“Natural orifice transendoluminal surgery and laparoendoscopic single-site surgery: the future of laparoscopic radical prostatectomy.”
Barret, E., R. Sanchez-Salas, et al. (2011).
Future Oncology 7(3): 427-434.
Techniques for minimally invasive radical prostatectomy (RP) have been carefully reviewed by surgical teams worldwide in order to identify possible weaknesses and facilitate further improvement in their overall performance. The initial plan of action has been to carefully study the best-practice techniques for open RP in order to reproduce and standardize performance from the laparoscopic perspective. Similar to open surgery, the learning curve of minimally invasive RP has been well documented in terms of objective evaluation of outcomes for cancer control and functional results. Natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have recently gained momentum as feasible techniques for minimal access urological surgery. NOTES-LESS drastically limit the surgeon’s ability to choose the site of entry for operative instruments; therefore, the advantages of NOTES-LESS are gained with the understanding that the surgical procedure is more technically challenging. There are several key elements in RP techniques (in particular, dorsal vein control, apex exposure and cavernosal nerve sparing) that can have significant implications on oncologic and functional results. These steps are hard to perform in a limited working field. LESS radical prostatectomy can clearly be facilitated by using robotic technology.
“Evaluation of a novel single-port robotic platform in the cadaver model for the performance of various procedures in gynecologic oncology.”
Escobar, P. F., M. Kebria, et al. (2011).
Gynecologic Oncology 120(3): 380-384.
Objectives: The purpose of this protocol was to evaluate the feasibility and reproducibility of a dedicated da Vinci® single-port robotic platform in cadavers for the performance of various gynecologic oncology procedures. Methods: Three fresh frozen female cadavers were used to evaluate the feasibility, reproducibility, and to develop the correct docking of the robotic column and trocars. Procedures performed in this training protocol included (hysterectomy, bilateral salpingo-oophorectomy, modified radical hysterectomy, six pelvic lymph node dissections, and one para-aortic node dissection). A data set was collected for each procedure, operative times were compared between cases and procedures by use of Wilcoxon rank sum test, a p-value < 0.05 was considered significant. Results: All the procedures were technically successful with no need of additional ports or conversions to a standard laparoscopy. The median time of port insertion and BMI was 6 min range (4-10) and 33 min range (25-56) respectively. The median time for a left and right pelvic lymph node dissection was 22 min range (22-23) and 28 min range (26-38) respectively. There was significant difference in operating times for symmetrical procedures (pelvic lymphadenectomy), p = 0.049. Conclusion: This preliminary data demonstrates that the performance of various oncology procedures using the new da Vinci® single-site robotic platform is feasible, and more importantly, reproducible in the cadaver model. © 2010 Elsevier Inc. All rights reserved.
“SILS extraperitoneal radical prostatectomy.”
Ferrara, V., W. Giannubilo, et al. (2010).
Minerva Urologica e Nefrologica 62(4): 363-369.
Aim. This paper presents the surgical technique for video-laparoscopic extraperitoneal radical prostatectomy carried out through a single incision of 2.5 cm below the navel. Methods. The technique involves the placement of a port of a new concept, the SILS-port, which has three channels through which you can insert instruments and camera. The study results were evaluated from the surgical, oncological and functional point of view. Ten patients undergoing prostatectomy were compared with the last 10 patients treated at our facilities with increasingly radical prostatectomy video-laparoscopic extraperitoneal, defined “conventional”. Results. There were no substantial differences between the two techniques, except for a modest lengthening of the operative time, at least initially. Conclusions. The results achieved with the adoption of this technique have shown its feasibility, security and undoubted advantages in terms of mini-invasiveness.
“Robot-assisted laparoscopy, natural orifice transluminal endoscopy, and single-site laparoscopy in reproductive surgery.”
Gargiulo, A. R. and C. Nezhat (2011).
Seminars in Reproductive Medicine 29(2): 155-168.
Minimally invasive gynecologic surgery is continuously pushing its limits by embracing ever more sophisticated technology. This is also true for reproductive surgery, arguably the birthplace of gynecologic endoscopy, where minimally invasive treatment of uterine, tubal, ovarian, and peritoneal pathology has long become the gold standard. This article describes in some detail three novel minimally invasive surgery approaches that have seen the light during the past decade: robot-assisted laparoscopic surgery, natural orifice transluminal endoscopic surgery, and single-incision laparoscopic surgery. These fascinating technologies, far from being widely adopted, are sure to generate scientific controversy for years to come. Nonetheless, they follow in the footsteps of the tradition of innovation that is a defining aspect of our specialty and hold the promise to potentially revolutionize the field of reproductive surgery.
“First Italian experience in single incision laparoscopic nephrectomy. Assessing and overcoming new challenges.”
Gidaro, S., L. Cindolo, et al. (2010).
Archivio Italiano di Urologia e Andrologia 82(4): 187-192.
Background: The need to enlarge one of laparoscopic holes for specimen retrieval at the end of a laparoscopic nephrectomy, suggested us to use this final access for the entire procedure. We describe our technique placing trocars directly on the fascia once the skin and the subcutaneous layers were prepared. Material and methods: A 10 consecutive patients series operated by Single Incision Laparoscopic Nephrectomy (SILN) is presented. With a 5 cm mean skin incision, the fascia was prepared and 3/4 trocars inserted separately directly on the fascia. Surgical strategy followed the standard technique, except for the use of articulating instruments and 5 mm optic. Demographics, Body Mass Index (BMI), operative time, blood loss, perioperative complications, transfusions, hemoglobin decrease, analgesic requirement, length of stay, final pathology were recorded. Postoperative and prior-to-discharge Video Analogue Scale Pain (VAS) evaluation were also collected, together with the limitations inherent to the instruments placing and parallel driving during the procedure. Results: SILN was successfully completed in all but one cases. The mean operative time was 169 min (mean blood loss 113 ml). Without major perioperative complications, the patients were discharged early (mean 5.3 days). Four patients had a BMI > 30. For specimen retrieval (neoplasms) two trocars holes were joined. One patient required analgesics; the mean post-operative and prior-to-discharge VAS scores were 5.7 and 1.4, respectively. Pathology examination confirmed 4 pyelonephritic kidneys, 4 renal carcinoma and 2 upper-urinary tract carcinoma. Conclusion: SILN is feasible, safe, with favourable perioperative and short-term outcomes. It’s technically more challenging than standard laparoscopy requiring advanced surgical skills.
“Robot-assisted laparoendoscopic single-site surgery: Partial nephrectomy for renal malignancy.”
Han, W. K., D. S. Kim, et al. (2011).
Urology 77(3): 612-616.
Objectives To describe our experience with robot-assisted laparoendoscopic single-site surgery (LESS) to perform partial nephrectomy and evaluate a hybrid homemade port system as an effective access technique. Methods From December 2008 to September 2009, robot-assisted LESS to perform partial nephrectomy through a hybrid homemade port was performed to treat 14 cases of renal cell carcinoma. The data, including patient characteristics, operative records, complications, and pathologic results, were analyzed. Results The mean tumor size was 3.2 cm, the mean ischemic time was 30 minutes, and the mean operative time was 233 minutes. We used the hybrid homemade port technique in 10 cases. All surgical margins after partial nephrectomy were negative for malignancy. No port-related complications were reported. Two cases required conversion to mini-incisional partial nephrectomy. Conclusions Robot-assisted LESS for performing partial nephrectomy using a hybrid homemade port system is a safe and feasible treatment technique. It provided access for meticulous suturing on the renal parenchyma using articulating robot arms and ready access to the surgical field for the assistant. © 2011 Elsevier Inc.
“Improvised Transumbilical Glove Port: A Cost Effective Method for Single Port Laparoscopic Surgery.”
Khiangte, E., I. Newme, et al. (2011).
Indian Journal of Surgery 73(2): 142-145.
Innovations in technology has changed the traditional laparoscopy to be less invasive. Singleport transumbilical laparoscopy has emerged to enhance the cosmetic benefits and to decrease the morbidity of the minimally invasive surgery. It has further minimized the minimally invasive surgery. However, this technique requires a specialized multichannel port (for introducing laparoscope and instruments) which is very costly and in fact, is not affordable by the majority of the population in a developing country like India. We have improvised a single-port access system using readily available materials like surgical gloves, towel ring, inner flexible ring and conventional laparoscopic trocars with no added cost burden to the patient. We have performed 40 single port surgeries using this method without any complications. © 2010 Association of Surgeons of India.
“Laparoendoscopic single-site surgery (LESS) prostatectomy – Robotic and conventional approach.”
Kumar, P., S. S. Kommu, et al. (2010).
Minerva Urologica e Nefrologica 62(4): 425-430.
This review deals with the preliminary advances in laparoendoscopic single-site surgery (LESS) as applied to prostate surgery including the simple and radical prostatectomy approaches both robot assisted and robot independent. It analyzed current publications based on animal models and human patients. The authors searched published reports in major urological meeting abstracts, Embase and Medline (1966 to 25 August 2008), with no language restrictions. Key word searches included: “prostate”, “prostatectomy”, “radical”, “surgery”, “robot”, “da Vinci”, “scarless”, “scar free”, “single port/trocar/incision”, “intraumbilical”, and ” transumbilical”, “natural orifice transluminal endoscopic surgery” (NOTES), “SILS”, “OPUS” and “LESS”. The role of LESS prostatectomy with or without robotic aid has been proven to be technically feasible; however, it is important to note that the approach has significant technical challenges. The da Vinci Surgical System allows some of these ergonomic challenges to be obviated with potentially reduced instrument clash, reduced surgeon and assistant fatigue and better precision with target tasking such as performing the vesicourethral anastomosis. Preliminary consensus regarding oncological control is not yet available on a large scale. Currently, no specific advantage of the LESS approach has been convincingly proven apart from the intuitive improvement in cosmesis. The development, and soon to be launched, flexible robotic platforms towards the end of 2010 will usher with it further refinements making the LESS approach to radical prostatectomy potentially more feasible ergonomically and could see the approach gain a more widespread acceptance.
“Laparoendoscopic single-site porcine nephrectomy using a novel valveless trocar system.”
Leppert, J. T., A. Breda, et al. (2011).
Journal of Endourology 25(1): 119-122.
Background and Purpose: The AirSealTM access system is a novel laparoscopic trocar that uses airflow to create insufflation pressure without the need for a physical seal or valve. By eliminating all valve elements within the lumen of the canula, the port provides a platform that accommodates multiple instruments of any diameter, shape, or combination and is ideally suited for laparoendoscopic single-site surgery (LESS). We present our initial experience with valveless trocars in traditional urologic laparoscopic cases and a porcine LESS nephrectomy series. Materials and Methods: Nine transperitoneal LESS nephrectomies were performed in a live porcine model using the 27-mm oval valveless trocar. All working instruments were placed through the single port, and the specimen was extracted through the 4-cm port site. Results: All cases were completed without technical or operative complications. The porcine single-port nephrectomy (n=9) was successfully performed in a mean operative time of 24 minutes through the single 27-mm oval trocar. This accommodated a 5-mm laparoscope, multiple 5-mm instruments, the Endo GIA stapler, and the 15-mm Endocatch bag without loss of insufflation pressure. Condensation and smudging of the laparoscope were minimized, improving visualization and efficiency. The system allowed for use of suction without significant loss of insufflation pressure. Conclusion: The initial experience with the AirSeal valveless trocar system in LESS is encouraging. This technology may offer significant benefits over traditional laparoscopic trocars and single -port platforms and appears particularly suited to facilitate LESS. Copyright © Mary Ann Liebert, Inc.
“Optimizing single port surgery: a case report and review of technique in colon resection.”
Singh, J., E. R. Podolsky, et al. (2011).
Int J Med Robot.
BACKGROUND: Minimally invasive colon surgery was first described in the early 1990s, decreasing the morbidity compared with open procedures. Recently, single port laparoscopy has emerged, with reports of applications to colon surgery. Although feasible, many new technical challenges exist. METHODS: An optimal operative technique for colon resection entirely through the umbilicus, using a robot and a GelPort is described. RESULTS: The robotic advantages of visualization and articulation minimize the disadvantages of single incision surgery. Programming the robotic arms in reverse decreases instrument clashing. In addition, the GelPort allows for trocar spacing and freedom of placement while providing a wound protector for specimen extraction. CONCLUSIONS: As single port surgery develops, disadvantages must be overcome. Using a combination of the robot and GelPort, these disadvantages are addressed and minimized. Copyright (c) 2011 John Wiley & Sons, Ltd.
“Laparoendoscopic single-site pyeloplasty: A comparison with the standard laparoscopic technique.”
Stein, R. J., A. K. Berger, et al. (2011).
BJU International 107(5): 811-815.
Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Laparoendoscopic single site surgery (LESS) is a novel technique for performing a variety of procedures including Urological upper tract reconstructive surgery. As of now few studies have compared perioperative factors and outcomes between LESS and standard laparoscopic or robotic approaches. In this comparison between LESS and standard laparoscopic pyeloplasty we identified no significant differences in terms of narcotic requirements, quality of life indicators, and outcomes although prospective evaluation is needed. OBJECTIVE To compare laparoendoscopic single-site (LESS) and standard laparoscopic pyeloplasty procedures with the aim of defining whether perioperative, recovery or health-related quality of life (HRQL) benefits exist for the LESS procedure. PATIENTS AND METHODS From November 2007 to August 2008, sixteen patients underwent LESS pyeloplasty at a tertiary care referral centre. These patients were compared with a matched cohort of patients undergoing standard laparoscopic pyeloplasty. Matching criteria included gender and age (within 10 years), as well as preoperative degree of obstruction (T within 15 min) and differential renal function (within 10% ipsilaterally) based on diuretic radionuclide scanning. Mean follow-up was 13 ± 4 months for the LESS group and 17 ± 3 months for the standard laparoscopic group. LESS pyeloplasty procedures were all performed using a single-port device in the umbilicus and suturing was assisted with a 2-mm grasping instrument. Perioperative variables, successful relief of obstruction and HRQL measurements were compared between the two groups. RESULTS Except for a lower body mass index in the LESS group (23 ± 6 kg/m2 vs 30 ± 7 kg/m2, P= 0.002), no difference was noted for perioperative variables between the two cohorts, including hospital stay and analgesic requirement. No significant HRQL advantage was noted for either group based on a six-item non-validated questionnaire. All patients in both groups experienced clinical resolution of their symptoms. A patient in the standard laparoscopy group and two patients in the LESS group had T > 20 min (0.063% vs 0.125%, P= 1.00) on diuretic radionuclide scanning. Limitations include the retrospective nature of the present study, as well as the relatively small study population and short follow-up. CONCLUSIONS No benefit was noted for LESS pyeloplasty over the standard laparoscopic procedure beyond aesthetic advantages. Further comparisons are needed to determine whether these results are generalizable to other LESS procedures. © 2010 BJU International.
“Laparoendoscopic single-site surgery radical nephrectomy.”
Stolzenburg, J. U., M. Do, et al. (2011).
Journal of Endourology 25(2): 159-165.
The indications, instrumentation, surgical technique, and complications of laparoendoscopic single-site radical nephrectomy (LESS-RN) are being described in detail in an attempt to familiarize urologists with this novel laparoscopic technique. Our initial experience of 30 consecutive cases of LESS-RN is reported. The results indicate that, in experienced hands, LESS-RN is feasible and safe, with results comparable to those of conventional laparoscopic radical nephrectomy. Nevertheless, larger series of patients are needed to prove if the increased technical difficulty of LESS-RN justifies its use in routine urologic practice. Copyright 2011, Mary Ann Liebert, Inc.
“Laparoendoscopic single-site bladder diverticulectomy: Technique and initial experience.” Stolzenburg, J. U., M. Do, et al. (2011).
Journal of Endourology 25(1): 85-90.
Purpose: To present our initial experience with the laparoendoscopic single-site surgery (LESS) approach to bladder diverticulectomy. Patients and Methods: Four patients underwent LESS bladder diverticulectomy for the management of diverticula that were associated with persistent symptoms. The median diameter of the diverticula was 8.5 cm (range 4-9 cm). Immediately before, a double-pigtail ureteral catheter was inserted in the ureter on the side of the diverticulum. An 18F urethral catheter was placed via guidewire, and its balloon was inflated into the diverticulum under fluoroscopic control. A TriPort inserted in the umbilicus and a combination of prebent and conventional laparoscopic instruments were used. The balloon inside the diverticulum was inflated and the diverticulum were incised. The diverticulum was dissected circumferentially and removed. Suturing of the bladder lesion followed. The specimen was extracted through the umbilical incision. Perioperative parameters were recorded. Postoperative follow-up included cystography, uroflowmetry, and ultrasonography measurement of postvoid residual urine. Results: Average patient age was 51 years (range 42-66 y) and the average body mass index was 26 kg=m2 (range 23.7-28.7 kg=m2). Average operative time was 130 minutes (range 101-154 min). Blood loss was minimal, with 150mL the higher loss. Complications were not observed during the follow-up period. The catheter was removed on postoperative day (POD) 8 (n=3) and on POD 9 (n=1). Histologic examination did not reveal malignancy. Postoperative pain and analgesic medication requirement were minimal. Conclusions: LESS bladder diverticulectomy proved to be feasible with comparable postoperative outcome to that of the laparoscopic procedure. Further clinical evaluation is deemed necessary. Copyright © Mary Ann Liebert, Inc.
“Early experience with isobaric laparoendoscopic single-site surgery using a wound retractor for the management of ectopic pregnancy.”
Takeda, A., S. Imoto, et al. (2011).
European Journal of Obstetrics Gynecology and Reproductive Biology 154(2): 209-214.
Objective: To report our initial experience with isobaric (gasless) transumbilical laparoendoscopic single-site (LESS) surgery using a wound retractor for the management of ectopic pregnancy. Study design: Twelve consecutive cases of ectopic pregnancy were managed by isobaric LESS surgery with the subcutaneous abdominal wall-lift method. In each case, a wound retractor was used as a transumbilical working port with insertion into the peritoneal cavity through a 2.5-cm vertical umbilical incision. Subsequent surgical procedures were performed with multiple conventional laparoscopic instruments through single umbilical port. Results: All cases of ectopic pregnancy were successfully managed by isobaric LESS surgery. Procedures included salpingectomy in eight cases of ampullary pregnancy and two cases of isthmic pregnancy, salpingectomy and local methotrexate injection in one case of isthmic pregnancy, and salpingo-oophorectomy for one case of ovarian pregnancy. Neither extraumbilical incisions nor conversion to laparotomy was required. In a case of ruptured ampullary pregnancy with massive hemoperitoneum, intraoperative autologous blood salvage and donation avoided the need for the transfusion of bank blood. Although postsurgical umbilical seroma was noted in one case and systemic methotrexate administration was required for persistent ectopic pregnancy in one case of isthmic pregnancy respectively, there were no major surgical complications in this series. The technique yielded excellent cosmetic results with minimum postoperative scar concealed within umbilicus. Retrospective comparison of surgical parameters including surgical duration, estimated blood loss, frequency of postoperative analgesic use, time of bowel recanalization, postoperative inflammatory response and postoperative hospital stay did not show any significant differences between isobaric LESS surgery group and conventional isobaric multiport laparoscopic surgery group. Conclusions: Based on the satisfactory outcome achieved in these initial 12 cases of ectopic pregnancy treated by isobaric LESS surgery, the wound retraction system combined with the subcutaneous abdominal wall-lift method appears to contribute favorably to LESS surgery for the management of ectopic pregnancy because the device permits free circumferential access and retraction during procedures without the closed condition required during pneumoperitoneum. © 2010 Elsevier Ireland Ltd.
“Robotic Laparoendoscopic Single-Site Radical Nephrectomy: Surgical Technique and Comparative Outcomes.”
White, M. A., R. Autorino, et al. (2011).
European Urology.
Background: Recent reports have suggested that robotic laparoendoscopic single-site surgery (R-LESS) is feasible, yet comparative studies to conventional laparoscopy are lacking. Objective: To report our early experience with R-LESS radical nephrectomy (RN). Design, setting, and participants: A retrospective review of R-LESS RN data was performed between May 2008 and November 2010. A total of 10 procedures were performed and subsequently matched to 10 conventional laparoscopic RN procedures (controls). The control group was matched with respect to patient age, body mass index (BMI), American Society of Anesthesiologists score, surgical indication, and tumor size. Surgical procedure: R-LESS RN was performed using methods outlined in the manuscript and . All patients underwent R-LESS RN by a single surgeon. Single-port access was achieved via two commercially available multichannel ports, and robotic trocars were inserted either through separate fascial stabs or through the port, depending on the type used. The da Vinci S and da Vinci-Si Surgical Systems (Intuitive Surgical, Sunnyvale, CA, USA) with pediatric and standard instruments were used. Measurements: Preoperative, perioperative, pathologic, and functional outcomes data were analyzed. Results and limitations: The mean patient age was 64.0 yr of age for both groups, and BMI was 29.2 kg/m2. There was no difference between R-LESS and conventional laparoscopy cases in median operative time, estimated blood loss, visual analogue scale, or complication rate. The R-LESS group had a lower median narcotic requirement during hospital admission (25.3 morphine equivalents vs 37.5 morphine equivalents; p = 0.049) and a shorter length of stay (2.5 d vs 3.0 d; p = 0.03). Study limitations include the small sample size, short follow-up period, and all the inherent biases introduced by a retrospective study design. Conclusions: R-LESS RN offers comparable perioperative outcomes to conventional laparoscopic RN. Prospective comparison is needed to definitively establish the position of R-LESS in minimally invasive urologic surgery. © 2011 European Association of Urology.
“Laparoendoscopic single-site surgery using a multi-functional miniature in vivo robot.”
Wortman, T. D., K. W. Strabala, et al. (2011).
Int J Med Robot 7(1): 17-21.
BACKGROUND: Existing methods used to perform laparoendoscopic single-site surgery (LESS) require multiple laparoscopic tools that are inserted into the peritoneal cavity through a single, specialized port. These methods are inherently limited in visualization and dextrous capabilities by working through a single access point. A miniature in vivo robotic platform that is completely inserted into the peritoneal cavity through a single incision can address these limitations, providing more intuitive manipulation capabilities and improved visualization. METHODS: The miniature in vivo robotic platform for LESS consists of a multi-functional robot and a remote surgeon interface. The robot has two arms and specialized end effectors that can be interchanged to provide monopolar cautery, tissue manipulation, and intracorporeal suturing capabilities. RESULTS: This robot has been demonstrated in multiple non-survival procedures in a porcine model, including four cholecystectomies. CONCLUSION: This study demonstrates the effectiveness of using a multi-functional miniature in vivo robot platform to perform LESS.
“PARAMIS parallel robot for laparoscopic surgery.”
Pisla, D., N. Plitea, et al. (2010).
Chirurgia (Bucharest, Romania : 1990) 105(5): 677-683.
The paper presents the parallel robot, which has been developed in Romania and it is used for laparoscope camera positioning. Based on its mathematical modeling, the first low-cost experimental model of the PARAMIS surgical robot has been built. The system has been built in such a way that it has the possibility to transform it in a multiarm robot controlled from the console. The control input allows the user to give commands in a large area for the positioning of the laparoscope using different interfaces: joystick, microphone, keyboard & mouse and haptic device. The first results have been obtained through the performing of an experimental laparoscopic cholecystectomy using PARAMIS surgical robot. The model which was used was a porcine liver, removed with the gall-bladder and the bile ducts. Due to its very easy use control system, surgeons have adapted rapidly to the use of PARAMIS in surgical procedures. Some of its advantages could be emphasized: precision of the movements; absence of the laparoscope operator’s natural tremor, direct control over a smooth, precise, stable view of the internal surgical field for the surgeon; no fatigue; allows the use of both hands for the actual procedure; reduces eye fatigue; eliminates the need for a second surgeon to be present for the entire procedure.
“[Innovation Forum - Application of Haptics in Robot-Assisted Surgery.].”
Wex, C., S. Jacob, et al. (2011).
Zentralblatt fur Chirurgie.