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

Laparoscopic Single-Incision Triangulated Umbilical Surgery Adrenalectomy for Large (>5 cm) Tumors of the Adrenal Gland: Initial Experience with 16 Cases

Background and ObjectivesLaparoscopic single-incision triangulated umbilical surgery (SITUS), which enables the extraction of intraabdominal specimens through a single umbilical incision, has yet to be used to perform adrenalectomy. We have modified SITUS to enable extraction of large (>5 cm) adrenal masses with optimal cosmetic outcomes and investigated efficacy and safety. Methods. In this retrospective study, we analyzed data of 16 patients with adrenal tumors >5 cm who had undergone adrenalectomy by SITUS between October 2015 and April 2018. Two C-shaped incisions were made around the umbilicus and sutured centripetally. After extracting the specimen, we evaluated these patients' operative/postoperative data. Results. SITUS was performed in all 16 patients without conversion to laparoscopic or open surgery. The mean operation time was 75.31 ± 21.54 min (intraperitoneal time 41.94 ± 17.57 min; incision suturing time 33.38 ± 6.34 min). The estimated median blood loss was 57.5 mL (range 30–610 mL). Drainage time and duration of hospital stay were 55.69 ± 12.92 h and 3.94 ± 0.90 d, respectively. After surgery, all incisions were hidden under the umbilicus. Three patients developed keloid diathesis, resulting in enlargement of their scars. Conclusions. SITUS is a safe and feasible procedure for removing large adrenal tumors. In addition to its cosmetic advantages, SITUS facilitates functional recovery, particularly in patients with large adrenal tumors.

Reduced port laparoscopic radical nephrectomy using an umbilical zigzag skin incision for renal cell carcinoma

Reduced port laparoscopic radical nephrectomy (RPLRN) is an equivalent approach to conventional laparoscopic radical nephrectomy (LRN). In LRN, one wound generally needs to be extended for specimen extraction; therefore, some ingenuity is needed to achieve a good cosmetic outcome. We herein describe our initial experience of RPLRN using an umbilical zigzag skin incision for renal cell carcinoma (RCC). A 64-year-old female [body mass index (BMI): 20.0 kg/m²] was diagnosed with right RCC, which was 35 mm in diameter (clinical T1aN0M0). Case 2: a 68-year-old male (BMI: 23.2 kg/m²) was diagnosed with right RCC, which was 58 mm in diameter (clinical T1bN0M1), and perinephric fat was relatively thick. The procedure was safely completed in both cases. Total operative times, pneumoperitoneal times, and estimated blood loss in Case 1 and 2 were 90 and 145 min, 49 and 90 min, and 5 and 80 ml, respectively, and the times required to construct umbilical ports and close umbilical wounds were 8 and 9 min and 33 and 46 min, respectively. In Case 1, the specimen was easily extracted without the extension of the umbilical skin incision, whereas it was extended by an additional 2 cm in Case 2. The umbilical wound was inconspicuous in both cases. RPLRN using an umbilical zigzag skin incision for RCC was safely performed without complications, and clashing between instruments was minimized. The high level of cosmesis is advantageous and an umbilical zigzag skin incision may contribute to more widespread use of RPLRN for RCC; however, further studies on long-term oncological outcomes are needed.

Laparoendoscopic single-site nephrectomy versus conventional laparoendoscopic nephrectomy for kidney tumor: a systematic review and meta-analysis

With the increasing application of laparoendoscopic single-site nephrectomy (LESS-N) in kidney tumor, accumulating studies compared it with conventional laparoendoscopic nephrectomy (CL-N). However, controversial outcomes were reported. Hence, this meta-analysis was carried out to clarify these issues. Online databases PubMed, EMBASE and the Cochrane Library were searched comprehensively for eligible studies published before 24 July 2018. Odds ratios (ORs) or standardized mean differences (SMDs) with corresponding 95% confidence intervals (CIs) were collected for evaluating the pooled results of relevant outcomes. Ultimately, 13 eligible articles were enrolled. Meanwhile, compared with CL-N, LESS-N was related to a longer operation time (SMD: 0.40; 95% CI, 0.23–0.58; P=0.000), a shorter length of hospital stay (LOS) (SMD: −0.32; 95% CI, −0.62 to −0.02; P=0.034), a lower visual analog scale (VAS) score (SMD: −0.89; 95% CI, −1.22 to −0.56; P=0.000) and a lower analgesic requirement (SMD: −0.55; 95% CI, −0.87 to −0.23; P=0.001). There was no statistical difference in the postoperative day of oral intake, estimated blood loss (EBL), conversion rate, perioperative complications, intraoperative complications, postoperative complications, minor complications and major complications between LESS-N and CL-N. Patients with LESS-N for kidney tumor could have a longer operation time and shorter LOS, and meanwhile could need less analgesics and suffer less pain after LESS-N.

Comparative study of multiport laparoscopy and umbilical laparoendoscopic single-site surgery with reusable platform for treating renal masses

INTRODUCTION

Umbilical laparoendoscopic single-site (LESS) surgery is an increasingly used modality for treating renal masses. We present a prospective comparison between LESS renal surgery and conventional laparoscopy.

MATERIAL AND METHOD

A comparative paired study was conducted that evaluated the surgical results and complications of patients with renal neoplasia treated with LESS surgery (n=49) or multiport laparoscopy (n=53). The LESS approach was performed with reusable material placed in the navel and double-rotation curved instruments. An additional 3.5-mm port was employed in 69.4% of the cases. We assessed demographic data, the type of technique (nephrectomy, partial nephrectomy and nephroureterectomy), surgical time, blood loss, haemoglobin, need for transfusion, number and severity of complications (Clavien-Dindo), hospital stay, histological data and prognosis.

RESULTS

There were no differences in follow-up, age, sex, body mass index, preoperative haemoglobin levels or type of surgery. Conversion occurred in 2 cases (1 in each group). The surgical time was equivalent (P=.6). Intraoperative transfusion (P=.03) and blood loss (P<.0001) was lower with LESS, postoperative haemoglobin levels were higher (P<.0001) and haemostatic agents were used more frequently (P<.0001). There were no differences in the number (P=.6) or severity (P=.47) of complications. The length of stay (P<.0001), the proportion of patients with drainage (P=.04) and the number of days with drainage (P=.0004) were lower in LESS. Twenty-five percent of the lesions operated on with LESS were benign, but the mean size was similar in the 2 groups (P=.5). Tumour recurrence and/or progression were more frequent in multiport laparoscopy (P=.0013).

CONCLUSIONS

Umbilical LESS surgery with reusable platform enables various surgical techniques to be performed when treating renal masses, with time consumption and safety comparable to conventional laparoscopy. The LESS approach is advantageous in terms of blood loss and hospital stay.

Trends in surgical management of T1 renal cell carcinoma

Historically, open radical nephrectomy (ORN) represented the standard of care for localized renal cell carcinoma (RCC). While the incidence of T1 RCC is rising, treatment options are developing fast and the standard of care according to European and American guidelines has changed to partial nephrectomy (PN), or laparoscopic radical nephrectomy in patients not suitable for PN. To assess the implementation of guideline recommendations and to profile recent surgical and technical innovations, we reviewed the current literature. We observed that ORN still represents the most commonly used treatment in T1 RCC patients. Utilization of PN increased over time but implementation is still in progress. Whereas PN is frequently used in tertiary care centers, population-based studies suggest discrepancies in the diffusion of standard of care treatments. Alternative minimally invasive approaches for PN are available but their superiority is not yet proven. Further efforts in improving the training of urologic surgeons are required to continue the implementation of guideline recommendations.

Dual-port distal gastrectomy for the early gastric cancer

Background

Although recent trends in laparoscopic procedures have been toward minimizing the number of incisions, four or five ports are normally required to complete laparoscopic gastrectomy because of the complexity of this procedure. Multi-channel ports, such as the SILS port (Covidien, JAPAN), are now available and are crucial for performing single-incision laparoscopic surgery (SILS) or reduced port surgery (RPS). We carried out reduced port distal gastrectomy (RPDG) using a dual-port method with a SILS port.

Methods

Ten patients who were diagnosed as early stage gastric cancer were offered the RPDG. Mean age and body mass index (BMI) were 68.1 and 21.4, respectively. No distant metastasis or regional lymph node swelling was seen in any case. A 5-mm flexible scope (Olympus, JAPAN) and SILS port were used and a nylon ligature with a straight needle, instead of a surgical instrument, was available to raise the gastric wall.

Results

The average operative time was 266.9 ± 38.3 min and blood loss was 37.8 ± 56.8 ml. Patients recovered well and experienced no complications after surgery. All patients could tolerate soft meals on the first day after surgery and the average hospital stay was 8.1 days. Past conventional LAG cases were evaluated to compare the short-term outcome and no difference was seen in the mean operative time or operative blood loss. The length of hospital stay after surgery was shorter for the RPDG group than the conventional operation group (p < 0.0001). Interestingly, the trend of serum CRP elevation after surgery was lower in the RPDG group than the conventional LAG group (p = 0.053).

Conclusions

Although the benefits of RPS have not been established, this type of surgery may be expected to have some advantages. Cosmetic benefits and shorter hospital stays are clear advantages. Less invasiveness can be expected according to the trend of serum CRP elevation after RPDG.

Single incision laparoscopic hepatectomy: Advances in laparoscopic liver surgery

BACKGROUND:

Laparoscopic liver surgery is now an established practice in many institutions. It is a safe and feasible approach in experienced hands. Single incision laparoscopic surgery (SILS) has been performed for cholecystectomies, nephrectomies, splenectomies and obesity surgery. However, the use of SILS in liver surgery has been rarely reported. We report our initial experience in seven patients on single incision laparoscopic hepatectomy (SILH).

PATIENTS AND METHODS:

From October 2010 to September 2012, seven patients underwent single-incision laparoscopic liver surgery. The abdomen was approached through a 25 mm periumbilical incision. No supplemental ports were required. The liver was transected using a combination of LigaSure™ (Covidien-Valleylab. Boulder. USA), Harmonic Scalpel and Ligaclips (Ethicon Endo-Surgery, Inc.).

RESULTS:

Liver resection was successfully completed for the seven patients. The procedures consisted of two partial resections of segment three, two partial resections of segment five and three partial resections of segment six. The mean operative time was 98.3 min (range: 60-150 min) and the mean estimated blood loss was 57 ml (range: 25-150 ml). The postoperative courses were uneventful and the mean hospital stay was 5.1 days (range: 1-13 days). Pathology identified three benign and four malignant liver tumours with clear margins.

CONCLUSION:

SILH is a technically feasible and safe approach for wedge resections of the liver without oncological compromise and with favourable cosmetic results. This surgical technique requires relatively advanced laparoscopic skills. Further studies are needed to determine the potential advantages of this technique, apart from the better cosmetic result, compared to the conventional laparoscopic approach.

Complications of laparo-endoscopic single-site surgery in urology

The objective was to give a general overview of common complications and rates reported in the current literature during performance of a variety of urologic procedures using laparo-endoscopic single-site surgery or LESS. A search of published reports using Pubmed and MEDLINE was performed with the following search terms: laparo-endoscopic single-site surgery, LESS or laparo-endoscopic single-site surgery complications within the date range of 2005--2011. Studies that were deemed appropriate and relevant to the current symposium were chosen for review. Overall complication rates were reported as ranging between 10% and 25%. In general, reconstructive procedures had consistently higher rates of complications than their extirpative/ablative counterparts (27% vs. 8%). There remain insufficient data to comment on differences in the rates or types of complications related to variations in the approach (transperitoneal vs. retroperitoneal), site of surgery (upper tract vs. lower tract) or specific technique used (instruments, access devices, robotic platforms, etc.). Complication rates associated with LESS in urology appear only slightly higher than with conventional laparoscopy. However, with proper patient selection and careful application of these techniques, proofs of concept and technical feasibility have been shown in several series. There continues to be a need for more standardization of the technique and reporting as well as more collaborative efforts to fully address questions of safety and efficacy of these new procedures.

Cost effective laparoendoscopic single-site surgery with a reusable platform

The authors found that laparoendoscopic single-site surgery with a reusable platform was feasible for various urologic entities, yielding favorable cosmetic and functional results.

Background and Objectives:

Many disposable platforms have been applied in laparoendoscopic single-site surgery (LESS). Besides technical issues, cost is one of the limiting factors for its widespread acceptance. The current study describes the first completely reusable LESS-platform.

Methods:

We performed LESS-procedures in 52 patients including nephrectomy (18), adrenalectomy (2), partial nephrectomy (3), pyeloplasty (4), renal cyst ablation (4), pelvic lymphadenectomy (15), and lymphocele ablation (6). All procedures were conducted using a novel reusable single-port device (X-Cone, Karl-Storz) with a simplified set of instruments. We obtained perioperative and demographic data, including a visual analogue pain scale (VAS), and a complication reporting system based on Clavien grading.

Results:

Mean age was 50.04 y. Conversion to standard laparoscopy was necessary in 3 cases and addition of a needlescopic instrument in 6 cases. There was no open conversion. Intra- and postoperative complications occurred in 3 (Clavien II in 2 and III in 1) cases. Mean operative time was 110, 90, and 89 min, and hospital stay was 4.9, 3.1, and 3.6 d for nephrectomy, pelvic lymphadenectomy, and pyeloplasty, respectively. Mean VAS was 2.13, 1.07, and 1.5 while blood loss was 81.3 mL, 25.67 mL, and 17.5 mL, respectively. Mean lymph node yield was 15 (range, 8 to 21).

Conclusions:

A completely reusable LESS-platform is applicable to various uses in urology, yielding favorable functional and cosmetic results. Reusable materials are useful to reduce the cost of LESS, further increasing its acceptance. LESS with a completely reusable platform is more cost effective than standard laparoscopy.

Laparoendoscopic single-site surgery in kidney surgery: clinical experience and future perspectives

Laparoscopic surgery of the upper urinary tract has reduced the morbidity related to large abdominal incisions and has resulted in significant advantages over open surgery. Nevertheless, the pursuit for even more minimally invasive alternatives to laparoscopy has led to the concept of scarless surgery and the approach of laparoendoscopic single-site surgery (LESS). LESS is currently a feasible approach for the majority of kidney surgical procedures, and there is intense debate regarding its efficiency and advantages. In the present review of the literature, the current status of upper urinary LESS and its advantages and disadvantages, as well the technological and technical evolution, are presented.

A comparative study of laparoendoscopic single-site surgery versus conventional laparoscopy for upper urinary tract malignancies

Purpose

The proper indication for laparoendoscopic single-site surgery (LESS) in urology is still under debate, especially for malignant diseases. We compared the perioperative outcomes between LESS and conventional laparoscopy (CL) for upper urinary tract malignancies.

Materials and Methods

We reviewed the records of 75 patients who underwent radical nephrectomy, nephroureterectomy with bladder cuff excision, or partial nephrectomy with the LESS or CL approach between December 2008 and December 2010. We compared characteristics and perioperative outcomes between patients who underwent LESS or CL. All operations were performed by three surgeons using the transperitoneal approach.

Results

For all three surgery types, no differences in patient characteristics, estimated blood losses, transfusion rates, or durations of hospital stay were found between the two groups. No complications were found between the two groups in those who underwent nephroureterectomy with bladder cuff excision; however, significantly more complications were found in the LESS group than in the CL group in those who underwent radical nephrectomy or partial nephrectomy. Most of the complications with LESS radical nephrectomy occurred in the early introduction period of the technique.

Conclusions

No significant differences in perioperative outcomes were found between the LESS and CL groups in those who underwent radical nephrectomy or nephroureterectomy with bladder cuff excision. Therefore, the use of LESS in these cases is expected to expand as surgeons gain more experience with this technique and as other technical advances in laparoscopic instruments occur. However, partial nephrectomy with LESS should be performed restrictively considering the current level of surgical skill.

A systematic review and meta-analysis of current evidence comparing laparoendoscopic single-site adrenalectomy and conventional laparoscopic adrenalectomy

PURPOSE

To assess the efficacy and safety of laparoendoscopic single-site adrenalectomy (LESS-A) and conventional laparoscopic adrenalectomy (LA) as a systematic review and meta-analysis of current evidence.

METHODS

We conducted a thorough search for comparative studies that compared LESS-A and conventional LA in the following databases: MEDLINE, EMBASE, and the Cochrane library. Studies were reviewed independently and rated by Newcastle-Ottawa Quality Assessment Scale. The operative time, estimated blood loss in operation, the time to resume oral intake after surgery, postoperative hospital stay, and the visual analog pain scale (VAPS) score were included for analysis to compare the efficacy, while the complications together with the analgesia use were included for analysis to compare the safety.

RESULTS

Nine studies with 171 LESS-A cases and 272 conventional LA cases were identified. Although operative time was longer in LESS-A (mean difference [MD] 15.46, 95% confidence interval [CI] 11.18 to 19.74), estimated blood loss (MD 4.72, 95% CI 12.08 to 21.52) and the time to resume oral intake (MD -0.04, 95% CI -0.19 to 0.11) were similar; LESS-A presented a shorter postoperative stay in hospital (MD -0.60, 95% CI -0.86 to -0.35) and lower VAPS score (MD -1.21, 95% CI -1.44 to -0.97). Besides, the risk of minor postoperative complications (risk ratio [RR] 1.74, 95% CI 0.78 to 3.87) was similar. The postoperative analgesia demand in total (RR 0.65, 95% CI 0.52 to 0.81) together with the analgesia usage lasting more than 24 hours after surgery (RR 0.35, 95% CI 0.21 to 0.58) were associated with lower risk in LESS-A, however.

CONCLUSIONS

Based on current evidence, the operative time seems to be longer in LESS-A; however, operative blood loss and complications are similar. In addition, LESS-A presents a shorter hospital stay after surgery and more acceptable perception of pain than conventional LA.

Upper urinary tract laparoendoscopic single-site surgery based on a novel cost-effective reusable platform

BACKGROUND AND PURPOSE

Several disposable platforms have been introduced for laparoendoscopic single-site (LESS) surgery. Besides technical issues, cost is one of the main limiting factors for their widespread use. We present our experience with LESS surgery for kidney pathologies using the first completely reusable LESS platform.

PATIENTS AND METHODS

We performed LESS kidney procedures in 29 patients including nephrectomy (18), partial nephrectomy (3), pyeloplasty (4), and renal cyst ablation (4). All procedures were performed using a completely reusable single-port device (X-Cone) with a simplified combination of standard and prebent instruments. We obtained perioperative and demographic data including a visual analog pain scale (VAS); complications were recorded using Clavien grading.

RESULTS

Mean patient age was 49.31 years. Conversion to standard laparoscopy was necessary in one and addition of a needlescopic instrument in four cases. No open conversion was necessary. Intra- and postoperative complications occurred in two (Clavien II) cases. Mean operative time was 110, 90, and 89 minutes, and hospital stay was 4.9, 3.1, and 3.6 days for nephrectomy, partial nephrectomy, and pyeloplasty, respectively. Mean VAS was 2.13, 1.67, and 1.5 while blood loss was 81.3 mL, 140 mL, and 17.5 mL, respectively. There were no positive resection margins.

CONCLUSIONS

LESS with a completely reusable platform is feasible for different upper urinary tract procedures yielding favorable functional and cosmetic results. A simplified combination of standard straight instruments and a single prebent grasper facilitates handling and shortens the learning curve. Reusable materials significantly reduce cost and may help to further adopt LESS surgery in surgical practice.

[Laparoendoscopic single-site surgery in urology using reusable systems]

PURPOSE

Many disposable platforms have been available for laparoendoscopic single-site surgery (LESS) for a long time. Besides technical challenges cost remains the limiting factor for the widespread use of LESS. We present our experiences with the first completely reusable LESS platform.

METHODS

We performed LESS procedures in 52 patients, including nephrectomy (n=18), adrenalectomy (2), partial nephrectomy (3), pyeloplasty (4), renal cyst ablation (4), pelvic lymphadenectomy (15) and lymphocele ablation (6). All procedures were carried out using a novel reusable single-port device (X-ConeR, Karl-Storz) with a simplified combination of standard and preformed instruments. Perioperative and demographic data including a visual analogue pain scale (VAS) were obtained. Complications were recorded using the Clavien classification.

RESULTS

The mean age of the patients was 50.04 years. Conversion to standard laparoscopy was necessary in 3 cases and the additional use of a 3 mm needle instrument in 6 cases. There were no open conversions. Intraoperative and postoperative complications occurred in 3 (Clavien II in 2 and III in 1) cases. Mean operating time was 110, 90, and 89 min and hospital stay was 4.9, 3.1 and 3.6 days for nephrectomy, pelvic lymphadenectomy, and pyeloplasty, respectively. The mean VAS was 2.13, 1.07 and 1.5 while blood loss was 81.3 ml, 25.67 ml and 17.5 ml, respectively.

CONCLUSIONS

The LESS technique with a completely reusable platform is applicable to various indications in urology yielding favorable functional and cosmetic results. This novel simplified combination of instruments facilitates handling and shortens the learning curve. Reusable materials may help to reduce cost leading to a wider acceptance of LESS.

Laparoendoscopic single-site radical nephrectomy for large renal masses

PURPOSE

To report our operative experience and short-term outcomes for the laparoendoscopic single-site (LESS) management of large renal tumors and tumors of advanced stage.

PATIENTS AND METHODS

Ten consecutive patients underwent LESS-radical nephrectomy (RN) for large (≥ 7 cm) and/or locally advanced tumors (>T(2)). Intraoperative, postoperative, and short-term follow-up data were analyzed.

RESULTS

Median surgical time was 146 minutes (range 73-164 min), and median estimated blood loss was 100 mL (range 25-400 mL). No procedure needed conversion to open RN or hand-assisted laparoscopic RN. The median hospital stay was 47 hours (range 42 hours-12 days). One (10%) patient had a minor complication (postoperative fever treated with antibiotics) and one (10%) patient had a major complication (small bowel obstruction necessitating reoperation). Of the 10 tumors, 2 were pathologic stage T(1b), 4 were pathologic stage T(2), and 4 were stage T(3a). At a median follow-up of 12.3 months (range 1-16 mos), six (60%) patients were alive without evidence of recurrence, and 4 (40%) patients were alive with disease. Of those four patients, all four had known metastatic disease before surgery.

CONCLUSION

LESS-RN for large or advanced stage renal masses is a technically challenging operation. In experienced hands, however, it is a safe and feasible therapeutic option for the management of these tumors.

Single-incision laparoscopic splenectomy: preliminary experience in consecutive patients and comparison to standard laparoscopic splenectomy

BACKGROUND

Since first being described in 2009, single-incision laparoscopic splenectomy has been described in a limited number of case reports and small case series. No studies have evaluated single-incision splenectomy in unselected patients, and outcomes of the procedure have not previously been compared to standard laparoscopy.

METHODS

A retrospective review was conducted to evaluate all single-incision splenectomies performed by a single surgeon between June 2010 and June 2011. Additionally, patients who underwent standard laparoscopic splenectomy by surgeons in the same tertiary referral surgical oncology group were evaluated to serve as a control group. Demographic data, operative parameters, and postoperative outcomes were assessed.

RESULTS

Eight patients underwent successful single-incision splenectomy during the study period without conversion to an open procedure or requiring additional ports. The median operative time was 92.5 min. There was 25 % morbidity and no mortality in the study group. Median length of stay was 4 days. Additionally, 18 patients who underwent standard laparoscopic splenectomy were evaluated for comparison. No significant differences were identified in the preoperative patient characteristics between the two groups. Single-incision splenectomy was associated with a shorter operative time (92.5 vs. 172 min, p = 0.003), lower conversion rate, equivalent length of stay, reduced mortality, similar morbidity, and comparable postoperative narcotic requirements.

CONCLUSIONS

Single-incision splenectomy is feasible, safe, and efficient in an unselected patient population in the hands of an experienced laparoscopic surgeon. The single-incision technique is comparable to standard laparoscopic splenectomy in terms of operative time and perioperative outcomes.

Laparoendoscopic single-site nephrectomy compared with conventional laparoscopic nephrectomy: a systematic review and meta-analysis of comparative studies

CONTEXT

Laparoendoscopic single-site (LESS) surgery has increasingly been used to perform radical, partial, simple, or donor nephrectomy to reduce the morbidity and scarring associated with surgical intervention. Studies comparing LESS nephrectomy (LESS-N) and conventional laparoscopic nephrectomy (CL-N) have reported conflicting results.

OBJECTIVE

To assess the current evidence regarding the efficiency, safety, and potential advantages of LESS-N compared with CL-N.

EVIDENCE ACQUISITION

We comprehensively searched PubMed, Embase, and the Cochrane Library and performed a systematic review and cumulative meta-analysis of all randomized controlled trials (RCTs) and retrospective comparative studies assessing the two techniques.

EVIDENCE SYNTHESIS

Two RCTs and 25 retrospective studies including a total of 1094 cases were identified. Although LESS-N was associated with a longer operative time (weighted mean difference [WMD]: 9.87 min; 95% confidence interval [CI], 3.37-16.38; p=0.003) and a higher conversion rate (6% compared with 0.3%; odds ratio: 4.83; 95% CI, 1.87-12.45; p=0.001), patients in this group might benefit from less postoperative pain (WMD: -0.48; 95% CI, -0.95 to -0.02; p=0.04), lower analgesic requirement (WMD: -4.78 mg; 95% CI, -8.59 to -0.97; p=0.01), shorter hospital stay (WMD: -0.32 d; 95% CI, -0.55 to -0.09; p=0.007), shorter recovery time (WMD: -5.08 d; 95% CI, -8.49 to -1.68; p=0.003), and better cosmetic outcome (WMD: 1.07; 95% CI, 0.67-1.48; p<0.00001). Perioperative complications, estimated blood loss, warm ischemia time, and postoperative serum creatinine levels of graft recipients did not differ significantly between techniques.

CONCLUSIONS

LESS-N offers a safe and efficient alternative to CL-N with less pain, shorter recovery time, and better cosmetic outcome. Given the inherent limitations of the included studies, future well-designed RCTs are awaited to confirm and update the findings of this analysis.

Laparoendoscopic single-site minor hepatectomy for liver tumors

BACKGROUND

Laparoscopic liver surgery is gaining increasing acceptance worldwide, but its frontiers are constantly challenged. Laparoendoscopic single-site surgery (LESS) has been performed for various organs, but the feasibility of LESS hepatectomies has yet to be explored fully.

METHODS

From May 2010 to March 2011, seven patients underwent LESS minor hepatectomies. Patient demographic, operative, and clinical data were reviewed.

RESULTS

Five left lateral sectionectomies, one segment 3, and one segment 5 resection were performed. The median operative time was 142 min (range, 104-171 min), and the median blood loss was 200 ml (range, 100-450 ml). The median hospital stay was 3 days (range, 1-11 days). For all the patients, the indications for surgery were suspected malignant tumors, and the surgical resection margins were clear for every patient.

CONCLUSIONS

Laparoendoscopic single-site minor hepatectomy is a novel modification to traditional laparoscopic surgery. The method is safe and feasible without any compromise to oncologic safety for selected patients with hepatocellular carcinoma (HCC) and colorectal liver metastases that are peripheral and smaller than 5 cm in size.

Is LESS really more?

In the last decade, laparoendoscopic single-site surgery (LESS) has been touted to be the part of the 'evolution' of minimally invasive surgery. The hope is that reduced access points will ultimately decrease pain, morbidity, convalescence, and improve cosmesis. However, what is unique about LESS is that while laparoscopic literature sought to demonstrate superiority of the technique over that of open surgery, the publications on LESS generally seem to seek to demonstrate equivalence with laparoscopy, with the major focus being on cosmesis. Unfortunately, even in that regard the objective cosmesis data is lacking. Furthermore, patients rate cosmesis the least important of all factors. LESS has also been associated with increased risk of complication, increased surgical cost, and longer operative times. In the current review, an objective assessment of the literature will be used for comparison between current standard laparoscopic techniques and LESS with the hopes of answering the question: is LESS really more?

Transumbilical laparoendoscopic single-site surgery: more than 1-year experience in radical nephrectomy and its learning curve study

PURPOSE

The aim is to report our 1-year experience in transumbilical Laparoendoscopic single-site (LESS) radical nephrectomy (LESS-RN) and assess its learning curve.

PATIENTS AND METHODS

From September 2009 to December 2010, 18 consecutive patients with a solitary renal tumor underwent transumbilical LESS-RN. We grouped measured parameters on the basis of the first nine (group A) and last nine (group B) patients, and compared both subgroups with the control group (C), which was composed of the initial nine consecutive patients who underwent conventional laparoscopic RNs performed by the same surgeon.

RESULTS

There was one LESS patient converted to conventional laparoscopic surgery for intraoperative hemorrhage and transfused. The mean for measured parameters of the groups A, B, C were: age: 58.6, 57.2, and 59.2 years, respectively (P>0.05); American Society of Aneshesiologists score: 1.9, 2.0, and 2.0, respectively (P>0.05); body mass index: 25.2, 23.5, and 23.1 kg/m(2), respectively (P>0.05); lesion size at CT scan: 5.0, 4.6, and 6.2 cm, respectively (P=0.039); operative skin to skin time: 191.6, 123.9, and 122.2 minutes, respectively (P=0.000); estimated blood loss: 172.2, 246.7, and 116.7 mL, respectively (P>0.05); incision length: 5.6, 5.9, and 7.4 cm, respectively (P=0.000); hospital stay: 5.8, 5.8, and 5.8 days, respectively (P>0.05). At the latest follow-up, all patients did not present any local recurrence or metastasis.

CONCLUSIONS

In selected patients, the transumbilical LESS-RN can be safely performed with favorable outcomes. While a learning curve certainly exists, it appears to be short for an experienced laparoscopic surgeon.

Clinical outcomes of laparo-endoscopic single-site surgery radical nephrectomy

INTRODUCTION

The conventional laparoscopic surgery is now paving way to the new technologies including robotic and laparoscopic single-site surgery (LESS). We present our updated experience on LESS radical nephrectomy (LESS-RN).

PATIENTS AND METHODS

The data from patients undergoing LESS-RN in our two institutions were reviewed along with various clinical and pathological parameters.

RESULTS

Between 2008 and 2011, 42 LESS-RN were performed (right = 22, left = 20) with mean (range) age and BMI of 63.7 (33-86) years and 25.1 (18-38.6) kg/m(2), respectively. In addition to the instruments in the single port, one extra 3-mm needlescopic instrument was required in 19 patients (right = 17, left = 2). In three patients, two additional 5-mm trocars and instruments were required. None required open conversion. The recorded adverse events include one bowel injury (intraoperative closure without the need for stoma), one postoperative bleeding requiring blood transfusion, one prolonged ileus, and one deep venous thrombosis. The resected specimens revealed pT1a (n = 3), pT1b (n = 33), pT2a (n = 4), and pT3b (n = 2) tumors. The finding of pT3b was incidental rather than planned procedure. None of the patients had positive margins.

CONCLUSION

LESS-RN has proven to be feasible and safe. Beyond cosmesis, further advantages of this approach need to be addressed by randomized trials.

Laparoendoscopic single-site surgery (LESS) for excision of a seminal vesicle cyst associated with ipsilateral renal agenesis

We report a case of laparoendoscopic single-site surgery (LESS) for a symptomatic left seminal vesicular cyst and ipsilateral renal agenesis. A 49-year-old man presented with a 1-year history of severe irritation upon voiding and intractable, recurrent hematospermia. A computed tomography scan showed a 68×41×38 mm sized left seminal vesicular cyst with ipsilateral renal agenesis. LESS was performed successfully to treat the seminal vesicle cyst. The total operative time was 125 minutes, and blood loss was minimal. The patient was discharged from the hospital on the second postoperative day.