Transumbilical laparoendoscopic single s pdf

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Review Article

iju_2963416..428

Transumbilical laparoendoscopic single-site surgery

in urology

John E Humphrey and David Canes

Department of Urology, Tufts University School of Medicine, Lahey Clinic Institute of Urology, Burlington, Massachusetts, USA

Abbreviations & Acronyms CL₌conventional

laparoscopy

DVT/PE=deep venous thrombosis/pulmonary embolus

EBL₌estimated blood loss E-NOTES=embryonic natural orifice

transumbilical endoscopic surgery

Lap₌laparoscopic LESS=laparoendoscopic single-site surgery LOS=length of hospital stay

MAG3=technetium-99m mercaptoacetyltriglycine MOT=mean operative time

OPUS₌one port umbilical surgery

SIL=single incision laparoscopy SILS₌single port laparoscopy

SPA=single port access SPL=single port laparoscopy

Correspondence:David Canes

M.D., Department of Urology, Tufts University School of Medicine, Lahey Clinic Institute of Urology, 41 Mall Road , Burlington, MA 01805, USA. Email: [email protected]

Received 18 October 2011; accepted 4 January 2012. Online publication 15 February 2012

Abstract: Laparoendoscopic single-site surgery has seen a dramatic rise in the uro-logical community. With the advent of new techniques and instrumentation, laparoen-doscopic single-site surgery has become more accessible for a wide variety of applications. The majority have been carried out through a transumbilical incision in order to effectively hide the scar within the umbilicus. Here, we review the history and clinical applications for transumbilical laparoendoscopic single-site surgery within urology. The current scope is broad , and great strides have been made, but the overall beneﬁt appears to be predominantly cosmetic. Diffusion of laparoendoscopic single-site surgery techniques from tertiary referral centers to the community urologist remains unknown. This review demonstrates the feasibility of transumbilical laparoendoscopic single-site surgery as shown in the urological literature.

Key words: laparoendoscopic single-site surgery, minimally invasive, review, transumbilical.

Introduction

Rise of minimally invasive surgery

Single-port surgery, like many advances in medicine, is the result of constant fine-tuning of prior techniques, and questioning how they can be improved on. The initial impetus driving towards minimally invasive surgery was the morbidity from an open laparotomy incision. The pain, recovery time and inherent wound complications, such as infection and incisional hernias, as well as the cosmetic nature of open surgery drove us to push the field towards laparoscopic surgery, and subsequently its robotic counterpart. The subsequent evolution of technique, ability and technology has led to the development of transumbilical single-port surgery. This is thought to be the next natural step in accomplishing safe, effective proce-dures while limiting the morbidity and cosmetic consequences of large and/or several incisions.

Assumptions that surgical morbidity is simply linearly related to the sum-total of incision length(s), however, have not held under scrutiny in the past. The present review is focused on the urological experience with single-port surgery specifically using a transumbilical approach. The umbilicus provides a location in which the resultant scar can be at least partially hidden from view, enhancing the benefit of improved cosmesis with single-port surgery. The application of transumbilical single-port surgery in urology is ever growing, and herein we describe the worldwide use of this technique to date.

The term now used to describe single-port surgery in the urological literature is LESS. This was developed to incorporate and standardize the various previous terms used to describe one overall concept of minimally invasive operations performed through a single incision using conventional laparoscopic or newer instrumentation such as fixed pre-bent or

deflectable flexible instruments.1 _{Previous terms included E-NOTES, SILS, OPUS, SPA,}

SPL and SIL, among others. The first transumbilical urological LESS procedure described

was by Raman et al. where three nephrectomies were carried out, each using a single

incision with multiple trocars.2 _{Since that time, the clinical experience has increased}

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International Journal of Urology (2012)19, 416–428 doi: 10.1111/j.1442-2042.2012.02963.x

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dramatically and LESS has cemented itself as an excellent technique for a broad range of urological procedures.

Early history

The first description of a true LESS procedure, evident now only in retrospect, was in the field of gynecology for tubal

ligation in 1972.3_{A 1-cm infraumbilical incision was made,}

through which a laparoscope was inserted to visualize and then cauterize each fallopian tube. The fallopian tubes were exposed using an external tenaculum placed on the uterus from the vagina. The cosmetic benefit of the technique was immediately evident, and eventually led gynecologists to explore similar techniques for larger procedures, including total abdominal hysterectomy and bilateral

salpingo-oophorectomy by 1991.4

General surgeons also began to explore the use of transumbilical LESS surgery for appendectomy and

cholecystectomy.5–7 _{During this process, a new technique}

was developed in 1999 for use in cholecystectomy, by which a single skin incision is made, but two fascial incisions are used to accommodate 5-mm trocars within this common

skin incision.8 _{This allows more ports for instruments}

without compromising the cosmetic benefit.

Initial urological applications

Although LESS procedures were being developed in these other arenas, the evolution from open to laparoscopic and finally robotic surgery was taking place in urology. The benefits realized during this transition included less bleed-ing, fewer complications and shorter hospital stays leading

to faster convalescence.9 _{It was thus inevitable that}

urolo-gists would also begin exploring the single-port system. Although we focus here on transumbilical LESS, in 2007, the first case in urology used a flank incision for placement of an R-port (Advanced Surgical Concepts, Wicklow, Ireland) to complete a nephrectomy on a small,

non-functioning kidney.10 _{This technique has also been}

used for radical nephrectomy with a 7-cm paramedian inci-sion just lateral to the rectus muscle for placement of a GelPort (Applied Medical, Rancho Santa Margarita, CA,

USA).11_{Another case report described a 4-cm flank}

inci-sion with a GelPort to carry out retroperitoneal radical

nephrectomy for renal cell carcinoma in a dialysis patient.12

The pfannenstiel incision has also been explored as a focal point for LESS. In one report, a 7.5-cm pfannenstiel inci-sion was used to carry out both nephrectomy and

neph-roureterectomy, using a GelPort as an access device.13

These approaches proved to be feasible options utilizing non-umbilical incisions. However, the majority of urologi-cal single-site experience, as described here, has been with transumbilical access.

Benefits of LESS

The transition from CL to LESS creates inherent technical challenges. In order for the urological community at large to embrace LESS, clear benefits of LESS over CL must be shown rigorously and scientifically. This has been difficult, as the salient advantage is improved cosmesis, a variable for which there is a paucity of objective measures. An early comparison between LESS and CL among patients under-going nephrectomy showed a subjective cosmetic advan-tage, while also showing comparable outcomes for operative

time, analgesic use, hospital stay and complication rate.14

Similar subjective outcomes have been reproduced with

various procedures,15–18_{but a recent study by Park}_{et al.}_used

an objective measure to quantify the cosmetic advantage.19

This group used a body image questionnaire to compare patient satisfaction after kidney surgery. Although the scale was non-validated , it does represent the first objective measure of improved cosmesis with LESS. As rigorous data continues to accumulate, by preliminary observation it seems clear that at least from the surgeon’s perspective, cosmesis is excellent after umbilical LESS surgery. Figure 1 shows the immediate intraoperative cosmetic result of a patient in our own group undergoing a LESS left renal cyst decortication. For this procedure, a 4-cm vertical intraum-bilical incision was made, with the result as shown at 6 weeks postoperatively in Figure 2.

Other theoretical benefits of LESS include decreased postoperative pain and fewer postoperative wound

compli-cations (infection, hernia). Jeong et al. presented data

among patients undergoing adrenalectomy (9 LESS, 17 CL) showing significantly lower postoperative pain in the LESS

cohort.17 _{However, most comparison series have not had}

long enough follow up or were powered with sample sizes necessary to show a meaningful difference in wound complications.

Fig. 1 LESS renal cyst decortication immediate cosmetic

result.

Transumbilical LESS in urology

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Technique and instruments

As with any new surgical platform, LESS has been associ-ated with unique ergonomic challenges to overcome and inherent difficulties, which continue to be present. Multiport laparoscopic surgery with strategically placed trocars achieves triangulation for improved tissue retraction and only rare instrument clashing. Triangulation and instrument crowding becomes even more difficult during LESS, whereby bulky instrument handles clash in preciously limited external “real estate”. These difficulties have put the onus not only on the surgeon to creatively overcome these limitations given current instruments, but also on industry to design purpose-built access devices and instrumentation. The technical and equipment challenges with LESS have

previously been described by Sawyer and Ponsky.20_They

note the rapid innovation seen with LESS and highlight the obstacles that are inherent to single-port surgery. Two approaches are described: (i) a coaxial approach in which instruments are used in parallel; or (ii) a novel platform. The coaxial approach leads to limited visual perspective, as instruments are in line with the operator’s vision. The tran-sition to novel platforms to overcome this challenge is described below.

Before the current devices were created , surgeons first experimented by using existing laparoscopic instruments through a single skin incision and multiple fascial incisions. This “keyhole” technique (as described above as the first urological transumbilical LESS procedure) was used to complete three nephrectomies (two for chronic infection, one for a 4.5-cm enhancing renal mass) with three adjacent

trocars in an umbilical incision.2_{Articulating graspers,}

stan-dard endoshears and a 45° 5-mm rigid laparoscope or 5-mm deflectable tip laparoscope were used. The authors cited internal and external instrument collision as a constant chal-lenge, as well as a difficult learning curve. Similarly,

adrena-lectomy has been carried out using a 2-cm incision with

adjacent trocars through multiple fascial punctures.21_The

fascial incisions were connected in these cases for specimen extraction. The three challenges noted were limited maneu-verability with tearing of port site fascia, difficult visualiza-tion and potential difficulty with vascular control. In order to meet these challenges, new access platforms were created that depended on only one fascial incision with the potential to accommodate up to three or four instruments at a time (such as with Triport and QuadPort; Advanced Surgical Concepts). The main concept behind new platforms is to provide access for multiple instruments through one incision while limiting device profile. One solution is provided by the GelPOINT Advanced Access Platform (Applied Medical), which allows the surgeon to place multiple trocars through any location in the device. Table 1 shows current access devices and instrumentation for LESS procedures. Figure 3 shows an intraoperative view of the GelPOINT Advanced Access Platform being used for the aforementioned LESS left renal cyst decortication.

One notable addition is that of mini-laparoscopic or needlescopic instruments, which have been and continue to be used as adjuncts during LESS procedures. For certain procedures, in addition to the transumbilical single-port, a small 2- or 3-mm port has been used for a retracting device, requiring no skin suturing and virtually no scar. This adjunct was embraced as a way to bridge the gap between standard laparoscopy and LESS in the consensus statement on LESS

in 2010.22

Applications

As described earlier, nephrectomy was the initial procedure reported for transumbilical LESS in 2007. Since that time in only 4 years, an impressive array of procedures have been successfully completed using a transumbilical LESS approach, spanning almost the full urological surgical arma-mentarium for intra-abdominal procedures. We summarize the literature here, including only those procedures

com-Fig. 2 Cosmetic result 6 weeks after LESS renal cyst

decortication.

Fig. 3 GelPOINT Advanced Access Platform intraoperatively.

JE HUMPHREY AND D CANES

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pleted through the umbilicus. We have extracted such data from series in which multiple techniques and access sites were included. As the literature is ever growing, this is not intended to be a comprehensive summary. We hope to give the reader the current scope of the clinical applications utilizing transumbilical LESS. Currently-reported transum-bilical LESS applications by organ systems are detailed below.

Kidney

Raman first described nephrectomy using three trocars

through a single umbilical incision.2 _{Kidney surgery}

com-prises the majority of transumbilical LESS surgery to date. It is therefore instructive to subdivide kidney procedures into the following categories: oncology, reconstructive, donor nephrectomy and other. Oncological procedures with

a LESS approach must be able to be completed without compromising cancer outcomes. This began by demonstra-tion of renal mass cryoablademonstra-tion using a 3.8-mm cryoprobe (Endocare, Irvine, CA, USA) through a Uni-X access

device.23_{The authors described this method with both}

tran-sumbilical and retroperitoneal approaches. The utility of this method was confirmed later in a review of a single-center’s

transumbilical LESS experience.24

Extirpative oncological surgery has also been shown to be

feasible. Aronet al. reported five partial nephrectomies in

200825_{using the R-Port access device. An extra 2-mm port}

was used for a grasper, and one patient needed an additional 5-mm port for liver retraction. The R-Port was again used when carried out on six patients in an overall review of

several LESS procedures by Desai.26 _{Other devices have}

been used for partial nephrectomy including the Uni-X27_and

GelPort,28_{as well as standard trocars through a single}

inci-Table 1 Current devices and instrumentation for LESS (alphabetical order)

Company Design Currently

available

Access devices

Airseal Surgiquest, Orange, CT, USA Maximize movement with small incision by using oval cannula

Yes

GelPOINT Advanced Access Platform

Applied Medical, Rancho Santa Margarita, CA, USA

1.5–7-cm incisions with self-retaining ports for 5–10-mm diameter instruments

Yes

Quadport Advanced Surgical Concepts, Wicklow, Ireland

Accommodates up to 4 instruments (1¥5 mm, 2¥10 mm, 1¥15 mm in

diameter)

Yes

SILS Port Covidien, Dublin, Ireland Accommodates up to 3

ports/instruments of variable sizes

Yes

Triport Advanced Surgical Concepts, Wicklow, Ireland

Accommodates up to 3 instruments (12 mm and two 5 mm in diameter)

Yes

Uni-X Pnavel Systems, Brooklyn, NY, USA Three 5-mm diameter ports/instruments No X-cone Storz, Tuttlingen, Germany Reusable, accommodates 3 working

channels (5 or 12.5 mm in diameter)

Yes

Camera systems

Endocameleon Storz, Tuttlingen, Germany 10-mm diameter with adjustable angle 0° to 120°

Yes

Endoeye LTF Olympus, Center Valley, PA, USA Deﬂectable tip 5–10-mm diameter scope Yes Extra long Storz, Tuttlingen, Germany 5-mm diameter with 30° lens Yes Eyemax Richard Wolf Medical Instruments

Corporation, Vernon Hills, IL, USA

5–10-mm diameter with 0–30° digital lens

Yes

Ideal Eyes HD Stryker, Kalamazoo, MI, USA 5-mm diameter articulating scope Yes

Instruments

Roticulator Covidien, Dublin, Ireland 5-mm diameter instruments Yes Prebent Various companies Basic curved instruments Yes Real Hand Novare, Cupertino, CA, USA 5-mm instruments No Autonomy laparo-angle Cambridge Endo, Framingham, MA, USA 5-mm articulating instruments Yes

Devices are presented in alphabetical order.

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sion29 _{and homemade access devices.}30 _Radical

nephrec-tomy has also seen broad use in several series.14,24,26,28–31_A

common practice for right-sided nephrectomy has been the addition of a small 2–3-mm port to aid with liver retraction. This gives the surgeon a technical advantage while not sac-rificing the cosmetic benefit of LESS. A more recent series has shown that non-ischemic partial nephrectomy is safe and

feasible with LESS.32_{Table 2 details LESS kidney surgery}

for malignancy.

The full cosmetic benefit of transumbilical LESS can be realized with reconstructive renal procedures. Unlike with many oncological indications, these do not require extension

of the original incision for specimen extraction. Desaiet al.

reported the first pyeloplasty using the R-Port with an addi-tional 2-mm port for a grasper and to aid with intracorporeal

suturing.33 _{A similar technique was described for simple}

nephrectomy in a patient with a poorly functioning left kidney. The same group later published results with single-session bilateral pyeloplasty in two patients, as well as an

ileal ureter and a ureteroneocystostomy with a psoas hitch.34

This shows the evolution of transumbilical LESS techniques to more complex procedures. When compared with conven-tional laparoscopic pyeloplasty, transumbilical LESS pyelo-plasty has been found to have similar immediate outcomes, including length of hospital stay, morphine equivalents, and

minor and major complications.15 _{Surprisingly, they also}

found that median operative times and median estimated blood loss were lower in patients undergoing LESS. This might represent increased attending involvement with LESS inherent at teaching institutions with new techniques.

The transplantation arena has been fertile ground for LESS application and investigation. Transumbilical LESS donor nephrectomy provides the patient cosmetic benefit and potentially faster recovery time with decreased periop-erative pain compared with conventional laparoscopic and open donor nephrectomy. The first experience with LESS donor nephrectomy used the R-Port, as well as a 2-mm port

without an incision to aid in retraction.35_{A comparison with}

conventional laparoscopy has shown that there is an associ-ated quicker convalescence with LESS patients, including days on oral pain medication, days off work and days to

100% recovery.36

Other miscellaneous renal procedures have been com-pleted successfully with transumbilical LESS. These include simple nephrectomy for benign indications and cyst decor-tication. See Table 3 for experience with these procedures, as well as the reconstructive and donor nephrectomy experience.

Adrenal

A rare application of transumbilical LESS has been for adrenalectomy, perhaps because retraction is so crucial to expose the gland. Several series have been published to

date,26,30_{including the largest that includes a matched case–}

control study comparing conventional laparoscopic with

transumbilical LESS adrenalectomy.17 _{Nine LESS}

proce-dures were compared with 17 conventional laparoscopic adrenalectomies matched to age, sex, surgical indications and tumor size. The indications for the LESS procedures

were benign adenoma (n=3), Cushing’s Syndrome (n=1)

and pheochromocytoma (n=5). Tumor size differed

signifi-cantly between groups, with an average size of 2.8 cm (1–5.4 cm) in the LESS cohort compared with 4.3 cm (2.5– 6.0 cm) in the CL group. However, the techniques were similar in terms of conversion rate, operative time, estimated blood loss, complications and hospital stay. The LESS group did have a shorter duration of patient controlled anesthesia

(0.9 days vs1.9 days). Table 4 summarizes the current

lit-erature in regard to transumbilical LESS adrenalectomy.

Ureter

One of the theoretical advantages of the umbilicus as a portal-of-entry is the ability to operate in all quadrants. As the ureter encompasses such a long path, ureteral pathology presents a potential opportunity to capitalize on the versa-tility of umbilical LESS. The variety of ureteral procedures spans oncology, reconstructive and stone diseases. Table 5 describes current literature for LESS ureteral surgeries across this spectrum.

The series of ureterolithotomy described by Leeet al.is the

largest report.42_{Here, 30 transumbilical LESS}

ureterolitho-tomies were carried out successfully with no conversions to conventional laparoscopy. A homemade device was used for access using a 2–3-cm umbilical incision. Patient satisfaction was analyzed and the authors found that 28 out of 30 patients (93.3%) were satisfied with their postoperative outcomes.

Bladder

Current LESS experience with bladder procedures includes those listed in Table 6. Procedures accomplished to date through a LESS approach include radical and partial cystec-tomy, augmentation enterocystoplasty, sacral colpopexy and vesicovaginal fistula repair. Of note, a comparative study

carried out by Whiteet al.looking at sacral colpopexy found

similar efficacy and improved cosmesis for transumbilical

LESS versus laparoscopic and robotic techniques.18_There

were no conversions and no immediate complications. The patients showed prolapse reduction at 6 months follow up, and were overall satisfied with the outcomes. The authors state that they are exploring this technique robotically to overcome the learning curve associated with the procedure.

Prostate

With tremendous experience in minimally invasive (laparo-scopic and robotic) prostatectomy, it is not surprising that

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Table 2 Current experience with oncological renal procedures using transumbilical LESS

Author, year

Procedure (n) Access

device

MOT (min) EBL (mL) LOS (days) Complications (n) Conversion

to open/lap

Comments

Goel,

200823

Renal cryoxablation (2) Uni-X 1.5 Flexible,

5 mm, 0°

Flexible grasper, 10 mm ﬂexible ultrasound probe,

None 0 Also performed 4 via

retroperitoneal

Partial nephrectomy (5) R-Port 2.5–4 Rigid, 5 mm,

30°

Straight, plus curved and articulating

3 (3–22) 1 patient with:

pseudoaneurysm,

All right-sided partial nephrectomies

Desai,

200926

Radical nephrectomy (3) nephroureterectomy (2), partial nephrectomy (6)

R-Port Not reported Rigid, 5 mm,

30° or injury, urinary tract infection, urine leak

1 conventional lap

Also performed 33 transvesical procedures through

Kaouk,

200927

Partial nephrectomy (4) Uni-X 1.8 Flexible,

5 mm, 0°

Bent and articulating No 160 420

(50–1200)

3.2 Parenchymal

bleeding ( convert to lap

1 Also performed 1

retroperitoneal and 2 robotic

White,

200924

Cryoablation (8), partial nephrectomy (15), radical nephrectomy (6), nephroureterectomy (7)

Variable, not reported

Not reported Not reported Straight and

articulating

No Varies with

procedure

Varies with procedure

Blood transfusion (7), deep vein thrombosis (1),

angio-Describe pure LESS as well as transition to robotic-assisted LESS

Rais-Bahrami,

200929

Radical nephrectomy (2) Staggered

ports in umbilical incision

Not reported Flexible,

5 mm, 0°

-3 (2–4) Delayed hemorrhage

requiring angio-embolization

0 Also performed 4

LESS donor nephrectomies through pfannenstiel incision

Partial nephrectomy (3)

-149.67

Radical nephrectomy (10) Triport 3.95 (3–6) Rigid, 5 mm,

30°

202 (50–900) Not

reported

Intraoperative bleed requiring blood transfusion

0 Suggest present

instruments would aid technique

Raman,

200914

Radical nephrectomy (6) Single

incision with

122 (90–210) 20 (10–600) 2.04

(1.25–3.08)

None 0 Compared to 22

conventional laparoscopic cases, LESS had lower mean

EBL (20vs100)

Stein,

201028

All robotic: pyeloplasty (2), radical nephrectomy (1), partial nephrectomy (1)

GelPort 2.5–5 12 mm

robotic scope, 30° and 0°

Standard robotic instruments

No Varies with

procedure

1–2 Blood transfusion (1) 0 Larger incision for

GelPort used for extraction of partial nephrectomy (2), robotic-LESS: partial nephrectomy (11), nephroureterectomy (3), radical nephrectomy (1)

Home-made

No Varies with

procedure

Bowel injury (2), diaphragm injury (1), transfusion (1) for various urological procedures

0° and rigid, 5 mm, 45°

Straight conventional instruments

No 177.4 148.1 2.57 Urine leak (1) 1 (converted

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Table 3 Non-oncological renal transumbilical LESS experience

Author, year Procedure (n) Access

device

Postoperative incision (cm)

Scope Instruments used Additional ports MOT (min) EBL (mL) LOS (days) Complications

(n) ileal ureter (1), uretero-neocystostomy with psoas hitch (1)

R-Port 1.5–3 Not reported Straight and bent Yes (2-mm port) 277

(180–360) 68.75 (50–100)

2 (1–3) None 0 Placed Jackson-Pratt

drains via umbilical incision

Tracy,

200915

Pyeloplasty (14) Single

incision with 3 adjacent trocars

2.5 Rigid, 5 mm, 45° Straight and

articulating

Yes (3-mm and 5-mm port)

202 (178–240)

35 (25–50) 77 (50–149) Hematuria (2),

urine leak (2), acute clot obstruction (1)

0 All outcome measures

were similar to 28 conventional laparoscopic pyeloplasties

Rais-Bahrami,

200929

Pyeloplasty (2) Staggered

ports in umbilical incision

Not reported Flexible, 5 mm,

0°

Straight and ﬂexible

No -203

(199–207)

-100 -2 None 0 Also performed 4 LESS

donor nephrectomies via pfannenstiel incision

Desai,

200926

Pyeloplasty (17) R-Port Not reported Rigid, 5 mm, 30°

or Flexible, 5 mm, 0°

Straight, bent, and articulating

Yes (5-mm port required in 2 cases)

236 (12–360) 79 (10–150) 2 (2–3) None 1

conventional lap

All patients symptom free

White,

200924

Pyeloplasty (8) Variable, not

reported directly

articulating

No Varies with

procedure

Hernia (1) None Part of larger series

examining ﬁrst 100 cases at single center

Stein,

201028

All robotic: pyeloplasty (2)

GelPort 2.5–5 12 mm robotic

scope, 30° and 0°

Standard robotic instruments

No Varies with

procedure

1–2 None 0 Robotic-assisted LESS

with GelPort affords greater spacing of ports

R-Port 4–5 Rigid, 5 mm, 30° Straight, plus

curved and articulating selectively

Yes (2-mm port) 198

(180–300)

50 (50–200) 3 None 0 Use of 2 mm port helps

improve triangulation without actual incision

Canes,

201036

Left donor nephrectomy (17)

R-Port 2–2.5 extended

to 4.1 cm (median)

Rigid, 5 mm, 30° Straight, curved,

and articulating

108 (50–200) 3 (1–6) Allograft

thrombosis in 1 patient

1 to conventional laparoscopy

Prolonged warm ischemia time when compared with

5.23 (4–7) Not reported Straight and bent Yes (3- or 5-mm

in 11 cases for retraction)

176.9 (90–240)

158.18 (50–300)

3 (2–5) None 0 Comment that

xiphoid-to-umbilicus

length>16 cm

increases difﬁculty

R-Port Not reported Rigid, 5 mm, 30°

or Flexible,

104 (50–200) 2.9 (1–6) Corneal abrasion

(1), dyskinesia from antiemetics (1), graft loss due to intravascular clotting (1)

None Median warm ischemia

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White,

articulating

No 218 116 3.4 None 2 to conventional

lap with 3 adjacent trocars

3 None 0 Note that single-use

access devices are expensive and may limit maneuverability

Other renal procedures Rane,

200939

Simple nephrectomy (3)

Triport Not reported Rigid, 5 mm, 30° Straight and

articulating

No 95 (45–150) 66.6

(50–100)

2.33 (2–3) Port-site

bruising, transient postoperative pyrexia

0 Also performed 2 cases

with port in mid-clavicular line

Yes (2-mm port required in 5 cases)

None 0 All simple

nephrectomies morcellated and extracted; cyst with unobstructed drainage -Kidney cyst

excision (1)

-60 -<50

articulating

No -156 -121 2.3 None 0 Part of larger series

examining ﬁrst 100 cases at single center -Cyst with 3 adjacent trocars

2.5 Rigid, 5 mm, 45° Straight and

articulating

Yes (3-mm subxyphoid trocar for right nephrectomy)

122 (90–210) 20 (10–600) 2.04 (1.25–3.08) None 0 Compared to 22

conventional laparoscopic cases, LESS had lower mean

EBL (20vs100)

R-Port 2 Flexible, 5 mm,

0°

Straight, ﬂexible, and bent

Yes (2-mm grasper in one case, 3-mm incision for 5 mm grasper in one case)

151 (45–290) 51 (20–100) 2.36 (1–4) Port-site

bruising, transient postoperative pyrexia

0 Compared to

traditional laparoscopy, cosmetic advantage, but no other signiﬁcant differences

2–3 Flexible, 5 mm,

0° or rigid, 10 mm, 0°

No 151 (85–230) 108 (0–500) 3.1 (2–6) Mild fever (1),

mild ileus (2)

0 Demonstrates ability to

use home-made device for access

Rigid, 5–10 mm, 30°; 12 mm

No Varies with

procedure

Bowel injury (1) during robotic LESS simple nephrectomy

0 Demonstrates

versatility of home-made device for various urological

30° and ﬂexible, 5 mm, 0°

Yes (3-mm port for liver retraction in 1 patient)

125 (96–165) 112 (50–250) 3.5 (2–7) Lymphatic

leakage (1)

0 No recurrence of

chyluria with average of 8.3 months follow up

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Table 4 Adrenal procedures using transumbilical LESS

Author, year Procedure (n) Access device Postoperative

incision (cm)

Scope Instruments used Additional ports MOT (min) EBL (mL) LOS (days) Complications (n) Conversion

to open/lap

Comments

Jeong, 200917 _{Adrenalectomy}

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Home-made device

2 Flexible, 5 mm,

0°

Straight and articulating

No 169.2 (89–289) 177.8 (50–400) 3.2 (2–4) Serosal tear (1) 0 Matched to

conventional laparoscopy with comparable results

Desai, 200926 _{Adrenalectomy}

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Yes (2-mm port) 150 350 3 Bleeding with

right renal vein injury, subsequent renal vein thrombus (1)

1 to conventional laparoscopy

Only case was converted due to right renal vein injury

Jeon, 201030 _{Adrenalectomy}

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Home-made device

Not reported Rigid, 5–10 mm,

30°; 12 mm robotic scope

Straight, articulating, and ﬂexible

N0 260 125 3 None 0 Demonstrates

versatility of home-made device for various urological procedures

Table 5 Ureteral procedures using transumbilical LESS (excluding nephroureterectomy)

Author, Year Procedure (n) Access device Postoperative

incision (cm)

to open/lap

Comments

Desai, 200933 _{Ileal ureter (1),}

uretero-neocystostomy with psoas hitch (1)

R-Port 1.5–3 Not reported Straight and bent Yes (2-mm port

for grasper, no true incision)

277 (180–360) 68.75 (50–100) 2 (1–3) None 0 Placed

Jackson-Pratt drains via umbilical incision

Desai, 200926 _-Ureteral

reimplant (2)

Yes (2-mm port) -175 (140–210) -175 (100–250) -4 Anastomotic leak

(1)

0 Part of larger

series examining ﬁrst 100 cases at single center

-Ileal ureter (3) -330 (300–360) -170 (90–250) -2

White, 200924 _Ureteral

reimplant (1)

Not reported Not reported Not reported Straight and

articulating

No 180 100 3 None 0 MAG3 normal

Jeon, 201030 _{-Ureterectomy (1)} _Home-made

device

Not reported Rigid, 5–10 mm,

30°; 12 mm robotic scope

No -80 -150 -3 None 0 Ureterectomy

for duplication, ectopic ureter -Ureterolithotomy

(1)

-2 -310 -210 -6

Lee, 201142 _{Ureterolithotomy}

(30)

Home-made device

2–3 Rigid, 10 mm, 0° Straight, ﬂexible,

and articulating Yes

(transcutaneous port for one patient, size not reported)

110.43 61.17 3.40 Fever (2), mild

ileus (1)

1 Useful if

ureteroscopy or shockwave lithotripsy not available

JE

HUMPHREY

AND

D

CANES

424

©

2012

The

Japanese

Urolo

gical

(10)

Table 6 Bladder Procedures using transumbilical LESS

Author, year Procedure (n) Access device Postoperative

incision (cm)

to open/lap

Comments

Noguera, 200943 _Augmentation

enterocystoplasty (1)

Quadport 5 Flexible, 5 mm,

0°

No 300 <100 6 None 0 Bowel resection

and anastomosis performed extracorporeally

White, 200918 _{Sacral colpopexy}

(10)

Uni-X 1.8 Flexible, 5 mm,

0°

Straight and articulating

No 162 47.5 1.5 Cystocele (1),

stress incontinence (2)

0 Single-port

comparable in series to matched laparoscopic and robotic cases

White, 200924 _Radical

cystectomy (3)

Variable, not reported directly

articulating

No -315 -216 -6.6 None 0 Cystectomy

lymph node

yield=16

Sacral colpopexy (13)

-182 -46.9 -1.6

Kaouk, 201044 _Radical

cystectomy (3)

Uni-X 4.5–5 (1.8 cm

before extraction)

Flexible, 5 mm, 0°

No 315 (285–360) 217 (200–250) 6 (5–7) None 0 Operative time

decreased from ﬁrst to third patient

Jeon, 201030 _Partial

cystectomy (1)

Home-made device

Variable with procedure

Rigid, 5–10 mm, 30°; 12 mm robotic scope

No 175 50 4 None 0 Demonstrates

versatility of home-made device for various urological procedures

Abdel-Karim,

201145

Vesicovaginal ﬁstula repair (5)

Triport 2 Flexible, 5 mm,

0°

Bent Yes (in all cases,

5-mm port added for suturing and triangulation)

198 (170–240) 90 (70–120) 2 None 0 Less pain and

shorter hospital stay than same group’s conventional laparoscopic cases

T

ransumbilical

LESS

in

urolo

gy

©

2012

The

Japanese

Urolo

gical

Association

(11)

LESS prostatectomy would ultimately be cautiously explored. This has been described both laparoscopically and with robotic LESS. Robotic instruments with articulating tips provide the surgeon with better dexterity when operat-ing through the LESS avenue. The largest series described 20 patients undergoing robotic LESS prostatectomy with reasonable mean operative time (187.6 min), estimated blood loss (128.8 mL) and average length of stay

(2.5 days).46 _They _concluded _that _robotic _assistance

“reduces or eliminates instrument crossing, has superior ergonomics, and instrument tip articulation significantly facilitates suturing.” Their series is compared with other LESS prostate series in Table 7.

Robotic LESS

Use of robotics for assistance with LESS procedures was intended to bring increased dexterity to offset some of the frustrations with standard laparoscopic LESS surgery. The da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA, USA) has been used successfully through a single

transum-bilical port in a variety of procedures. In 2009, Raneet al.

discussed the use of robotics with LESS and its implications

for future directions.49_{They described how robotics can aid}

LESS with superior visualization of the operative field , enhanced surgical dexterity and excellent ergonomics.

However, the original da Vinci robotic system was not designed specifically for single-site surgery, and therefore has its own limitations. First, the external size and straight shape of the robotic arms lead to external clashing over a single port. Second , the original robotic instrument shafts themselves do not articulate, and therefore intracorporeal clashing can occur as well.

To this end , the newer da Vinci Si surgical system has been modified to be more amenable to single-site surgery. There has been development of VeSPA surgical instruments (Intuitive Surgical) to overcome the aforementioned limita-tions. These instruments are inserted through curved cannu-lae and allow multiple ports through one incision while still allowing intra-abdominal triangulation. The feasibility of this technique was shown in a porcine model in 2010, in which the authors completed various kidney procedures (pyeloplasty, partial nephrectomy, nephrectomy) showing

improved ergonomics and minimal instrument clashing.50

Disadvantages

Transumbilical LESS does have difficulties associated with it that the surgeon must weigh with the cosmetic benefit. As aforementioned , in general utilizing a LESS technique will lead to either no true triangulation or a reliance on curved or bent instruments in order to create triangulation. Thus, there is a learning curve to LESS that might dissuade community

urologists from accepting LESS into their practice. Another Table

7

Radical prostatectomy (4)

Uni-X

Radical prostatectomy (6)

V

Robotic-assisted radical prostatectomy (1)

Single

Robotic-assisted radical prostatectomy (20)

SIL

instrument crossing, impr

o

ves

suturing

ability

(12)

important aspect of incorporating transumbilical LESS is the potential cost of newer instruments and access devices. It might not be worth both the training and cost associated with LESS for the urologist who only has a limited use for LESS. However, there has been no dedicated analysis of cost associated with LESS to this date.

Conclusion

The progression of minimally invasive surgery has led urologists to explore LESS. Born out of a desire for improved cosmesis, and the potential for reduced operative trauma, decreased postoperative pain and complications, transumbilical LESS has successfully been implemented into the urologist’s armamentarium. However, the future role of LESS is still uncertain. Although large specialty centers have described LESS for virtually all urological laparoscopic procedures, it is unclear whether LESS will diffuse beyond select centers. The majority of data available are based on non-randomized series, whereby selection bias might play a significant role. However, a randomized pro-spective trial would be very difficult to complete comparing LESS to conventional laparoscopy. It does seem evident that the cosmetic benefit from LESS is real and reproducible, but any incremental benefit apart from cosmesis seems unlikely to match the leap previously witnessed from open surgery to laparoscopy.

Surgical device companies have responded by developing access devices, scopes and instruments more specifically aimed towards LESS. As technology improves, this will no doubt continue to make the transition to LESS easier for more surgeons. Currently-available LESS training courses should be considered for surgeons interested in LESS techniques to benefit from the collective experience of early adopters.

The urological transumbilical LESS experience is rapidly growing, but many questions remain. Whether the benefits of LESS truly outweigh its technical challenges is currently un-known. We also cannot predict whether LESS in some form will become a permanent fixture in our arsenal, or a historical footnote. For now, LESS surgery remains the subject of intense scrutiny, and is a laudable example of surgical cre-ativity aimed at minimizing surgical trauma for our patients.

Conflict of interest

None declared.

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