LESS Partial Nephrectomy

Commentary on “Laparoendoscopic single-site (LESS) partial nephrectomy short-term outcomes.” Rais-Bahrami S, George AK, Montag S, Okhunov Z, Richstone L, The Arthur Smith Institute for Urology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY: BJU Int 2012 (Epub ahead of print)

Objective: We evaluated reconstructive and oncological laparoendoscopic single-site surgery (LESS) combined with mini-laparoscopic instruments as standard equipment. Patients and Methods: 30 patients underwent reconstructive and oncological LESS: mini-laparoscopic-assisted LESS pyeloplasty (LESS-P, n = 18), mini-laparoscopic-assisted LESS partial nephrectomy (LESS-PN, n = 7) or mini-laparoscopic-assisted LESS radical prostatectomy (LESS-RP, n = 5). Perioperative data were prospectively collected. Results: The 18 LESS-P cases had operative times ranging between 120 and 180 min (average 147.9 min). Estimated blood loss ranged between 100 and 300 ml (average 202.1 ml). Two patients required additional management for failed reconstruction. LESS-PN was performed in 7 patients with tumor size ranging between 2.5 and 3.8 cm (average 2.7 cm). Average operative time and blood loss were 155 (140-180) min and 321.4 (250-550) ml, respectively. Renal artery clamping took place in 1 case. LESS-RP was performed in 5 patients; average operative time was 156 (140-180) min and average blood loss 196 (100-400) ml. Functional and oncological outcome was directly comparable to laparoscopic radical prostatectomy. Conclusion: The combination of LESS and mini-laparoscopic instrumentation as routine equipment of reconstructive LESS reveals a different perspective for ‘scarless' urologic surgery.

Recently, an increasing interest in less invasive surgery has led to the advent of laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES). LESS and NOTES could be technically challenging, but available literature has demonstrated the feasibility and safety of LESS for benign gynecologic diseases. However, the evidence is not strong enough to recommend the use of LESS over that of conventional multiport laparoscopic surgery (MLS). As per the results of the most recently published meta-analysis, the majority of surgical outcomes are equivalent between LESS and MLS, except for the longer operative time in LESS for both adnexal surgery and hysterectomy. Although an increasing number of studies have reported on robotic LESS, NOTES, and LESS for gynecologic malignancy, definite conclusions have not been drawn owing to the lack of sufficient information.

As laparoscopy becomes more commonplace for urologists, ongoing attempts are under way to minimize the number and size of incisions used for access. Laparoendoscopic single-site surgery (LESS) was developed and has been increasingly attempted as an extension of classic laparoscopy. Investigators hypothesize that LESS may offer a superior cosmetic result, faster recovery, and equivalent efficacy to laparoscopic surgery. Our aim is to present our experience with renal LESS. A prospective data collection was performed on all patients who were undergoing renal LESS at our institution. A total of 11 renal LESS procedures were performed between July and November 2008: four LESS donor nephrectomies, two LESS radical nephrectomies, three LESS partial nephrectomies, and two LESS pyeloplasties. All LESS procedures replicated laparoscopic techniques but were performed through a single operative site using a 5-mm flexible-tip laparoscope and flexible working instruments. Six of the patients were men. The mean operative time was 162.4 +/- 38.5 minutes. The mean estimated blood loss was 104.5 +/- 41.6 mL, with a mean length of hospitalization of 2.4 +/- 0.8 days. There were no intraoperative complications or blood transfusions. Postoperative pain requirements were tabulated and revealed a mean in-hospital analgesic requirement of 44.8 +/- 46.7 mg (range 7-158 mg) of morphine equivalents with three patients receiving intravenous ketorolac. Renal LESS is feasible as flexible laparoscopes and instruments continue to develop. In our initial experience, expert laparoscopic surgeons were able to perform these LESS procedures with equivalent efficacy without compromising perioperative measures, including operative time, blood loss, and hospital stay. Further prospective investigation through randomized studies is necessary to elucidate differences, if any, in postoperative analgesic requirements and patient satisfaction with postoperative cosmesis, and to confirm equivalent efficacy when compared with current standards.

Pediatric urological laparoendoscopic single site surgery: Single surgeon experience

Introduction: Laparoendoscopic single-site surgery (LESS), robot-assisted (RA), and retroperitoneoscopic (R) surgery expand the armamentarium of minimally invasive surgery (MIS). As information on the use of these surgical approaches in daily routine is limited, we conducted a survey among German urologists. Materials and Methods: In 2017, all urology departments in Germany received a questionnaire evaluating practice patterns of MIS in the retroperitoneum. Chi-Square test was performed for statistical analyses. The response rate was 51.1% (162/311) including 23 universities. Results: R adrenalectomy and (partial) nephrectomy are performed by 32.7–40.1% of all departments. Transperitoneal LESS adrenalectomy and nephrectomy are performed by 8.6–11.7%. Retroperitoneal RA adrenalectomy and (partial) nephrectomy are performed by 6.2–13.0%. There was no difference in the R and LESS approach between (non)-university departments. Retroperitoneal RA access is more frequently used in university hospitals (all p < 0.01). If performed, mean counts within the last 12 months were < 5 for R, LESS, and RA adrenalectomy; and < 20 for R, LESS, and RA (partial) nephrectomy. Conclusion: Our survey provides a detailed insight into MIS in the retroperitoneum in German urology departments. Numbers of adrenalectomies as well as R, transperitoneal LESS and retroperitoneal RA procedures are low. Retroperitoneal RA surgery is more common in universities. Comprehensively, our survey proves that these approaches are not standard approaches yet.

REVIEW OBJECTIVE:To review the recent developments and published literature on laparoendoscopic single-site (LESS) surgery in gynaecology.RECENT FINDINGS:Minimally invasive surgery has become a standard of care for the treatment of many benign and malignant gynaecological conditions. Recent advances in conventional laparoscopy and robotic-assisted surgery have favorably impacted the entire spectrum of gynaecological surgery. With the goal of improving morbidity and cosmesis, continued efforts towards refinement of laparoscopic techniques have lead to minimization of size and number of ports required for these procedures. LESS surgery is a recently proposed surgical term used to describe various techniques that aim at performing laparoscopic surgery through a single, small-skin incision concealed within the umbilicus. In the last 5 years, there has been a surge in the developments in surgical technology and techniques for LESS surgery, which have resulted in a significant increase in utilisation of LESS across many surgical subspecialties. Recently published outcomes data demonstrate feasibility, safety and reproducibility for LESS in gynaecology. The contemporary LESS literature, extent of gynaecological procedures utilising these techniques and limitations of current technology will be reviewed in this manuscript.CONCLUSIONS:LESS surgery represents the newest frontier in minimally invasive surgery. Comparative data and prospective trials are necessary in order to determine the clinical impact of LESS in treatment of gynaecological conditions.

Laparoendoscopic single-site surgery (LESS) in pediatric patients has emerged as a viable alternative to standard laparoscopy. The aim of our investigation was to assess different surgical approaches for LESS, stratifying by weight. From March 2010 to April 2012 LESS was performed in 42 children. Children weighing below 10 kg underwent LESS through an umbilical incision using two 3-mm trocars and one 5-mm trocar. Patients above 10 kg were operated on using a metal multiuse single-site single port (X-Cone; Karl Storz Endoskope, Tuttlingen, Germany). Conventional straight laparoscopic instruments were used in all cases. Mean age at operation was 100 months (range, 0.25-207 months), and mean weight was 27 kg (range, 3.1-82 kg). Median operating time was 74 minutes (range, 36-300 minutes). Eighteen children underwent LESS using two 3-mm trocars and one 5-mm trocar; 1 case required two 5-mm trocars and one 10-mm trocar. Twenty-three patients were operated on with the multiuse device. All operations were carried out safely in a standard laparoscopic transperitoneal technique with full achievement of the surgical target. In none of the patients was an intraoperative complication noticed. Postoperatively two complications were noted, which resolved spontaneously. LESS for pediatric patients can be done safely and efficiently with even less trauma than in conventional laparoscopy irrespective of age and weight. However, different surgical approaches have to be considered as disposable single-site ports are not available for infants and small children. To decrease operative expenses, conventional multiuse trocars and a multiuse single-site port were used with conventional laparoscopic instruments.

Since the introduction of laparoscopic surgery, the promise of lower postoperative morbidity and improved cosmesis has been achieved. Laparoendoscopic single-site surgery (LESS) potentially takes this further. Following the first human urological LESS report in 2007, numerous case series have emerged, as well as comparative studies comparing LESS with standard laparoscopy. However, comparative series between conventional laparoscopy and LESS for different procedures suggest a non-inferiority of LESS over standard laparoscopy, but the only objective benefit remains an improved cosmetic outcome. Challenging ergonomics, instrument clashing, lack of true triangulation, and in-line vision are the main concerns with LESS surgery. Various new instruments have been designed, but only experienced laparoscopists and well-selected patients are pivotal for a successful LESS procedure. Robotic-assisted LESS procedures have been performed. The available robotic platform remains bulky, but development of instrumentation and application of robotic technology are expected to define the actual role of these techniques in minimally invasive urologic surgery.

Introduction. Laparo-endoscopic single-site surgery (LESS) may diminish morbidity of laparoscopic surgery. We prospectively evaluated feasibility and outcomes of LESS-Radical Nephrectomy (LESS-RN) and Partial Nephrectomy (LESS-PN). Methods. 10 patients underwent LESS-RN (6) and LESS-PN (4) between 2/2009-5/2009. LESS-RN included 2 with renal vein thrombectomy, one of which was also cytoreductive. Transperitoneal LESS access was obtained by periumbilical incision. Patient/tumor characteristics, oncologic, and quality of life (QoL) outcomes were analyzed. Results. 3 Men/7 Women (mean age 58.7 years, median follow-up 9.8 months) underwent LESS. 9/10 cases were completed successfully. All had negative margins. Mean operative time was 161 minutes, estimated blood loss was 125 mL, and incision size was 4.4 cm. Median tumor size for LESS-RN and -PN was 5.0 and 1.7 cm (P = .045). Median LESS-PN ischemia time was 24 minutes; mean preoperative/postoperative creatinine were 0.7/0.8 mg/dL (P = .19). Mean pain score at discharge was 1.3. Mean preoperative, 3-, and 6-month postoperative SF-36 QoL Score was 73.8, 74.4 and 77.1 (P = .222). All patients are currently alive. Conclusions. LESS-RN, renal vein thrombectomy, and PN are technically feasible and safe while maintaining adherence to oncologic principles, with excellent QoL preservation and low discharge pain scores. Further study is requisite.

Kinematic and ergonomic assessment of laparoendoscopic single-site surgical instruments during simulator training tasks

Laparoendoscopic single-site surgery (LESS) continues to evolve. Advances in instrument and endoscope design have addressed some of the challenges with instrument clashing and triangulation that were encountered earlier on. Studies comparing LESS to standard laparoscopy reveal that perioperative outcomes are equivalent, with a trend towards improved cosmesis and less pain. However it has been shown that LESS is challenging, and stringent patient selection criteria and extensive laparoscopic experience is required to achieve successful outcomes. An increasing amount of urologic procedures have been attempted using LESS, and the application of the robotic platform (R-LESS) has facilitated intracorporeal suturing and dissection during reconstructive surgeries. Furthermore, LESS and R-LESS has been used for a number of different procedures in the pelvis, including simple and radical prostatectomy, radical cystectomy, sacral colpopopexy, and ureteral reimplantation. Pelvic malignancies in Gynecology and General surgery have also been tackled using a LESS approach. While LESS/R-LESS has not yet been widely adopted, application specific instrumentation and access platforms will likely lead to increased utilization of this approach, in the pursuit of truly “scarless” surgery.

Objective:The aim of this study was to evaluate the effect of three training methodologies on the acquisition of psychomotor skills for laparoendoscopic single-site surgery (LESS), using straight and articulating instruments.Methods: A prospective study was conducted with subjects randomly divided into three groups, who performed a specific training for 12 days using three laparoscopic tasks in a laparoscopic simulator.Group-A trained in conventional laparoscopy setting using straight instruments and in LESS setting using both straight and articulating instruments.Group-B trained in LESS setting using straight and articulating instruments, whereas Group-C trained in LESS setting using articulating instruments.Participants' performance was recorded with a video-tracking system and evaluated with 12 motion analysis parameters (MAPs).Results: All groups obtained significant differences in their performance in most of the MAPs.Group-C showed an improvement in nine MAPs, with a high level of technical competence.Group-A presented a marked improvement in bimanual dexterity skills.Conclusions: Training in LESS surgery using articulating laparoscopic instruments improves the quality of skills and allows smoother learning curves.

Increases in technical expertise in gynecological surgery and advances in surgical instrumentation have led to the development of laparoendoscopic single-site surgery (LESS). Between March and September 2009, 24 patients underwent adnexal surgery at our institution with laparoendoscopic single-site surgery. The LESS technique was performed using the TriPort through an umbilical incision of 10 mm and bent laparoscopic instruments. We furthermore compared the LESS technique with a control group of 24 patients operated consecutively in the same period and for the same procedures with conventional multiport laparoscopy. Comparing the two techniques we found differences between the operation time and mean hospital stay. The surgeon must master the use of novel bent instruments in close proximity to each another. The LESS technique for benign adnexal surgery is technically feasible and safe, representing a reproducible alternative to conventional multiport laparoscopy.

Natural orifice translumenal endoscopic surgery (NOTES™) and laparoendoscopic single-site surgery (LESS) are exciting new developments in the evolution of minimally invasive surgery with potential application to urologic reconstructive surgery. Both represent a natural progression of laparoscopic surgery with ever fewer and smaller incisions and each shares common challenges. NOTES™ as a concept offers the potential for surgery without any transcutaneous abdominal incisions. LESS appears to offer a natural intermediate step toward a NOTES™ approach and may prove more practical for many applications. LESS may be described as a laparoscopic procedure with a single cutaneous incision through which multiple trocars or ports are placed. The advantages of either approach relative to standard laparoscopy will need to be established. There are rapid technological advances that are propelling both approaches forward, making an exhaustive description of the techniques and equipment unfeasible.KeywordsNOTES (natural orifice translumenal endoscopic surgery)LESS (laparoendoscopic single-site surgery)Single-site surgeryMinimally invasive surgeryEndoscopic surgery