Laparoendoscopic Single-site Surgery Procedure Research Articles

Quantifying the cognitive cost of laparo-endoscopic single-site surgeries: Gaze-based indices

BackgroundDespite the growing interest concerning the laparo-endoscopic single-site surgery (LESS) procedure, LESS presents multiple difficulties and challenges that are likely to increase the surgeon's cognitive cost, in terms of both cognitive load and performance. Nevertheless, there is currently no objective index capable of assessing the surgeon cognitive cost while performing LESS. We assessed if gaze-based indices might offer unique and unbiased measures to quantify LESS complexity and its cognitive cost. We expect that the assessment of surgeon's cognitive cost to improve patient safety by measuring fitness-for-duty and reducing surgeons overload. MethodsUsing a wearable eye tracker device, we measured gaze entropy and velocity of surgical trainees and attending surgeons during two surgical procedures (LESS vs. multiport laparoscopy surgery [MPS]). None of the participants had previous experience with LESS. They performed two exercises with different complexity levels (Low: Pattern Cut vs. High: Peg Transfer). We also collected performance and subjective data. ResultsLESS caused higher cognitive demand than MPS, as indicated by increased gaze entropy in both surgical trainees and attending surgeons (exploration pattern became more random). Furthermore, gaze velocity was higher (exploration pattern became more rapid) for the LESS procedure independently of the surgeon's expertise. Perceived task complexity and laparoscopic accuracy confirmed gaze-based results. ConclusionGaze-based indices have great potential as objective and non-intrusive measures to assess surgeons' cognitive cost and fitness-for-duty. Furthermore, gaze-based indices might play a relevant role in defining future guidelines on surgeons' examinations to mark their achievements during the entire training (e.g. analyzing surgical learning curves).

The use of expanding ports in laparo-endoscopic single-site surgery may cause more pain: a meta-analysis of randomized clinical trials

Previous meta-analyses on the clinical outcome after laparo-endoscopic single-site surgery (LESS) versus conventional laparoscopic surgery (CLS) have not revealed any major differences in postoperative pain between the two procedures. This meta-analysis aims to evaluate the difference in postoperative pain between the two procedures, focusing on whether LESS was conducted with a non-expanding port (LESSnonex) or a port expanding (LESSex) within the incision. EMBASE, Medline, PubMed, Science Citation Index Expanded, and Cochrane Central Register of Controlled Trials were searched for randomized clinical trials (RCTs) on LESS versus CLS for general abdominal procedures. Weighted mean difference (WMD) and Odds ratios (OR) were calculated with 95% confidence intervals (CI). A total of 29 RCTs with 2999 procedures were included. Pain (VAS 0-10) 6h after surgery was significantly lower in the group where LESS was conducted with LESSnonex compared to CLS, WMD=-0.72 (- 1.10 to - 0.33). Pain 18-24h was significantly higher in the group where LESS was conducted with LESSex compared to CLS, WMD = 0.38 (0.01-0.75). Wound-related complications were significantly more frequent in LESSex procedures compared to CLS, OR = 1.94 (1.03-3.63). The present meta-analysis indirectly indicates that the type of access device that is used for an abdominal LESS procedure may contribute to the development of early postoperative pain as the use of a non-expanding model was associated with a more advantageous outcome. Direct randomized comparison of LESSnonex and LESSex is warranted to confirm if the use of expanding access devices generates more pain and wound complications.

L’annexectomie par cœlio-chirurgie mono-trocart pour tous

ObjectivesTo study the adnexectomy by laparoendoscopic single-site surgery with conventional laparoscopic instruments, we standardised the technique of salpingo-oophorectomy. Patients and methodsIn this prospective study, all patients with adnexectomies from June 2010 to January 2014 were included. Laparoendoscopic single-site adnexectomy with conventional instruments is described step by step in order to make it available for the majority of gynecologic surgeons. Laparoconversions and complications are also noted. ResultsWe realized 42 bilateral salpingo-oophorectomies, 16 single salpingo-oophorectomy. The average operative time was 45min (15–120) with negligible blood losses. There were no laparoconversions and very few complications. After 15–20 adnexectomies, the procedure took less and less time. Discussion and conclusionAdnexectomy by laparoendoscopic single-site surgery procedure with conventional laparoscopic instruments is easily reproducible with standardized steps and has many advantages.

Reply

The editorial comments and the interest in our technique of laparoendoscopic single-site surgery (LESS) are greatly appreciated. We certainly acknowledge the limitations of our study. All the nephrectomies by conventional laparoscopy (CL) were performed by experienced attending surgeons who were definitely not in the early phase of the learning curve for such a procedure. The mean operating time below a hundred minutes for our CL nephrectomy compares favorably with those reported by others. 1 Kim C. McKay K. Docimo S.G. Laparoscopic nephrectomy in children: systematic review of transperitoneal and retroperitoneal approaches. Urology. 2009; 73: 280-284 Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar We expect to see improvement in our LESS with further accumulation of experience. However, it is doubtful whether our improved skills could make the LESS procedure comparable to CL in operating time at the end of the day, given all the technical challenges intrinsic to LESS. Editorial CommentUrologyVol. 82Issue 2PreviewLaparoendoscopic single-site surgery (LESS) is an evolution of conventional laparoscopy and specific instruments have been devised for it. The need for specific instruments, however, makes LESS unpractical and increases costs. The authors of the present study should be commended for their efforts to develop a technique to perform LESS nephrectomy and heminephroureterectomy in children using conventional laparoscopic instruments. The present report includes the largest series to date of patients undergoing such a procedure. Full-Text PDF

Laparoendoscopic single-site surgery in gynecology: LESS is actually how much less?

Gynecological surgery is evolving continuously. Laparoendoscopic single-site surgery (LESS) is the recent addition in this field that stands to benefit almost 40% of women in midlife who will eventually undergo adnexal surgery or hysterectomy. Carried out through a single umbilical incision, the potential benefit of single site surgery is improvement in operative morbidity and cosmesis. The safety, feasibility and efficacy of laparoendoscopic single site procedures have been established in studies over the last few years. In this article, we will review the nomenclature, instruments, and the evidence around the commonly performed gynecologic surgeries using the LESS procedure.

Retroperitoneal laparoscopic single‐site nephroureterectomy: Initial operative experience

Our aim was to describe our early experience with laparoendoscopic single-site surgery (LESS) via the retroperitoneal approach for upper urinary tract tumors. Since April 2010, 21 patients with upper urinary tract cell carcinoma were treated by our team: 12 patients have undergone LESS nephroureterectomy and 9 have undergone standard retroperitoneal laparoscopic surgery. In our LESS procedure, we employed a bendable grasper in the non-dominant hand and a standard straight laparoscopic instrument in the dominant hand. Nephrectomy was performed using procedures similar to those of conventional laparoscopic nephrectomy. In standard laparoscopic nephroureterectomy, the distal ureter and bladder cuff were excised by using the open method. All operations using retroperitoneal LESS nephroureterectomy were completed without conversion to standard laparoscopy or open surgery. No intraoperative or acute postoperative complications occurred. We compared the results of the retroperitoneal single-port laparoscopic surgery group to the standard retroperitoneal laparoscopic surgery group and found that the retroperitoneal LESS nephroureterectomy had significantly less estimated blood loss (P = 0.034). No significant difference was noted with respect to age, BMI, operation time, time to oral intake, length of hospitalization, and the visual analog pain scale score at discharge ( P > 0.05). The initial reports of retroperitoneal LESS nephroureterectomy demonstrate that the technique is a safe and feasible procedure for upper urinary tract urothelial carcinoma.

Laparoendoscopic single‐site surgery for urachal remnants

Urachal remnants are relatively rare but may potentially cause various symptoms and an increased risk for developing adenocarcinoma. Open or laparoscopic surgery is usually used for their resection. Laparoendoscopic single-site surgery has been recently applied in several surgical procedures. This report describes two cases of vesicourachal diverticulum treated by resection using laparoendoscopic single-site surgery. In each case, laparoendoscopic single-site surgery was performed transperitoneally via one port at a subumbilical semicircular incision. Except for a flexible camera and SILS Port, traditional, non-flexible laparoscopic instruments were used. After the induction of general anesthesia, the patient was placed in a supine position (or lithotomy position). A 2.0-cm incision was made semicircumferentially following the natural subumbilical folds. After the umbilical ligament was cut under direct vision, a SILS Port was placed at the incision. The urachus was liberated distally down to the roof of the urinary bladder using 0° 5-mm flexible camera. Vesicourachal diverticulum with a bladder cuff was completely excised under the supporting view of cystoscopy. Both patients' perioperative days were uneventful. Our findings suggest that the laparoendoscopic single-site surgery procedure is safe, minimally invasive and cosmetically acceptable. Therefore, this procedure is an excellent option for the radical resection of urachal remnants.

Laparoendoscopic single site surgery in urology: A single centre experience

OBJECTIVE:To analyze our experience of 87 cases with single port surgery, which is also known as laparoendoscopic single site surgery (LESS).MATERIALS AND METHODS:Case records of all LESS procedures performed between December 2007 and June 2010 were analysed. The procedures performed were donor nephrectomy (n=45), simple nephrectomy (n=27), radical nephrectomy (n=5), pyeloplasty (n=9), and ureteroneocystostomy (n=1). Parameters analysed were operating room (OR) time, estimated blood loss (EBL), visual analogue score (VAS), and complications in all patients undergoing LESS procedure and additionally, warm ischaemia time (WIT) and graft outcome in patients undergoing LESS donor nephrectomy. In reconstructive procedures, the functional assessment was performed with a diuretic renogram at 6 months.RESULTS:In LESS donor nephrectomy, the mean WIT was 6.9 ± 1.9 min. Mean serum creatinine in recipients at 1 month was 0.96 ± 0.21 mg%. We encountered one instance each of renal artery injury, renal vein injury, large bowel injury, minor cortical laceration at the upper pole and two instances of diaphragmatic injury. In LESS simple nephrectomy, the average OR time was 148.7 ± 52.2 min and hospital stay was 3.7 ± 1.2 days. There was one instance of large bowel injury during specimen retrieval. In LESS radical nephrectomy, the average OR time was 202.5 ± 35.7 min and average hospital stay was 4.2 ± 1.3 days. 6 patients of LESS pyeloplasty completed follow up with a diuretic renogram showing a good drainage. LESS ureteroneocystostomy could also be performed successfully without any complications.CONCLUSION:LESS surgery can be accomplished safely in nephrectomy and reconstructive procedures such as pyeloplasty and ureteroneocystostomy with equivalent outcomes as standard laparoscopy and with added benefits of cosmesis and quicker convalescence. LESS donor nephrectomy is a technically feasible procedure; current status of procedure needs to be proved with randomised controlled studies.

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.

Umbilical laparoendoscopic single site surgery versus inguinal varicocelectomy for bilateral varicocele: A comparative study

We aimed to determine the efficacy of umbilical laparoendoscopic single site surgery (LESS) bilateral varicocelectomy on the basis of a comparative study versus open inguinal bilateral varicocelectomy. We enrolled 39 patients who underwent bilateral varicocelectomy with predetermined surgical indications at two hospitals with either the LESS (n = 19) or the open inguinal approach (n = 20). Operative time, operation-related pain (10-point visual analog pain scale), catch-up growth of the testes, semen parameters, and complications after surgery between the LESS group and the open group at 3 months after surgery were compared. Operative times were 46.8 and 72.8 min (P < 0.001) in the LESS and open surgery groups, respectively. Patients in the LESS group reported lower surgery-related pain than those in the open surgery group at 3 months (2.5 vs 1.2, P = 0.029). A significant improvement in terms of semen concentration, motility, catch-up growth of the bilateral testes was observed in both groups, although no significant differences were detected between the groups. Postoperative complications were also similar between the two groups. LESS varicocelectomy required a shorter operative time than inguinal varicocelectomy for bilateral cases. In addition, the LESS procedure showed less postoperative pain and cosmetic benefits with similar seminal outcomes. Thus, LESS for patients undergoing bilateral varicocelectomy represents a promising surgical approach.

079 AN UNUSUAL PRESENTATION OF ACUTE HUMORAL REJECTION POST-RENAL TRANSPLANTATION TREATED WITH AN UNCOMMON REGIMEN

Despite the growing interest concerning the laparo-endoscopic single-site surgery (LESS) procedure, LESS presents multiple difficulties and challenges that are likely to increase the surgeon's cognitive cost, in terms of both cognitive load and performance. Nevertheless, there is currently no objective index capable of assessing the surgeon cognitive cost while performing LESS. We assessed if gaze-based indices might offer unique and unbiased measures to quantify LESS complexity and its cognitive cost. We expect that the assessment of surgeon's cognitive cost to improve patient safety by measuring fitness-for-duty and reducing surgeons overload.Using a wearable eye tracker device, we measured gaze entropy and velocity of surgical trainees and attending surgeons during two surgical procedures (LESS vs. multiport laparoscopy surgery [MPS]). None of the participants had previous experience with LESS. They performed two exercises with different complexity levels (Low: Pattern Cut vs. High: Peg Transfer). We also collected performance and subjective data.LESS caused higher cognitive demand than MPS, as indicated by increased gaze entropy in both surgical trainees and attending surgeons (exploration pattern became more random). Furthermore, gaze velocity was higher (exploration pattern became more rapid) for the LESS procedure independently of the surgeon's expertise. Perceived task complexity and laparoscopic accuracy confirmed gaze-based results.Gaze-based indices have great potential as objective and non-intrusive measures to assess surgeons' cognitive cost and fitness-for-duty. Furthermore, gaze-based indices might play a relevant role in defining future guidelines on surgeons' examinations to mark their achievements during the entire training (e.g. analyzing surgical learning curves).

Urologic Laparoendoscopic Single-Site Surgery (LESS): Current Status

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

Laparoendoscopic Single Site (LESS) Versus Classic Video-Laparoscopic Cholecystectomy: A Randomized Prospective Study

Laparoscopic cholecystectomy (LC) is the gold-standard for the treatment of gallbladder stone disease. In recent years laparoendoscopic single site surgery (LESS) has gained greater interest and diffusion for the treatment of gallstones and also in bariatric and colonic surgery. However, no randomized controlled trials are present in the literature that confirm the clinical advantages of LESS compared with the classic laparoscopic procedures. For this reason, we present the preliminary results of this randomized prospective study regarding the feasibility and safety of LESS cholecystectomy versus classic laparoscopic technique. Between October 2009 and April 2010, 50 patients were randomly assigned to three-port classic laparoscopic cholecystectomy (n = 25) or LESS procedure (n = 25). Exclusion criteria were: (1) previous abdominal surgery, (2) signs of acute cholecystitis, choledocholithiasis, or acute pancreatitis, (3) ASA grade III or more, (4) lack of written informed consent, and (5) BMI ≥ 30 Kg/m(2).All the patients' details were recorded: age, weight, height, body mass index, operative time, length of hospital stay, patients' pain and wound satisfaction score. Abdominal pain was registered at 6, 12, and 24 h postoperatively. Wound satisfaction score (very unsatisfied = 1, unsatisfied = 2, acceptable = 3, satisfied = 4, very satisfied = 5) was registered for each patient at the seventh postoperative day. No differences were registered between the two groups about gender, age, weight, height, and BMI. Also postoperative hospital stay was similar (P = 0.71). In three patients (1 in group A and 2 in group B) a 5-mm trocar was added. Intraoperative cholangiography was performed in five patients (2 in group A and 3 in group B). Mean operative time was significantly longer in LESS procedures (41.3 ± 12.0 versus 35.6 ± 5.8; P = 0.04). Abdominal postoperative pain was similar in LC and LESS cholecystectomy. Wound satisfaction score showed statistically significant differences between the two groups: in LESS group, patients were more satisfied with the presence of a small umbilical medication (P < 0.05). In this randomized prospective study, we conclude that LESS cholecystectomy is an excellent alternative to traditional three-port cholecystectomy for patients with uncomplicated disease, and no previous abdominal surgery. Although no differences are present about hospital stay and postoperative pain compared with classic laparoscopic cholecystectomy, in our experience LESS has had a significant impact on patients' wound satisfaction.

Initial Experience With Laparoendoscopic Single-site Nephrectomy and Nephroureterectomy in Children

To assess the clinical utility and safety of laparoendoscopic single-site surgery (LESS) nephrectomy and nephroureterectomy in children by analyzing 6 consecutive cases performed by a single surgeon. Since March 2009, we have been performing LESS nephrectomy and nephroureterectomy in children. The indications have been recurrent pyelonephritis related to vesicoureteral reflux with an atrophic kidney and continuous urinary incontinence related to an ectopic ureter. A homemade port was placed through an umbilical incision, and the laparoscopic transperitoneal nephrectomy procedures were performed using various combinations of standard and articulating laparoscopic instruments. The patients undergoing a LESS procedure were evaluated prospectively, and the data were collected during and after surgery. A total of 6 procedures, including nephrectomy (4 cases) and nephroureterectomy (2 cases), were completed without intraoperative or postoperative complications. The median operation time was 112 minutes (range 90-148), and the median blood loss was 0 mL (range 0-50). All patients received only oral ibuprofen syrup for pain control and were discharged on postoperative day 2. As the surgeon gained experience, the length of the umbilical incision was decreased from 2.0 to 1.0 cm. Pediatric LESS nephrectomy and nephroureterectomy can be performed safely with a very small incision. LESS performed by an experienced laparoscopic surgeon has the potential to become an alternative first-line therapy for ablative procedures in children.

Laparoendoscopic single-site surgery appendectomy

Laparoscopic appendectomy via the three-trocar technique is widely used for appendectomy. This report describes the initial experience with laparoendoscopic single-site surgery (LESS) appendectomy. Between December 2008 and March 2009, patients with acute appendicitis admitted to the General Surgery and Emergency Unit of the authors' institution who agreed to undergo LESS appendectomy were included in a prospective study. All operations were performed by the same surgical team specially trained in this type of emergency surgery. The umbilicus was the sole point of entry for all patients, and the same operative technique was used in all cases. The data for patients undergoing LESS appendectomy were compared with the data from an uncontrolled group of patients undergoing standard laparoscopic appendectomy during the same study period. The LESS and standard appendectomy groups included 15 patients each. The LESS procedure was performed successfully for all the patients, and none required conversion to an open procedure or a conventional laparoscopic appendectomy by the addition of more entry ports. The mean operating time of 51 min in the LESS group was not significantly different from the 46 min in the standard laparoscopic appendectomy group. In this study, LESS appendectomy was technically feasible and safe, representing a reproducible alternative to standard laparoscopic appendectomy.