Laparoendoscopic Single-site Surgery Procedures Research Articles

Development of a novel robotic platform with controllable stiffness manipulation arms for laparoendoscopic single-site surgery (LESS).

For current LESS robotic systems, the trade-off between dexterity and payload capability is always present. This paper presents a novel LESS robotic platform equipped with controllable stiffness manipulation arms. Each manipulation arm with an articulated section and a controllable stiffness continuum section (CSCS) can be switched between a 7-DoF compliant status and 5-DoF rigid status according to the operation requirement. Screw theory and product exponential formula are used to quantify the kinematic performance. The stiffness of the manipulation arm promotes 3.03 to 4.12 times from compliant to rigid CSCS with maximum payload of 10N in rigid status. The shortest rigid/compliant switching time is 5s. The precision of a tracking test and an ex vivo procedure verified the accuracy and effectiveness of the controllable stiffness manipulation arms. This robot could potentially improve the surgical performance and further expand robotic LESS procedures.

Laparoendoscopic single-site surgery for the treatment of different urological pathologies: Defining the learning curve of an experienced laparoscopist

ObjectivesTo define the learning curve of laparoendoscopic single-site surgery (LESS) of an experienced laparoscopist. Patients and methodsPatients who had LESS, since its implementation in December 2009 until December 2014, were retrospectively analysed. Procedures were divided into groups of 10 and scored according to the European Scoring System for Laparoscopic Operations in Urology. Different LESS indications were done by one experienced laparoscopist. Technical feasibility, surgical safety, outcome, as well as the number of patients required to achieve professional competence were assessed. ResultsIn all, 179 patients were included, with mean (SD) age of 36.3 (17.5)years and 25.4% of the patients had had previous surgeries. Upper urinary tract procedures were done in 65.9% of patients and 54.7% of the procedures were extirpative. Both transperitoneal and retroperitoneal LESS were performed in 92.8% and 7.2% of the patients, respectively. The intraoperative and postoperative complication rates were 2.2% and 5.6% (Clavien–Dindo Grade II 3.9% and IIIa 1.7%), respectively. In all, 75% of intraoperative complications and all conversions were reported during the first 30 LESS procedures; despite the significantly higher difficulty score in the subsequent LESS procedures. One 5-mm extra port, conversion to conventional laparoscopy and open surgery was reported in 14%, 1.7%, and 1.1% of the cases, respectively. At mean (SD) follow-up of 39.7 (11.4) months, all the patients that underwent reconstructive LESS procedures but one were successful. ConclusionIn experienced hands, at least 30 LESS procedures are required to achieve professional competence. Although difficult, both conversion and complication rates of LESS are low in experienced hands.

Impact of novel techniques on minimally invasive adrenal surgery: trends and outcomes from a contemporary international large series in urology.

To evaluate contemporary international trends in the implementation of minimally invasive adrenalectomy and to assess contemporary outcomes of different minimally invasive techniques performed at urologic centers worldwide. A retrospective multinational multicenter study of patients who underwent minimally invasive adrenalectomy from 2008 to 2013 at 14 urology institutions worldwide was included in the analysis. Cases were categorized based on the minimally invasive adrenalectomy technique: conventional laparoscopy (CL), robot-assisted laparoscopy (RAL), laparoendoscopic single-site surgery (LESS), and mini-laparoscopy (ML). The rates of the four treatment modalities were determined according to the year of surgery, and a regression analysis was performed for trends in all surgical modalities. Overall, a total of 737 adrenalectomies were performed across participating institutions and included in this analysis: 337 CL (46% of cases), 57 ML (8%), 263 LESS (36%), and 80 RA (11%). Overall, 204 (28%) operations were performed with a retroperitoneal approach. The overall number of adrenalectomies increased from 2008 to 2013 (p=0.05). A transperitoneal approach was preferred in all but the ML group (p<0.001). European centers mostly adopted CL and ML techniques, whereas those from Asia and South America reported the highest rate in LESS procedures, and RAL was adopted to larger extent in the USA. LESS had the fastest increase in utilization at 6%/year. The rate of RAL procedures increased at slower rates (2.2%/year), similar to ML (1.7%/year). Limitations of this study are the retrospective design and the lack of a cost analysis. Several minimally invasive surgical techniques for the management of adrenal masses are successfully implemented in urology institutions worldwide. CL and LESS seem to represent the most commonly adopted techniques, whereas ML and RAL are growing at a slower rate. All the MIS techniques can be safely and effectively performed for a variety of adrenal disease.

Laparo-endoscopic single site surgery in pediatrics: Feasibility and surgical outcomes from a preliminary prospective Canadian experience.

Laparo-endoscopic single-site surgery (LESS) is becoming an alternative to standard laparoscopic surgery. Proposed advantages include enhanced cosmesis and faster recovery. We assessed the early post-operative surgical outcomes of LESS surgery utilizing different instruments in the pediatric urological population in Canada. We prospectively captured data on all patients undergoing LESS at our institution between February 2011 and August 2012. This included patient age, operative time, length of stay, complications and short-term surgical outcomes. Different instruments/devices were used to perform the procedures. Access was achieved through a transumbilical incision. A total of 16 LESS procedures were performed, including seven pyeloplasties, four unilateral and one bilateral varicocelectomies, two simple nephrectomies, one renal cyst decortication and one pyelolithotomy. There was no statistical difference in the operative times, hospital length of stay and cost (pyeloplasty only) in patients undergoing pyeloplasty and varicocelectomy using the LESS technique when compared to an age matched cohort of patients managed with the traditional laparoscopic approach. One pyeloplasty in the LESS group required conversion to open due to a small intra-renal pelvis. There were no immediate or short term post-operative complications; however, one patient experienced a decrease in renal function status post LESS pyeloplasty. Since all procedures were performed by a vastly experienced surgeon at a tertiary center, the generalizability of the results cannot be assessed. There are only a few series that have assessed the role of LESS in pediatric urological surgery. Although our experience is limited by a heterogeneous group of patients with a short follow-up period, the present cohort demonstrates the safety and feasibility of LESS. Further evaluation with randomized studies is required to better assess the role of LESS in pediatric urology.

Laparoendoscopic single-site surgery (LESS) for the treatment of different urologic pathologies in pediatrics: Single-center single-surgeon experience

Recently LESS has been reported as a valid minimally option for treatment of some urologic pathologies in pediatrics. However, the initial reports of pediatric LESS are still limited to case reports and initial case series. This may be due to the inherent technical difficulty of LESS and the currently available LESS instruments. In this report, we present the largest case series of pediatric LESS for treatment of different urologic pathologies in pediatrics. Included in this study are children who had LESS during the period of January 2011 to June 2013. Both Olympus TriPort (Olympus, New York, USA and Advance Surgical Concept, Wicklow, Ireland) and Covedien SILS access port (Covedien, Chicopec, Massachusetts, USA) were used and were inserted through the umbilicus. Exclusion criteria included children less than 3 years old, history of previous transperitoneal abdominal surgery, malignant indications, and complex urogenital congenital anomalies. All LESS procedures were done by a single experienced laparoscopist and data were reviewed retrospectively. Twenty-two children had 39 LESS procedures without conversion to conventional laparoscopy or open surgery. No intraoperative or postoperative complications were reported and no extra-port was added in any of the patients. The following table shows the mean age, operative time, hospital stay, VAS as well as the overall mean of different LESS procedures. In all patients the umbilical scar was invisible and all patients and their parents had high wound satisfaction. At a mean follow up of 18.6 ± 6.4 months, all patients with UPJO had successful repair. Our study included 13 boys with undescended testis who were managed in different ways according to the length of spermatic vessels and the size of the testis. One of the arguments against LESS management of undescended testis is that it requires a 2.5-cm incision, which is collectively larger than a 5-mm camera and two 3-mm working ports of conventional laparoscopy. However, the Triport access can be inserted through a 12-15-mm single umbilical incision without any additional openings in the abdomen as required with conventional laparoscopy which may increase the risk of internal organ injury and other port-related complications. Our results of five LESS varicocelectomies correlate with reports in the literature; regarding the operative time and hospital stay. LESS pediatric nephrectomy has been reported by many authors and our results correlates with that have been published. Compared with conventional laparoscopic nephrectomy, LESS nephrectomy seems to have shorter operative time and hospital stay. Although both cases of LESS nephrectomy were on the right side, we did not add any extra-ports which could be related to technical modifications during the surgery as well as the experience of the surgeon. To date, few data are available about LESS pyeloplasty in pediatrics. Our study included three patients who had left LESS pyeloplasties. In these patients, no extra-port was added. Despite of the technical difficulty of intracorporeal suturing during LESS, LESS pyeloplasty seems to be feasible with adequate training. Our patients had short hospital stay, low VAS at discharge, received a low dose of NSAID as postoperative analgesic and in all cases there was high wound satisfaction. One of the limitations of the current study could be the selection criteria of the patients, with children younger than 3 years and children who may be more technically difficult, being excluded. Furthermore, the number of patients in some indications is small and more patients are required to give solid conclusions and detect possible complications. Our study demonstrates the technical feasibility and safety of LESS for both ablative and reconstructive pathologies in pediatrics. However, more applications including a larger scale of pediatric patients as well as prospective comparative studies with conventional laparoscopy, are necessary.

Laparoendoscopic Single-Site Surgery Using Conventional Laparoscopic Instruments and Glove Port Technique in Gynecology: A Single Surgeon's Experience

Study ObjectiveTo report a single surgeon's experience with 120 laparoendoscopic single-site surgery (LESS) procedures using conventional laparoscopic instruments and a homemade glove port system to treat benign gynecologic diseases. DesignRetrospective chart analysis (Canadian Task Force classification III). SettingEulji University Hospital. PatientsOne hundred twenty patients who underwent LESS performed by a single surgeon to treat benign gynecologic diseases between November 2010 and November 2012. InterventionLESS using conventional instrumentation was performed using our specialized glove port technique, which consists of the combination of the homemade glove port system designed to minimalize collision of the trocar on the tip of the finger of the surgical glove, a sufficient rectus fasciotomy, the surgeon's position at the patient's head, and adequate positioning of the instruments. Measurements and Main ResultsThe LESS procedures performed were laparoscopically assisted vaginal hysterectomy (n = 50), ovarian cystectomy (n = 25), myomectomy (n = 14), oophorectomy (n = 11), salpingectomy (n = 9), fimbrioplasty or neosalpingstomy (n = 7), and adhesiolysis only (n = 4). Median patient age was 40 years, and median body mass index was 23. Median operative time was 100 minutes (range, 50–145 minutes) for laparoscopically assisted vaginal hysterectomy, 70 minutes (range, 30–150 minutes) for ovarian cystectomy, 107 minutes (range, 65–180 minutes) for myomectomy, 55 minutes (range, 25–130 minutes) for oophorectomy, 85 minutes (range, 35–110 minutes) for salpingectomy, 70 minutes (range, 25–140 minutes) for neosalpingostomy or fimbrioplasty, and 35 minutes (range, 30–60-minutes) for adhesiolysis only. All procedures were completed successfully without the need for additional ports or conversion to the standard laparoscopic approach. One perioperative complication occurred. The complication rate was 83% (1 of 120). Other postoperative complications were not observed at follow-up. ConclusionOur experience shows that LESS using conventional laparoscopic instruments and our glove port technique is a feasible and safe technique for the surgical management of various gynecologic conditions. Therefore, our homemade glove port laparoscopic system used in our specialized technique provides a simple, cost-effective approach to LESS and would probably make laparoscopic procedures using conventional instruments easier.

Miniature surgical robots in the era of NOTES and LESS: dream or reality?

Laparoscopy is an established method for the treatment of numerous surgical conditions. Natural orifice transluminal endoscopic surgery (NOTES) is a novel surgical technique that uses the natural orifices of the human body as entrances to the abdominal cavity. An alternative concept of minimally invasive approach to the abdominal cavity is to insert all the laparoscopic instruments through ports using a single small incision on the abdominal wall. A suggested name for this technique is laparoendoscopic single-site surgery (LESS). Considering the technical difficulties in NOTES and LESS and the progress in informatics and robotics, the use of robots seems ideal. The aim of this study is to investigate if there is at present, a realistic possibility of using miniature robots in NOTES or LESS in daily clinical practice. An up-to-date review on in vivo surgical miniature robots is made. A Web-based research of the English literature up to March 2013 using PubMed, Scopus, and Google Scholar as search engines was performed. The development of in vivo miniature robots for use in NOTES or LESS is a reality with great advancements, potential advantages, and possible application in minimally invasive surgery in the future. However, true totally NOTES or LESS procedures on humans using miniature robots either solely or as assistance, remain a dream at present.

Development of urologic laparoscopy in Germany, Austria, and Switzerland: a survey among urologists

Laparoscopy introduction has dramatically changed urology. Novel techniques, such as laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery (NOTES), might also have substantial influence. This 2012 survey evaluated present laparoscopy use, its appraisal among urologic surgeons, laparoscopy training, and use of new techniques. Results were compared to the previous surveys, demonstrating the 10-year development of laparoscopy. A detailed questionnaire regarding demographic data, laparoscopy use, attitudes concerning laparoscopy, and novel techniques was send to 424 departments in Germany, Austria, and Switzerland. Procedures performed in 25 indications were quantitatively evaluated. The response rate was 63 % (269). Eighty-six percent of the respondents reported performing laparoscopy, compared to 54 % in 2002. Only 16 % expected economic advantages with laparoscopy, whereas 67 % expected shorter hospitalization. Seventy percent of responders anticipated comparable functional and oncological results between laparoscopic procedures and open surgery. Slow learning curves (81 %) and insufficient training facilities (32 %) were reported to impair laparoscopic surgery. On average, laparoscopic and non-laparoscopic surgical teams consisted of 2.5 and 3.5 members, respectively. LESS procedures were performed at 15 % of institutions. Twenty-two percent of respondents considered NOTES techniques valuable for future urology. Few indications (laparoscopic prostatectomies or nephrectomies) were performed frequently in specialized centers, and the rapidly increasing procedure numbers observed between 2002 and 2007 had dropped to a mild accretion. The results demonstrate broad acceptance of laparoscopy in German urologic surgery, depict the need for structured training facilities, and indicate limited impact of novel techniques (LESS and NOTES). The survey demonstrates the 10-year development of urologic laparoscopy and the broad acceptance of laparoscopic techniques.

Laparoendoscopic single-site surgery adrenalectomy - own experience and matched case-control study with standard laparoscopic adrenalectomy.

IntroductionAt our institution, laparoendoscopic single-site surgery (LESS) has been established as a technique for laparoscopic nephrectomy since 2011, and since 2012 in selected cases for adrenalectomy (AE) as well.AimTo compare LESS AE with standard laparoscopic AE (SLAE).Material and methodsBetween 3/2012 and 7/2014, 35 adrenalectomies were performed. In 18 (51.4%), a LESS approach was chosen. Indications were strictly non-complicated cases (body mass index (BMI) < 34 kg/m2, tumour ≤ 7 cm, non-malignant aetiology, no previous surgery). All LESS procedures were done by one surgeon. Standard equipment was a 10 mm rigid 0° camera, Triport+, one pre-bent grasper, and a sealing instrument. The approach was pararectal in all cases except one (transumbilical in a slim man). Three patients with LESS were excluded (2 partial AEs only, one adrenal cancer converted to SLAE and then to open surgery). These 15 LESS AE procedures were compared to 15 SLAEs with similar characteristics chosen among 54 SLAEs performed in the period 1/2008–2/2012.ResultsIn 8 cases (53.3%) of LESS AE, a 3 mm port was added to elevate the liver/spleen. Mean parameters of LESS AE vs. SLAE (Wilcoxon test): maximal tumour diameter 43.7 mm vs. 36.1 mm (p = 0.28), time of surgery 63.3 min vs. 55.3 min (p = 0.22), blood loss 38.0 ml vs. 38.0 ml (p = 0.38), BMI 26.9 kg/m2 vs. 28.5 kg/m2 (p = 0.13), discharge from hospital 5.4 days vs. 3.9 days (p = 0.038). There were no complications in either group.ConclusionsThe LESS AE is feasible in selected cases, especially small left-sided tumours in thin patients with no history of previous abdominal operations, but requires an additional port in half of the cases.

New technologies for single‐site robotic surgery in hepato‐biliary‐pancreatic surgery

Laparoendoscopic single-site surgery (LESS) aims to reduce incision-related complications by using a single surgical access through which multiple instruments are inserted simultaneously. First descriptions of LESS procedures date back to the early 90 s, but the approach initially failed to gain popularity because of technical challenges that markedly impair the principles of laparoscopic ergonomics. In recent years LESS has been increasingly applied to hepatobiliary procedures including cholecystectomies and liver resections. However, the uptake of LESS in hepatobiliary is limited. The surgical robotic platform might play a fundamental role in facilitating the uptake of LESS by the surgical community since robotic science made it possible to develop adequate technology to deal with some of the LESS issues such as restoring surgical triangulation. In this paper the current state-of-the-art for robotic LESS applied to the hepatobiliary system and emerging technologies enabling safer LESS procedures have been reviewed and future perspectives commented on the light of our experience.

Hand Instrument Performance in A Single Site Surgery Simulator With Novices

Laparoendoscopic single-site surgery (LESS) is a new minimally invasive surgical technique that presents physical and mental challenges to surgeons. Currently, LESS procedures are commonly performed using surgical instruments designed for traditional multi-incision laparoscopic surgery. A pilot study was conducted to determine which laparoscopic instruments were the most efficient for LESS procedures. In a LESS surgical trainer, 24 novice users completed a simple surgical task using standard (non-articulating) straight laparoscopic graspers and two different articulating instruments. Task performance was scored based on completion time and the number of errors. Analyses showed that the use of the simpler straight instruments produced significantly faster times (p = 0.004 and p = 0.014) and higher task scores (p = 0.005 and p = 0.021) than the articulating instruments. These results suggest that standard laparoscopic hand instruments enable better novice performance for a basic LESS task.

Laparoendoscopic Single-Site (LESS) Renal Cyst Decortication During Pacific Partnership Humanitarian Assistance Mission

We describe the first laparoendoscopic single-site surgery (LESS) performed during a U.S. Navy humanitarian assistance mission. In conjunction with host nation surgeons, we performed a LESS renal cyst decortication in a 72-year-old woman during Pacific Partnership aboard the USNS Mercy (T-AH19). LESS procedures during humanitarian assistance missions offer advantages of rapid recovery and minimal convalescence. This case illustrates an innovative way to transfer technology and techniques between mission personnel and host nation providers during missions designed to build stronger relationships and disaster response capabilities in the Asia-Pacific region.

Cosmetic Outcomes of Laparoendoscopic Single-Site Hysterectomy Compared With Multi-Port Surgery: Randomized Controlled Trial

Study ObjectiveTo compare cosmetic satisfaction with laparoendoscopic single-site surgery (LESS) compared with multi-port surgery. DesignRandomized controlled trial (Canadian Task Force classification I). SettingUniversity hospital. PatientsTwenty women who underwent laparoscopically-assisted vaginal hysterectomy (LAVH) via LESS or multi-port surgery. InterventionsLaparoendoscopic single-site surgery or multi-port surgery. Measurement and Main ResultsCosmetic satisfaction was assessed using the Body Image Questionnaire at baseline and at 1, 4, and 24 weeks after surgery. Of the 20 LESS procedures, 1 was converted to multi-port surgery because of severe adhesions, and 1 woman assigned to undergo multi-port surgery was lost to follow-up. The 2 surgery groups did not differ in clinical demographic data and surgical results or postoperative pain scores at 12, 24, and 36 hours. Compared with the multi-port group, the LESS group reported significantly higher cosmetic satisfaction at 1, 4, and 24 weeks after surgery (p < .01). ConclusionCompared with multi-port surgery, LESS is not only a feasible approach with comparable operative outcomes but also has an advantage insofar as cosmetic outcome.

Laparoendoskopische Single-site-Chirurgie in der Urologie durch Einsatz eines wieder verwendbaren Systems

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. 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. 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. 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.

Ergonomic and geometric tricks of laparoendoscopic single-site surgery (LESS) by using conventional laparoscopic instruments

The aim of this study was to explore the feasibility and safety of performing laparoendoscopic single-site surgery (LESS) with conventional laparoscopic instruments. We retrospectively reviewed our data from 175 patients who underwent various urological LESS procedures via the same ergonomic and geometric principles between 2008 and 2011. LESS procedures performed included adrenalectomy (N = 23), radical nephrectomy (N = 5), radical nephroureterectomy with bladder cuff resection (N = 5), varicocelectomy (N = 12), nephropexy (N = 4), lumbar sympathectomy (N = 4), orchiectomy for intra-abdominal testis (N = 1), pyeloureterostomy (N = 1), dismembered pyeloplasty (N = 1), and adult inguinal hernia mesh repair (N = 119). All procedures were completed successfully without the use of ancillary ports or articulating instruments except two cases that required laparoscopic conversion. The mean patient age was 48.9 years. Mean operative time was 99.7 min, mean estimated blood loss was 17.3 ml, and mean hospital stay was 2.1 days. There were no intraoperative complications. According to our ergonomic and geometric principles, use of conventional laparoscopic instruments is feasible and safe in LESS procedures.

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.

: Urologic LESS: complications and risk factors

The aim of laparoendoscopic single-site surgery (LESS) is to reduce the morbidity and scarring associated with regular laparoscopic procedures. Over the past 4 years, a number of urological LESS procedures have been shown to be feasible, and have been taken up by surgeons worldwide. According to current recommendations, suitable candidates for these procedures are generally thinner, with limited previous abdominal surgery. However, detailed, specific analyses of the complication rates of these techniques—and the most important risk factors associated with these complications—has not yet been performed. Greco et al. retrospectively evaluated the morbidity outcomes and risk factors associated with complications in 192 patients who underwent LESS for upper urinary tract disease.

Laparoendoscopic single-site surgery in urology: worldwide multi-institutional analysis of 1076 cases

Background: Laparoendoscopic single-site surgery (LESS) has gained popularity in urology over the last few years. Objective: To report a large multi-institutional worldwide series of LESS in urology. Design, setting, and participants: Consecutive cases of LESS done between August 2007 and November 2010 at 18 participating institutions were included in this retrospective analysis. Intervention: Each group performed a variety of LESS procedures according to its own protocols, entry criteria, and techniques. Measurements: Demographic data, main perioperative outcome parameters, and information related to the surgical technique were gathered and analyzed. Conversions to reduced-port laparoscopy, conventional laparoscopy, or open surgery were evaluated, as were intraoperative and postoperative complications. Results and limitations: Overall, 1076 patients were included in the analysis. The most common procedures were extirpative or ablative operations in the upper urinary tract. The da Vinci robot was used to operate on 143 patients (13%). A single-port technique was most commonly used and the umbilicus represented the most common access site.

Laparoendoscopic single-site surgery (LESS) for adnexal tumors: one surgeon's initial experience over a one-year period

In this article, we present our initial experience with laparoendoscopic single-site surgery (LESS) for adnexal tumors and report on the safety and feasibility of this technique. We retrospectively reviewed the medical records of the first 94 consecutive patients who underwent LESS for adnexal tumors at Cheil General Hospital and Women's Healthcare Center, Seoul, Korea between March 2009 and July 2010. Our retrospective chart review was approved by our local Institutional Review Board (IRB). We used a homemade wound retractor and surgical glove as the single-port device. All LESS procedures were performed by a single surgeon. Of 94 patients, 90 (95.7%) successfully underwent LESS for the treatment of an adnexal tumor. The mean age of the patients was 38.51 ± 11.65 years, and the mean body mass index was 21.22 ± 2.79 kg/m(2). The mean operative time was 50.33 ± 13.26 min, and the mean diameter of the adnexal tumors was 6.26 ± 3.19 cm. The procedures included enucleation of an ovarian cyst (n=56), salpingo-oophorectomy (n=32), and salpingectomy (n=4). Two cases with suspicion for malignancy underwent conversion to laparotomy (2.1%), and frozen sections revealed serous ovarian adenocarcinoma (n=1) and chronic inflammation (n=1). Except for those two cases, the pathologic diagnoses were confirmed as mature cystic teratoma (n=30), endometriosis (n=24), mucinous cystadenoma (n=14), serous cystadenoma (n=14), borderline ovarian tumor (n=4), hydrosalpinx (n=4), serous adenocarcinoma of the salpinx (n=1), and ectopic pregnancy (n=1). Two cases required an additional trocar for adhesiolysis of severe pelvic adhesion. No major intraoperative or postoperative complications occurred. Our results suggest that LESS is a safe and feasible alternative to conventional laparoscopic surgery for the treatment of adnexal tumors.