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Keywords:

  • laparoendoscopic single-site surgery;
  • minimally invasive;
  • review;
  • transumbilical

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Technique and instruments
  5. Applications
  6. Disadvantages
  7. Conclusion
  8. Conflict of interest
  9. References

Laparoendoscopic single-site surgery has seen a dramatic rise in the urological community. With the advent of new techniques and instrumentation, laparoendoscopic 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.


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

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Technique and instruments
  5. Applications
  6. Disadvantages
  7. Conclusion
  8. Conflict of interest
  9. References

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 procedures 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 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 bleeding, fewer complications and shorter hospital stays leading to faster convalescence.9 It was thus inevitable that urologists 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 incision 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 incision 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 incision was used to carry out both nephrectomy and nephroureterectomy, using a GelPort as an access device.13 These approaches proved to be feasible options utilizing non-umbilical incisions. However, the majority of urological 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 undergoing nephrectomy showed a subjective cosmetic advantage, 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 intraumbilical incision was made, with the result as shown at 6 weeks postoperatively in Figure 2.

image

Figure 1. LESS renal cyst decortication immediate cosmetic result.

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Figure 2. Cosmetic result 6 weeks after LESS renal cyst decortication.

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

Technique and instruments

  1. Top of page
  2. Abstract
  3. Introduction
  4. Technique and instruments
  5. Applications
  6. Disadvantages
  7. Conclusion
  8. Conflict of interest
  9. References

As with any new surgical platform, LESS has been associated 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 transition 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, standard 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 challenge, as well as a difficult learning curve. Similarly, adrenalectomy 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 maneuverability with tearing of port site fascia, difficult visualization 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.

Table 1.  Current devices and instrumentation for LESS (alphabetical order)
 CompanyDesignCurrently available
  1. Devices are presented in alphabetical order.

Access devices   
 AirsealSurgiquest, Orange, CT, USAMaximize movement with small incision by using oval cannulaYes
 GelPOINT Advanced Access PlatformApplied Medical, Rancho Santa Margarita, CA, USA1.5–7-cm incisions with self-retaining ports for 5–10-mm diameter instrumentsYes
 QuadportAdvanced Surgical Concepts, Wicklow, IrelandAccommodates up to 4 instruments (1 × 5 mm, 2 × 10 mm, 1 × 15 mm in diameter)Yes
 SILS PortCovidien, Dublin, IrelandAccommodates up to 3 ports/instruments of variable sizesYes
 TriportAdvanced Surgical Concepts, Wicklow, IrelandAccommodates up to 3 instruments (12 mm and two 5 mm in diameter)Yes
 Uni-XPnavel Systems, Brooklyn, NY, USAThree 5-mm diameter ports/instrumentsNo
 X-coneStorz, Tuttlingen, GermanyReusable, accommodates 3 working channels (5 or 12.5 mm in diameter)Yes
Camera systems   
 EndocameleonStorz, Tuttlingen, Germany10-mm diameter with adjustable angle 0° to 120°Yes
 Endoeye LTFOlympus, Center Valley, PA, USADeflectable tip 5–10-mm diameter scopeYes
 Extra longStorz, Tuttlingen, Germany5-mm diameter with 30° lensYes
 EyemaxRichard Wolf Medical Instruments Corporation, Vernon Hills, IL, USA5–10-mm diameter with 0–30° digital lensYes
 Ideal Eyes HDStryker, Kalamazoo, MI, USA5-mm diameter articulating scopeYes
Instruments   
 RoticulatorCovidien, Dublin, Ireland5-mm diameter instrumentsYes
 PrebentVarious companiesBasic curved instrumentsYes
 Real HandNovare, Cupertino, CA, USA5-mm instrumentsNo
 Autonomy laparo-angleCambridge Endo, Framingham, MA, USA5-mm articulating instrumentsYes
image

Figure 3. GelPOINT Advanced Access Platform intraoperatively.

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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

  1. Top of page
  2. Abstract
  3. Introduction
  4. Technique and instruments
  5. Applications
  6. Disadvantages
  7. Conclusion
  8. Conflict of interest
  9. References

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 armamentarium for intra-abdominal procedures. We summarize the literature here, including only those procedures completed 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 transumbilical LESS applications by organ systems are detailed below.

Kidney

Raman first described nephrectomy using three trocars through a single umbilical incision.2 Kidney surgery comprises 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 demonstration of renal mass cryoablation using a 3.8-mm cryoprobe (Endocare, Irvine, CA, USA) through a Uni-X access device.23 The authors described this method with both transumbilical 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. Aron et 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 incision29 and homemade access devices.30 Radical nephrectomy 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 sacrificing the cosmetic benefit of LESS. A more recent series has shown that non-ischemic partial nephrectomy is safe and feasible with LESS.32Table 2 details LESS kidney surgery for malignancy.

Table 2.  Current experience with oncological renal procedures using transumbilical LESS
Author, yearProcedure (n)Access devicePostoperative incision (cm)ScopeInstruments usedAdditional portsMOT (min)EBL (mL)LOS (days)Complications (n)Conversion to open/lapComments
Goel, 200823Renal cryoxablation (2)Uni-X1.5Flexible, 5 mm, 0°Flexible grasper, 10 mm flexible ultrasound probe, Argon beamNo165 (150–180)100Not reportedNone0Also performed 4 via retroperitoneal approach (not transumbilical) not included here
Aron, 200825Partial nephrectomy (5)R-Port2.5–4Rigid, 5 mm, 30°Straight, plus curved and articulatingYes (2-mm port for grasper)270 (240–345)150 (100–600)3 (3–22)1 patient with: pseudoaneurysm, DVT/PE, subsequent perirenal hematoma1 (additional 5 mm port for liver retraction)All right-sided partial nephrectomies
Desai, 200926Radical nephrectomy (3) nephroureterectomy (2), partial nephrectomy (6)R-PortNot reportedRigid, 5 mm, 30° or Flexible, 5 mm, 0°Straight, bent, and articulatingYes (5-mm port)Varies with procedureVaries with procedureVaries with procedureBleeding, bowel injury, urinary tract infection, urine leak1 conventional lapAlso performed 33 transvesical procedures through
Kaouk, 200927Partial nephrectomy (4)Uni-X1.8Flexible, 5 mm, 0°Bent and articulatingNo160420 (50–1200)3.2Parenchymal bleeding ( convert to lap1Also performed 1 retroperitoneal and 2 robotic
White, 200924Cryoablation (8), partial nephrectomy (15), radical nephrectomy (6), nephroureterectomy (7)Variable, not reportedNot reportedNot reportedStraight and articulatingNoVaries with procedureVaries with procedureVaries with procedureBlood transfusion (7), deep vein thrombosis (1), angio-embolization (1)2 partial nephrectomies, 1 nephro-ureterectomyDescribe pure LESS as well as transition to robotic-assisted LESS
Rais-Bahrami, 200929Radical nephrectomy (2)Staggered ports in umbilical incisionNot reportedFlexible, 5 mm, 0°Straight and flexibleNo−124 (111–137)−125 (50–200)−3 (2–4)Delayed hemorrhage requiring angio-embolization0Also performed 4 LESS donor nephrectomies through pfannenstiel incision
Partial nephrectomy (3)−149.67 (120–184)−100 (50–200)−2
Stolzenburg, 200931Radical nephrectomy (10)Triport3.95 (3–6)Rigid, 5 mm, 30°Straight and flexibleYes (3-mm grasper)146.4 (120–180)202 (50–900)Not reportedIntraoperative bleed requiring blood transfusion0Suggest present instruments would aid technique
Raman, 200914Radical nephrectomy (6)Single incision with 3 adjacent trocars2.5Rigid, 5 mm, 45°Straight and articulatingYes (3-mm subxyphoid trocar)122 (90–210)20 (10–600)2.04 (1.25–3.08)None0Compared to 22 conventional laparoscopic cases, LESS had lower mean EBL (20 vs 100)
Stein, 201028All robotic: pyeloplasty (2), radical nephrectomy (1), partial nephrectomy (1)GelPort2.5–512 mm robotic scope, 30° and 0°Standard robotic instrumentsNoVaries with procedureVaries with procedure1–2Blood transfusion (1)0Larger incision for GelPort used for extraction of specimens
Jeon, 201030LESS: radical nephrectomy (8), nephroureterectomy (3), partial nephrectomy (2), robotic-LESS: partial nephrectomy (11), nephroureterectomy (3), radical nephrectomy (1)Home-made deviceVariable with procedureRigid, 5–10 mm, 30°; 12 mm robotic scopeStraight, articulating, and flexibleNoVaries with procedureVaries with procedureVaries with procedureBowel injury (2), diaphragm injury (1), transfusion (1)1 (robotic partial nephrectomy due to bleeding)Demonstrates versatility of home-made device for various urological procedures
Bazzi, 201132Nonischemic partial nephrectomy (14)Single incision with 3 adjacent trocars3–4Rigid, 5 mm, 0° and rigid, 5 mm, 45°Straight conventional instrumentsNo177.4148.12.57Urine leak (1)1 (converted to open due to adhesions)Demonstrate ability to perform non-clamping partial nephrectomy with LESS

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. Desai et al. reported the first pyeloplasty using the R-Port with an additional 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 conventional laparoscopic pyeloplasty, transumbilical LESS pyeloplasty 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 perioperative 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 associated 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 completed successfully with transumbilical LESS. These include simple nephrectomy for benign indications and cyst decortication. See Table 3 for experience with these procedures, as well as the reconstructive and donor nephrectomy experience.

Table 3.  Non-oncological renal transumbilical LESS experience
Author, yearProcedure (n)Access devicePostoperative incision (cm)ScopeInstruments usedAdditional portsMOT (min)EBL (mL)LOS (days)Complications (n)Conversion to open/lapComments
Reconstructive
Desai, 200833Simple nephrectomy (1)R-Port1–2Rigid, 5 mm, 30°Straight and bentYes (2-mm port)−220−100−1None02 mm port aids with intracorporeal suturing
Pyeloplasty (1)−160−50−2
Desai, 200934Bilateral pyeloplasty (2), ileal ureter (1), uretero-neocystostomy with psoas hitch (1)R-Port1.5–3Not reportedStraight and bentYes (2-mm port)277 (180–360)68.75 (50–100)2 (1–3)None0Placed Jackson-Pratt drains via umbilical incision
Tracy, 200915Pyeloplasty (14)Single incision with 3 adjacent trocars2.5Rigid, 5 mm, 45°Straight and articulatingYes (3-mm and 5-mm port)202 (178–240)35 (25–50)77 (50–149)Hematuria (2), urine leak (2), acute clot obstruction (1)0All outcome measures were similar to 28 conventional laparoscopic pyeloplasties
Rais-Bahrami, 200929Pyeloplasty (2)Staggered ports in umbilical incisionNot reportedFlexible, 5 mm, 0°Straight and flexibleNo−203 (199–207)−100−2None0Also performed 4 LESS donor nephrectomies via pfannenstiel incision
Desai, 200926Pyeloplasty (17)R-PortNot reportedRigid, 5 mm, 30° or Flexible, 5 mm, 0°Straight, bent, and articulatingYes (5-mm port required in 2 cases)236 (12–360)79 (10–150)2 (2–3)None1 conventional lapAll patients symptom free
White, 200924Pyeloplasty (8)Variable, not reported directlyNot reportedNot reportedStraight and articulatingNoVaries with procedureVaries with procedureVaries with procedureHernia (1)NonePart of larger series examining first 100 cases at single center
Stein, 201028All robotic: pyeloplasty (2)GelPort2.5–512 mm robotic scope, 30° and 0°Standard robotic instrumentsNoVaries with procedureVaries with procedure1–2None0Robotic-assisted LESS with GelPort affords greater spacing of ports
Donor nephrectomy
Gill, 200835Donor nephrectomy (4)R-Port4–5Rigid, 5 mm, 30°Straight, plus curved and articulating selectivelyYes (2-mm port)198 (180–300)50 (50–200)3None0Use of 2 mm port helps improve triangulation without actual incision
Canes, 201036Left donor nephrectomy (17)R-Port2–2.5 extended to 4.1 cm (median)Rigid, 5 mm, 30°Straight, curved, and articulatingYes (2-mm needlescopic grasper)269 (180–495)108 (50–200)3 (1–6)Allograft thrombosis in 1 patient1 to conventional laparoscopyProlonged warm ischemia time when compared with conventional laparoscopy
Ganpule, 200937Donor nephrectomy (13)Triport/Quadport5.23 (4–7)Not reportedStraight and bentYes (3- or 5-mm in 11 cases for retraction)176.9 (90–240)158.18 (50–300)3 (2–5)None0Comment that xiphoid-to-umbilicus length >16 cm increases difficulty
Desai, 200926Donor nephrectomy (17)R-PortNot reportedRigid, 5 mm, 30° or Flexible, 5 mm, 0°Straight, bent, and articulatingNo230 (180–320)104 (50–200)2.9 (1–6)Corneal abrasion (1), dyskinesia from antiemetics (1), graft loss due to intravascular clotting (1)NoneMedian warm ischemia 5.8 min
White, 200924Donor nephrectomy (19)Variable, not reported directlyNot reportedNot reportedStraight and articulatingNo2181163.4None2 to conventional lapMean warm ischemia 5.29 min
Dubey, 201138Donor nephrectomy (5)Single incision with 3 adjacent trocars4.5Rigid, 10 mm, 45°Straight conventional instrumentsYes (1.5-mm port)157.2 (134–184)150 (135–180)3None0Note that single-use access devices are expensive and may limit maneuverability
Other renal procedures
Rane, 200939Simple nephrectomy (3)TriportNot reportedRigid, 5 mm, 30°Straight and articulatingNo95 (45–150)66.6 (50–100)2.33 (2–3)Port-site bruising, transient postoperative pyrexia0Also performed 2 cases with port in mid-clavicular line
Desai, 200926Simple nephrectomy (14)R-PortNot reportedRigid, 5 mm, 30° or Flexible, 5 mm, 0°Straight, bent, and articulatingYes (2-mm port required in 5 cases)−145 (70–300)−109 (20–300)Varies with procedureNone0All simple nephrectomies morcellated and extracted; cyst with unobstructed drainage
-Kidney cyst excision (1)−60−<50
White, 200924-Simple nephrectomy (7)Variable, not reported directlyNot reportedNot reportedStraight and articulatingNo−156−1212.3None0Part of larger series examining first 100 cases at single center
-Cyst decortication (2)
Raman, 200914Simple nephrectomy (5)Single incision with 3 adjacent trocars2.5Rigid, 5 mm, 45°Straight and articulatingYes (3-mm subxyphoid trocar for right nephrectomy)122 (90–210)20 (10–600)2.04 (1.25–3.08)None0Compared to 22 conventional laparoscopic cases, LESS had lower mean EBL (20 vs 100)
Raybourn, 201016Simple nephrectomy (11)R-Port2Flexible, 5 mm, 0°Straight, flexible, and bentYes (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 pyrexia0Compared to traditional laparoscopy, cosmetic advantage, but no other significant differences
Han, 201040Simple nephrectomy (14)Home-made device2–3Flexible, 5 mm, 0° or rigid, 10 mm, 0°Straight and flexibleNo151 (85–230)108 (0–500)3.1 (2–6)Mild fever (1), mild ileus (2)0Demonstrates ability to use home-made device for access
Jeon, 201030LESS: simple nephrectomy (8), cyst decortication (8)Home-made deviceVariable with procedureRigid, 5–10 mm, 30°; 12 mm robotic scopeStraight, articulating, and flexible; standard robotic instrumentsNoVaries with procedureVaries with procedureVaries with procedureBowel injury (1) during robotic LESS simple nephrectomy0Demonstrates versatility of home-made device for various urological procedures
Robotic-LESS: simple nephrectomy (1)
Zhang, 201141Renal pedicle lymphatic disconnection for refractory chyluriaHome-made device2–3Rigid, 10 mm, 30° and flexible, 5 mm, 0°Straight and flexibleYes (3-mm port for liver retraction in 1 patient)125 (96–165)112 (50–250)3.5 (2–7)Lymphatic leakage (1)0No recurrence of chyluria with average of 8.3 months follow up

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 procedures 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 significantly 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 vs 1.9 days). Table 4 summarizes the current literature in regard to transumbilical LESS adrenalectomy.

Table 4.  Adrenal procedures using transumbilical LESS
Author, yearProcedure (n)Access devicePostoperative incision (cm)ScopeInstruments usedAdditional portsMOT (min)EBL (mL)LOS (days)Complications (n)Conversion to open/lapComments
Jeong, 200917Adrenalectomy (9)Home-made device2Flexible, 5 mm, 0°Straight and articulatingNo169.2 (89–289)177.8 (50–400)3.2 (2–4)Serosal tear (1)0Matched to conventional laparoscopy with comparable results
Desai, 200926Adrenalectomy (1)R-PortNot reportedRigid, 5 mm, 30° or Flexible, 5 mm, 0°Straight, bent, and articulatingYes (2-mm port)1503503Bleeding with right renal vein injury, subsequent renal vein thrombus (1)1 to conventional laparoscopyOnly case was converted due to right renal vein injury
Jeon, 201030Adrenalectomy (2)Home-made deviceNot reportedRigid, 5–10 mm, 30°; 12 mm robotic scopeStraight, articulating, and flexibleN02601253None0Demonstrates versatility of home-made device for various urological procedures

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 versatility 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.

Table 5.  Ureteral procedures using transumbilical LESS (excluding nephroureterectomy)
Author, YearProcedure (n)Access devicePostoperative incision (cm)ScopeInstruments usedAdditional portsMOT (min)EBL (mL)LOS (days)Complications (n)Conversion to open/lapComments
Desai, 200933Ileal ureter (1), uretero-neocystostomy with psoas hitch (1)R-Port1.5–3Not reportedStraight and bentYes (2-mm port for grasper, no true incision)277 (180–360)68.75 (50–100)2 (1–3)None0Placed Jackson-Pratt drains via umbilical incision
Desai, 200926-Ureteral reimplant (2)R-PortNot reportedRigid, 5 mm, 30° or Flexible, 5 mm, 0°Straight, bent, and articulatingYes (2-mm port)−175 (140–210)−175 (100–250)−4Anastomotic leak (1)0Part of larger series examining first 100 cases at single center
-Ileal ureter (3)−330 (300–360)−170 (90–250)−2
White, 200924Ureteral reimplant (1)Not reportedNot reportedNot reportedStraight and articulatingNo1801003None0MAG3 normal
Jeon, 201030-Ureterectomy (1)Home-made deviceNot reportedRigid, 5–10 mm, 30°; 12 mm robotic scopeStraight, articulating, and flexibleNo−80−150−3None0Ureterectomy for duplication, ectopic ureter
-Ureterolithotomy (1)−2−310−210−6
Lee, 201142Ureterolithotomy (30)Home-made device2–3Rigid, 10 mm, 0°Straight, flexible, and articulatingYes (transcutaneous port for one patient, size not reported)110.4361.173.40Fever (2), mild ileus (1)1Useful if ureteroscopy or shockwave lithotripsy not available

The series of ureterolithotomy described by Lee et al. is the largest report.42 Here, 30 transumbilical LESS ureterolithotomies 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 cystectomy, augmentation enterocystoplasty, sacral colpopexy and vesicovaginal fistula repair. Of note, a comparative study carried out by White et 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.

Table 6.  Bladder Procedures using transumbilical LESS
Author, yearProcedure (n)Access devicePostoperative incision (cm)ScopeInstruments usedAdditional portsMOT (min)EBL (mL)LOS (days)Complications (n)Conversion to open/lapComments
Noguera, 200943Augmentation enterocystoplasty (1)Quadport5Flexible, 5 mm, 0°Straight and flexibleNo300<1006None0Bowel resection and anastomosis performed extracorporeally
White, 200918Sacral colpopexy (10)Uni-X1.8Flexible, 5 mm, 0°Straight and articulatingNo16247.51.5Cystocele (1), stress incontinence (2)0Single-port comparable in series to matched laparoscopic and robotic cases
White, 200924Radical cystectomy (3)Variable, not reported directlyNot reportedNot reportedStraight and articulatingNo−315−216−6.6None0Cystectomy lymph node yield = 16
Sacral colpopexy (13)−182−46.9−1.6
Kaouk, 201044Radical cystectomy (3)Uni-X4.5–5 (1.8 cm before extraction)Flexible, 5 mm, 0°Straight and flexibleNo315 (285–360)217 (200–250)6 (5–7)None0Operative time decreased from first to third patient
Jeon, 201030Partial cystectomy (1)Home-made deviceVariable with procedureRigid, 5–10 mm, 30°; 12 mm robotic scopeStraight, articulating, and flexibleNo175504None0Demonstrates versatility of home-made device for various urological procedures
Abdel-Karim, 201145Vesicovaginal fistula repair (5)Triport2Flexible, 5 mm, 0°BentYes (in all cases, 5-mm port added for suturing and triangulation)198 (170–240)90 (70–120)2None0Less pain and shorter hospital stay than same group's conventional laparoscopic cases

Prostate

With tremendous experience in minimally invasive (laparoscopic and robotic) prostatectomy, it is not surprising that 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 operating 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.

Table 7.  Prostate procedures using transumbilical LESS
Author, yearProcedure (n)Access devicePostoperative incision (cm)ScopeInstruments usedAdditional portsMOT (min)EBL (mL)LOS (days)Complications (n)Conversion to open/lapComments
Kaouk, 200847Radical prostatectomy (4)Uni-X2–3Flexible, 5 mm, 0°Flexible shears, curved and articulatingNo285 (240–300)287 (150–400)2.5 (2–3)Rectourethral fistula0Flexible-tip scope helps limit instrument clashing
White, 200924Radical prostatectomy (6)Variable, not reported directlyNot reportedNot reportedStraight and articulatingNo2702502.3Fistula (1)03 focally positive margins
Barret, 200948Robotic-assisted radical prostatectomy (1)Single incisions with 3 adjacent trocars412 mm robotic scopeStandard robotic instrumentsYes (5-mm right lower abdominal port for suction and counter traction)150500Not ReportedNone0Used 5 mm additional port for help in transition to single-port surgery
White, 201046Robotic-assisted radical prostatectomy (20)SILS3–4.512 mm robotic scopeStandard robotic instrumentsYes (two cases with 8-mm robotic port due to excessive external clashing)187.6 (120–300)128.8 (50–350)2.5 (1–6)Ileus (1), blood transfusion (1), pulmonary embolus (1), urosepsis (1)1 (to standard robotic-assisted laparoscopic prostatectomy)Robotics reduces instrument crossing, improves suturing ability

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 transumbilical port in a variety of procedures. In 2009, Rane et 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 limitations. These instruments are inserted through curved cannulae 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

  1. Top of page
  2. Abstract
  3. Introduction
  4. Technique and instruments
  5. Applications
  6. Disadvantages
  7. Conclusion
  8. Conflict of interest
  9. References

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 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

  1. Top of page
  2. Abstract
  3. Introduction
  4. Technique and instruments
  5. Applications
  6. Disadvantages
  7. Conclusion
  8. Conflict of interest
  9. References

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 prospective 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 unknown. 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 creativity aimed at minimizing surgical trauma for our patients.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Technique and instruments
  5. Applications
  6. Disadvantages
  7. Conclusion
  8. Conflict of interest
  9. References