Single Umbilical Incision Research Articles

Synchronous Bilateral Laparoendoscopic Single-Site Adrenalectomy

Abstract We present the first report of simultaneous laparoendoscopic single-site surgery (LESS) for bilateral primary aldosterone-producing adrenal adenomas. A 40-year-old man with hypertension that was resistant to pharmacotherapy was shown to have bilateral aldosterone-producing adrenal adenomas. A right partial and a left total adrenalectomy were performed at the same time via a single umbilical incision. The surgery and recovery were uncomplicated. This is the first report of synchronous bilateral LESS.

Single umbilical incision laparoscopic cholecystectomy: Initial experience of the Coelio Club

To assess the initial results of single umbilical incision laparoscopic cholecystectomies (SUILC) performed by the members of the Club Coelio. This multicenter study involved 65 consecutive patients undergoing SUILC between September 2008 and December 2009. The operation was performed with a 0° scope in 35 and with a 30° scope in 30 patients. There were 56 women and nine men with a mean age of 49 ± 14 years and a mean body mass index of 25 ± 4. The main perioperative parameters analyzed were duration of operation, conversion, morbidity and duration of hospitalization. One month after surgery, the esthetic result was assessed by each patient on a visual analogue scale (VAS). A VAS score between 9 and 10 was considered as an excellent result. During laparoscopy, some degree of cholecystitis was seen in 10 patients. Intraoperative cholangiography was performed in 57 patients and the mean duration of operation was 68 ± 22 min. Conversion to conventional laparoscopic cholecystectomy (CLC) was required in eight patients (12%). We noted three complications (4%): two wound abscesses and one hemoperitoneum. The mean hospital stay was 2 ± 1 days. The esthetic result was considered as excellent by 45 patients (69%). Multivariable analysis revealed that duration of operation was shorter after five procedures (61 ± 25 vs. 72 ± 18 min, regression coefficient: -7, P<0.032) and when a 30° scope was used (56 ± 18 vs. 76 ± 20 min, regression coefficient: -14, P<0.011), the conversion rate was higher in cholecystitis (60% [6/10] vs. 4% [2/55], OR: 33, P<0.002) and the percentage of excellent esthetic results was greater in patients who did not required a conversion to CLC (77% [44/57] vs. 12% [1/8], OR: 18, P<0.012). Our study showed that SUILC is feasible with low morbidity but duration of operation is long and conversion to CLC is frequent in cholecystitis. However, duration of operation decreases with rising experience of the surgeon and when a 30° scope is used. The major value of this technique is cosmetic.

A Novel Surgical Technique: Single-Incision Transumbilical Laparoscopic Roux-en-Y Gastric Bypass

Conventional laparoscopic Roux-en-Y gastric bypass (LRYGB) is a gold standard for bariatric surgery, but the procedure requires five to seven incisions for placement of multiple trocars and thus may produce less-than-ideal cosmetic results. We have developed a new approach, single-incision transumbilical LRYGB (SITU-LRYGB) to treat morbid obesity. We compared the surgical results and patient satisfaction in a study of five-port LRYGB and SITU-LRYGB. Fifty morbidly obese patients (14 males, 36 females) underwent either Roux-en-Y gastric bypass with five-port LRYGB or the SITU-LRYGB approach. During the operation, we used a novel intraoperative liver traction method with a “liver suspension tape” that we specifically designed for SITU-LRYGB. Compared to five-port surgery with SITU-LRYGB, there were no intraoperative complications, wound healing was excellent, and there was no abdominal scarring. SITU surgical time was longer than that with five-port LRYGB (99.8 vs. 67.6 min, P < 0.001). Patients treated with the five-port method were more obese than those in the SITU group (127.9 vs. 112.4 kg, P = 0.016). After the bariatric surgery, no difference in comorbidity was found in both groups. Patient satisfaction was greater with SITU than with the five-port method (4.48 vs. 3.96, P = 0.006). Roux-en-Y gastric bypass can be successfully achieved via a single umbilical incision, a method that provides a short operative time and good recovery and eliminates abdominal scarring.

Single Incision Laparoscopic Surgery Cholecystectomy

Single incision laparoscopic surgery (SILS) has recently been introduced as an alternative to natural orifice transluminal endoscopic surgery for scarless abdominal surgery. We report our preliminary experience with SILS cholecystectomy. Six patients underwent elective laparoscopic cholecystectomy for symptomatic gallbladder stones through a single umbilical incision. All procedures were completed successfully except for 1 case of gallbladder wall perforation by cautery that required 2 additional 5-mm ports. Mean operating time was 50 min (range, 20-110 min). There were no postoperative complications. Four patients were discharged within 24 hours and the other 2 within 48 hours. The cosmetic results were scored as excellent by all patients. SILS cholecystectomy is feasible with standard laparoscopic instruments, and provides a promising alternative to natural orifice transluminal endoscopic surgery for scarless laparoscopic cholecystectomy.

Application of laparoscopic urologic surgery using three ports through single incision

Objective To explore the feasibility of the three-port laparoscopic surgery through single umbilical incision with urological desease. Methods Thirty-two patients (10 males and 22 females) were taken the laparoscopic surgery using three ports through single incision. Including varicocele 7 cases, simple kidney cyst 12 cases, double kidney cyst 1 case, polycystic kidney 1 case, left adrenal tumor 3 cases, right adrenal tumor 1 cases, left upper ureteral calculi 1 cases, giant hydronephrosis 1 case and atrophic kidney 4 cases. The surgery procedures were including make a 1.0-3.0 cm long incision in the navel, followed by inserting three 10 mm or 5 mm trocars in the incision for observation and operation. Conventional laparoscopic techniques were used to complete the urological surgery. Results The operation time of varicoeele ligation was 10--20 rain, mean 15 min, no intraoperative bleeding. The operation time of renal cysts was 30-53 min, mean 40 rain, no intraoperative bleeding. The operation time of resection of adrenal tumor was 57--120 min, mean 68 rain, intraoperative bleeding was 20-60 ml, mean 30 ml. The operation time of ureterolithotomy was 86 min, intraoperative bleeding was 50 ml. The operation time of nephrectomy was 45-135 min, mean 65 min, intraoperative bleeding was 90-150 ml, mean 110 ml. Length of stay 3-8 days, average 5.5 days.With average follow-up time 2 months, all cases were fully recovered without complication and no visible scar in the abdominal region. Conclusion The laparoscopic surgery using three ports through single incision is safe and effective in selected urological surgery. Key words: Urologic diseases; Navel; Laparoscopy

Single-Incision Multiport Laparoendoscopic (SIMPLE) Cholecystectomy

We thank you for your most astute comments regarding our article. We address these comments based not only on our original article on a series of 10 procedures, submitted in September 2008, but also on our experience that well exceeds 100 procedures in the past 1 years. Our method has changed with our experience. For example, we no longer perform this procedure during lithotomy. We have moved from a three-port trocar technique to a more stable and flexible port platform (Gelpoint; Applied Medical, Rancho Santa Margarita, CA, USA), which allows the insertion of multiple ports. We continue to use straight instruments preferentially, with occasional need for a right-angled instrument and even less need for articulating instruments. We also continue to use a rigid 30 angled scope. These technique changes address the issues raised in your letter. First, a critical view of safety is obtained in all cases. We have found that for most procedures this indeed can be achieved with a two-instrument technique [1] (Fig. 1). Retraction is imperative to obtaining this maneuver. Instead of reflecting the fundus of the gallbladder superolaterally and the infundibulum inferolaterally, as with the three-instrument dissection technique, we retract the only the infundibulum. But we grasp the infundibulum as close to the cystic duct as possible. This is important for two reasons. First, we create sufficient tension to achieve the dissection, thereby opening up Calot’s triangle, pulling the cystic duct and artery away from the liver’s edge and the underlying common bile duct. Second, internal retraction as close as possible to the area of dissection minimizes exterior lateral hand movement, thereby eliminating hand crisscrossing and clashing. Positioning the patient in the reverse Trendelenburg and slightly left laterally recumbent position has aided us in this maneuver. However, as you point out, a two-instrument technique is not possible in all cases, most notably when the patients have a high body mass index (BMI), fatty or enlarged liver, or acute cholecystitis. In these circumstances, we add a fourth port and proceed with the traditional three-instrument dissection. Often, we add this through our single umbilical incision, but occasionally we add it through an additional port, transforming the single-incision multiport laparoendoscopic (SIMPLE) procedure into a reduced-port procedure (or in our vernacular, a ‘‘DIMPLE’’). The second issue you raised questions the maneuverability restrictions of three trocars. We have found that extending the skin incision at the time of pneumoperitoneum, using the locking trocars, minimizes restriction and preserves the small single incision. A 4-cm skin incision with maximal abdominal distention decreases to a 2– 2.5 cm incision at desufflation. Nonetheless, our early experience with the locking trocars, as you mentioned, was limiting. We have since found that the Gelpoint system allows for much more freedom of movement through the same small skin incision. The fascial incision is a single incision as well, not the ‘‘Swiss cheese’’ type of penetration from closely approximated trocars, which can be problematic [2]. Also, the fascial incision can be as large as 5 cm or more through a small 2.5-cm skin incision. In addition, the fulcrum of the instruments is more external, at the level of the concaved Gelpoint, which is located 5 cm above skin level. Finally, four ports can be placed comfortably through the Gelpoint platform. All these factors contribute to minimal restriction of movement. B. M. Molinelli (&) A. Petrotos Department of Surgery, Greenwich Hospital, Greenwich, CT, USA e-mail: ssg06830@hotmail.com

Single Port Access (SPA) Splenectomy

Over the last decade, laparoscopic splenectomy has become the standard of care for spleen removal. Elimination of a large incision and difficult exposure has decreased postoperative morbidity and length of stay. Single port access (SPA) surgery was developed as an alternative to traditional multiport laparoscopy, potentially exploiting the already proven benefits of minimally invasive surgery. We apply the SPA technique to splenectomy via a single umbilical incision. SPA splenectomy was performed in a 36-year-old male for staging. The single-port access technique was used to gain abdominal entry. Exposure, dissection, and removal were performed via a single incision within the umbilicus. The final incision was extended for removal of a complete specimen for pathologic evaluation. Splenic mobilization and control of the short gastrics was successfully performed via a single umbilical incision. The final incision was extended inferiorly for en bloc organ removal. Follow-up at 18 months revealed a well-healed incision with no signs of hernia formation. The single-port access technique has been successfully applied to splenectomy as an available alternative to multiport laparoscopic splenectomy. Use of standard instrumentation and trocars maintains costs and familiarity of the procedure. Exposure, visualization, and dissection are the same as in standard laparoscopy. SPA surgery may be more ergonomically pleasing to the surgeon and offer patient benefits, such as faster recovery and decreased adhesion formation in the long term.

Single-Incision Laparoscopic-Assisted Right Colon Resection for Cancer

We present an approach to laparoscopic right colon resection utilizing a single port placed through the umbilicus. The technique described is performed through a single small umbilical incision with a virtually scar-free result. A 77-year-old woman with a tubulovillous adenoma in her cecum underwent a laparoscopic right colectomy using a single port placed through the umbilicus. Straight and reticulating laparoscopic instruments were utilized. The total operative time was 112 minutes. No intraoperative or postoperative complications occurred. The patient was discharged home on day 5 postoperatively with normal bowel function and tolerance of a solid diet. Laparoscopic right colectomy can be safely performed through a single incision through the umbilicus with an excellent cosmetic result.

Initial Surgeon Training for Single Port Access Surgery: Our First Year Experience

We have developed a single port access (SPA) surgical technique that allows for procedures to be done through a single umbilical port incision <20 mm in length. For a new approach to be universally beneficial, it needs to be easily learned and applied. Single port access abdominal procedures are performed through one umbilical incision where skin and soft tissue flaps are raised from the underlying fascia to allow insertion of up to 4 instruments. Fifty surgeons with varying degrees of laparoscopic training participated in SPA training programs at Drexel University to learn and apply the SPA technique through participation in an animate (porcine) laboratory. All surgeons successfully performed the SPA access technique without difficulty and completed the cholecystectomy in <55 minutes (average, 42). Eight surgeons successfully performed placement of a cholangiogram catheter. All recognized the value of a formal training symposium to learn SPA techniques before performing SPA procedures in their practice. The SPA technique has been successfully shown to be an approach that is easily learned and accomplished. We believe this is a necessary and important bridge towards proficiency in performing SPA procedures in clinical patients.

True single-port appendectomy: first experience with the “puppeteer technique”

We read with interest the recently published report by Dr. Roberts describing a novel ‘‘puppeteer technique’’ for single-port appendectomy, which is an intriguing modification of conventional laparoscopic surgery. However we have performed single-port appendectomy using multichannel ports, an approach based on well-established laparoscopic principles that can be transferred easily to trainees. Our current experience includes 44 cases performed through a single umbilical incision using a threechannel flexible port. This allows insertion of a camera and two instruments through a 12-mm incision. The procedure is performed in a fashion similar to conventional laparoscopy [1]. We use reusable straight graspers, hook diathermy, and pretied loops to perform the dissection under good vision and achieve triangulation by crossing instruments at the point of insertion. The appendix is removed inside the port, minimizing contamination. Our 44 consecutive cases consist of 42 emergencies (including 1 appendix mass and 2 perforated appendixes) and two elective interval appendectomies. Of the 44 patients, 32 were women with a body mass index (BMI) ranging from 18 to 32 kg/m. The operating time ranged from 20 to 65 min, which is comparable with our standard time for laparoscopic technique. Only one case required an additional 5-mm port (for the appendix mass) to complete the dissection safely. All the patients were discharged within 48 h after the operation and followed up after 6 weeks. Our series involved four minor complications. Two patients were readmitted, one with a small intraabdominal hematoma (treated conservatively) and one with gastroenteritis. Other complications involved a wound infection and a superficial hematoma, both treated without the need for additional surgery. The potential benefit of using a multichannel port rather than the ‘‘puppeteer’’ technique appears to be a shorter operating time because no intracorporeal loop needs to be fashioned to act as a pulley. Moreover, the dissection is performed in a manner familiar to those experienced in laparoscopic surgery. We have shown that our technique is teachable to trainees experienced in conventional laparoscopic appendectomy and has a short learning curve [2]. Although the port costs more than a standard single channel port, this cost difference is offset by avoiding the use of extra equipment such as an energy device (e.g., Ligasure/Harmonic scalpel) or a laparoscope with an extra working channel. Our use of additional ports also results in a lower cost. We therefore suggest that a single multichannel port allows a result similar to that of the puppeteer technique in terms of minimal incision and cosmesis but requires less time to perform and is more cost effective. The puppeteer technique may be useful in allowing a different point for retraction in difficult cases or other advanced procedures.

Single-Incision Transureteral Laparoscopic Nephrectomy: A Proof of Concept

Single-umbilical incision laparoscopic nephrectomy has been recently advocated as an alternative to pure natural orifice transluminal endoscopic surgery. We present a novel, hybrid technique for laparoscopic nephrectomy that combines single-incision laparoscopy with natural orifice transluminal endoscopic surgery principles consisting of using the ureteral stump as a natural orifice. Six renal units were operated in a nonsurvival pig study by combining a single umbilical incision with a novel natural orifice, the divided ureter. A transurethral 16F Amplatz sleeve inserted in the ureter under cystoscopic guidance became a natural orifice port after transection of the ureter. Regular laparoscopic instruments and scopes were used through two adjacent single-incision umbilical ports. The camera was placed in one of the umbilical ports and two operating instruments were introduced through the additional umbilical port and the "natural orifice port," respectively. Right and left laparoscopic nephrectomy were successfully performed. No complications occurred except one case of a periureteral hematoma due to the dilation of the ureter. The hylar blood vessels were thoroughly dissected and controlled by either clips or vascular staplers. The operative time decreased from 140 minutes in the first procedure to 70 minutes in the last (median time: 85 minutes). The learning curve was short because the basic principles of laparoscopy such as correct instrument angulation and geometry could be achieved through the inferior, natural orifice port. Laparoscopic nephrectomy combining a single umbilical incision with a natural orifice provided by the ipsilateral ureter is technically feasible in a large animal model. Further studies in human patients together with assessment of advantages over classic laparoscopic nephrectomy are needed.

Single-incision laparoscopically assisted colectomy using standard laparoscopic instrumentation

A prospective case series of transumbilical single-incision laparoscopic colectomies using conventional laparoscopic trocars and instruments is described. Seven selected patients with colonic neoplasm underwent transumbilical SIL colectomy between November 2008 and March 2009. Three trocars via a single small umbilical incision were used. The bowel was mobilized and the vessels ligated intracorporeally with an extracorporeal anastomosis. This series of seven patients (6 men and 1 woman) had no conversion to standard multiport laparoscopy or open surgery. Six of the patients had pathology in the right colon, and one had a carcinoma at the splenic flexure. The patients had an average age of 71 years (range, 63-83 years) and an average body mass index (BMI) of 24.3 kg/m(2) (range, 21-28 kg/m(2)). The average operating time was 89 min (range, 75-115 min). No significant blood loss or complications occurred. The average length of hospital stay was 5.4 days (range, 4-11 days). The average incision length was 3.1 cm (range, 2.5-4.5 cm). Histopathology showed adequate tumor excision margins and an average lymph node yield of 15 nodes (range, 7-26 nodes). Single-incision laparoscopic surgery for colectomy is feasible. It can be performed without specialized instrumentation and at no extra cost. Further evaluation is required.

Single-Incision Laparoscopic Cholecystectomy Using a Flexible Endoscope—Invited Critique

Objective: To describe our experience with a single-incision laparoscopic cholecystectomy (SILC) performed using a flexible endoscope as the means of visualization and surgical dissection. The use of flexible endoscopy in intra-abdominal surgery has never been described. Design: Prospective observational case series. Patients: Eleven patients with symptomatic cholelithiasis were selected based on age, clinical presentation, body habitus, and history of previous abdominal surgery. Patients with acute or chronic cholecystitis were excluded. Results: All procedures were completed laparoscopically via the single umbilical incision without the need to convert to an open operation and without introduction of any additional laparoscopic instruments or trocars. The mean operative time was 149.5 minutes (range, 99-240 minutes). The mean length of hospital stay was 0.36 days. There were no associated intraoperative or postoperative complications. Conclusions: In our experience, SILC performed with a flexible endoscope is feasible and safe. Further studies are needed to determine its advantages in reference to postoperative pain and complication rate in juxtaposition with the current standard laparoscopic cholecystectomy.

Single-Incision Laparoscopic Cholecystectomy Using a Flexible Endoscope

To describe our experience with a single-incision laparoscopic cholecystectomy (SILC) performed using a flexible endoscope as the means of visualization and surgical dissection. The use of flexible endoscopy in intra-abdominal surgery has never been described. Prospective observational case series. Eleven patients with symptomatic cholelithiasis were selected based on age, clinical presentation, body habitus, and history of previous abdominal surgery. Patients with acute or chronic cholecystitis were excluded. All procedures were completed laparoscopically via the single umbilical incision without the need to convert to an open operation and without introduction of any additional laparoscopic instruments or trocars. The mean operative time was 149.5 minutes (range, 99-240 minutes). The mean length of hospital stay was 0.36 days. There were no associated intraoperative or postoperative complications. In our experience, SILC performed with a flexible endoscope is feasible and safe. Further studies are needed to determine its advantages in reference to postoperative pain and complication rate in juxtaposition with the current standard laparoscopic cholecystectomy.

First single-incision type 7 total laparoscopic hysterectomy, adnexectomy, and appendectomy

We report two cases of use of a single umbilical skin incision for a type 7 total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and appendectomy. This study is a retrospective chart review and discussion of two patients who underwent a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and appendectomy (Canadian Task Force Level III). Both patients underwent a type 7 total laparoscopic hysterectomy for benign indications in July 2007 and sustained no complications. The evidence from these two cases suggests that advanced laparoscopic procedures are possible using a single skin incision for multiple ports. Technological advances, including those in port structure, are needed to enable surgeons to employ strategies that effectively enhance instrument coordination and suturing. Benefits to the patient need to be documented prospectively before this procedure can be recommended widely.

314 Single-Port Access (SPA™) Surgery of the Alimentray Tract: 18 Months Experience with a Single Umbilical Incision Approach to Laparoscopy

314 Single-Port Access (SPA™) Surgery of the Alimentray Tract: 18 Months Experience with a Single Umbilical Incision Approach to Laparoscopy

The Initial Experience with a Single Incision Laparoscopic Appendectomy

Purpose: A laparoscopic appendectomy (LA) is becoming popular for the treatment of acute and perforated appendicitis. Since it was first described, the LA has been modified many times. We present the result for a new technique of LA, in which the LA is conducted through a single umbilical incision without exteriorizing the appendix to perform the operation. Methods: A single incision laparoscopic appendectomy was attempted in 25 patients (17 men, 8 women). Under general anesthesia, a wound retractor was inserted through the umbilicus. The appendix was grasped and dissected from surrounding tissues with a single flexible dissector or grasper. After mesenteric dissection with ultrasonic shear, the base of the appendix was ligated with an Endoloop. The appendix was withdrawn into the wound protector and extracted from the abdomen. Results: A single incision laparoscopic appendectomy was completed in 25 patients. No major intraoperative or postoperative complications were encountered. The average duration of the procedure was 50.321.3 min. The average hospital stay was 4.12.4 days. Conclusion: This new technique, a single incision laparoscopic appendectomy, further improves the minimal invasiveness of a LA because a single incision is used. This procedure is a safe, very minimally invasive procedure with excellent cosmetic results.

Single port access (SPA) cholecystectomy: two year follow-up.

Laparoscopy is a constantly evolving field of surgery. New technology, applications, and benefits prompt continual improvement. We have developed a Single Port Access (SPA) surgical technique that allows for the entire cholecystectomy to be performed through a single incision within the umbilicus while maintaining safe standard dissection and retraction techniques of currently performed multiport laparoscopic cholecystectomy. Fifteen consecutive patients underwent SPA cholecystectomy. Indications were cholelithiasis, cholecystitis, CBD stones, and biliary akinesia. The entire procedure was performed through a single umbilical incision measuring <1.8 cm within the umbilicus. Three trocars and a rigid grasper were inserted through separate fascial sites within the same skin incision. The cholecystectomy procedures are then performed in the standard fashion described in multi-port cholecystectomy. Fifteen patients successfully underwent Single Port Access cholecystectomy. One patient required a second 5-mm port site secondary to difficulty with retraction of a large liver. Operative times averaged 107 minutes. Blood loss, patient recovery, and outcomes have been comparable to those of standard multi-port procedures. No umbilical hernias have been seen at 2 years of follow-up. We present the SPA cholecystectomy as an alternative to multi-port cholecystectomy. In the first 2 years, SPA surgery has evolved into a technique easily taught and performed without the restrictions of new equipment or added cost.

Single Incision Laparoscopic Sleeve Gastrectomy (SILS): A Novel Technique

Laparoscopic sleeve gastrectomy is an emerging bariatric procedure that typically necessitates five to seven small skin incisions to place five to seven trocars. The senior author (Saber) has developed a single umbilical incision approach to laparoscopic sleeve gastrectomy. Seven patients underwent single access transumbilical laparoscopic sleeve gastrectomy between March 2008 and July 2008. The same surgeon performed all surgical interventions. The umbilicus was the sole point of entry for all patients, and the same operative technique and perioperative protocol were used in all patients. A total of seven single-incision laparoscopic sleeve gastrectomies were performed. The procedure was successfully performed in all patients. Mean operating time was 125 min. None of the patients required conversion to an open procedure. There were no mortalities or postoperative complications noted during the mean follow-up period of 3.4 months. Single-incision transumbilical laparoscopic sleeve gastrectomy is safe, technically feasible, and reproducible.

Takeda to build Api plant

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.