Instruments Interaction in Laparoendoscopic Single-Site Nephrectomy: An Endoscopic Perspective

Abstract

Introduction and Objectives: Reduced triangulation and instrument collision remain obstacles to widespread clinical adoption of laparoendoscopic single-site (LESS) surgery.1 Our aim was to study interaction of instruments in a LESS radical nephrectomy (LESS RN) by placing an additional endoscope to monitor instrument movements during the procedure and develop methods to bypass observed difficulties. Materials and Methods: Our patient was a 62-year-old woman with a 6-cm right renal tumor and multiple abnormal cysts. Through a 3-cm omega-shaped incision, a transperitoneal transumbilical approach was employed with a Gelpoint® platform (Applied Medical, Inc., Rancho Santa Margarita, CA) for access. Four 5-mm reusable trocars were positioned. One was exchanged with a 10-mm trocar for Hem-o-lok® (Teleflex, Inc., Limerick, PA) clip delivery. Surgery was performed with a 5-mm 30° endoscope and standard laparoscopic instruments. A 5-mm trocar was inserted in the right flank to observe and record the procedure through another 5-mm 30° endoscope in its entirety. The surgeon did not have access to this extra camera view during the procedure. Conventional laparoscopic radical nephrectomy (LRN) steps were utilized (colon/liver mobilization, vena cava and pedicle dissection/control, ureteral sectioning, and final specimen dissection). The specimen was extracted through the umbilical incision. Operative time was under 2 hours. The patient had a normal postoperative course without complications. Results: The procedure was completed in comparable time to LRN with standard laparoscopic instruments. Video observations of all surgical steps were reviewed. From the endoscopic perspective, clashing of the endoscope and the main instrument occurred most frequently during the upper-pole dissection when the instruments entered in the same axis. This prevented triangulation and reduced mobility. Avoiding collisions required surgeon/assistant coordination and minor adjustments to trocars placed within the Gelpoint. The remainder of the procedure had minimal instrument-related difficulties as shown in the video. The multifunctionality of the ultrasonic shears facilitated the procedure by reducing instrument switching. Conclusions: LESS RN can be performed with standard laparoscopic instruments in a comparable amount of time to standard LRN with excellent cosmesis and no significant change in cost or morbidity.1 The observation endoscope in the flank clearly demonstrated that although some instrument clashing and decreased triangulation were seen, the use of the Gelpoint access system and low-profile trocars allowed the operation to progress smoothly. We believe that these observations further support the use of LESS RN as a feasible alternative to LRN in appropriately selected patients.1,2 The authors have nothing to disclose Runtime of video: 09 mins 49 secs This video was presented in part at the 2011 European Association of Urology Congress in Vienna.