7Laparoendoscopic Single Site (LESS) Surgery Principles:Limit trocars to single incision – usually umbilicalPeriumbilical specimen extractionImproved cosmesisLess transmural trocars = Less painFaster recovery
8The RationaleDecrease number or eliminating ports to minimize morbidity while simultaneously improving cosmesis
20LESS in General Surgery CholecystectomyAdrenalectomyAppendectomy
21LESS in Urology: Laparoscopic Nephrectomy 3-4 trocarsKidney extracted through small incision
22August 2007: First report of single incision laparoscopic nephrectomy Urology 70:1039, 2007Urology 70:1039, 2007August 2007: First report of single incision laparoscopic nephrectomyUrology 70:1039, 200722
23LESS Nephrectomy at UTSW (Urology, 2010) Clinical experience30 cases 8/2007 – 12/200947% of all lap nephIndication: 50% benign dz
24LESS Pyeloplasty Since 10/07: 50 LESS Pyeloplasties for primary UPJOs 20 robotic LESS
26PrinciplesTrocars positioned at umbilical incision crossing similar to conventional LESSMultiport access technique limited by gas leak and crowding/collision of trocars/armsUse commercial port to minimize
27Trocars/Instruments 8 or 12 mm camera port 5 or 8 mm robotic port 5 mm assistant port
28Robotic Solution Instruments cross at midline Align trocar lines at level of skin to minimize incisional bruising
30Instrumentation 30 degree UP scope Nonconventional image Creates space at GelPoint for assistant!8 mm scissor + 5 mm graspers5/8 mm graspers + 5 mm hook cautery5 and/or 8 mm needle drivers
31Pearls Instruments and camera moved in tandem short distances Cross instruments at incision above camera (30 deg up) and reassign instruments to right and left hands.At crossing point, top instrument can retract tissue upwards. To retract downwards need to re-cross so that grasper is below scissors/cautery.
33Experience UTSW 5 R-LESS nephrectomies Difficulty with dividing hilum. Assistant challenged to introduce stapler if ~ 3-4 cm incision. Must use clips.1 converted to Lap nephrectomy20 R-LESS pyeloplastiesEase of anastomosis, no need for additional 3 mm assistant ports.Pre-place stent/ureteral access.
38Is LESS Surgery Ready for Prime Time? Does single incision laparoscopy decrease convalescence in comparison to traditional laparoscopy while maintaining surgical outcomes?
39Case-control comparison of early outcomes in SILS vs Case-control comparison of early outcomes in SILS vs. Conventional Lap Nephretomy (Eur Urol, 2009)IRB-approved, retrospective case-match series11 SILN performed from August 2007 to March 2008 (cases)Extra 3 mm sub-xyphoid trocar for liver retraction22 CLN performed from September 2004 to February 2007 (controls)39
41Case-matched LESS Pyeloplasty vs. Lap Pyeloplasty Urology 2009 Conventional Lap (Range)LESS (Range)p-valueMean LOS (hrs)74 (36-215)77 (50-149)0.69*Mean Operative time (min)257 ( )202 ( )< 0.001*Mean EBL (mL)85 (25-200)35 (25-50)0.002*Mean MSO4 Eq 38 (0-119) 34 (0-117) 0.93*Grade I/II complications (%)4 (14.3%)2 (14.3%)1**Grade IIIa/IIIb complications (%)2 (10%)3 (21.4%)0.31**Maybe extraction incision or morcellation for nephrectomy creates additional pain?Reconstructive procedures may have more benefit?
42LESS vs Standard Lap Donor Nephrectomy: Case-Match Canes, Desai, Gill et al. Eur Urol 57:95, 2010 Conventional Lap(N = 17)LESS(N = 18)p-valueMean Days on Oral Pain Meds2060.01Mean Days Off Work4618<0.01Days to 100% recovery83290.03No differences in LOS, OR time, EBL, analgesia equivalents or visual analog pain scores, but…Too good to be true? Confirmation Bias?
43LESS vs. Standard Lap Donor Neph: Randomized Prospective Trial Group A (Standard)Group B (LESS)p ValueOperating time (minutes)175.83±47.57172.20±38.330.38Conversion to Open surgeryConversion to multiple ports LDN (%)-2 (8%)Estimated blood loss (milliliters)92.40±28.3384.00±29.150.16Graft artery length (millimeters)24.36±2.4325.25±6.230.26Graft vein length (millimeters)28.68±3.4228.80±7.150.47Graft ureter length (millimeters)113.96±24.79123.00±18.440.08Length of incised wounds (millimeters)133.60±16.9951.47±14.37<0.0001Blood transfusionHemoglobin drop (gm/dL)0.87±0.770.68±0.870.21Intra-operative complications (%)4 (16%)0.20Mahesh Desai et al.Nadiad, IndiaAAGUS 201025 left DN in each group
44LESS vs. Standard Lap Donor Neph: Randomized Prospective Trial courtesy M. Desai
47Importance of Cosmesis (BJUI 2011) UTSW Survey – all kidney and prostate patients (80 Lap, 17 LESS, 15 Open)PRE-OP: Ranked importance of various surgical outcomesMost important factor: Surgeon reputationLeast important factor: Scar size & #Unless: Age < 50 or Benign IndicationBucher et al. Surg Endosc 2010; Jul 3.75% would choose LESS over Lap if complication rate similar
48Importance of Cosmesis (Eur Urol 2011) UTSW Survey – kidney surgery onlyLESS vs. Lap vs OpenOverall scar satisfaction by surgery type:67% - 43% - 40%Entire cohort cosmetic appeal of photographs of scars:69% very pleased with LESS vs. 46% and 23%Satisfaction with their scar after viewing other scars:80% vs. 57% vs. 50%
49Observations Feasible surgical technique – the next revolution in MIS Triangulation made possible by articulating instrumentation or roboticsLearning curve due to close proximity of instrumentsLimitations:Instrument collision due to umbilical crowdingTriangulation still a problem…working envelope restrictionsLimited to 3 working trocars – 4 possible if bigger incision?
50Natural Orifice Translumenal Endoscopic Surgery (NOTES) “Incisionless Surgery”Transgastric (mouth)Transcolonic (anus)TransvaginalTransvesical (urethra)Advantages?: less pain, less scarring, faster recoveryProof of conceptUTSW: Gettman, Cadeddu et al.: U.S., 2001, Porcine ModelReddy & Rao: India, 2004, Human Appendectomy
51NOTES: Transgastric Appendectomy Reddy & Rao: India, 2004
52NOTES Human Cases USA Bessler/Fowler, Columbia – 8 TV Chole Horgan/Talamini, UCSD – > 45 TV Chole (+ TG chole, TG Appy, TV Appy)Swanstrom/Soper/Hungness, Legacy (Portland) + Northwestern – > 8 TG CholeAbroadBrazil, > 200 cases, mostly TVFrance, ~ 20 cases, mostly TVGermany, > 200 cases, TV, rigid scopeItaly, ~ 20 cases, TV
53Urology NOTES NOTES nephrectomy 2002 Gettman et al. 2008 Clayman et al.2009 human case reports
54Equipment Limitations LaparoscopyEndoscopyLack of stability and torqueLack of maneuverability and reachInability to triangulateLack of “surgical” instrumentsInability to use multiple instruments simultaneouslyVisual disorientation
55LESS vs. NOTESBoth LESS and NOTES are contemporary minimally invasive techniques with obvious cosmetic and morbidity benefits.LESS is here and now.NOTES is still largely preclinical or investigational.