Early comparison of nephrectomy options in children (open, transperitoneal laparoscopic, laparo-endoscopic single site (LESS), and robotic surgery)

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? For pediatric patients with nonfunctioning or poorly‐functioning kidneys, laparoscopic nephrectomy has been shown to be a safe, viable option to traditional open surgery, with potential advantages of shorter hospital stays, decreased postoperative pain medication usage, and improved cosmesis. Technological advances have expanded the surgical options for nephrectomy beyond traditional laparoscopy to robot‐assisted laparoscopy and, more recently, to laparo‐ endoscopic single‐site (LESS) surgery, which is also known as single incision laparoscopic surgery (SILS) or “belly‐button” surgery. This study compares the perioperative parameters of three minimally invasive modalities for pediatric nephrectomy: traditional laparoscopic nephrectomy (LAP), robotic‐assisted laparoscopic nephrectomy (RALN), and laparo‐endoscopic single‐site nephrectomy (LESS), where these parameters are compared to those of a comparable series of patients undergoing traditional open nephrectomy (OPEN) during the same time period. This study demonstrates that the minimally invasive modalities for nephrectomy in children, including LESS nephrectomy, are associated with shorter lengths of hospital stay and decreased postoperative pain medication usage when compared to open surgery, and where LESS nephrectomy is associated with similar surgical times, lengths of hospital stay, and postoperative pain medication usage as the other minimally invasive modalities (LAP and RALN).

OBJECTIVE

• ? To compare the perioperative parameters of paediatric patients who underwent nephrectomy via laparo‐endoscopic single site (LESS) surgery (also known as single incision laparoscopic surgery or SILS) with those who underwent nephrectomy via conventional laparoscopy (LAP), robotic‐assisted laparoscopy (RALN), and open surgery (OPEN).

PATIENTS AND METHODS

• ? The medical records of 69 paediatric patients at a single institution who underwent nephrectomies for non‐functioning kidneys in 72 renal units (39 OPEN, 11 LAP, 11 RALN and 11 LESS) were reviewed for patient demographics and perioperative clinical parameters.

RESULTS

• ? The minimally invasive modalities in children, including LESS nephrectomy, were associated with shorter lengths of hospital stay (P < 0.001) and decreased postoperative pain medication usage (P < 0.001) than with open surgery.
• ? Similar surgical times were noted with LESS and the other minimally invasive modalities (LAP and RALN) (P= 0.056). However, the minimally invasive modalities (LESS, LAP and RALN) were associated with slightly longer surgical times when compared with open surgery (P < 0.001), which may, in part, be secondary to learning curve factors.
• ? No differences were noted among the minimally invasive modalities for postoperative pain medication usage (P= 0.354) and length of hospital stay (P= 0.86).

CONCLUSIONS

• ? The minimally invasive modalities for nephrectomy in children, including LESS nephrectomy, are associated with shorter lengths of hospital stay and decreased postoperative pain medication use when compared with open surgery.
• ? LESS nephrectomy in children is associated with similar surgical times, lengths of hospital stay and postoperative pain medication use as the other minimally invasive modalities (LAP and RALN).
• ? Slightly longer surgical times are noted with the minimally invasive modalities, including LESS nephrectomy, when compared with open surgery, which may, in part, be secondary to learning curve factors.

     

Laparo-endoscopic single-site (LESS) cholecystectomy with epidural vs. general anesthesia

Background

Laparo-endoscopic single-site (LESS) surgery involves a single umbilical incision, lending itself to epidural anesthesia. This prospective, randomized study was undertaken to evaluate epidural anesthesia for patients undergoing LESS cholecystectomy, to assess the feasibility, and to analyze all intraoperative and postoperative complications. The secondary objectives were to determine differences in postoperative pain and time until PACU discharge-to-home readiness between patients.

Methods

With institutional review board approval, 20 patients with chronic cholecystitis, cholelithiasis, and/or biliary dyskinesia were randomized to receive spinal epidural anesthesia (n = 10) or general anesthesia (n = 10). Postoperative pain at rest was recorded in the PACU every 10 min, and at rest and walking at discharge using the visual analog scale (VAS). Operative time and time until PACU discharge-to-home readiness were recorded. Results are expressed as mean ± SD.

Results

Patient age, American Society of Anesthesiologists class, and body mass index were similar. There were no additional ports/incisions, conversions to “open” operations, or conversions to general anesthesia. There were no differences in operative duration. Time until postanesthesia care unit discharge-to-home ready was not significantly different. The most common postoperative adverse event was urinary retention (1 epidural and 3 general anesthesia patients). Resting postoperative VAS pain score at discharge was 4.7 ± 2.5 vs. 2.2 ± 1.6 (p = 0.02, general versus epidural anesthesia respectively); the stressed VAS pain score at discharge was 6.1 ± 2.3 vs. 3.1 ± 2.8 (p = 0.02, general versus epidural anesthesia respectively).

Conclusions

LESS cholecystectomy with epidural anesthesia was completed with no operative or anesthetic conversions, and less postoperative pain at discharge. Epidural anesthesia appears to be a preferable alternative to general anesthesia for patients undergoing LESS cholecystectomy.     

Completely intracorporeal retraction of the gallbladder for laparoendoscopic single site (LESS) surgery

Laparoendoscopic single site surgery (LESS) cholecystectomy requires a creative solution to retract the gallbladder. Transabdominal suture retraction is a commonly used technique to achieve adequate exposure of the critical structures within Calot's triangle. To avoid the multiple punctures of the gallbladder and abdominal wall required by such suture retraction, we developed a novel internal retractor specifically for use during LESS cholecystectomy. This retractor consists of a laparoscopic bulldog clamp fitted with a small metal hook, and was successfully used in a recent case of LESS cholecystectomy.     

Laparoendoscopic single site (LESS) splenectomy with a conventional laparoscope and instruments

Background and Objectives:

We present 2 cases of laparoendoscopic single site surgery (LESS) splenectomy performed with a conventional laparoscope and instruments, and the use of a novel internal retraction device.

Methods:

One patient underwent LESS splenectomy for idiopathic thrombocytopenia purpura (ITP), and a pediatric patient with sickle cell disease underwent LESS splenectomy and cholecystectomy. In each case, a 2-cm vertical incision was made within the confines of the umbilical ring, and a SILS port (Covidien, Norwalk CT) inserted. A 5-mm, 30-degree laparoscope and standard 5-mm instruments were used. After isolation of the splenic hilum, one 5-mm trocar of the SILS port was upsized to 12mm, and a laparoscopic stapler was used to divide the splenic artery and vein. An internal retractor consisting of a laparoscopic bulldog clamp with a hook attachment was used to retract the gallbladder, and to secure the specimen retrieval bag during splenic extraction, which eliminated the need for a fourth trocar.

Results:

Total operative time was 160 minutes for the LESS splenectomy, and 216 minutes for the LESS splenectomy and cholecystectomy. Both procedures were successfully completed with conventional instrumentation and a SILS port, without the need for additional incisions or trocars. No complications occurred, and both patients had an uneventful recovery.

Conclusions:

LESS splenectomy is a feasible procedure that can be performed safely. Although articulating instruments and laparoscopes may offer advantages, they are not necessary for performing LESS splenectomy.     

Laparoendoscopic single site (LESS) radical prostatectomy: a review of the initial experience

Surgical treatment for prostate cancer has changed dramatically in recent years due to the incorporation of minimally invasive techniques in the surgical armamentarium. Open surgical approaches to the prostate have largely given way to laparoscopic and robotic techniques. In order to further reduce incisional morbidity and improve cosmesis, there has been a recent interest in laparoendoscopic single site (LESS) approaches to the prostate. Despite a rising interest, there is little available data on these procedures. We performed a systematic review of the literature using MEDLINE, OVID, and Web of Science to identify all publications including LESS radical prostatectomy to date. Manual bibliographic review of cross-referenced items was also performed. We attempt to identify and summarize existing data on these procedures both with and without robotic assistance. Additionally, we review the emerging devices, instruments, cameras, and ports that have made these procedures possible. Next, we offer insight into how this rapidly moving field may transition in the future. Finally, we provide our commentary on this surgical approach, its impact on urology, and how it may help us evolve in the future.     

A case of androgen insensitivity syndrome (AIS) treated by Laparoendoscopic single site surgery (LESS)

A 20-year-old woman referred to our hospital for further examination of primary amenorrhea with high levels of testosterone (998 ng/ml). Inspite of having normal female external genitalia, she had 5 cm deep blind-ending vagina, absence of uterus and ovaries with the karyotype of 46,XY. Abdominal magnetic resonance imaging localized bilateral intra abdominal structures, which indicated bilateral testes. Thus, she was diagnosed with androgen insensitivity syndrome(AIS) based on both clinical and karyotypic evidence. She underwent laparoscopic bilateral gonadalectomy through a single incision at the navel and histological examination showed intratubular germ cell neoplasia (ITGCN). Her postoperative course was uneventful with less pain and a small surgical wound was only at the navel. Laparoendoscopic single site surgery (LESS) can be considered a surgical procedure for gonadalectomy in AIS patients.     

Performance analysis on physical simulator of four different instrument setups in laparo-endoscopic single-site (LESS) surgery

Background

Over the past decades, minimally invasive surgery has undergone continuous development due to the demand for scarless results, with laparo-endoscopic single-site (LESS) surgery constituting one of today’s most favored alternatives. In this study, we aim to assess the relative technical difficulty and performance benefits of dynamic articulating and pre-bent instruments, either combined with conventional laparoscopic tools or not, during the completion of two basic tasks hands-on simulator.

Methods

A total of 20 surgeons were included and performed two basic simulator tasks—coordination and cutting—carried out using four different combinations of LESS-designed and straight conventional laparoscopy instruments. Assessment took place before and after the completion of a 14-week training program. Performance data were objectively analyzed over video recordings with an adapted global rating scale (a-GRS) for performance evaluation, combined with a registry of total trial completion time.

Results

In the coordination task, the worst performance scores (p < 0.001) and longest completion times (p < 0.001 on first assessment and p < 0.01 on last assessment) were obtained with the two dynamic articulating tip instruments. On the cut trials, no significant differences between the different setups were found in a-GRS scores. The two dynamic articulating tip instruments also constituted the most time-demanding setup on both assessment trials (p < 0.05). The use of two dynamic articulating tip instruments showed significant improvement with training in all measured parameters except for performance in the cut task, in which the increase in a-GRS score was not significant.

Conclusions

We conclude that the least adequate instrument set for initiation in LESS surgery is the one that combines two dynamic articulating tip instruments, as this has consistently obtained the worst results in all trials. Further data on more complex tasks and on a complete learning and skills-acquisition program must be obtained to confirm these findings.     

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

Background

Laparoscopy is considered the “gold standard” to perform left-lateral sectionectomy with results identical to those of open surgery, yielding decreased postoperative pain and disability, reduced hospital stay, and shortened patient recovery time. As the emphasis on minimizing the invasiveness of surgical techniques continues, laparoendoscopic single site (LESS) surgery is quickly evolving. The purpose of this study was to compare the results of laparoscopic left-lateral sectionectomy performed using the traditional approach or LESS approach with a case-matched analysis for tumor size, type of resection, and surgical indications.

Methods

Thirteen patients who underwent LESS left-lateral sectionectomy are considered the study group (LESS group) and compared with 13 patients who underwent left-lateral sectionectomy with traditional laparoscopic approach (conventional group).

Results

There were no significant differences between groups for length of surgery (165?min in conventional group vs. 195?min in LESS group), blood loss (150?mL in conventional group vs. 175?mL in LESS group), conversion to open surgery, histological tumor exposure, and requirements of postoperative analgesics. One patient in the LESS group died of cardiac failure due to an unknown severe aortic valve stenosis. No differences were recorded for postoperative complications (23.1% in both groups) and median length of postoperative stay (4?days in both groups).

Conclusions

For left-lateral hepatic sectionectomy, LESS surgery is technically feasible and as safe as traditional laparoscopic surgery in terms of intraoperative and postoperative results, even though requiring both hepatobiliary and laparoscopic technique experience.     

Laparo-endoscopic single site cholecystectomy versus standard laparoscopic cholecystectomy: results of a pilot randomized trial

Background

In recent years, new devices providing multiple channels have made the performance of laparoscopic cholecystectomy through a single access site not only feasible but much easier. The potential benefits of laparoendoscopic single-site (LESS) cholecystectomy may include scarless surgery, reduced postoperative pain, reduced postoperative length of stay, and improved postoperative quality of life. There are no comparative data between LESS cholecystectomy and standard laparoscopic cholecystectomy (LC) available at present with which to quantify these benefits.

Methods

This study was a prospective, randomized, dual-institutional pilot trial comparing LESS cholecystectomy with standard LC. The primary end point was postoperative quality of life, measured as length of hospital stay, postoperative pain, cosmetic results, and SF-36 questionnaire scores. Secondary end points included operative time, conversion to standard LC, difficulty of exposure, difficulty of dissection, and complication rate.

Results

No significant differences in postoperative lengths of stay were found in the two groups. Postoperative pain evaluation using a visual analogue scale showed significantly better outcomes in the standard LC arm on the same day of surgery (P = .041). No differences in postoperative pain were found at the next visual analogue scale evaluation or in the postoperative administration of pain-relieving medications. Cosmetic satisfaction was significantly higher in the LESS group at 1-month follow-up (mean, 94.5 ± 9.4% vs 86 ± 22.3%; median, 100% vs 90%; P = .025). Among the 8 scales of the SF-36 assessing patients' physical and mental health, scores on the Role Emotional scale were significantly better in the LESS group (mean, 80.05 ± 29.42 vs 68.33 ± 25.31; median, 100 vs 66.67; P < .0001).

Conclusions

In this pilot trial, LESS cholecystectomy resulted in similar lengths of stay and improved cosmetic results and SF-36 Role Emotional scores but performed less well on pain immediately after surgery. A larger multicenter trial is needed to confirm and further investigate these results.     

Different anesthesia methods for laparoscopic cholecystectomy

Objectives

The aim of the study was to compare the possibility of performing laparoscopic cholecystectomy using two different anesthesia procedures (spinal anesthesia versus general anesthesia).

Methods

The study included 68 patients with symptoms of cholelithiasis examined in the 309th Hospital of PLA from 2006 to 2009. Patients were randomly selected to undergo laparoscopic cholecystectomy with low tension pneumoperitoneum with CO₂ under general anesthesia (n=33) or spinal anesthesia (n=35). The study used propofol, fentanyl, rocuronium, sevoflurane and tracheal intubation for general anesthesia and hyperbaric 15?mg bupivacaine and 20???g fentanyl were used to achieve a sensorial level of T₃ for spinal anesthesia. Intraoperative parameters, postoperative pain, complications, recovery, patient satisfaction and cost were compared between both groups.

Results

All surgical procedures were completed with the chosen method with the exception of one case, in which spinal anesthesia was converted to general anesthesia. Shoulder pain was significantly less frequent in the spinal anesthesia group (6%) compared with the general anesthesia group (24%). The level of pain at 2, 4, and 6?h after the procedure under spinal anesthesia was significantly lower than that under general anesthesia. At 12?h both groups had the same evaluation in the visual analogue scale. In the spinal anesthesia group all patients recovered 6?h after surgery, while patients in the general anesthesia group spent more time in recovery. All patients were discharged from hospital after 24?h. In the postoperative evaluation all patients were satisfied with the spinal anesthesia and would recommend this procedure, while only 78.9% of patients were very satisfied in the general anesthesia group. The cost of spinal anesthesia was significantly lower than that of general anesthesia.

Conclusions

Laparoscopic cholecystectomy with low pressure pneumoperitoneum with CO₂ can be safely performed under spinal anesthesia. Spinal anesthesia was associated with an extremely low level of postoperative pain, better recovery and lower cost than general anesthesia.     

经脐单孔腹腔镜胆囊切除术在基层医院的运用体会

目的;总结在基层医院开展经脐单孔腹腔镜胆囊切除术的临床经验,方法:回顾分析成飞医院普通外科2010年5月～2011年3月运用原有普通腹腔镜器械进行的40例行经脐单孔腹腔镜胆囊切除术患者的临床资料.结果:本组患者中运用该方式完成38例胆囊切除,2例转为传统三孔腹腔镜手术,手术时间47～85min(平均68±10.46min),手术出血量5～30ml(平均14.9士5.10ml),平均住院6d.患者术后切口愈合良好,瘢痕隐蔽.随访1～10个月,无漏胆、肛管损伤、切口疝等并发症.结论:通过简单的改进,使用原有的普通度腔镜器械就能够达到单孔腹腔镜的手术效果,并且安全易行,适合基层医院推广.     

Staging lymphadenectomy in patients with localized high risk prostate cancer: comparison of the laparoendoscopic single site (LESS) technique with conventional multiport laparoscopy

Background

Laser lithotripsy is an established endourological modality. Ho:YAG laser have broadened the indications for ureteroscopic stone managements to include larger stone sizes throughout the whole upper urinary tract. Aim of current work is to assess efficacy and safety of Ho:YAG laser lithotripsy during retrograde ureteroscopic management of ureteral calculi in different locations.

Methods

88 patients were treated with ureteroscopic Ho:YAG laser lithotripsy in our institute. Study endpoint was the number of treatments until the patient was stone-free. Patients were classified according to the location of their stones as Group I (distal ureteric stones, 51 patients) and group II (proximal ureteral stones, 37). Group I patients have larger stones as Group II (10.70 mm vs. 8.24 mm, respectively, P = 0.020).

Results

Overall stone free rate for both groups was 95.8%. The mean number of procedures for proximal calculi was 1.1 ± 0.1 (1–3) and for distal calculi was 1.0 ± 0.0. The initial treatment was more successful in patients with distal ureteral calculi (100% vs. 82.40%, respectively, P = 0.008). No significant difference in the stone free rate was noticed after the second laser procedure for stones smaller versus larger than 10 mm (100% versus 94.1%, P = 0.13). Overall complication rate was 7.9% (Clavien II und IIIb). Overall and grade-adjusted complication rates were not dependant on the stone location. No laser induced complications were noticed.

Conclusions

The use of the Ho:YAG laser appears to be an adequate tool to disintegrate ureteral calculi independent of primary location. Combination of the semirigid and flexible ureteroscopes as well as the appropriate endourologic tools could likely improve the stone clearance rates for proximal calculi regardless of stone-size.