Traditional Laparoscopic Approach Research Articles

Laparoscopic uncinate process first pancreatoduodenectomy\u2014feasibility study of a modified \u2018artery first\u2019 approach to pancreatic head cancer

PurposeThe aim of this study was to discuss the feasibility of laparoscopic ‘uncinate first’ pancreatoduodenectomy.MethodsThe analysis included prospectively collected data from 12 consecutive patients undergoing elective pure laparoscopic ‘uncinate process first’ pancreatoduodenectomy (Group 1). They were compared with patients previously operated on with a classical laparoscopic approach (Group 2). The primary outcome was the quality of the resected specimen (lymph node (LN) yield, R0 rate, involved resection margins). Secondary outcomes were perioperative parameters.ResultsThe LN yield in Group 1 was 19.3 and in Group 2 it was 13.9 (p = 0.03). R0 resection rates did not vary (66.7 vs. 63.2%, p = 0.84). Although the involvement of the superior mesenteric artery margin and uncinate process margin seemed lower in Group 1, the difference was not significant. Total operative time (467 vs. 425 min, p = 0.13) and resection time (221 vs. 232 min, p = 0.34) were similar in both groups. The estimated blood loss in Group 1 was 408 ml, whereas in Group 2 it was 392 ml (p = 0.33). Complication rates were 66.7% in Group 1 and 63.2% in Group 2 (p = 0.84). Median length of stay was 9 days in both groups (p = 0.36). Postoperative complication rates did not differ between groups.ConclusionsLaparoscopic uncinate first approach is a feasible method for pancreatic head neoplasms. Achieved quality of the specimen is comparable with the traditional laparoscopic approach, whereas intra- and postoperative course is not inferior. However, further studies on larger cohorts are required to fully establish whether the novel approach has potential advantages over classical access in pancreatic head cancer.

A Laparoendoscopic Single-site Surgical Approach to Laparoscopic Salpingectomy

Study ObjectiveTo demonstrate a laparoendoscopic single-site (LESS) surgical approach to salpingectomy. DesignA technical video showing step-by-step a LESS surgical approach to salpingectomy (Canadian Task Force classification level III). Institutional review board approval was not required for this study. SettingOf all gynecologic cancer types, ovarian cancer has the highest mortality rate and is the fifth leading cause of cancer deaths among women [1,2]. The leading theory of epithelial ovarian carcinogenesis indicates that serous, endometrioid, and clear cell ovarian carcinomas originated from the fallopian tube and endometrium and not directly from the ovary itself [1-10]. This has led to the use of prophylactic salpingectomy as a theoretical form of ovarian cancer risk reduction at the time of hysterectomy or as a means of tubal sterilization. Prophylactic salpingectomy does not appear to increase the risk of complications and appears to be safe [2]. Ovarian function does not seem to be compromised by salpingectomy based on serum markers or response rates with in vitro fertilization [11-16]. A LESS approach may reduce the morbidity associated with the placement of multiple ports and can improve cosmetic outcomes. Prophylactic LESS bilateral salpingo-oohorectomy was shown to be feasible and safe for high-risk patients for ovarian cancer [17]. InterventionsLaparoscopic salpingectomy at the time of hysterectomy or as a means of tubal sterilization using the LESS technique. ConclusionThis is a simple and reproducible technique for preventing major complications associated with LESS salpingectomy. This approach permits easier specimen retrieval because of the large solitary incision that is made. There is a significant improvement in cosmetic satisfaction when compared with a traditional laparoscopic approach in the setting of prophylactic risk reduction surgery [18].

Complications of Minimally Invasive Surgery and Their Management.

Minimally invasive surgery, including both traditional laparoscopic and robot-assisted laparoscopic approaches, has increasingly become the standard of care for urologic abdominal and pelvic surgery. This is a comprehensive review of the contemporary literature regarding complications of laparoscopic and robotic urologic surgery. The review highlights pertinent studies with the goal of providing the minimally invasive urologic surgeon with an up-to-date overview of general and procedure-specific complications and their management.

Robotic-Assisted Renal Surgery.

Minimally invasive surgical techniques have revolutionized the surgical management of kidney cancer. Current evidence suggests that the surgical developments gained by traditional laparoscopy have been advanced by the robotic platform, particularly as it has been applied to techniques for nephron preservation. The medical literature from peer-reviewed journals was reviewed to evaluate the feasibility and efficacy of robotic-assisted surgery in the management of renal cell carcinoma. Particular attention was paid to studies comparing robotic-assisted surgery with more traditional surgical techniques. In this review, we have highlighted the evolution of robotic assistance for renal surgery as it pertains to renal oncology. The differing approaches to standard surgeries are discussed as well as current trends to improve perioperative outcomes.In addition, we have reviewed the application of robotic assistance to more complex cases and highlight technological advancements that have pushed the boundaries of surgical care. Robotic-assisted renal surgery is effective for appropriately selected patients. Robotic-assisted radical nephrectomy provides equivalent outcomes to traditional open and laparoscopic approaches, albeit with added financial burden. Robotic-assisted partial nephrectomy - through either transperitoneal or retroperitoneal access - can provide superior outcomes to laparoscopic approaches due to several technical advantages,including improved instrument articulation. Robotic assistance has transformed the delivery of surgical care to the patient with renal cell carcinoma. For renal surgery, morbidity and patient satisfaction are potentially improved when using robotic platforms compared with open and traditional laparoscopic approaches without compromising oncological control, and this is particularly true for nephron-sparing surgery.

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.

Minimally invasive specialists and rates of laparoscopic hysterectomy.

Background and Objective:Despite the prevalence of hysterectomy for treatment of benign gynecologic conditions, providers nationwide have been slow to adopt minimally-invasive surgical techniques. Our objective is to investigate the impact of a department for minimally invasive gynecologic surgery (MIGS) on the rate of laparoscopic hysterectomy at an academic community hospital without robotic technology.Methods:This retrospective observational study included all patients who underwent hysterectomy for benign indications from January 1, 2004, through December 31, 2012. The primary outcome was route of hysterectomy: open, laparoscopic, or vaginal. Secondary outcomes of interest included length of stay and factors associated with an open procedure.Results:In 2004, only 24 (8%) of the 292 hysterectomies performed for benign conditions at Newton-Wellesley Hospital (NWH) were laparoscopic. The rate increased to more than 50% (189/365) by 2008, and, in 2012, 72% (316/439) of hysterectomies were performed via a traditional laparoscopic approach. By 2012, more than 93% (411/439) of all hysterectomies were performed in a minimally invasive manner (including total laparoscopic hysterectomy [TLH], laparoscopic supracervical hysterectomy [LSH], total vaginal hysterectomy [TVH], and laparoscopy-assisted vaginal hysterectomy [LAVH]). More than 85% of the hysterectomies at NWH in 2012 were outpatient procedures. By this time, the surgeon's preference or lack of expertise was rarely cited as a factor leading to open hysterectomy.Conclusions:A large diverse gynecologic surgery department transformed surgical practice from primarily open hysterectomy to a majority (>72%) performed via the traditional laparoscopic route and a large majority (>93%) performed in a minimally invasive manner in less than 8 years, without the use of robotic technology. This paradigm shift was fueled by patient demand and by MIGS department surgical mentorship for generalist obstetrician/gynecologists.

The use of robotics in surgery: a review.

There is an ever-increasing drive to improve surgical patient outcomes. Given the benefits which robotics has bestowed upon a wide range of industries, from vehicle manufacturing to space exploration, robots have been highlighted by many as essential for continued improvements in surgery. The goal of this review is to outline the history of robotic surgery, and detail the key studies which have investigated its effects on surgical outcomes. Issues of cost-effectiveness and patient acceptability will also be discussed. Robotic surgery has been shown to shorten hospital stays, decrease complication rates and allow surgeons to perform finer tasks, when compared to the traditional laparoscopic and open approaches. These benefits, however, must be balanced against increased intraoperative times, vast financial costs and the increased training burden associated with robotic techniques. The outcome of such a cost-benefit analysis appears to vary depending on the procedure being conducted; indeed the strongest evidence in favour of its use comes from the fields of urology and gynaecology. It is hoped that with the large-scale, randomised, prospective clinical trials underway, and an ever-expanding research base, many of the outstanding questions surrounding robotic surgery will be answered in the near future.

Same-day discharge is feasible and safe in patients undergoing minimally invasive staging for gynecologic malignancies

The objective of the study was to evaluate the feasibility and safety of same-day discharge of patients undergoing minimally invasive comprehensive surgical staging for endometrial and cervical cancer. We performed a retrospective review of consecutive patients from January 2008 to December 2011 undergoing comprehensive staging for endometrial or cervical cancer by traditional laparoscopy or robotic-assisted laparoscopy and intended for same-day discharge. Patients accomplishing same-day discharge were compared with those who required admission. Clinical and demographic data, perioperative outcomes, and postoperative patient contacts within 6 weeks were collected. Multivariate logistic regression modeling was used to determine factors associated with admission and unscheduled patient contacts within 2 weeks of surgery. A total of 141 patients were identified. One hundred eighteen patients (83.7%) underwent same-day discharge and 23 (16.3%) required overnight admission. The variables that significantly predicted overnight admission were severe pain in the postanesthesia care unit (odds ratio [OR], 6.81; 95% confidence interval [CI], 1.74-26.6; P = .006), delayed ability to tolerate oral intake (OR, 9.3; 95% CI, 2.25-38.6, P = .002), traditional laparoscopic vs robotic-assisted surgical approach (OR, 9.05; 95% CI, 2.34-35.1; P = .001), and surgery start time at 2:00 pm or later (OR, 36.8; 95% CI, 6.19-219.3; P < .0001). There was no difference in the readmission rate between patients undergoing same-day discharge compared with overnight admission (11% vs 17%, P = .48). No variables significantly predicted unscheduled patient contact within 2 weeks of surgery at P < .01. Same-day discharge for patients undergoing laparoscopic or robotic-assisted laparoscopic staging for endometrial or cervical cancer is feasible and safe. There are low complication rates and few readmissions or unscheduled patient contacts within 2 weeks of surgery.

Robotic left hepatectomy with revision of hepaticojejunostomy

Laparoscopic hepatectomy and hepaticojejunostomy remain a surgical challenge despite the recent advances in minimally invasive surgery. A robotic surgical system has been developed to overcome the inherent limitations of the traditional laparoscopic approach. However, techniques of robotic hepatectomy have not been well described, and a description of robotic major hepatectomy with bilioenteric anastomosis can be found only in two previous reports. Here, we report a 33-year-old man with a history of choledochocyst resection. The patient experienced repeat cholangitis with left hepatolithiasis during follow-up. Robotic left hepatectomy and revision of hepaticojejunostomy were performed smoothly. The patient recovered uneventfully and remained symptoms-free at a follow-up of 20 months. The robotic approach is beneficial in the fine dissection of the hepatic hilum and revision of hepaticojejunostomy in this particular patient.

Laparoscopic robotic liver surgery: the Henri Mondor initial experience of 20 cases.

Laparoscopic liver surgery is now an established practice in many institutions. It is a safe and feasible approach in the hands of trained surgeons. The introduction of robotics into surgery represents progression in the field of minimally invasive surgery but has seen a slow uptake in the hepatopancreaticobiliary subspeciality. We report our initial experience in 20 cases of laparoscopic robotic liver resection (LRLR). From March 2011 to April 2013 patients with lesions within the liver were assessed and consented for laparoscopic robotic liver surgery. This is a retrospective analysis of a prospectively kept database on preoperative details and intraoperative and postoperative outcomes. During the time period there were 20 LRLRs. The median age was 62years (range 39-80years) with a male to female ratio of 14:6. Ten patients had left lateral sectionectomies, 10 patients had atypical segmental resections; 14 patients had resections for malignancies, 6 patients had resections for benign disease. One case was converted to open resection. The mean operating time was 176.4±74.6min (range 60-300min), the mean blood loss was 107±106ml (range 50-700ml) and the mean hospital stay was 6.5±3.7days (range 2-16days). Two patients required blood transfusions. The incidence of postoperative complications was 10% (n=2). LRLR overcomes some of the disadvantages of conventional laparoscopic surgery. It is a technically feasible and safe approach for wedge resections and left lateral sectionectomy of the liver without oncological compromise. However, this surgical technique requires advanced laparoscopic skills and there is an associated steep learning curve. Further studies are needed to determine the potential advantages of this technique for the patient compared to the traditional laparoscopic approach.

Analysis of postoperative pain in robotic versus traditional laparoscopic hysterectomy.

The aim of this study was to assess postoperative pain and narcotic use in the first 23h following robotic versus traditional laparoscopic hysterectomy for benign pathology. The study design was that of a retrospective case-control study of robotic (first 100 consecutive) versus traditional (last 100 consecutive) total laparoscopic hysterectomy cases at an obstetrics and gynecology multi-institutional community practice. Patient characteristics were equivalent in both groups (age, p=0.364; body mass index, p=0.326; uterine weight, p=0.565), except for a higher number of Caucasians in the traditional laparoscopic group (p=0.017). Compared to patients who underwent robotic laparoscopic hysterectomy, those who underwent the traditional procedure had higher visual analog scale pain scores (3.1±1.5 vs. 4.6±2.4, respectively; p<0.001) and used more narcotics (27.5 vs. 35.4mg hydrocodone, respectively; p<0.05). Factors that could potentially increase pain (more procedures, more ports, total incision size, and longer operative time) were significantly higher in the robotic group, but only surgical approach, amount of narcotic, and age correlated with pain levels when evaluated with regression analysis. Complication rates were equivalent between groups. In conclusion, patients who underwent robotic assisted laparoscopic hysterectomy had statistically decreased postoperative pain scores and narcotic use than those who underwent the traditional laparoscopic approach, even when the robotic cases involved more procedures and ports and were associated with longer operative time.

A comparison of outcomes between the traditional laparoscopic and totally robotic Roux-en-Y gastric bypass procedures.

Background Roux-en-Y gastric bypass is considered to be the gold standard of bariatric procedures. Minimally invasive surgical techniques have been demonstrated to decrease recovery time and provide for favorable cosmetic outcomes. The drawback of traditional laparoscopic techniques for the surgeon comes in the form of 2D monitoring of not always intuitive instrument manipulation. The da Vinci Surgical System provides surgeons with a 3D view and more intuitive instrument manipulation. This study was conducted in order to compare the surgical outcomes and assess the learning curve of traditional laparoscopic Roux-en-Y gastric bypasses (LRYGB) to totally robotic Roux-en-Y gastric bypasses (TRRYGB). A single surgeon's 100 most recent patients who underwent traditional LRYGB and the first 100 patients who underwent TRRYGB were included in this study. Data was collected on patient age, gender, body mass index (BMI), co-morbidities, surgical time, length of admission, and complication rates. No significant differences were found between study groups with respect to age, gender, BMI or any recorded co-morbidities. The mean operative times for patients 1-50 in the TRRYGB and LRYGB groups were 204.34±90.19min and 151.16±47.16min, respectively (P=0.0004). Mean operative times were 159.60±48.26min and 166.66±44.95min for patients 51-100 in the TRRYGB and LRYGB groups, respectively (P=0.45). No significant differences were found between study groups with respect to post-surgical complications or 30-day outcomes. Our data shows that TRRYGB compares favorably to the traditional laparoscopic approach, while maintaining patient safety.

Comparison of robotic adrenalectomy with traditional laparoscopic adrenalectomy with a lateral transperitoneal approach: a single‐surgeon experience

Although several recent studies have demonstrated the feasibility and safety of robotic adrenalectomy, it is unknown whether this procedure has advantages over the traditional laparoscopic approach. This study compared our initial experience using the da Vinci-S® robotic surgical system during laparoscopic adrenalectomy with our experience with traditional laparoscopic adrenalectomy. From October 2009 to May 2012, 23 consecutive patients (13 women, 10 men) underwent laparoscopic adrenalectomy by the same surgeon at Anam Hospital, Korea University Medical Center. Fifteen patients (9 women, 6 men) underwent robot-assisted adrenalectomy (right-sided, 4 patients; left-sided, 11 patients). Eight patients (4 women, 4 men) underwent traditional laparoscopic adrenalectomy (right-sided, 5 patients; left-sided, 3 patients). The lateral transperitoneal approach was used for all patients. There were no cases of conversion to traditional laparoscopic or open surgery. The mean operative time was longer in the robotic group (208.2 minutes, range 120-320) than the laparoscopic group (181.13 minutes, range 75-270). There were no cases of intraoperative complications or mortality. The mean hospital stay did not differ significantly between groups (robotic group, 5.86 days (SD 1.16); laparoscopic group, 6.71 days (SD 1.38)). With its magnified stereoscopic three-dimensional vision, elimination of tremor, and ability to articulate and rotate surgical instruments, the da Vinci-S® robotic system may be an ideal surgical tool for the operation of adrenal lesions. Robotic adrenalectomy appears to be a safe and effective alternative to traditional laparoscopic adrenalectomy.

Robotic-assisted transabdominal cerclage (RoboTAC) in the non-pregnant patient

The use of cerclage, either through vaginal or abdominal routes, to assist in delaying pre-term delivery among select women with cervical insufficiency may be beneficial, but can also carry significant morbidity. Robotic-assisted transabdominal cervical cerclage (RoboTAC) in the non-pregnant patient has the ability to not only reduce associated morbidity, but also offer the same benefits as the more traditional laparotomy and laparoscopic approaches, while removing the risk to an in situ fetus. We report the use of robotic-assisted transabdominal cervical cerclage in 24 non-pregnant women. Feasibility of the procedure is discussed along with a description of the technical surgical details. In addition, limited pregnancy outcomes are presented. Our results suggest that RoboTAC is a safe alternative to the traditional laparotomy procedure with quicker recovery time.

Risk Factors for Postoperative Urinary Retention After Laparoscopic and Robotic Hysterectomy for Benign Indications

To estimate the occurrence of postoperative urinary retention after traditional laparoscopic and robotic hysterectomy. We performed a chart review of all patients who underwent total or supracervical hysterectomy using a laparoscopic (n=253) or robotic approach (n=281) from March 2001 until June 2010 for benign indications at the division for minimally invasive surgery. Urinary retention was defined as the inability to spontaneously void or as incomplete voiding requiring either self-catheterization or Foley catheter replacement in the first postoperative week. Urinary retention occurred in 7.3% (95% confidence interval [CI] 5.2-9.8%) of women and was more than twice as common among women who underwent robotic hysterectomy compared with laparoscopic hysterectomy (10.3%, 95% CI 7.0-14.5% compared with 4.0%, 95% CI 1.9-7.1%, P=.005). No statistically significant differences in those with and without urinary retention were seen in age, body mass index, smoking status, number of prior cesarean deliveries, operative time, presence of severe adhesions, or findings of endometriosis. In a multivariable logistic regression analysis, only the robotic approach relative to traditional laparoscopic approach was found to be significantly associated with urinary retention (odds ratio 2.6, 95% CI 1.2-5.6). Postoperative urinary retention was associated with a higher incidence of lower urinary tract infection, occurring in 15.4% (95% CI 5.9-30.5%) of cases compared with 4.0% (95% CI 2.5-6.2%) of those without urinary retention (P=.008). Transient urinary retention is relatively more common after robotic hysterectomy when compared with laparoscopic hysterectomy. We postulate that more aggressive bladder dissection performed with robot assistance may be associated with an increased risk of urinary retention.

Robotic assistance may reduce conversion to open in rectal carcinoma laparoscopic surgery: systematic review and meta‐analysis

We hypothesized that robotic assistance (RARS) could provide better intraoperative and short-term outcomes than a traditional laparoscopic approach (LARS) to rectal cancer surgery. Systematic review of the literature, including electronic searches and communications to international robotic meetings. studies involving rectal cancer patients and comparing outcomes of robotic surgery vs laparoscopic surgery. Primary end-points: conversion and postoperative short-term complications. Meta-analysis performed using Review Manager 5.0 software. Five case-control studies involving 486 patients (203 RARS-283 LARS) were finally included. Conversion to open rate (RR = 0.31; 95% CI 0.12,0.78) was lower for RARS. No differences were found in oncological outcomes, hospital stay or anastomotic leakage. This meta-analysis of available non-randomized studies suggests that conversion to open rate may be reduced when using RARS instead of LARS for rectal cancer.

Laparoendoscopic single site (LESS) surgery for left-lateral hepatic sectionectomy as an alternative to traditional laparoscopy: case-matched analysis from a single center

Laparoscopy is considered the "gold standard" to perform left-lateral sectionectomy with results identical to those of open surgery, yielding decreased postoperative pain and disability, reduced hospital stay, and shortened patient recovery time. As the emphasis on minimizing the invasiveness of surgical techniques continues, laparoendoscopic single site (LESS) surgery is quickly evolving. The purpose of this study was to compare the results of laparoscopic left-lateral sectionectomy performed using the traditional approach or LESS approach with a case-matched analysis for tumor size, type of resection, and surgical indications. Thirteen patients who underwent LESS left-lateral sectionectomy are considered the study group (LESS group) and compared with 13 patients who underwent left-lateral sectionectomy with traditional laparoscopic approach (conventional group). There were no significant differences between groups for length of surgery (165 min in conventional group vs. 195 min in LESS group), blood loss (150 mL in conventional group vs. 175 mL in LESS group), conversion to open surgery, histological tumor exposure, and requirements of postoperative analgesics. One patient in the LESS group died of cardiac failure due to an unknown severe aortic valve stenosis. No differences were recorded for postoperative complications (23.1% in both groups) and median length of postoperative stay (4 days in both groups). For left-lateral hepatic sectionectomy, LESS surgery is technically feasible and as safe as traditional laparoscopic surgery in terms of intraoperative and postoperative results, even though requiring both hepatobiliary and laparoscopic technique experience.

Standard laparoscopic versus single-incision laparoscopic colectomy for cancer: early results of a randomized prospective study

BackgroundStandard laparoscopic colectomy (SLC) for cancer is a safe, feasible, and oncologically effective procedure with better short-term and similar long-term results of open colectomy. Conversely, owing to technical difficulties in colonic resection and full mesenteric dissection, single-incision laparoscopic colectomy (SILC) has been considered unsuitable for oncologic purposes. We compared the technical feasibility and early clinical outcomes of SLC and SILC for cancer. MethodsIn this prospective randomized clinical trial, 16 (50%) patients underwent SLC (10 left and 6 right) and 16 (50%) patients underwent SILC (8 left and 8 right). ResultsDemographics, preoperative data, and characteristics of the tumor were similar. The mean number of resected lymph nodes was 16 ± 5 in the SLC and 18 ± 6 in the SILC group (P = NS). Surgical time was 124 ± 8 minutes and 147 ± 5 minutes, respectively (P = NS). Surgical mortality was nil and the major morbidity rate was 6.3% in both groups. ConclusionsSILC for cancer is a technically feasible and safe oncologic procedure with short-term results similar to those obtained with a traditional laparoscopic approach.

Author’s reply to V. Fazio’s invited comment on “Single incision laparoscopic colorectal surgery: a single surgeon experience of 102 consecutive cases”

The authors are thankful for the opportunity to address the comments made by Dr. Fazio and by Dr. Bergamaschi regarding our manuscript entitled ‘‘Single Incision Laparoscopic Colorectal Surgery: A Single Surgeon Experience of 102 Consecutive Cases.’’ The authors greatly appreciate both the insightful comments offered by Dr. Vic Fazio as well as his understanding that single-incision laparoscopic colorectal surgery is in its infancy. We also agree that benefits and outcomes will prove to be at least equivalent and likely superior to traditional laparoscopy, as its superiority to hand-assist surgery has been shown by others [1]. We are now indeed in the process of defining patient selection, disease processes, and limitations of a single-port technique. Further work is in process and results are forthcoming. As far as Dr. Bergamaschi’s comments, we agree that institutional review board (IRB) approval should be mandatory for such studies and greatly appreciate Dr. Bergamaschi’s acknowledgement that this was indeed the case in our study as we consider it routine. We also agree that there is a need for innovation in surgery and that this must be implemented in accordance with the rules of evidence. However, we cannot agree with his statement that laparoendoscopic single-site surgery (LESS) is neither technically simple nor random. Given the tremendous advances in new technology (Olympus endo-eye flexible tip 5-mm camera and 5-mm energy devices to name a couple), we are now able to perform even complex abdominal operations in an even less invasive fashion. In fact, the ergonomic challenges and time constraints of traditional laparoscopy are often greatly improved with a single-port technique. LESS is nothing more than grouping the ports together and operating through a single incision. Having performed well over 1,000 laparoscopic colorectal procedures primarily through a three-port technique popularized in the United States by John Marks, MD, the transition to single-incision surgery is quite simple. This has become our routine access as it is essentially a three-trocar technique with the grouping of the ports at a single-site. The authors also agree with Dr. Bergamaschi that the goal for innovative advances in surgery should be the improvement of patient benefit as that was the sole purpose of this study while better defining the patient selection, disease processes, and optimal technique. With regard to the actual technique, single-incision laparoscopy is in its infancy while standardized techniques have not yet been defined. However, it remains a three-trocar laparoscopic procedure. As we are now quickly approaching our second 100 cases, much has been learned. With the ports arranged in a triangular configuration directed to the pathology, the camera is best placed through the apical port with a grasper in the surgeon’s right hand and the energy device in the left. The same surgical principles that pertain to open surgery and utilized for a traditional laparoscopic approach are strongly adhered to with this access technique. Again, this simplified approach is a traditional three-trocar technique with the ports bunched together and we feel that this is readily adoptable by surgeons with the appropriate skill set utilized for a traditional laparoscopic resection. To date, over 100 surgeons with advanced laparoscopic experience have been proctored and report an excellent adoption rate. While others have D. Geisler (&) T. Garrett Pittsburgh, PA, USA e-mail: dgeisler@ma.rr.com

Laparoendoscopic single-site (LESS) hysteropexy

Uterine prolapse is one of the common reasons for hysterectomy throughout the world. However, recent data has shown that uterine-sparing techniques appear to be equivocal to that of hysterectomy. Older reports of intra-abdominal uterine suspension describe open approaches and more recent descriptions involve robotic and laparoscopic approaches utilizing mesh. We describe the first reported laparoendoscopic single-site (LESS) sacral hysteropexy utilizing a strip of polypropylene mesh placed posteriorly on the uterus and attached to the sacral promontory. A 45-year-old female with grade 3 uterine prolapse, cystocele, and rectocele underwent the procedure. The procedure involved access utilizing a single-port system placed transumbilically, and dissection using articulating laparoscopic instruments. The hysteropexy was completed by placing a 3-cm wide strip of polypropylene mesh along the posterior vaginal wall and cervicouterine junction, and suturing the proximal end to the anterior longitudinal ligament overlying the sacral promontory. The patient was discharged home within 18 h of the procedure. At 6 month follow-up, the patient has excellent anatomic support, with no evidence for recurrence of prolapse. LESS hysteropexy appears to be a safe, effective procedure for uterine prolapse and provides patients with excellent outcome with no visible scar. Additional studies will determine whether the LESS approach provides any benefit when compared with robotic or traditional laparoscopic approaches with respect to blood loss, pain, and time of full recovery.