Laparo‐endoscopic single‐site surgery: preliminary advances in renal surgery

We reviewed the preliminary advances in laparo‐endoscopic single‐site surgery (LESS) as applied to renal surgery, and analyzed current publications based on animal models and human patients. We searched published reports in major urological meeting abstracts, Embase and Medline (1966 to 25 August 2008), with no language restrictions. Keyword searches included: ‘scarless’, ‘scar free’, ‘single port/trocar/incision’, ‘intraumbilical’, and ‘transumbilical’, ‘natural orifice transluminal endoscopic surgery’ (NOTES), ‘SILS’, ‘OPUS’ and ‘LESS’. The lessons learnt from the studies using the porcine model are that further advances in instrumentation are essential to achieve optimum results, and that testing survival in animals is also necessary to further expand the NOTES and LESS techniques. Further advances in instrument technology together with increasing experience in NOTES and LESS approaches have driven the transition from porcine models to human patients. In the latter, studies show that the techniques are feasible provided that both optimal surgical technical expertise with advanced skills, and optimal instrumentation, are available. The next step towards minimal access/minimally invasive urological surgery is NOTES and LESS. It is inevitable that LESS will be extended to involve more complex and technically demanding procedures such as laparoscopic radical prostatectomy and partial nephrectomy.     

Development of a novel robotic platform with controllable stiffness manipulation arms for laparoendoscopic single‐site surgery (LESS)

Background

For current LESS robotic systems, the trade‐off between dexterity and payload capability is always present. This paper presents a novel LESS robotic platform equipped with controllable stiffness manipulation arms.

Methods

Each manipulation arm with an articulated section and a controllable stiffness continuum section (CSCS) can be switched between a 7‐DoF compliant status and 5‐DoF rigid status according to the operation requirement. Screw theory and product exponential formula are used to quantify the kinematic performance.

Results

The stiffness of the manipulation arm promotes 3.03 to 4.12 times from compliant to rigid CSCS with maximum payload of 10 N in rigid status. The shortest rigid/compliant switching time is 5 s. The precision of a tracking test and an ex vivo procedure verified the accuracy and effectiveness of the controllable stiffness manipulation arms.

Conclusions

This robot could potentially improve the surgical performance and further expand robotic LESS procedures.     

Urological laparoendoscopic single‐site and reduced port surgery: A nationwide survey in Japan

Objectives

To evaluate the current status of urological laparoendoscopic single‐site and reduced port surgery in Japan.

Methods

Of the 152 institutions to which councilors of the Japanese Society of Endourology belong, 42 (28%) have carried out laparoendoscopic single‐site and reduced port surgery. A total of 32 of these institutions agreed to participate in this survey. Patients who had undergone surgery between January 2008 and March 2014 were included in the present study.

Results

Overall, 1145 cases of laparoendoscopic single‐site and reduced port surgery were recorded during the study period. The most frequent procedures were adrenalectomy and radical nephrectomy. Laparoendoscopic single‐site and reduced port surgery represented 12% (872/7311) of all laparoscopic procedures carried out at participating institutions. The number of patients who underwent pyeloplasty, donor nephrectomy and simple nephrectomy tended to increase, whereas those who underwent adrenalectomy, radical nephrectomy and nephroureterectomy peaked in 2012, and then tended to decrease in 2013. The rates of conversion, perioperative and postoperative complications, were 2.7%, 2.2% and 4.5%, respectively.

Conclusions

The number of laparoendoscopic single‐site and reduced port urological surgeries in Japan has increased for benign indications, such as pyeloplasty, donor nephrectomy and simple nephrectomy. In contrast, procedures such as adrenalectomy and radical nephrectomy are trending down after reaching a peak in 2012. Overall, laparoendoscopic single‐site and reduced port urological surgery in Japan is being safely carried out when compared with other reported series of laparoendoscopic single‐site surgery and conventional laparoscopic surgery.     

Complications and conversions of upper tract urological laparoendoscopic single‐site surgery (LESS): multicentre experience: results from the NOTES Working Group

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Several studies have shown the feasibility of performing both complex and reconstructive laparoendoscopic single site (LESS) surgical procedures in urology. To date, no studies have evaluated the rates of conversion to conventional laparoscopy and complications at the time of LESS procedures in urology. This study, a compilation of results from members of the NOTES working group, is the first study to address the rates of complications and conversions to conventional laparoscopy at the time of LESS surgery in urology.

OBJECTIVE

? To present complications and rates of conversion from LESS to conventional laparoscopy (CL) at the time of upper tract LESS urologic procedures.

PATIENTS AND METHODS

? Patients undergoing LESS upper tract procedures between September, 2007 and November, 2008 (n = 125) were identified at six high‐volume academic centers pioneering urologic LESS procedures. All LESS procedures were performed transperitoneally via a single umbilical incision using either adjacent conventional trocars or a dedicated single‐site access device. Reconstructive procedures incorporating a single planned 2 mm accessory needle port were included as LESS procedures and were not considered conversions. ? Patients, undergoing LESS procedures requiring conversion to CL with the placement of additional ports were identified. Conversion was defined as the placement of additional 5 or 10/12 mm ports beyond the primary incision. In each case the operative reports were reviewed, the reason for conversion was determined, and the number and types of additional ports and complications were noted.

RESULTS

? Upper tract LESS procedures were performed in 125 patients comprising 13.3% of the total 937 laparoscopic procedures performed at the participating institutions during this time period. Conversion to CL was necessary in 7 patients (5.6%) undergoing LESS requiring the addition of 2–5 ports. ? Reasons for conversion included: facilitate dissection in 3 (43%), facilitate reconstruction in 3 (43%), and control of bleeding in 1 (14%). All attempted LESS cases were completed laparoscopically without need for open conversion. ? Complications occurred in 15.2% of patients undergoing LESS surgery. Three of the 7 patients that required conversion to CL developed postoperative complications (Clavien grade II in two and IIIa in one). ? Limitations of this study included the inability to standardize LESS patient selection criteria, instrumentation and surgical technique as well as the lack of available complete data from a CL control group for comparison.

CONCLUSION

? LESS surgery is technically feasible for a variety of upper urinary tract reconstructive and ablative procedures, although it appears to be associated with higher rates of complications than in mature CL series. Conversion to CL occurs infrequently and may be a reflection of stringent patient selection.     

Laparoendoscopic single‐site cholecystectomy versus conventional laparoscopic cholecystectomy: a systematic review of randomized controlled trials

Background: Laparoendoscopic single‐site surgery is a revolution in minimally invasive surgery in recent years, and cholecystectomy is the most common intervention. However, laparoendoscopic single‐site cholecystectomy (LESSC) is a controversial procedure. Its safety, cosmetic results, complications, post‐operative pain and post‐operative stay are not confirmed by multi‐centre randomized controlled studies. Objectives: This review examined the impact of LESSC versus conventional laparoscopic cholecystectomy (CLC). The primary outcomes were conversional rate and intraoperative and post‐operative complications, and other outcomes were cosmetic results, operative time, post‐operative pain and post‐operative stay. Data sources: Pubmed, EMbase, Web of Science, Ovid, clinical trials of the US National Institutes of Health and Cochrane Database of Systematic Reviews and Controlled Trials Register were searched to identify all possible randomized controlled trials (RCTs). Methods: Two reviewers completed article search, and eligible data were entered into a computerized spreadsheet for analysis. Results: Nine studies were obtained using the search strategy. Patients accepting LESSC had a higher conversion rate than those having CLC (7.17 (3.00, 17.11) (P < 0.01)). There was no significant difference for total complications between the two groups (1.17 (0.76, 1.80) (P= 0.46)), but incidence of incisional hernia and haemorrhage (seroma) in the LESSC group was obviously higher than that in the CLC group. Operative time was much longer in the LESSC group (mean difference: 10.69 (3.14, 18.24) (P= 0.006)). Cosmetic results favoured LESSC; however, post‐operative abdominal pain and post‐operative stay were not significantly different between the two groups in most of the nine studies. Conclusions: LESSC can be safely performed with better cosmetic results; however, it carries a higher conversion rate and a longer operative time, and offers no benefit in terms of post‐operative abdominal pain and post‐operative stay. Further RCTs, according to the CONSORT statement, are advocated to validate its objective benefits.     

Current status and future perspectives in laparoendoscopic single‐site and natural orifice transluminal endoscopic urological surgery

Objective of this study is to provide an evidence‐based analysis of the current status and future perspectives of scarless urological surgery. A PubMed search has been performed for all relevant urological literature regarding natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single‐site surgery (LESS). In addition, experience with LESS and NOTES at our own institution has been considered. All clinical and investigative reports for LESS and NOTES procedures in the urological literature have been considered. A wide variety of clinical procedures in urology have been succesfully completed by using LESS techniques. Thus far, experience with NOTES has largely been investigational, although early clinical reports are emerging. Further development of instrumentation and platforms is necessary for both techniques to become more widely adopted throughout the urological community.