), 266 hybrid transvaginal NOTES (TV-NOTES) and 27 pure TV-NOTES. The TV-NOSE procedure was performed in five transumbilical laparoendoscopic single-site (U-LESS) nephrectomies, four suprapubic-assisted laparoendoscopic single-site surgery (SA-LESS) nephroureterectomies, and three laparoscopic radical cystectomies. The hybrid TV-NOTES procedure included 210 nephrectomies, 31 adrenalectomies, eight nephroureterectomies, 13 partial nephrectomies, and four heminephrectomies. The pure TV-NOTES procedure included five renal cyst decortications and 22 nephrectomies. Results A total of 29 animal experiments were successfully performed. One partial nephrectomy was converted to standard laparoscopic surgery. Two kidney biopsies and two nephrectomies were unsuccessful. A total of 297 clinical surgeries were successfully performed. Six patients who underwent hybrid TV-NOTES were converted to open surgery. Two patients who underwent pure TV-NOTES were converted to SA-LESS. There were 22 major complications, 16 occurred intraoperatively and six postoperatively. The mean visual analog score (VAS) of 48 h after the operation was 2.5 points in TV-NOSE, 2.3 points in hybrid TV-NOTES and 1.7 points in pure TV-NOTES. The mean follow-up of 50.6 (3.0–87.0) months showed that all patients were in good condition. The umbilicus scars were nearly invisible in TV-NOSE and hybrid TV-NOTES. The vaginal incision healed well. Conclusions TV-NOSE and TV-NOTES are feasible, safe, and effective with little injury, low pain, fast recovery, and good cosmetic outcomes in properly selected patients. They are worth consideration for urological clinical practice.
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Affiliation(s)
- Xiaofeng Zou
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Research Center of Jiangxi Province for Engineering Technology of Calculus Prevention and Control, Ganzhou, China
| | - Guoxi Zhang
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Research Center of Jiangxi Province for Engineering Technology of Calculus Prevention and Control, Ganzhou, China
| | - Tianpeng Xie
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Research Center of Jiangxi Province for Engineering Technology of Calculus Prevention and Control, Ganzhou, China
| | - Yuanhu Yuan
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Research Center of Jiangxi Province for Engineering Technology of Calculus Prevention and Control, Ganzhou, China
| | - Rihai Xiao
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Research Center of Jiangxi Province for Engineering Technology of Calculus Prevention and Control, Ganzhou, China
| | - Gengqing Wu
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Research Center of Jiangxi Province for Engineering Technology of Calculus Prevention and Control, Ganzhou, China
| | - Xiaoning Wang
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Research Center of Jiangxi Province for Engineering Technology of Calculus Prevention and Control, Ganzhou, China
| | - Hui Xu
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Research Center of Jiangxi Province for Engineering Technology of Calculus Prevention and Control, Ganzhou, China
| | - Folin Liu
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Research Center of Jiangxi Province for Engineering Technology of Calculus Prevention and Control, Ganzhou, China
| | - Yuting Wu
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Research Center of Jiangxi Province for Engineering Technology of Calculus Prevention and Control, Ganzhou, China
| | - Yunfeng Liao
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Research Center of Jiangxi Province for Engineering Technology of Calculus Prevention and Control, Ganzhou, China
| | - Quanliang Liu
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Research Center of Jiangxi Province for Engineering Technology of Calculus Prevention and Control, Ganzhou, China
| | - Yinghao Sun
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Bo Yang
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Linhui Wang
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Chuanliang Xu
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Xiaofeng Gao
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
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Abstract
The last two decades witnessed the inception and exponential implementation of key technological advancements in laparoscopic urology. While some of these technologies thrived and became part of daily practice, others are still hindered by major challenges. This review was conducted through a comprehensive literature search in order to highlight some of the most promising technologies in laparoscopic visualization, augmented reality, and insufflation. Additionally, this review will provide an update regarding the current status of single-site and natural orifice surgery in urology.
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Kim DK, Yoon YE, Han WK, Rha KH. Roles of NOTES and LESS in management of small renal masses. Int J Surg 2015; 36:574-582. [PMID: 26607854 DOI: 10.1016/j.ijsu.2015.11.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 10/27/2015] [Accepted: 11/10/2015] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Over the last 2 decades, open surgery has been largely displaced by laparoscopic surgery for the treatment of renal masses. Recently, minimally invasive surgical techniques, such as laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES), have been developed for such purpose. METHODS In the present literature review, the current status of treatment for small renal masses was investigated. The advantages and disadvantages of LESS and NOTES are presented to confirm the feasibility and reproducibility of these techniques. RESULTS LESS significantly reduces pain and offers excellent cosmetic outcomes with comparable oncological and perioperative results, and NOTES offers the potential for surgery by various approach without any transcutaneous abdominal incision in management of small renal masses. CONCLUSION When the technical limitations are overcome, clinical application of LESS and NOTES is expected to increase. Further prospective and comparative studies are needed to clarify the application of these new techniques.
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Affiliation(s)
- Dae Keun Kim
- Department of Urology, CHA Gangnam Hospital, CHA University, CHA Medical School, Seoul, Republic of Korea; Department of Urology, School of Medicine, Graduate School, Hanyang University, Seoul, Republic of Korea.
| | - Young Eun Yoon
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Yonseiro 50-1, Seodaemun-gu, Seoul 120-752, Republic of Korea.
| | - Woong Kyu Han
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Yonseiro 50-1, Seodaemun-gu, Seoul 120-752, Republic of Korea.
| | - Koon Ho Rha
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Yonseiro 50-1, Seodaemun-gu, Seoul 120-752, Republic of Korea.
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Xue Y, Zou X, Zhang G, Yuan Y, Xiao R, Liao Y, Zhong X, Jiang B, Xu R, Zou Y, Xu G, Xie K, Zhang X. Transvaginal Natural Orifice Transluminal Endoscopic Nephrectomy in a Series of 63 Cases: Stepwise Transition From Hybrid to Pure NOTES. Eur Urol 2015; 68:302-10. [PMID: 25837534 DOI: 10.1016/j.eururo.2015.03.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/14/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND The feasibility of hybrid transvaginal NOTES (natural orifice transluminal endoscopic surgery) nephrectomy (HTNN) has already been demonstrated. However, pure transvaginal NOTES nephrectomy (PTNN) has been limited to animal experiments with only one report of its use in humans. OBJECTIVE To describe our initial experience with HTNN and a stepwise transition towards PTNN. DESIGN, SETTING, AND PARTICIPANTS Between May 2010 and September 2011, 63 patients underwent nephrectomy (60 HTNNs and 3 PTNNs) in our institution, including 45 patients with benign renal disease and 18 patients with malignant renal disease. SURGICAL PROCEDURE Of the HTNNs, 33 were performed using two umbilical trocars and one transvaginal trocar, and 27 were performed using one umbilical trocar and a transvaginal multi-instrument access port; 3 PTNNs were performed using a self-developed, three-channel ZOU-port without any transumbilical assistance. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS All data referring to patient demographics, surgery, pathology, and perioperative outcomes were recorded. Sexual function was assessed with the Female Sexual Function Index (FSFI) questionnaire before and after surgery. The cosmetic result was investigated by administering the Patient Scar Assessment Questionnaire and Scoring System (PSAQ). RESULTS AND LIMITATIONS A total of 59 HTNNs and 3 PTNNs were successfully performed. One patient was converted to open surgery because of injury to the inferior vena cava. The mean operative time was 130min (range: 100-260min) for HTNN and 193min (range: 180-210min) for PTNN. The mean estimated blood loss was 150ml. The mean postoperative hospital stay was 7.4 d. Forty-eight patients completed the FSFI questionnaire, and analysis did not show differences in FSFI scores before and after surgery. The better cosmetic results were confirmed by the PSAQ score. CONCLUSIONS HTNN is feasible and safe in appropriate patients. Existing instruments are adequate for HTNN, but significant improvement is still needed. PTNN is technically challenging, but is feasible and may be performed safely. Further improvement of instruments is necessary for PTNN. Clinical investigation in comparison to the established techniques should take place to evaluate the outcome of technique. PATIENT SUMMARY Pure transvaginal natural orifice transluminal endoscopic nephrectomy (PTNN) is technically challenging but feasible and may be performed safely. Further improvements in instruments are necessary for PTNN.
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Affiliation(s)
- Yijun Xue
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China
| | - Xiaofeng Zou
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China.
| | - Guoxi Zhang
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China
| | - Yuanhu Yuan
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China
| | - Rihai Xiao
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China
| | - Yunfeng Liao
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China
| | - Xin Zhong
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China
| | - Bo Jiang
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China
| | - Ruiquan Xu
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China
| | - Yuhua Zou
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China
| | - Gang Xu
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China
| | - Kunlin Xie
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China
| | - Xu Zhang
- Department of Urology, Clinical Division of Surgery, Chinese PLA General Hospital, Beijing, People's Republic of China
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Anderson KM, Alsyouf M, Richards G, Agarwal G, Heldt JP, Schlaifer AE, Baldwin DD. Hybrid transureteral nephrectomy in a survival porcine model. JSLS 2014; 18:JSLS-D-14-00144. [PMID: 25489210 PMCID: PMC4254474 DOI: 10.4293/jsls.2014.00144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background and Objectives: Natural-orifice approaches for nephrectomy have included access via the stomach, vagina, bladder, and rectum. Recently, the feasibility of using the ureter as a natural orifice for natural-orifice transluminal endoscopic surgery nephrectomy has been demonstrated in a nonsurvival porcine model. The purpose of this study was to assess the outcomes of transureteral laparoscopic natural-orifice transluminal endoscopic surgery nephrectomy in a survival porcine model. Methods: Three pigs underwent hybrid transureteral natural-orifice transluminal endoscopic surgery nephrectomy. An experimental balloon/dilating sheath was inserted over a wire to dilate the urethra, ureteral orifice, and ureter. Through a bariatric 12-mm laparoscopic port, the ureter was opened medially and the hilar dissection was performed. Next, 2 needlescopic ports were placed transabdominally to facilitate hilar transection. The kidney was morcellated using a bipolar sealing device and extracted via the ureter using the housing of a bariatric stapling device. The ureteral orifice was closed with a laparoscopic suturing device. The bladder was drained by a catheter for 10 to 14 days postoperatively. Pigs were euthanized on postoperative day 21. Results: All surgical procedures were successfully completed, with no intraoperative complications. One pig had an episode of postoperative clot retention that resolved with catheter irrigation. Each pig was healthy and eating a normal diet prior to euthanasia. Conclusions: This study demonstrates the feasibility of a hybrid transureteral approach to nephrectomy in a survival porcine model. This technique avoids the intentional violation of a second organ system and the risk for peritoneal contamination. Improved instrumentation is needed prior to implementation in the human population.
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Affiliation(s)
- Kirk M Anderson
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Muhannad Alsyouf
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Gideon Richards
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Gautum Agarwal
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Jonathan P Heldt
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Amy E Schlaifer
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - D Duane Baldwin
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California, USA
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Abstract
Improvements in surgical techniques, and particularly the development and widespread clinical introduction of laparoscopy in the past two decades, have revolutionized the management of urological disease. Natural orifice transluminal endoscopic surgery (NOTES) holds promise in further advancing treatment outcomes in urology. This novel minimally invasive surgical approach can negate the requirement for skin incisions and, therefore, could potentially improve morbidity, convalescence, and cosmesis. After considerable preclinical development, the feasibility of 'hybrid' NOTES-involving concurrent laparoscopy-and 'pure' NOTES nephrectomy and prostatectomy procedures has now been successfully demonstrated in patients with urological conditions, whereas proof-of-concept studies of NOTES partial cystectomy have been performed in animal models. Whether such procedures offer therapeutic and safety benefits compared with traditional laparoscopic techniques remains unknown; indeed, concerns remain over the potential perioperative and postoperative adverse events associated with NOTES, such as incomplete closure of the entry-point incision, infection, and haemorrhage. In particular, however, the requirement for the development of specific rationally designed NOTES instrumentation as well as specially trained, highly skilled personnel to perform the surgery continues to restrict the utility of NOTES. Thus, considerable effort is now needed to shift the focus of research to refining NOTES methodologies to enable translation of these promising proof-of-principle studies into the clinic.
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Bazzi WM, Stroup SP, Cohen SA, Sisul DM, Liss MA, Masterson JH, Kopp RP, Gudeman SR, Leeflang E, Palazzi KL, Ramamoorthy S, Kane CJ, Horgan S, Derweesh IH. Comparison of transrectal and transvaginal hybrid natural orifice transluminal endoscopic surgery partial nephrectomy in the porcine model. Urology 2013; 82:84-9. [PMID: 23676357 DOI: 10.1016/j.urology.2013.03.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Revised: 02/13/2013] [Accepted: 03/05/2013] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To compare the feasibility of porcine transrectal (TR) and transvaginal (TV) hybrid natural orifice transluminal endoscopic surgery (NOTES) partial nephrectomy (PN), as NOTES nephrectomy has recently been performed in the porcine model. MATERIALS AND METHODS A total of 10 female pigs (weight 45 kg) underwent TR (n = 5) or TV (n = 5) NOTES PN. The pneumoperitoneum was created by a periumbilical 12-mm trocar, through which a laparoscope was advanced for intra-abdominal visualization. For TV-NOTES PN, a gastroscope was used to obtain TV peritoneal access. For TR-NOTES PN, a horizontal incision was made 2 cm above the dentate line, and a submucosal tunnel was created in the posterior rectal wall. The gastroscope was advanced through the submucosal tunnel and retroperitoneum to the kidney, and a peritoneal window was created. For both TR- and TV-NOTES PN, the gastroscope was exchanged for the SPIDER Surgical System. Flexible dissecting instruments and hook cautery introduced through the SPIDER Surgical System were used to mobilize the kidney. A harmonic scalpel introduced periumbilically was used to excise a portion of the lower pole. LAPRA-TY-secured sutured renorrhaphy was performed, followed by TR or TV specimen extraction. RESULTS TR- and TV-NOTES PN was successfully performed in all 10 pigs. A comparison of TR- and TV-NOTES PN revealed no significant differences in the mean access time (29.2 vs 29.6 minutes, P = .944), operative time (196.0 vs 183.0 minutes, P = .631), and estimated blood loss (59.0 vs 54.0 mL, P = .861). Necropsy did not demonstrate abdominal injuries. CONCLUSION We have demonstrated proof-of-principle for TR and TV-NOTES PN in swine, with comparable perioperative parameters. Preclinical survival studies are requisite to assess the potential of TR-NOTES as an alternative to TV-NOTES.
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Affiliation(s)
- Wassim M Bazzi
- Department of Surgery, University of California, La Jolla, CA, USA
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Feasibility of transrectal hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy in the cadaveric model. Urology 2012; 80:590-5. [PMID: 22925236 DOI: 10.1016/j.urology.2012.06.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 05/16/2012] [Accepted: 06/13/2012] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To examine feasibility of transrectal hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy in human cadavers in the evolution of this technique, as transrectal hybrid NOTES nephrectomy has been demonstrated in the porcine model. METHODS Four hybrid transrectal NOTES nephrectomies were performed on 4 cadavers (3 female/1 male, 2 right/2 left). Pneumoperitoneum was created by periumbilical 12-mm trocar, through which a laparoscope was advanced to obtain intra-abdominal visualization. A 4-cm horizontal incision was made 2-cm above the dentate line and a submucosal tunnel was created in the posterior rectal wall/presacral space. A dual-channel gastroscope was advanced through the submucosal tunnel and retroperitoneum to the level of the kidney using air insufflation. A peritoneal window was created and renal mobilization was completed. A transumbilically applied laparoscopic 45-mm stapler was used to transect the ureter and renal hilum. A specimen entrapment bag was deployed transrectally for specimen extraction, followed by transrectal incision closure. RESULTS Transrectal NOTES nephrectomy was successfully performed in all cases, with intact specimen extraction. Median weight was 77 kg (range 74-85 kg); median body mass index (BMI) was 30.1 kg/m(2) (range 25.6-31.2 kg/m(2)). Mean operative time was 175 minutes (range 150-210 minutes). Median transrectal access time was 36 minutes (range 24-47 minutes). Median dimensions of removed kidneys were length 11.2 cm (range 10-12 cm), width 5 cm (range 4.5-6 cm), and thickness 3.8 cm (range 3-4.5 cm). CONCLUSION Transrectal hybrid NOTES nephrectomy in the cadaver model is feasible with intact specimen extraction and acceptable operative times. Preclinical survival studies are requisite to assess sterility and complications. This approach may be an alternative to transvaginal access.
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Bazzi WM, Raheem OA, Cohen SA, Derweesh IH. Natural orifice transluminal endoscopic surgery in urology: Review of the world literature. Urol Ann 2012; 4:1-5. [PMID: 22346092 PMCID: PMC3271442 DOI: 10.4103/0974-7796.91611] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 08/14/2011] [Indexed: 12/12/2022] Open
Abstract
Natural orifice transluminal endoscopic surgery (NOTES) has gained momentum in the recent urologic literature as a new surgical approach for intra-abdominal organs with scarless and painless postoperative recoveries. We sought to review the published literature concerning the safety and reproducibility of NOTES in urology. PubMed literature review of articles published in the English language was performed over a 10-year period, i.e., between 2001 and 2011; all articles were critically reviewed and analyzed. Despite its novelty, pure or hybrid surgical approaches have been adapted in performing NOTES. NOTES essentially utilizes transluminal flexible endoscopic instruments along with laparoscopic instruments to gain access to abdominal, pelvic, and/or retroperitoneal cavities. The preliminary results of NOTES in surgery and to a limited extent in urology appear promising, yet further research in animal survival and human cadaveric models is requisite prior to human applications, especially for complex surgeries. Future innovative research, particularly biomedical engineering, should be directed to improving the technicality and mechanistic application of NOTES; hence, better safety and efficacy of NOTES.
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Affiliation(s)
- Wassim M Bazzi
- Department of Surgery, Division of Urology, University of California San Diego School of Medicine, La Jolla, San Diego, CA, USA
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Evolution and simplified terminology of natural orifice transluminal endoscopic surgery (NOTES), laparoendoscopic single-site surgery (LESS), and mini-laparoscopy (ML). World J Urol 2012; 30:573-80. [PMID: 22790450 DOI: 10.1007/s00345-012-0899-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Accepted: 06/19/2012] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) are the next steps in the evolution of laparoscopic surgery, promising reduced morbidity and improved cosmetic result. The inconsistent terminology initially used led to confusion. Understanding the technical evolution, the current status and a unified and simplified terminology are key issues for further acceptance of both approaches. OBJECTIVE To present LESS and NOTES in its historical context and to clarify the associated terminology. METHOD Extensive literature search took place using the PubMed. Several hundred publications in general surgery and urology regarding LESS are present including the expert opinion of members the European Society of Uro-technology (ESUT). RESULTS The increasing interest on NOTES and LESS is reflected by a raising number of publications during the last 4 years. The initial confusion with the terminology of single-incision surgery represented a significant issue for further evolution of the technique. Thus, consortiums of experts searched a universally acceptable name for single-incision surgery. They determined that 'laparoendoscopic single-site surgery' (LESS) was both scientifically accurate and colloquially appropriate, the term being also ratified by the NOTES working group (Endourological Society) and the ESUT. For additional use of instruments, the terms hybrid NOTES and hybrid LESS should be used. Any single use of miniaturized instruments for laparoscopy should be called mini-laparoscopy. DISCUSSION The evolution of LESS and most likely NOTES to a new standard of minimally invasive surgery could represent an evolutionary step even greater than the one performed by the establishment of laparoscopy over open surgery.
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