Laparoendoscopic Single-site Surgery Radical Research Articles

Chopstick technique used in laparoendoscopic single site radical hysterectomy for early stage cervical cancer

Laparoendoscopic single-site surgery (LESS) further minimizes the invasiveness of traditional laparoscopic surgery. However, the "chopstick" effect caused by the parallel arrangement of the instruments in the umbilicus is considered an obstacle indelicate operations. The purpose of this study was to introduce a new technique characterized by a double fulcrum formed by instruments, named the "chopstick" technique, which facilitates the expedient accomplishment of complicated surgeries such as LESS radical hysterectomy (LESS-RH). Seventy-three patients who underwent LESS-RH using the "chopstick" technique were retrospectively analyzed. The procedure was performed successfully in 72 patients. The median operative duration was 225 min, and the median intraoperative blood loss was 200 ml. Among the operations in the first 20 patients, intraoperative vascular injuries and bladder injury occurred in two patients and were repaired by LESS. Patients responded positively regarding minimal postoperative pain control. The score of satisfaction with the cosmetic outcome expressed by the patients was eight at discharge and nine 30 days later. In conclusion, this study presents the feasibility of accomplishing complicated procedures, such as radical hysterectomy, by LESS using the “chopstick” technique. This approach provides more options for both selected patients and surgeons.

Hybrid laparoendoscopic single-site surgery of upper urinary tract with the use of mini-laparoscopic instruments: cosmetic outcome and midterm oncological outcome.

To evaluate the efficacy of mini-laparoscopic instruments in combination with laparoendoscopic single-site surgery (LESS) instruments for the performance of oncological urological surgery. Thirty-five patients underwent oncological hybrid LESS either mini-laparoscopic-assisted LESS partial nephrectomy (LESS-PN, n=12) or mini-laparoscopic-assisted LESS radical nephrectomy (LESS-RN, n=23). Perioperative data were prospectively collected. The patient and observer scar assessment scale (POSAS) was used for the evaluation of the cosmetic outcome. Mean tumor size treated by LESS-PNs was 28.8 (IQR 20.5-37.3) mm. Average operative time and blood loss were 123 (IQR 112.5-145) min and 158.3 (IQR 100-200) ml, respectively. Renal artery clamping took place in seven cases. LESS-RN was performed in cases with a mean tumor size of 60 (IQR 48-71.5) mm. The average operative time was 116.8 (IQR 100-130) min. Average blood loss was 137 (IQR 100-150) ml. Complications were limited to grade II according to Clavien classification. The oncological outcome, including midterm results, was directly comparable to the literature. Patients reported low pain scores and high satisfaction in terms of postoperative scarring. The POSAS scores confirmed the excellent cosmetic outcome of hybrid LESS. The combination of mini-laparoscopic and LESS instrumentation as routine equipment of oncological surgery provided an efficient option for urologic surgery. The combination of mini-laparoscopic and LESS instruments improves the intraoperative ergonomics of LESS-PN and LESS-RN. The provided surgical and oncological outcome compares favorably to the LESS and conventional laparoscopic literature.

‘Scarless' Laparoscopic Urologic Surgery by the Combination of Mini-Laparoscopic and Laparoendoscopic Single-Site Surgery Equipment

Objective: We evaluated reconstructive and oncological laparoendoscopic single-site surgery (LESS) combined with mini-laparoscopic instruments as standard equipment. Patients and Methods: 30 patients underwent reconstructive and oncological LESS: mini-laparoscopic-assisted LESS pyeloplasty (LESS-P, n = 18), mini-laparoscopic-assisted LESS partial nephrectomy (LESS-PN, n = 7) or mini-laparoscopic-assisted LESS radical prostatectomy (LESS-RP, n = 5). Perioperative data were prospectively collected. Results: The 18 LESS-P cases had operative times ranging between 120 and 180 min (average 147.9 min). Estimated blood loss ranged between 100 and 300 ml (average 202.1 ml). Two patients required additional management for failed reconstruction. LESS-PN was performed in 7 patients with tumor size ranging between 2.5 and 3.8 cm (average 2.7 cm). Average operative time and blood loss were 155 (140-180) min and 321.4 (250-550) ml, respectively. Renal artery clamping took place in 1 case. LESS-RP was performed in 5 patients; average operative time was 156 (140-180) min and average blood loss 196 (100-400) ml. Functional and oncological outcome was directly comparable to laparoscopic radical prostatectomy. Conclusion: The combination of LESS and mini-laparoscopic instrumentation as routine equipment of reconstructive LESS reveals a different perspective for ‘scarless' urologic surgery.

A Comparative Study of Laparoendoscopic Single-Site Surgery Versus Conventional Laparoscopy for Upper Urinary Tract Malignancies

PurposeThe 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 MethodsWe 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.ResultsFor 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.ConclusionsNo 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.

Laparoendoscopic single-site surgery (LESS) radical hysterectomy for the treatment of early stage cervical cancer

BackgroundLaparoendoscopic single-site surgery (LESS) represents one of the latest innovations in minimally invasive surgery and has several potential applications in gynecologic oncology surgery. The purpose of this surgical video is to demonstrate the indication and technique for LESS radical hysterectomy for the treatment of early stage cervical cancer. CaseA 48year-old menopausal woman with a body mass index of 29 was diagnosed with a well differentiated, Stage IB1 cervical adenocarcinoma. She underwent a LESS radical hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy through a 2.0 centimeter (cm) umbilical incision. Estimated blood loss was 200ml and total operative time was 251min. No perioperative complications occurred and the patient was discharged the day after surgery. Final pathology revealed a residual 1.5cm tumor with a depth of invasion of 5.8mm and no lymph vascular space invasion. The parametria, ovaries and 16 lymph nodes were negative for malignancy. All margins, including a vaginal margin 3.5cm from the cervical tumor, were negative. Her umbilical incision healed well and was not visible at her 4week post operative visit. She did not require adjuvant therapy and is without evidence of disease 6months after surgery. ConclusionsThe performance of LESS radical hysterectomy is feasible and safe in select women with apparent early-stage cervical cancer. In an effort to optimize operative and long-term oncologic outcomes, it is critical to continue exploring novel surgical approaches for the treatment of gynecologic cancers.

841 PROSPECTIVE RANDOMIZED CONTROLLED TRIAL OF CONVENTIONAL LAPAROSCOPIC VERSUS LAPAROENDOSCOPIC SINGLE-SITE RADICAL NEPHRECTOMY FOR LOCALIZED RENAL CELL CARCINOMA: REPORT OF PRELIMINARY DATA

You have accessJournal of UrologyTechnology & Instruments: Laparoscopy - Malignant Disease1 Apr 2012841 PROSPECTIVE RANDOMIZED CONTROLLED TRIAL OF CONVENTIONAL LAPAROSCOPIC VERSUS LAPAROENDOSCOPIC SINGLE-SITE RADICAL NEPHRECTOMY FOR LOCALIZED RENAL CELL CARCINOMA: REPORT OF PRELIMINARY DATA Yong Hyun Park, Hyeon-Jun Kim, Min Soo Choo, Kyung Don Baik, and Hyeon Hoe Kim Yong Hyun ParkYong Hyun Park Seoul, Korea, Republic of More articles by this author , Hyeon-Jun KimHyeon-Jun Kim Seoul, Korea, Republic of More articles by this author , Min Soo ChooMin Soo Choo Seoul, Korea, Republic of More articles by this author , Kyung Don BaikKyung Don Baik Seoul, Korea, Republic of More articles by this author , and Hyeon Hoe KimHyeon Hoe Kim Seoul, Korea, Republic of More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.933AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The safety and efficacy of laparoendoscopic single-site surgery (LESS) for renal cell carcinoma (RCC) has not been clearly demonstrated. We aimed to present preliminary data from a prospective randomized controlled trial of LESS versus conventional laparoscopic radical nephrectomy (CLS) for localized RCC. METHODS From October 2010 to August 2011, a prospective, randomized pilot trial was performed to compare conventional laparoscopic (n=10) and LESS radical nephrectomy (n=10) in patients with clinically localized RCC. Short-term outcomes assessed were perioperative morbidity, postoperative pain, and quality of recovery measured by QoR-40. RESULTS No significant differences were observed in operative time (128.6 vs. 117.2 min, p=0.689), blood loss (95.0 vs. 80.5 ml, p=0.280), hospital stay (3.4 vs. 2.4 days, p=0.202), analgesics requirement (84.4 vs. 65.0 mg, p=0.747), and complication rate (37.5 vs. 30.0 %, p=1.000) between the LESS and CLS groups. Postoperative pain at postoperative day 1 (5.1 vs. 5.3 points, p=0.464), 2 (4.2 vs. 4.2 points, p=0.705), and 3 (3.6 vs. 3.5 points, p=1.000) was not significantly different between two groups. However, postoperative quality of recovery measured by QoR-40 scores was higher in the LESS group compared with the CLS group (173 vs. 146, p=0.037). In the LESS group, improved QoR was observed in the QoR-40 dimensions of emotional state (39.8 vs. 31.1, p=0.007), and pain (31.5 vs. 26.1, p=0.012), but, not in physical comfort (50.9 vs. 44.3, p=0.162), psychological support (31.4 vs. 26.6, p=0.061), and physical independence (19.9 vs. 17.7, p=0.448). CONCLUSIONS Preliminary results from this prospective trial showed that LESS could be a safe and effective treatment option for localized RCC with equivalent surgical outcomes and improved postoperative quality of life compared with CLS. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e343 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Yong Hyun Park Seoul, Korea, Republic of More articles by this author Hyeon-Jun Kim Seoul, Korea, Republic of More articles by this author Min Soo Choo Seoul, Korea, Republic of More articles by this author Kyung Don Baik Seoul, Korea, Republic of More articles by this author Hyeon Hoe Kim Seoul, Korea, Republic of More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

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.

Natural Orifice Transendoluminal Surgery and Laparoendoscopic Single-Site Surgery: The Future of Laparoscopic Radical Prostatectomy

Techniques for minimally invasive radical prostatectomy (RP) have been carefully reviewed by surgical teams worldwide in order to identify possible weaknesses and facilitate further improvement in their overall performance. The initial plan of action has been to carefully study the best-practice techniques for open RP in order to reproduce and standardize performance from the laparoscopic perspective. Similar to open surgery, the learning curve of minimally invasive RP has been well documented in terms of objective evaluation of outcomes for cancer control and functional results. Natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have recently gained momentum as feasible techniques for minimal access urological surgery. NOTES-LESS drastically limit the surgeon's ability to choose the site of entry for operative instruments; therefore, the advantages of NOTES-LESS are gained with the understanding that the surgical procedure is more technically challenging. There are several key elements in RP techniques (in particular, dorsal vein control, apex exposure and cavernosal nerve sparing) that can have significant implications on oncologic and functional results. These steps are hard to perform in a limited working field. LESS radical prostatectomy can clearly be facilitated by using robotic technology.

Single-Port Laparoscopy, NOTES, and Endoluminal Surgery

Minimally invasive surgery has become the standard treatment for many disease processes. In the last decade, numerous studies have demonstrated that laparoscopic approaches to various conditions have improved the quality of life with comparable surgical and oncologic outcomes to standard open procedures. Recently, an alternative to conventional laparoscopy or robotic surgery has been developed: laparoendoscopic single-site surgery (LESS), also known as single-port surgery. Single-port laparoscopy is an attempt to further enhance the cosmetic benefits of minimally invasive surgery while minimizing the potential morbidity associated with multiple incisions. In this special issue, we will focus on 2 articles relevant to the advancement and practice of LESS. This new modality presents unique challenges, such as instrument crowding and the need to move and control a flexible camera and articulating instruments together, requiring even more advanced laparoscopic skills. Information about training and education on single-port laparoscopy is scarce in the current literature: Ramalingam et al. present their initial experience and methodology in training and education regarding this new technique. Formal training in this technique is not widely available. Expensive ports and instrumentation may be factors deterring the training. The authors address a major gap in the literature, how to train surgeons in this technique? They modified the standard laparoscopic endotrainer with improvised ports, to make it suitable for single-port laparoscopic training. For the animal lab training, they improvised ports and low-cost instruments. Thus, the overall cost of the training in LESS was reduced, and better confidence levels were achieved prior to human applications. Perhaps this will stimulate others to look at adopting this relatively low-tech technique for training in LESS. Emerging data on LESS has been reported in general surgical, gynecologic, and urologic procedures. LESS, for renal surgery, was first reported in 2007, and, since then, a handful of authors have described variations of their techniques. Derweesh and coauthors present the first prospective report in the literature of LESS radical nephrectomy with renal vein thrombectomy and cytoreductive nephrectomy. As such, this report further corroborates that increasingly complex procedures can be safely performed with the LESS platform. The feasibility of LESS for complex surgical procedures is no longer an issue. Current research and development in single-port robotics is ongoing. A single-port robotic platform may overcome technical limitations of single-site surgery (instrument crowding, lack of triangulation, and loss of depth of perception/instability with current 2D flexible optics). More importantly, it may play an essential role in the reproducibility and diffusion of LESS. Prospective studies are needed to assess the relative benefits of LESS compared with more conventional minimally invasive approaches. Pedro F. Escobar Jihad H. Kaouk Daniel Geisler Matthew Kroh Amanda Nickles Fader Tommaso Falcone

Extraperitoneal laparo-endoscopic single-site radical prostatectomy: first experience

Up to now, laparo-endoscopic single-site surgery (LESS) represents the closest surgical technique to scar-free surgery. The objective of the study is to report the first clinical experience with a LESS endoscopic extraperitoneal radical prostatectomy. A 74-year-old man presented with a clinically localized prostate cancer (PSA 9.9, Gleason score 3 + 3 = 6). Consent was obtained for LESS radical prostatectomy. After a 2-cm midline subumbilical incision, the preperitoneal space was created using a balloon trocar. Then, the Triport™ was introduced. Using straight, as well as pre-curved instruments, the radical prostatectomy was performed in accordance with the well-described technique of endoscopic extraperitoneal radical prostatectomy. The procedure was completed successfully. Overall operation time was 290 min. The estimated blood loss was 100 mL. There were no intra-or postoperative complications. No additional ports were required. On the 6th postoperative day, a cystogram was performed. No leak was demonstrated, enabling catheter removal. Histopathology revealed bilateral adenocarcinoma with no extracapsular extension and a Gleason sum of 3 + 4 = 7. Surgical margins were negative. Two weeks postoperatively, the patient reported the use of only one safety pad for continence. An extraperitoneal laparo-endoscopic single-site radical prostatectomy is technically challenging but can be accomplished. A multi-instrument port and purpose-built equipment are mandatory. The oncologic outcome was not compromised. Additional short- and long-term studies are necessary to clarify the role of LESS in radical prostatectomy regarding the oncologic and functional outcome as well as the potential benefits like reduced tissue trauma and pain.

Laparoendoscopic Single-Site Surgery of the Kidney with No Accessory Trocars: An Initial Experience

As laparoscopy becomes more commonplace for urologists, ongoing attempts are under way to minimize the number and size of incisions used for access. Laparoendoscopic single-site surgery (LESS) was developed and has been increasingly attempted as an extension of classic laparoscopy. Investigators hypothesize that LESS may offer a superior cosmetic result, faster recovery, and equivalent efficacy to laparoscopic surgery. Our aim is to present our experience with renal LESS. A prospective data collection was performed on all patients who were undergoing renal LESS at our institution. A total of 11 renal LESS procedures were performed between July and November 2008: four LESS donor nephrectomies, two LESS radical nephrectomies, three LESS partial nephrectomies, and two LESS pyeloplasties. All LESS procedures replicated laparoscopic techniques but were performed through a single operative site using a 5-mm flexible-tip laparoscope and flexible working instruments. Six of the patients were men. The mean operative time was 162.4 +/- 38.5 minutes. The mean estimated blood loss was 104.5 +/- 41.6 mL, with a mean length of hospitalization of 2.4 +/- 0.8 days. There were no intraoperative complications or blood transfusions. Postoperative pain requirements were tabulated and revealed a mean in-hospital analgesic requirement of 44.8 +/- 46.7 mg (range 7-158 mg) of morphine equivalents with three patients receiving intravenous ketorolac. Renal LESS is feasible as flexible laparoscopes and instruments continue to develop. In our initial experience, expert laparoscopic surgeons were able to perform these LESS procedures with equivalent efficacy without compromising perioperative measures, including operative time, blood loss, and hospital stay. Further prospective investigation through randomized studies is necessary to elucidate differences, if any, in postoperative analgesic requirements and patient satisfaction with postoperative cosmesis, and to confirm equivalent efficacy when compared with current standards.

A Transition to Laparoendoscopic Single-Site Surgery (LESS) Radical Prostatectomy: Human Cadaver Experimental and Initial Clinical Experience

Laparoendoscopic single-site surgery (LESS) represents a novel approach to abdominal surgery. Several applications have already been described. Drawbacks include limited range of motion and need for articulated instruments. Robotic technology could overcome such technical difficulties. We report our experience with LESS radical prostatectomy (LESS-RP) in a cadaver and LESS robot-assisted radical prostatectomy (LESS-RARP) in a human patient. Standard laparoscopic instruments (SLI) and articulated laparoscopic instruments were used in the cadaveric LESS-RP. The da Vinci system was used in the LESS-RARP. Both procedures reproduced standard extraperitoneal laparoscopic prostatectomy as performed at Institut Montsouris. Control of the dorsal venous complex (DVC) and urethrovesical anastomosis (UVA) were key elements evaluated for feasibility. Cadaveric model: Total operative time (TOT) was 160 minutes, with 5 minutes for the DVC (one stitch) and 35 minutes for the UVA (six stitches). Although articulated instruments were helpful in the operation, SLI remained essential for the procedure. Clinical experience: LESS-RARP was performed for T(1c) prostate cancer. TOT was 150 minutes, including 5 minutes for the DVC (one figure-of-eight stitch) and 30 minutes for the UVA (six interrupted stitches). Blood loss was 500 mL. Bilateral neurovascular preservation was performed, and results of final pathologic examination showed negative surgical margins. The human cadaver is an adequate model for LESS-RP, and LESS-RARP is feasible to be performed in the clinical arena. The synergy of robotic technology and LESS represents a new generation of surgery.