Single-site Laparoscopy Research Articles

Magnetically Anchored Cautery Dissector Improves Triangulation, Depth Perception, and Workload During Single-Site Laparoscopic Cholecystectomy

IntroductionThis study evaluated operative outcomes and workload during single-site laparoscopy (SSL) using a magnetically anchored cautery dissector (MAGS) compared with a conventional laparoscopic hook cautery (LAP). MethodsEach cautery was used to perform six SSL porcine cholecystectomies. For MAGS, the cautery device was inserted through the umbilical incision, magnetically coupled, and deployed; two graspers and a laparoscope were used. For LAP, two percutaneous retraction sutures, one grasper, a hook cautery dissector, and a laparoscope were used. Operative outcomes, surgeon ratings (scale, 1–5; 1 = superior), and workload (scale, 1–10; 1 = superior) were evaluated. ResultsNo significant differences were detected for operative outcomes and surgeon ratings, however, trends were detected favoring MAGS. Surgeon workload ratings were significantly better for MAGS (2.6 ± 0.2) vs. LAP (5.6 ± 1.1; p < 0.05). For MAGS, depth perception and triangulation were excellent and the safe handling protocol was followed with no complications. For LAP, the parallelism of instruments and lack of triangulation hindered depth perception, caused instrument conflicts, and resulted in two minor complications (one superficial liver laceration and one inadvertent burn to the diaphragm). ConclusionThese data suggest that using the MAGS device for SSL cholecystectomy results in equivalent (or better) operative outcomes and less workload compared with LAP.

Risk reducing Salpingo-oophorectomy by laparoscopic single site surgery (LESS) versus traditional laparoscopy: A comparison of short term outcomes and immediate costs

Risk reducing Salpingo-oophorectomy by laparoscopic single site surgery (LESS) versus traditional laparoscopy: A comparison of short term outcomes and immediate costs

Salpingectomy for ectopic pregnancy by transumbilical single-site laparoscopy with the SILS® system

To evaluate the feasibility in everyday practice and the advantages of salpingectomy for ectopic pregnancy by single-incision laparoscopic surgery with the SILS system. This single-center prospective observational study included 37 women requiring salpingectomy for ectopic pregnancy who underwent single-incision laparoscopic salpingectomy with the SILS system. Information about feasibility and intra- and post-operative data were collected. The data for these patients were compared with those of a control group of 40 women treated by standard laparoscopy. Thirty-six (97%) patients were treated successfully with the SILS system. After laparoscopic confirmation of the ectopic pregnancy, salpingectomy was performed with bipolar forceps and scissors. In one case, conversion to classic laparoscopy was performed because SILS was not feasible. Compared with the control group, operative time was longer (50 ± 35 vs 35 ± 30 min, p=0.001) but duration of hospitalization shorter with single-site laparoscopy (1.5 ± 1.5 vs 2.3 ± 1.5 days, p=0.02). Laparoscopic salpingectomy for ectopic pregnancy appears to be feasible in everyday practice by single-incision laparoscopic surgery with the SILS system and appears to reduce the duration of hospitalization. Larger series are necessary to confirm this conclusion.

Laparoendoscopic single-site(LESS) radical nephrectomy and standard laparoscopy: a comparison of therapeutic outcomes

Objective To compare the therapeutic outcomes of laparoendoscopic single-site(LESS)radical nephrectomy and standard laparoscopy,so as to understand the clinical advantages of transumbilical LESS radical nephrectomy.Methods Between Sep.2008 and Jan.2011,a single urologist in our center performed 105transperitoneal laparoscopic radical nephrectomies,including 21transumbilical LESS radical nephrectomies(Group A,Sep.2009and Jan.2011).This group was subsequently matched to 21standard laparoscopic RN procedures(Group B,Sep.2008 and Mar.2010).The perioperative outcomes and follow-up information,including scores of cosmetic satisfaction,were retrospectively analyzed in the two groups.The two groups were matched in patient age,body mass index,tumor size and location,and surgical indication(T1 stage).Results The LESS group had significantly quicker bowel function recovery([31.6±17.98]h vs[42.3±19.94]h,P 0.05),lower postoperative pain score(3.5±0.84vs 4.1±1.06,P0.05),and a better cosmetic satisfaction score(8.2± 0.71vs 7.3±0.85,P0.05).Notably,the mean operation periods for the first 10cases were significantly different between the two groups(P=0.030),but not significantly for the last 10cases(P=0.495)and for the whole group(P=0.076).Both groups remained metastasis-and recurrence-free during mean follow-up periods of(8.4±4.41)and(20.0±3.95)months(P=0.000).Conclusion The transumbilical LESS radical nephrectomy offers a better postoperative pain control,quicker recovery of bowel function,and a better cosmetic satisfaction compared with standard nephrectomy,but its therapeutic effect needs to be verified by long-term follow-up.The learning curve of this procedure appears not so steep for an experienced laparoscopist following a strict specialized training course.

A randomized comparison of laparoscopic, magnetically anchored, and flexible endoscopic cameras in performance and workload between laparoscopic and single-incision surgery

This study aimed to evaluate the surgeon performance and workload of a next-generation magnetically anchored camera compared with laparoscopic and flexible endoscopic imaging systems for laparoscopic and single-site laparoscopy (SSL) settings. The cameras included a 5-mm 30° laparoscope (LAP), a magnetically anchored (MAGS) camera, and a flexible endoscope (ENDO). The three camera systems were evaluated using standardized optical characteristic tests. Each system was used in random order for visualization during performance of a standardized suturing task by four surgeons. Each participant performed three to five consecutive repetitions as a surgeon and also served as a camera driver for other surgeons. Ex vivo testing was conducted in a laparoscopic multiport and SSL layout using a box trainer. In vivo testing was performed only in the multiport configuration and used a previously validated live porcine Nissen model. Optical testing showed superior resolution for MAGS at 5 and 10 cm compared with LAP or ENDO. The field of view ranged from 39 to 99°. The depth of focus was almost three times greater for MAGS (6-270 mm) than for LAP (2-88 mm) or ENDO (1-93 mm). Both ex vivo and in vivo multiport combined surgeon performance was significantly better for LAP than for ENDO, but no significant differences were detected for MAGS. For multiport testing, workload ratings were significantly less ex vivo for LAP and MAGS than for ENDO and less in vivo for LAP than for MAGS or ENDO. For ex vivo SSL, no significant performance differences were detected, but camera drivers rated the workload significantly less for MAGS than for LAP or ENDO. The data suggest that the improved imaging element of the next-generation MAGS camera has optical and performance characteristics that meet or exceed those of the LAP or ENDO systems and that the MAGS camera may be especially useful for SSL. Further refinements of the MAGS camera are encouraged.

Early experience with single-site laparoscopic surgery for complicated ileocolic Crohn’s disease at a tertiary-referral center

The role of single-site laparoscopy (SSL) for the treatment of ileocolic Crohn's disease complicated by an abscess, a phlegmon, or fistulizing disease has not been thoroughly assessed. A prospectively maintained database of SSL surgeries performed between October 2010 and March 2011 was reviewed. Consecutive patients with ileocolic Crohn's disease complicated by a paracolic abscess, a phlegmon, or a fistula were included for analysis. Data recorded included demographic information, body mass index (BMI), estimated blood loss (EBL), length of surgery, rate of conversion to standard laparoscopic surgery or open surgery, length of hospital stay, and rate of complications. A total of six patients were identified. Complications from Crohn's disease included four (66%) patients who developed a paracolic abscess that required drainage upon admission, one (16%) patient who developed a phlegmon, and one (16%) patient who developed an enterocutaneous fistula. Mean age of the study population was 25 years, with a mean BMI of 21 and a mean ASA score of 3. Five (83%) of the patients were immunosuppressed with high-dose steroids. Mean operative time was 160 min, with a median EBL of 60 mL. One patient required the insertion of an additional trocar, whereas there were no conversions to laparotomy. Four (66%) patients required diversion with a loop ileostomy. Median time to flatus was 1 day. All patients tolerated a diet on the day of surgery, with a median length of stay of 3 days. There were no deaths and no complications related to bleeding, organ injury, surgical site infections, or anastomotic leaks. A single-site laparoscopic approach for complicated ileocolic Crohn's disease can be performed safely, with short lengths of hospital stay and with a low rate of complications. A multicenter study would be beneficial to validate these findings.

Laparoscopic Single Site Surgery: Initial Experience and Description of Techniques in the Pediatric Population

Recently new approaches to laparoscopic surgery, named natural orifice transluminal endoscopy and laparoendoscopic single site surgery, have been proposed to improve the cosmesis and decrease the morbidity associated with multiple ports sites. Experience with laparoendoscopic single site surgery technique in pediatric urology is still limited. We present our initial results with this technique in children. Since laparoendoscopic single site surgery received Food and Drug Administration approval, 11 patients have undergone a total of 14 procedures at our department, including nephrectomy due to nonfunctioning kidneys in 4, removal of bilateral intra-abdominal gonads in 2, unilateral varicocelectomy in 4 and bilateral varicocelectomy in 1. In all patients a multi-channel single laparoscopic port inserted through a 2 cm skin incision was used to achieve access to the abdominal cavity. All patients underwent laparoendoscopic single site surgery without complications within a reasonable operative time. None required conversion to open or conventional laparoscopic surgery. All except 1 patient were discharged home on the day of surgery or the day after surgery. Our initial data show that laparoendoscopic single site surgery is an effective technique for various pediatric and adolescent urology indications. Further application of this procedure in a large patient group will show whether there is a place for laparoendoscopic single site surgery in the pediatric urology surgical armamentarium.

A Triangulating Operating Platform Enhances Bimanual Performance and Reduces Surgical Workload in Single-Incision Laparoscopy

Single-site laparoscopy (SSL) attempts to further reduce the surgical impact of minimally invasive surgery. However, crossed instruments and the proximity of the endoscope to the operating instruments placed through one single site leads to inevitable instrument or trocar collision. We hypothesized that a novel, single-port, triangulating surgical platform (SPSP) might enhance performance by improving bimanual coordination and decreasing the surgeon's mental workload. Fourteen participants, proficient in basic laparoscopic skills, were tested on their ability to perform a validated intracorporeal suturing task by either an SSL approach with crossed articulated instruments or a novel SPSP, providing true-right and true-left manipulation. Standard laparoscopic (SL) access served as control. Sutures were evaluated using validated scoring methods and the National Aeronautics and Space Administration Task Load Index was used to rate mental workload. All participants proficiently performed intracorporeal knots by SL (mean score 99.0; 95% CI 97.0 to 100.9). Performance decreased significantly (more than 50%, p < 0.001) with the SSL approach using 1 rigid and 1 articulating instrument in a cross-wise manner (mean score 39.2; 95% CI 28.3 to 50.1). The use of the SPSP significantly enhanced bimanual coordination (mean score 67.6; 95% CI 61.3 to 73.9; p < 0.001). Participants recorded lower mental workload when using true-right and true-left manipulation. This study objectively assessed SSL performance and current attempts for instrumentation improvement in single-site access. While SSL significantly impairs basic laparoscopic skills, surgical platforms providing true-left and true-right maneuvering of instruments appear to be more intuitive and address some of the current challenges of SSL that may otherwise limit its widespread acceptance.

Bilateral Salpingo-Oophorectomy by Laparoscopic Single Site Surgery (LESS) Versus Conventional Laparoscopy: A Comparison of Short Term Outcomes and Immediate Costs

Bilateral Salpingo-Oophorectomy by Laparoscopic Single Site Surgery (LESS) Versus Conventional Laparoscopy: A Comparison of Short Term Outcomes and Immediate Costs

Single site laparoscopic right hemicolectomy: an oncological feasible option

IntroductionWe present the first 7 cases of single site right hemicolectomy in Asia using the new Single Site Laparoscopy (SSL) access system from Ethicon Endo-surgery.MethodsRight hemicolectomy was performed using the new Single Site Laparoscopy (SSL) access system. Patient demographics, operative time, histology and post operative recovery and complications were collected and analysed.ResultsThe median operative time was 90 mins (range 60 - 150 mins) and a median wound size of 2.5 cm (range 2 to 4.5 cm). The median number of lymph nodes harvested was 24 (range 20 to 34 lymph nodes). The median length of proximal margin was 70 mm (range 30 to 145 mm) and that of distal margin was 50 mm (35 to 120 mm). All patients had a median hospital stay of 7 days (range 5 to 11) and there were no significant perioperative complications except for 1 patient who had a minor myocardial event.ConclusionRight hemicolectomy using SSL access system is feasible and safe for oncologic surgery.

Single access laparoscopy for adnexal pathologies using a novel reusable port and curved instruments

Objective To present our initial experience using single access laparoscopic surgery for the treatment of benign adnexal pathologies. Methods Sixteen patients with benign adnexal pathologies underwent salpingoophorectomy (n = 9), ovarian cyst enucleation (n = 5), or salpingectomy (n = 2) using a laparoendoscopic single site approach with a new multiport reusable trocar and flexible and curved—as well as standard—laparoscopic instruments. Results Conversion to a multi-access standard laparoscopic technique was not required in any patient and no intraoperative complications were observed. Postoperatively, one umbilical scar infection was detected. Mean operative time was 42 minutes. Conclusion Laparoscopic single site enucleation for adnexal pathologies is feasible, safe, and effective, and has good results for cosmetic appearance and postoperative pain. Use of specialized instruments and standardization of the technique affect surgical ergonomy and operating time.

Laparo-endoscopic single-site surgery hysterectomy using robotic lightweight endoscope assistants.

Current laparoscopic and robotic hysterectomy techniques require three to five small incisions in the abdominal wall. Each additional port contributes an additional risk for port site complications. Because of these risks, and in an effort to improve cosmesis, surgery through a single incision is being explored. New versatile robot devices can provide a less cumbersome and less expensive alternative to the conventional multi-arm robot devices. In the case reported here, that of a 37-year-old female undergoing hysterectomy, we combined the use of these two technologies in a novel way. By utilizing a single laparoscopic port site in addition to two lightweight robotic endoscope assistants, we were able to decrease risk and improve cosmesis while allowing single-operator control of all instrumentation. The novel use of this robotic device demonstrates a potential decrease in the need for surgical assistants and thus a decrease in cost. When combined with single-site laparoscopy, it also allows the surgeon complete control of the operative environment and may enable more surgeons to embrace the single-incision technique.

Single-Site Laparoscopic Sleeve Gastrectomy: Preclinical Use of a Novel Multi-Access Port Device

Single-site laparoscopy (SSL) has emerged as an alternative technique for sleeve gastrectomy. The author describes the preclinical technique of SSL sleeve gastrectomy through a novel multichannel port device in the porcine model. Anesthetized swine underwent 3-cm longitudinal supra-umbilical incision. A multichannel port device was inserted. A gastric sleeve was created by multiple applications of a 60-mm stapler. The access device's channel housing was removed and the sleeve specimen exteriorized. The mean operative time was 60+/-10 minutes, and the mean estimated blood loss was 30+/-5 cc. The multichannel port device allowed induction and maintenance of pneumoperitoneum throughout the procedure (range 12-15 mm Hg) with efficient rotation and substantial abdominal wall torque and minimal instrument clashing. SSL sleeve gastrectomy in the porcine model was facilitated by the use of a novel multichannel port device. Clinical studies are warranted.

The Development and Testing of An Adaptable Minimally-Invasive Surgical Platform - The Hydra

Introduction: Progress has been made in developing new platforms for NOTES, but limitations in stability, instrumentation, navigation, closure, and triangulation, as identified by NOSCAR, remain to be addressed. Interest in less-invasive surgery beyond laparoscopy has also expanded beyond NOTES into approaches such as Single Site Laparoscopy (SSL), enabled by both rigid and flexible instruments. New platforms, capable of adaptation to a range of developing surgical approaches, seem necessary. Methods: Clinicians and engineers partnered together to develop a new platform, the Hydra, which is adaptable to transgastric and transvaginal hybrid/pure NOTES approaches, as well as SSL. The foundation of the platform is a multi-directional Steerable Flexible Trocar (15 mm internal diameter) that allows navigation to the targeted area. The Trocar is passed into the peritoneal cavity via a needle knife/balloon; through it, an operative tool with three 4mm channels is advanced. Two of these channels articulate independently in multiple directions, allowing triangulation. The third channel carries a unique 3.7 mm, joystick-controlled, endoscope (Karl Storz EndoVision, Charlton, MA) that can be elevated over the articulating channels, providing a view independent of the operative tools. The system is controlled by a laparoscopy-like interface that allows a surgeon to use 2 hands to manipulate at least 2 tools with degrees of freedom not available in conventional endoscopes. Changes in system length and flexibility can be made to accommodate a variety of surgical approaches. Additional tools under development include a range of flexible staplers, next-generation closure, and remote retraction. The entire Toolbox of NOTES devices, including Bela bipolar forceps, a clip applier, flexible Marylands, etc., is compatible with the Hydra. Results: The Hydra has been used in a series of 8 acute porcine labs via transgastric and transvaginal approaches. Pure NOTES uterine horn resection and hybrid cholecystectomy are feasible. The elevated view from the Storz camera has eliminated the need for laparoscopic vision. A wide variety of surgical interventions, including dissection, ligation, and retrieval have been demonstrated. The control interface, coupled with stiffness in the system, provides for a stable operating platform. Further improvements are necessary in targeting, tissue manipulation, and system robustness. Conclusions: The Hydra provides the foundation for development of a new generation of minimally-invasive surgical instrumentation. Its straightforward design, complemented by NOTES Toolbox 1.0, is amenable to application in a range of approaches.

The beger procedure

Single site laparoscopy for appendectomy is a technique with several case series suggesting a cosmetic advantage, but without prospective comparative data. We conducted a prospective, randomized trial comparing single site laparoscopic appendectomy to the standard 3-port approach, including scar assessment at early and long-term follow-up.Enrolled patients over 12 years old and parents of patients less than 12 years old were asked to complete the validated Patient Scar Assessment Questionnaire (PSAQ) at early follow-up around 6 weeks and by phone after 18 months. The PSAQ consists of 4 scored subscales: Appearance, Consciousness, Appearance Satisfaction, and Symptom Satisfaction. Each subscale has a set of questions with a 4-point categorical response (1 = most favorable, 4 = least favorable). The sum of the scores quantifies each subscale.Early questionnaires were obtained from 98 3-port and 100 single-site patients with the single-site approach producing superior overall scar assessment (P = 0.003). By telephone follow-up, questionnaires were completed by 49 3-port and 56 single-site patients at a median of 25 (18–32) months. In this longer-term follow-up, overall scar assessment was not significantly different between groups (P = 0.06).Patients or parents express superior scar assessment with the single site approach at early follow-up, but this difference disappears in the long-term.