Transumbilical Single-port Surgery Research Articles

Hysterectomy and Adnexal Procedures by Vaginal Natural Orifice Transluminal Endoscopic Surgery (VNH): Initial Findings From a Korean Surgeon.

Objective: To evaluate feasibility and safety of hysterectomy and adnexal procedures by vaginal natural orifice transluminal endoscopic surgery (vNOTES).Study Design: This is a prospective observational study at a tertiary center and teaching University hospital. We enrolled prospectively 34 patients with benign diseases sequentially.Results: We measured baseline characteristics, surgical data, and pain score (VAS) after surgery. We surveyed before/after surgery. The time of port installation and each stage of surgery was measured. The learning curve was assessed through the graph according to the number of operations using linear and logarithmic regression curve estimation. The complications of surgery were investigated. The median age of the patients was 47.5 years (38–73). Median BMI was 22.4 (18.2–30.0). 20 cases of leiomyoma, four cases of adenomyosis, three cases of uterine prolapse, four cases of endometrial hyperplasia, and three cases of CIN were diagnosed. The median uterine weight was 180.0 g. The median port-installation time was 15.0 min (range, 4–35 min) and median total operation time was 85.5 min (range 43.0–132.0). Complications occurred in three patients. Two cases of bladder injury happened during vesicovaginal space dissection before the installation of the Wound Retractor (WR). One patient underwent transumbilical single-port surgery because of late-onset postoperative bleeding on the 13th postoperative day. The mean postoperative VAS scores were 3.36 immediately after surgery and 3.06, 2.79, and 2.45 at 6, 12, and 24 h after surgery, respectively. In continuous variable analysis, we detected a correlation between port-installation time and postoperative VAS ≥4 (pain score as need for medication). Based on a learning curve, port-installation time and total operation time appeared to reach the proficiency level by the 10th case.Conclusions: Although there were three complications, vNOTES offers advantages to patients and surgeons. More surgical techniques will be developed in vNOTES.

The String Puppet Technique: A Useful Tool for Transumbilical Surgery

Introduction: Transumbilical single-port surgery (TSPS) has emerged to outdare minimally invasive surgery by trying to obtain better aesthetic results, further reduction of morbidity, and further enhanced postoperative recovery. Nonetheless, TSPS entails many challenges. One of them is the limited triangulation of the surgical instruments, which does not contribute to proper organ retraction during surgery. This makes dissection uncomfortable and difficult for the surgeon, and tissue retraction has to be accomplished by using fixation or sling sutures instead of another trocar. The learning curve of TSPS is harsh, because experience is needed to learn to manage the external crowding and collision of instruments, select the most adequate surgical instrument set to be used, and also wisely choose the best patient candidates for this type of procedure.1 The string puppet technique described in this article and displayed in the video (run time 1 minute, 51 seconds) is a useful TSPS maneuver that helps achieve optimal organ retraction. An internal grasper is used to hold organs or tissues inside the abdominal cavity but can be moved, directed, and controlled externally through leashes, just like a puppeteer manipulates a puppet. Materials and Methods: A straight needle with a 2.0 nylon suture is introduced through the skin in the epigastric region. The needle is then externalized through a 12-mm umbilical trocar using a 10-mm scope with a 6-mm working channel. The needle is removed from the suture and the loose end of the suture is held or fixed externally to avoid sliding inside the abdominal cavity. The procedure is repeated on the right flank. Once the two loose ends of the sutures are outside of the abdomen, they are both tied up to a stainless steel alligator clamp. The grasper is placed at the tip of the laparoscope with its jaws open and descends into the abdominal cavity through the operating channel. Once inside, the grasper can be directed and secured to the target area with the aid of a Thomas forceps. The alligator clamp allows for strong organ retraction but also easy repositioning. In this video, the infundibulum is held by the grasper and external traction is provided by means of both sutures. Movement and position of the organ or tissue can be adjusted and corrected during the surgery to accommodate to the surgeon's needs. Once no longer necessary, the grasper can be withdrawn along with both sutures through the umbilical port. Results and Conclusions: One of the major difficulties of TSPS is to achieve proper organ retraction. The string puppet technique is a useful maneuver to overcome this problem and can be used in any area of the abdomen. It is easy to perform, unexpensive, and does not require any sophisticated instruments. No competing financial interests exist. Runtime of video: 1 mins 51 secs

Lung resection using transumbilical incision: an animal survival study.

Introduction:Transumbilical single-port surgery is a potentially less invasive approach to many types of abdominal surgeries and offers better cosmetic outcomes than conventional 3-port laparoscopic surgery. It avoids the complication of intercostal neuralgia and may reduce the risk of pulmonary complications after video-assisted thoracic surgery. This study evaluated the feasibility of transumbilical lung wedge resection.Methods:Lung resection was performed in 11 beagle dogs weighing 5.9 to 8.5 kg. A 3-cm umbilical incision and one diaphragmatic incision were made, and an endoscopic stapler was used. The diaphragmatic incisions were repaired under video guidance using a V-Loc knotless suturing device (Covidien, Mansfield, Massachusetts). Animals were monitored daily for signs of postoperative infection. White blood cell count, C-reactive protein level, and IL-6 level were measured in all animals. Animals were euthanized 14 days after surgery and underwent necropsy evaluation.Results:Accurate lung resection was achieved in 10 of 11 animals during a median operative time of 98 minutes (range 60–165). In 1 animal, transumbilical lung resection was not possible and was converted to thoracotomy. All animals survived without major postoperative complications. At necropsy, evidence of uneventful healing of the stapled resection margin and diaphragmatic wound were found. There was no evidence of vital organ injury or intrathoracic infection.Conclusion:A transumbilical approach to thoracic cavity exploration and stapled lung resection is technically feasible. Primary suturing of the diaphragmatic incision is a simple and effective means of diaphragmatic wound closure. This may be an alternative to video-assisted thoracic surgery for the management of simple thoracic disease.

Transumbilical Thoracoscopy Versus Conventional Thoracoscopy for Lung Wedge Resection: Safety and Efficacy in a Live Canine Model.

Transumbilical single-port surgery has been associated with less postoperative pain and offers better cosmetic outcomes than conventional 3-port laparoscopic surgery. This study compares the safety and efficacy of transumbilical thoracoscopy and conventional thoracoscopy for lung wedge resection. The animals (n = 16) were randomly assigned to the transumbilical thoracoscopic approach group (n = 8) or conventional thoracoscopic approach group (n = 8). Transumbilical lung resection was performed via an umbilical incision and a diaphragmatic incision. In the conventional thoracoscopic group, lung resection was completed through a thoracic incision. For both procedures, we compared the surgical outcomes, for example, operating time and operative complications; physiologic parameters, for example, respiratory rate and body temperature; inflammatory parameters, for example, white blood cell count; and pulmonary parameters, for example, arterial blood gas levels. The animals were euthanized 2 weeks after the surgery for gross and histologic evaluations. The lung wedge resection was successfully performed in all animals. There was no significant difference in the mean operating times or complications between the transumbilical and the conventional thoracoscopic approach groups. With regard to the physiologic impact of the surgeries, the transumbilical approach was associated with significant elevations in body temperature on postoperative day 1, when compared with the standard thoracoscopic approach. This study suggests that both approaches for performing lung wedge resection were comparable in efficacy and postoperative complications.

Single-port transumbilical laparoendoscopic surgery for simple renal cysts (a report of 6 cases )

Objective To explore the feasibility of single-port transumbilical laparoscopic unroofing of renal cysts by using the TriPort system. Methods Single-port transumbilical laparoscopic unroofing of renal cysts was performed in six patients with simple renal cyst confirmed by ultrasound, IVP,and CT scans during June 2010 to december 2010, three patients with right-sided, two with left-sided,and one with bilateral cysts. Results The procedure was successfully completed in all the patients, with a median surgical duration of 93 min ( 75 ～ 110 rmin ) and a median blood loss of 25 ml ( 10 ～ 40 ml ). No open surgery or blood transfusion was needed in all the patients and no complications occurred during a follow-up of 1 to 6 months. Conclusions Single-port transumbilical laparoscopic unroofing of renal cysts is safe, feasible, and effective. Skillful laparoscopic operation and suitable indications are the key to successful surgery. Key words: Transumbilical access ; Single-port laparoscopy ; Simple renal cysts

Single-Incision Laparoscopic Colectomy for Colon Cancer: Early Experience With 31 Cases

Transumbilical single-port surgery has been developed with the aim to further reduce the invasiveness of conventional laparoscopy. This study aimed to report our experience with 31 patients who were treated with transumbilical single-incision laparoscopic colectomy for colon cancer. This is a retrospective review of prospectively gathered data. This study was conducted at the Department of Surgery of Juntendo University Urayasu Hospital between April 2009 and April 2010. Data were obtained from a prospectively maintained single-institution laparoscopic colon cancer database. Thirty-one consecutively selected patients (mean BMI, 22.5 ± 2.3) were evaluated. All patients underwent single-incision laparoscopic colectomy for colon cancer. Two different approaches were used for single-incision laparoscopic colectomy: the trocar insertion method and the SILS port method. The trocar insertion method was adopted in 22 of 31 patients, and the SILS port method was used in 9 patients. The main measures of outcomes were intraoperative findings, postoperative course, and oncological outcomes. The most common procedure was sigmoid colon resection performed in 12 of 31 (39%) patients. The mean skin incision was 2.72 ± 0.79 (range, 3-5) cm. The operating time ranged from 101 to 263 (mean, 156 ± 45) minutes. The volume of bleeding ranged from 5 to 60 (mean, 27 ± 19) mL. No intraoperative complications were observed in this series. Postoperatively, there was no mortality. Wound infection was observed in 1 patient. The number of harvested lymph nodes was 18 ± 2.1, and the mean tumor-free resection margin was 11 ± 4.8 cm. Our experience indicates that single-incision laparoscopic colectomy is feasible for selected patients with colon cancer.

Laparo-Endoscopic Single Site Anatomical Retroperitoneoscopic Adrenalectomy Using Conventional Instruments: Initial Experience and Short-Term Outcome

To our knowledge we present the initial experience with and the short-term outcome of laparo-endoscopic single site anatomical retroperitoneoscopic adrenalectomy using conventional instruments. Between June 2009 and April 2010, 25 patients underwent laparo-endoscopic single site anatomical retroperitoneoscopic adrenalectomy. A TriPort™ Access System was inserted through a 2.5 to 3.0 cm transverse skin incision below the tip of the 12th rib. Adrenalectomy was done using a 5 mm 30-degree laparoscopic camera and 2 conventional laparoscopic instruments. After Gerota's fascia was incised we explored the first dissection plane between the perirenal fat and the anterior renal fascia at the superomedial side of the kidney. The adrenal gland was identified at the initial stage of the operation. Laparo-endoscopic single site anatomical retroperitoneoscopic adrenalectomy was successfully accomplished in 23 patients. An additional 5 mm port was required in 1 of the 2 unsuccessful cases and in the other it was necessary to convert to standard anatomical retroperitoneoscopic adrenalectomy. Median incision length was 3.0 cm, median operative time was 55 minutes and median estimated blood loss was 15 ml. No major intraoperative complications occurred. In the initial 10 cases median operative time was significantly longer (62 vs 50 minutes) and median blood loss was significantly higher (75 vs 10, each p <0.001) than in the subsequent 15. In 3 cases pheochromocytoma was successfully excised without undesirable hemodynamic oscillation. Postoperative complications developed in 2 patients, including angina and contralateral atelectasis in 1 each. In properly selected patients laparo-endoscopic single site anatomical retroperitoneoscopic adrenalectomy with conventional instruments is feasible, safe and effective, causes minimal morbidity and results in excellent cosmesis.

Reply

We appreciate the constructive comments by the editors and Dr. Elder regarding our initial series of LESS nephrectomy in infants, children, and adolescents. We agree with Dr. Elder's comment that the benefits of LESS surgery compared with other modalities, such as conventional laparoscopic surgery and robotic surgery, have not yet been demonstrated, and that future investigations, such as prospective multicenter comparisons of the different minimally invasive modalities, are necessary. However, initial data from the adult literature may suggest a trend towards lower morbidity in evaluating post-discharge parameters. 1 Canes D. Desai M.M. Aron M. et al. Transumbilical single-port surgery: evolution and current status. Eur Urol. 2008; 53: 1020-1030 Abstract Full Text Full Text PDF Scopus (348) Google Scholar The design of new specific tools may be necessary to assess differences in morbidity between LESS and conventional multi-port minimally invasive surgery. Editorial CommentUrologyVol. 76Issue 6PreviewThe authors present a nice series of children who underwent successful laparoscopic simple nephrectomy using single-port technology. Two of the study's co-authors are internationally renowned for laparoendoscopic single-site (LESS) urologic surgical procedures in adults, and Koh et al1 have demonstrated its application in children. Is LESS nephrectomy better than standard laparoscopic nephrectomy in children? I think it will be difficult to identify any significant advantages in measurable outcomes, such as blood loss, operative time, cost, analgesic use, length of stay, and complication rate, just as there have been no apparent differences in adults. Full-Text PDF

Editorial Comment on: Transumbilical Single-Port Surgery: Evolution and Current Status

Canes and colleagues focus our attention on a further modification of laparoscopic surgery: the transumbilical single-port surgery [1]. Their historical overview demonstrates clearly that this is an old technique pioneered by gynecologists in the 1960s using an operative laparoscope with an offset eyepiece comparable to the rigid nephroscopes used during percutaneous renal surgery [2,3]. However, in the year 2008, it seems that things have to be more fancy. Whereas laparoscopists initially used the umbilicus as an easy-to-hide entrance for the trocar, in the era of natural orifice transluminal endoscopic surgery (NOTES), the umbilicus has gained more importance, being recognized as an ‘‘embryonic natural orifice.’’ This has resulted in the new term ‘‘E-NOTES.’’ But the reader should be aware of the distinct differences between NOTES and the transumbilical laparoscopic single port technique. NOTES has been pioneered by gastroenterologists and surgeons who used the technology of a flexible gastroscope with different working channels to perforate the stomach and then to reach the peritoneal cavity. In the peritoneal cavity, complex procedures such as appendectomy and cholecystectomy have been carried out using specialized flexible endoscopes and devices (ie, intraluminal clip appliers). After transoral removal of the organ, the gastric wall was closed with intraluminal suturing techniques [4]. Single-port surgery is completely different and goes back to the operative resectoscope developed by Buess in the 1980s for transanal endoscopic microsurgery [5]. This device consists of a rectoscope 40 mm in diameter with up to five ports for insertion of the telescope and curved instruments. The principle of this device has been modified for transumbilical laparoscopy with three ports for insertion of a rigid or flexible telescope and flexible or bent instruments. Although the necessity and importance of an operative nephroscope, a complex gastroor coloscope, and an operative resectoscope has been proven over decades for intraluminal surgery, the role of such devices for transluminal and laparoscopic surgery remains uncertain. It is impressive to see what type of laparoscopic procedures have been carried out, but in my view, there is still no argument for not using the standard trocar technique, which provides efficient solutions to the main problems of E-NOTES, such as triangulation, retraction, instrument crowding, and in-line vision. However, endoscopic surgey will definitely benefit from the technological input (ie, flexible instruments, staplers) of these ‘‘new old’’ techniques.