Wednesday, February 26, 2014

Laparoscopic Single Site (LESS) Surgery: Innovation in Urology

Mohamad E. Allaf, MD
Laparoendoscopic single-site surgery (LESS), or surgery through a single incision, has been utilized to perform every urologic surgery that can be accomplished by traditional laparoscopy. [1]  However, LESS is only routinely performed in approximately 10% of cases as it requires a unique laparoscopic skill set and technology. [2]

Mohamad E. Allaf, MD, Associate Professor of Urology, Oncology, and Biomedical Engineering and the Director, Minimally Invasive and Robotic Surgery at Johns Hopkins routinely performs LESS nephrectomies, both for living donor kidney transplants and for patients with diseased or cancerous kidneys.

See Dr. Allaf's video on LESS nephrectomy (below).

Here we review some of the new tools, technologies and approaches with LESS urological surgeries.

To successfully perform LESS, a surgeon may use a variety of LESS-instruments.  

Covidien Single Incision Laparoscopic (SILS) Instruments
These may include articulating instruments that attempt to recapitulate the triangulation of traditional laparoscopy by using surgeon-controlled intracorporal deflection.  These instruments allow the surgeon to keep his or her hands apart while focusing the instrument tips in the patient's body.[3]  They have full range of motion, however can have difficulty tying knots as the joint forces are not as strong as standard laparoscopic instruments and have a significant learning curve associated with them.[4,5]

Novare RealHand TM (Cupertino, CA, USA) demonstrated on Vimeo.

S-Portal TM Series (Karl Storz, Tuttlingen, Germany)
Pre-bent instruments restore triangulation may have an increased ease of use and shorter learning curve, but the surgeon is unable to adjust the deflection of the instrument in difficult cases.[6]

Surgeons also have the option to use needlescopic instruments, which are 3mm or smaller (see video below).  They can be used through a LESS port or "needle-sized" skin punctures.  They use traditional laparoscopic triangulation techniques and have been demonstrated to have excellent outcomes for patients undergoing adrenal surgery.[7]

New platforms are under development to make LESS easier to learn and incorporate into larger practice models.

The Magnetic Anchoring and Guidance System (MAGS) has a intra-abdominal, moveable magnet that is stabilized externally by a larger magnet on the abdominal wall.  The magnetic system allows spacing of instruments independent of the single port access site, improving triangulation and reducing clashing of instruments.

da Vinci single port system with curved robotic cannulas,
robotic camera and laparoscopic assistant port.
Robot assisted LESS (RA-LESS)  has been demonstrated for radical prostatectomy, dismembered pyeloplasty and radical nephrectomy [8].  While safe and feasible, the current, large profile of the DaVinci robotic system, robotic arm collisions and unfamiliar camera angles prevent the widespread adoption of this technique.  A single port system has been developed for use with robotic technology and successful reports exist for RA-LESS cholecystectomy. [9]

This entry was written by Mark W. Ball, MD,  4th year resident at the Brady Urological Institute.  This entry is extracted from the chapter "Future Directions in LESS" which will appear in Atlas of Laparoscopic and Robotic Single Site Surgery [Jihad H. Kaouk (Editor), Robert J. Stein (Associate Editor), and Georges-Pascal Haber (Associate Editor)].

[1] Kaouk JH, Autorino R, Kim FJ, Han DH, Lee SW, Yinghao S, et al. Laparoendoscopic single-site surgery in urology: worldwide multi-institutional analysis of 1076 cases. Eur Urol 2011 Nov;60(5):998-1005.
[2] Irwin BH, Rao PP, Stein RJ, Desai MM. Laparoendoscopic single site surgery in urology. Urol Clin North Am 2009 May;36(2):223-35, ix.
[3] Autorino R, Cadeddu JA, Desai MM, Gettman M, Gill IS, Kavoussi LR, et al. Laparoendoscopic single-site and natural orifice transluminal endoscopic surgery in urology: a critical analysis of the literature. Eur Urol 2011 Jan;59(1):26-45.
[4] Jeong CW, Kim SH, Kim HT, Jeong SJ, Hong SK, Byun SS, et al. Insufficient joint forces of first-generation articulating instruments for laparoendoscopic single-site surgery. Surg Innov 2013 Oct;20(5):466-470.
[5] Tuncel A, Lucas S, Bensalah K, Zeltser IS, Jenkins A, Saeedi O, et al. A randomized comparison of conventional vs articulating laparoscopic needle-drivers for performing standardized suturing tasks by laparoscopy-naive subjects. BJU Int 2008 Mar;101(6):727-730.
[6] Stolzenburg JU, Kallidonis P, Oh MA, Ghulam N, Do M, Haefner T, et al. Comparative assessment of laparoscopic single-site surgery instruments to conventional laparoscopic in laboratory setting. J Endourol 2010 Feb;24(2):239-245.
[7] Gill IS, Soble JJ, Sung GT, Winfield HN, Bravo EL, Novick AC. Needlescopic adrenalectomy--the initial series: comparison with conventional laparoscopic adrenalectomy. Urology 1998 Aug;52(2):180-186.
[8] Kaouk JH, Goel RK, Haber GP, Crouzet S, Stein RJ. Robotic single-port transumbilical surgery in humans: initial report. BJU Int 2009 Feb;103(3):366-369.
[9] Kroh M, El-Hayek K, Rosenblatt S, Chand B, Escobar P, Kaouk J, et al. First human surgery with a novel single-port robotic system: cholecystectomy using the da Vinci Single-Site platform. Surg Endosc 2011 Nov;25(11):3566-3573.


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