Ergonomic learning curves on gynecological laparoendoscopic single-site (LESS) surgery.

BACKGROUND: Few previous studies have introduced general techniques to overcome the "chopstick effect" in laparoendoscopic single-site surgery (LESS). We aim to investigate and highlight the key ergonomic methodologies for gynaecologic LESS based on the surgeon's hands-on performance. METHODS: The first author surgeon A reviewed and analyzed the LESS procedures performed by herself and how she taught surgeon B from January 2021 to April 2022. The procedures were classified based on technical difficulty and learning periods, and the hands-on technical skills of LESS module were evaluated. RESULTS: Surgeon A conducted 580 LESS procedures, which were divided into the novice (n = 48) and intermediate (n = 33) periods, and the remaining cases were included in the routine period. We formed a special ergonomic LESS operating methodology: Maintain good LESS laparoscopic spatial sensation, keep hand-eye coordination, well cooperation between the main surgeon and the assistant; Experienced multiport laparoscopy surgery (MPS) skills, improve basic LESS technique: grasp, lift, transfer, place, blunt separating, coagulation and cutting. Coordination location, orientation, movements, and flexion or extension of shoulders, arms, elbow, wrist and finger joints; Maintain strength, tension and ambidexterity postures with joint and muscular efforts to control instruments. Surgeon B learned the above experiences by performing 39 LESS procedures under the guidance of surgeon A. CONCLUSION: This educational research sheds light on the common challenges faced in LESS and presents the importance of ergonomic hands-on performance skills in improving surgical outcomes, which could serve as a guide for future training and education in LESS.

Robotic natural orifice transluminal endoscopic surgery (NOTES) hysterectomy as a scarless and gasless surgery.

BACKGROUND: To report a new surgical technique for hysterectomy using robotic natural orifice transluminal endoscopic surgery (NOTES) as a scarless and gasless procedure. METHODS: Thirteen consecutive patients with benign uterine disease underwent robotic NOTES hysterectomy at Eulji University Hospital between February 2017 and May 2018. RESULTS: Due to the presence of pelvic adhesions, one of these patients underwent hybrid robotic NOTES hysterectomy with the assistance of isobaric single port laparoscopy; however, there was no conversion to another hysterectomy type such as conventional laparoscopy, laparotomy, or traditional multiport robotic surgery. Median uterine weight was 290 g (range 115-892 g). Median docking and console times were 15 min (range 5-25 min) and 135 min (range 92-215 min), respectively. Mean change in hemoglobin on the first postoperative day was 0.67 ± 0.7 g/dL. Median EBL was 50 mL (20-450 mL). Median postoperative hospital stay was 3 days (3-4 days). No patients experienced postoperative complications such as damage to adjacent organs, re-operation, or vaginal cuff hematoma. CONCLUSIONS: Our findings show that robotic NOTES hysterectomy is a feasible and safe scarless and gasless surgical technique. It is an effective, minimally invasive vaginal access alternate to NOTES-assisted vaginal hysterectomy or conventional robotic laparoendoscopic single-site surgery hysterectomy in the surgical management of benign uterine disease. Nevertheless, further prospective controlled studies are needed to determine its full clinical application.

[Suprapubic-assisted laparoendoscopic single-site surgery in nephroureterectomy A case series of 4 patients].

Objective: To evaluate the feasibility and clinical value of suprapubic-assisted laparoendoscopic single-site surgery (SA-LESS) in nephroureterectomy using method of transvaginal natural orifice specimen extraction (NOSE) (SA-LESS+TV-NOSE NU). Methods: Four patients (three cases of renal pelvic carcinoma and one case of ureteral carcinoma) undergoing SA-LESS+TV-NOSE NU were enrolled between April 2015 and January 2016. After general anesthesia, the patients were placed in the lithotomy position with the affected side elevated by 60°. Two trocars were inserted at the medial margin of umbilicus, and the third one was inserted into abdominal cavity at the superior margin of pubic symphysis. The operation was performed under a direct vision with a 5.4 mm 0° flexible-tip laparoscope. Firstly, the distal ureter was isolated completely and blocked by a Hem-O-lok clip. Then, the laparoscopic nephrectomy was performed according to the standard method. Finally, the bladder cuff excision was executed and the incision was sutured. The intact specimen was placed inside a homemade bag and removed through the incision at posterior vaginal fornix. Results: All the procedures were successfully performed. The median operative time was 150 (range: 120 to 210) minutes, and the median estimated blood loss was 180 (range: 80 to 350) ml. No major perioperative complications occurred. The mean visual analogue score (VAS) of 24 hours and 48 hours after operation were 3.25 (range: 2 to 5) and 2.25 (range: 2 to 3). All the patients resumed ambulation on postoperative day 1. Pelvic drainage tube was removed on postoperative day 2-4. On postoperative day 7, urethral catheter was removed. The patients were discharged on postoperative day 7-9. During the follow-up of 20-29 months, the patient recovered well with no case of incisional hernia and pelvic, abdominal infections. The vaginal fornix incision healed well, and the umbilical and suprapubic puncture scars were not obvious. All the patients completed the patient-assessed acromegaly symptom questionnaire PASQ. The average PSAQ score of 3 months after surgery was 34.5. Three of them restarted their sex lives, with an average female sexual function index score of 16.0, which was not significantly different with that of preoperation (15.6). There was no tumor recurrence, metastasis and implantation in all cases. Conclusion: SA-LESS+TV-NOSE NU is safe and feasible for upper tract urothelial carcinoma with faster postoperative recovery, less pain, shorter hospitalization time, better cosmetic results, and does not cause negative effect on the female sexual function.

Laparoendoscopic single-site surgery using conventional laparoscopic instruments and glove port technique in gynecology: a single surgeon's experience.

STUDY OBJECTIVE: To report a single surgeon's experience with 120 laparoendoscopic single-site surgery (LESS) procedures using conventional laparoscopic instruments and a homemade glove port system to treat benign gynecologic diseases. DESIGN: Retrospective chart analysis (Canadian Task Force classification III). SETTING: Eulji University Hospital. PATIENTS: One hundred twenty patients who underwent LESS performed by a single surgeon to treat benign gynecologic diseases between November 2010 and November 2012. INTERVENTION: LESS using conventional instrumentation was performed using our specialized glove port technique, which consists of the combination of the homemade glove port system designed to minimalize collision of the trocar on the tip of the finger of the surgical glove, a sufficient rectus fasciotomy, the surgeon's position at the patient's head, and adequate positioning of the instruments. MEASUREMENTS AND MAIN RESULTS: The LESS procedures performed were laparoscopically assisted vaginal hysterectomy (n = 50), ovarian cystectomy (n = 25), myomectomy (n = 14), oophorectomy (n = 11), salpingectomy (n = 9), fimbrioplasty or neosalpingstomy (n = 7), and adhesiolysis only (n = 4). Median patient age was 40 years, and median body mass index was 23. Median operative time was 100 minutes (range, 50-145 minutes) for laparoscopically assisted vaginal hysterectomy, 70 minutes (range, 30-150 minutes) for ovarian cystectomy, 107 minutes (range, 65-180 minutes) for myomectomy, 55 minutes (range, 25-130 minutes) for oophorectomy, 85 minutes (range, 35-110 minutes) for salpingectomy, 70 minutes (range, 25-140 minutes) for neosalpingostomy or fimbrioplasty, and 35 minutes (range, 30-60-minutes) for adhesiolysis only. All procedures were completed successfully without the need for additional ports or conversion to the standard laparoscopic approach. One perioperative complication occurred. The complication rate was 83% (1 of 120). Other postoperative complications were not observed at follow-up. CONCLUSION: Our experience shows that LESS using conventional laparoscopic instruments and our glove port technique is a feasible and safe technique for the surgical management of various gynecologic conditions. Therefore, our homemade glove port laparoscopic system used in our specialized technique provides a simple, cost-effective approach to LESS and would probably make laparoscopic procedures using conventional instruments easier.

An analysis of skills acquisition during a training program for experienced laparoscopists in laparoendoscopic single-site surgery.

BACKGROUND: Laparoendoscopic single-site surgery has been presented in the past few years as an innovative minimally invasive approach, one which despite its advantages is also challenging and requires specific training. We propose to analyze the performance of attendants in a specific LESS training course. METHODS: Following the LESSCAR 2010 guidelines, we focused on level 1 hands-on simulator tasks and level 2 hands-on training on animal model for skills acquisition during a LESS-specific training course. Each attendant completed coordination and cut tasks on simulator, followed by a cholecystectomy on an ex vivo porcine liver. Hands-on animal model each trainee performed 1 cholecystectomy and at least 2 nephrectomies (N1, N2). Performance was analyzed through video recording and reviewed by 3 independent observers. Each result was registered according to a modified objective structured assessment of technical skills. Total task or procedure completion time was also determined. RESULTS: Regarding coordination and cut tasks, attendants improved on their performance from first to third attempts with an accompanying decrease in completion time. Surgeons completed the cholecystectomy on animal model significantly faster than on simulator, although with lower performance quality. Regarding N1 and N2, attendants showed improvement both in quality and total completion time. CONCLUSIONS: A gradual and positive evolution of attendants was observed throughout the training course. Thus, we believe a structured program for the acquisition of basic skills in new minimally invasive surgical approaches should be recommended. Considering that this is a small study, it would be advisable to increase the number of study subjects on future opportunities.

Suprapubic appendectomy: a different single-incision approach.

INTRODUCTION: Appendectomy is performed on almost 700 000 patients per year in the European Community, rendering it the most common acute surgical procedure. Since the introduction of laparoscopic surgery, there has been increased interest in carrying out procedures with fewer incisions and less ports. MATERIALS AND METHODS: After the inception of single-port access, it is possible to insert into the abdominal cavity multiple instruments through a single device. A total of 15 patients--mean age 22 years and mean body mass index 27 kg/m(2)--with acute appendicitis were included in this study. RESULTS: Mean operative time was 35 minutes with no conversions. Local suction drain was needed in 2 patients. Mean hospital stay was less than 24 hours with no complications. CONCLUSION: Single-port suprapubic appendectomy is feasible and safe, and can allow a more direct vision of the operating field depending on the position of the appendix and presents good cosmetic and postoperative outcomes.

Transvaginal natural orifice transluminal endoscopic surgery-assisted versus transumbilical laparoendoscopic single-site ovarian cystectomy for ovarian mature cystic teratoma. A randomized controlled trial.

OBJECTIVES: Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and transumbilical laparoendoscopic single-site surgery (LESS) have shown the prospection as minimally invasive procedures. Here we aimed to compare ovarian cystectomy assisted by vNOTES and by LESS for ovarian mature cystic teratoma (OMCT). MATERIAL AND METHODS: A total of 81 premenopausal women with OMCT were randomized to undergo ovarian cystectomy assisted by either vNOTES (n = 41) or LESS (n = 40). The main outcome was the operative time. Secondary outcomes included the length of hospital stay, visual analog scale (VAS) pain scores, abdominal contamination by teratoma contents, and intraoperative and postoperative complications. RESULTS: There were no intergroup differences in age, body mass index, tumor size, or bilaterality of tumor. The operative time for the vNOTES group was significantly shorter than that for the LESS group (68.41 ± 20.92 min vs 85.05 ± 32.94 min, p = 0.008). The highest VAS pain score 24 hours postoperatively was 1.21 ± 0.48 in the vNOTES group and 2.43 ± 0.57 in the LESS group (p < 0.001). Twenty-four of the 40 patients in the LESS group experienced teratoma rupture intraoperatively, leading to abdominal contamination by the teratoma content, while 5 abdominal contamination was observed in the vNOTES group （p = 0.005. No significant differences between the two groups were observed in the other outcomes. CONCLUSIONS: vNOTES assisted ovarian cystectomy has short operative time, fast recovery, no scarring, less pain, and low rate of abdominal contamination. Consequently, vNOTES might be superior to LESS for treating OMCTs.

An investigation for public acceptance of laparoendoscopic single-site surgery.

UNLABELLED: Objective : Laparoendoscopic single-site surgery (LESS) is the latest innovation in minimally invasive surgery with unconfirmed advantages. The public perception of LESS is the basis of carrying out the surgery. METHODOLOGY: Participants from the outpatient department were invited to rate, on a 5-point Likert scale, the important factors including scar, complications, cost, pain and hospital stay in choosing surgery. In addition, those who preferred LESS would continue to make their choices as the risks of LESS in above mentioned aspects rose. RESULTS: About 85% of the questionnaires were included in the analysis. Complication was the most important factor with an average score of 4.77±0.43, followed by pain (3.84±0.96), scar (3.57±1.17), cost (3.41±0.87) and hospital stay (3.04±0.86). Of the 196 participants, 132 (67%) preferred LESS with younger age (35.3±10.64 versus 40.4 ±9.6, P=0.001). Better cosmesis was the only factor that made the participants choose LESS (3.78±1.11 versus 3.13±1.19, P<0.005). Almost 90% of the participants could accept the hypothesis (incision length of 3.5cm, cost up to 120%, pain up to 120%, hospital stay of 5 days), while only 50% of participants could accept the risk of complications of 6%. CONCLUSIONS: Complication is the most important factor that the public are concerned about in choosing surgery. LESS is preferred by young who care more concerned about the cosmesis, even with moderately elevated risks of extending incision and increasing hospital cost, postoperative pain and hospital stay.

Laparoendoscopic single-site radical nephrectomy for localized renal cancer: a descriptive research study with at least a 10-year follow-up.

Background: Laparoendoscopic single-site (LESS) surgery is performed to further narrow the incisions and reduce tissue injury. It has been more than10 years since the surgery was first described. However, there is still no report on the results of 10-year follow-up. This study evaluated the use of long-term oncology and the renal outcomes of LESS radical nephrectomy (LESS-RN) in the treatment of localized renal cancer. Methods: We retrospectively analyzed the clinical data of patients treated with LESS-RN at Changhai Hospital from 2009 to 2012. Patients with localized kidney cancer who were followed-up for at least 10 years were included in the study. The baseline data and major perioperative outcome variables were analyzed. Overall survival (OS) and cancer-specific survival (CSS) were calculated using the Kaplan-Meier method. Results: A total of 48 patients were included in the study, which had a median follow-up of 11 years (interquartile range, 10.7-11.8 years). The 10-year OS and CSS rates were 87.5% [42/48; 95% confidence interval (CI): 0.778-0.972] and 97.9% (47/48; 95% CI: 0.937-1.021), respectively. At the most recent follow-up, there were 5 patients with a chronic kidney disease stage ≥3. Among these 5 patients, 3 developed uremia and required continuous dialysis. Conclusions: For localized renal cancer, LESS-RN is safe and effective with excellent long-term oncology controllability and good functional outcomes. Prospective studies with large sample sizes need to be conducted to validate our results.

Laparoendoscopic Single-Site Inguinal Herniorrhaphy: Experience of a Single Institute.

Background: Minimally invasive techniques for inguinal herniorrhaphy have focused on developing the laparoendoscopic single-site (LESS) procedure to improve cosmesis. Outcomes of total extraperitoneal (TEP) herniorrhaphy vary considerably because of being performed by different surgeons. We aimed to evaluate the perioperative characteristics and outcomes of patients undergoing the LESS-TEP approach for inguinal herniorrhaphy and to determine its overall safety and effectiveness. Methods: Data of 233 patients who underwent 288 laparoendoscopic single-site total extraperitoneal approach (LESS-TEP) herniorrhaphies at Kaohsiung Chang Gung Memorial Hospital between January 2014 and July 2021 were reviewed retrospectively. We reviewed the experiences and results of LESS-TEP herniorrhaphy performed by a single surgeon (CHC) using homemade glove access and standard laparoscopic instruments with a 50 cm long 30° telescope. Results: Among 233 patients, 178 patients had unilateral hernias and 55 patients had bilateral hernias. About 32% (n = 57) of patients in the unilateral group and 29% (n = 16) of patients in the bilateral group were obese (body mass index ≥ 25). The mean operative time was 66 min for the unilateral group and 100 min for the bilateral group. Postoperative complications occurred in 27 (11%) cases, which were minor morbidities except for one mesh infection. Three (1.2%) cases were converted to open surgery. Comparison of the variables between obese and non-obese patients found no significant differences in operative times or postoperative complications. Conclusion: LESS-TEP herniorrhaphy is a safe and feasible operation with excellent cosmetic results and a low rate of complication, even in obese patients. Further large-scale prospective controlled studies and long-term analyses are needed to confirm these results.

Laparoendoscopic single-site surgery for urachal remnant with extraperitoneal approach through a suprapubic port.

INTRODUCTION: No standard procedure has been established for laparoendoscopic single-site surgery for urachal remnants (LESS-U). This study aimed to report the novel surgical techniques and initial outcomes of laparoendoscopic single-site surgery with an extraperitoneal approach through a suprapubic port for urachal remnants (spLESS). METHODS: Fifty-five patients (median age, 27 years; range, 15-69 years) who underwent LESS-U were analyzed. To overcome the limitations inherent in the conventional procedure (LESS-U through an umbilical port: uLESS), we modified the port placement and approached via the extraperitoneal space. spLESS is a novel procedure which reduces intestinal damage caused by the extraperitoneal approach and overcomes incomplete resection of the urachal remnant, especially in the bladder dome. Three trocars are inserted into the extraperitoneal space through a suprapubic port in spLESS, and complete resection of the urachal remnant from the umbilicus to the bladder is performed with an appropriate incision line. Patient characteristics and perioperative results were retrospectively collected. Cosmetic outcomes were prospectively evaluated using self-administered questionnaires (body image and photo-series questionnaire). RESULTS: spLESS and uLESS were performed in 43 and 12 patients, respectively. No differences were observed between the perioperative results. The cosmetic outcomes were compared between the groups using body image and photo-series questionnaires. No patient developed major complications; there was no recurrence in either group. CONCLUSIONS: spLESS is a novel procedure which can completely resect the urachal remnant and reduce the risk of intestinal damage. spLESS is a safe, effective, and feasible procedure with high postoperative cosmesis.

Transumbilical laparoendoscopic single-site surgery versus conventional laparoscopic surgery for patients with symptomatic urachal remnants: an experience with 57 patients.

PURPOSE: To evaluate the surgical feasibility and postoperative cosmesis of a novel transumbilical laparoendoscopic single-site (LESS) surgical approach involving Y-shaped incisions and three-flap umbilicoplasty in urachal remnant patients. METHODS: Patients with symptomatic urachal remnants who underwent either conventional laparoscopic surgery (CL group, n = 21) or LESS surgery with Y-shaped incisions and three-flap umbilicoplasty (LESS group, n = 36) between May 2010 and September 2019 were retrospectively assessed. Perioperative factors and postoperative esthetic outcomes were compared between the groups using univariate and multivariate analyses. Esthetic outcomes were assessed using the body image questionnaire consisting of the body image scale (BIS) and the cosmetic scale (CS); a higher score indicated a better outcome. RESULTS: The median operative time was greater and the insufflation time was shorter in the LESS group than in the CL group. The estimated blood loss and postoperative hospital stay and surgical site infection rate did not differ significantly between the groups. While the BIS score also did not differ significantly between the groups, the CS score was greater in the LESS group than in the CL group. Multivariate analysis revealed that the surgery type (LESS surgery) was an independent predictor of greater postoperative esthetic satisfaction. CONCLUSION: Transumbilical LESS surgery with Y-shaped incisions and subsequent three-flap umbilicoplasty is feasible in patients with symptomatic urachal remnants. Regarding postoperative cosmesis, the higher CS score suggests that this technique is superior to CL surgery. Furthermore, the selection of this procedure was an independent predictor of good postoperative esthetic outcomes.

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.

What's the best minimal invasive approach to pediatric nephrectomy and heminephrectomy: conventional laparoscopy (CL), single-site (LESS) or robotics (RAS)?

BACKGROUND: Conventional laparoscopy (CL) using 3-5 mm ports has become the goldstandard for pediatric nephrectomy (N), heminephrectomy (HN) and heminephrecto-ureterectomy (HNU) for many years now. Recently the spectrum of minimal invasive surgery (MIS) has been extended by variants like laparoendoscopic single-site surgery (LESS) or robot-assisted surgery (RAS). However such technical developments tend to drive surgical euphoria and feasibility studies, but may miss adequate academic research about function and proven patients' benefits. This article delivers a comprehensive analysis of present pediatric studies comparing at least two MIS approaches to N, HN and HNU. METHODS: A systematic literature-based search for studies published between 2011-2016 about CL versus LESS or RAS for pediatric N, HN, and HNU was performed using multiple electronic databases and sources. The level of evidence was determined using the Oxford Centre for Evidence-based Medicine (OCEBM) criteria. Single arm observational studies about N, HN or HNU using CL, LESS or RAS as well as publications including adult patients were excluded. RESULTS: A total of 11 studies met defined inclusion criteria, reporting on CL versus LESS or RAS. No studies of OCEBM Level 1 or 2 were identified. Performing CL for N and HN limited evidence indicated reduced analgesic requirements and shorter hospital stay over open surgery, but longer operating time. Preservation of renal function of the remaining moiety after CL-HN was 95%. Importantly, of patients losing their remaining moiety, median age at surgery was 9 months (range, 4-42 months), and all except 1 (6/7) had an upper pole HN. Several authors compared TNP versus RPN access for CL and confirmed a longer operating time for RPN versus TPN-NU. Moreover one study reported a longer ureteric stump in RPN versus TPN-HNU (range, 2-5 cm vs. 3-7 mm). Disadvantages of LESS or RAS over CL were longer operative time and higher total costs (RAS). There were no differences regarding complications, success rates, or short-term outcomes between pediatric RAS versus CL. No long-term studies about preservation of renal function or length of ureteric stump using LESS or RAS could be retrieved. CONCLUSIONS: Several approaches to MIS-NU and HNU are available today. CL represents the method of choice for any age group. TPN or RPN can be chosen according to age of the patient. LESS and RAS offer distinct advantages, but also lack evident patients' benefits over CL at present. Hopefully, as pediatric MIS advances over the next decade, larger studies comparing CL, LESS or RAS directly for pediatric NU and HNU will be published to gain a higher level of evidence what's really best for the child.

[Influencing factors on surgical duration of ovarian cystectomy by single-port access]. / Facteurs influençant la durée opératoire de la kystectomie ovarienne par accès endoscopique unique.

OBJECTIVES: To evaluate the factors influencing the operative duration of ovarian cystectomy by single-port access (SPA). MATERIALS AND METHODS: Observational monocentric study from June 2010 to September 2012. Inclusive patients were patients with an indication of ovarian cystectomy may be done by laparoscopy. The procedures were performed by the SPA system LESS®. Factors evaluated were BMI of the patient, histological nature and size of the cyst. RESULTS: We performed 54 cystectomy in 49 patients. SPA surgery was successfully completed in 53 patients. The median operative time was statistically longer for endometriotic cysts than dermoid cysts or serous-mucinous cysts (P=0.003). Cases exceeding 60minutes were significantly higher in the endometriosis group (P=0.005). There wasn't correlation found between the BMI of the patient and operative time (P=0.5). The operating time wasn't increased according to the size of the cyst (P=0.9). CONCLUSION: Endometriotic cysts nature appears to be the only limiting factor of cystectomy by SPA. Further studies are needed to evaluate the factors that may limit the SPA actions.

Single-incision multiport laparoscopy versus multichannel-tipped single port laparoscopy in gynecologic surgery: outcomes and benefits.

OBJECTIVE: To estimate the feasibility and safety of single-incision multiport laparoscopy (SIMPL) used in patients who underwent laparoendoscopic single-site surgery (LESS) for gynecologic disease, and the cosmetic outcome and economic benefit compared with multichannel-tipped single port laparoscopy (MSPL). INTERVENTION: We underwent LESS via a single 2.5- to 3.0-cm umbilical incision with the Single-Incision Multiport Laparoscopic Surgery Trocar available on the market, briefly named MSPL. Since January 2014, we improved the procedure and named SIMPL. In SIMPL group, two traditional laparoscopic trocar (diameter=5 mm) and one mini-laparoscopic trocar (diameter =3 mm) were inserted into the peritoneum separately through a single 1.5- to 1.8-cm umbilical transcutaneous incision. Subject demographics and clinical variables were collected and perioperative outcomes analyzed. In addition, the size of umbilicus was measured in all patients prior to the operation and the levels of cosmetic satisfaction were evaluated at 4 weeks after surgery. MEASUREMENTS AND MAIN RESULTS: From January 2014 to December 2014, there were 32 patients who underwent SIMPL for ovarian cystectomy. Hospital cost was significantly lower in SIMPL group compared with MSPL group (RMB 10207.0 vs 17973.7 yuan), P<0.001. Compared with MSPL group, the SIMPL group reported significantly higher cosmetic satisfaction at 4 weeks afer surgery (P<0.1). Besides, the SIMPL procedures performed in benign gynecologic surgery were myomectomy (n=8), salpingpoophorectomy (n=2), salpingectomy (n=5), adhesiolysis and fimbrioplasty (n=32), ovarian drilling (n=3), salpingotomy for ectopic pregnancy (n=3). All surgeries were completed successfully without conversion to the traditional laparoscopic approach. Two postoperative complications occurred were delay healing of umbilicus incision after myomectomy. The cosmetic satisfactory rate was 100%. CONCLUSION: According to our experience, SIMPL is safe and efficient for simple gynecologic operation, with lower cost and better cosmetic results than MSPL. Beyond cosmetic and economic results, further randomized studies are needed to identify a possible benefit.

Next step in minimally invasive surgery: hybrid image-guided surgery.

Surgery, interventional radiology, and advanced endoscopy have all developed minimally invasive techniques to effectively treat a variety of diseases with positive impact on patients' postoperative outcomes. However, those techniques are challenging and require extensive training. Robotics and computer sciences can help facilitate minimally invasive approaches. Furthermore, surgery, advanced endoscopy, and interventional radiology could converge towards a new hybrid specialty, hybrid image-guided minimally invasive therapies, in which the three fundamental disciplines could complement one another to maximize the positive effects and reduce the iatrogenic footprint on patients. The present manuscript describes the fundamental steps of this new paradigm shift in surgical therapies that, in our opinion, will be the next revolutionary step in minimally invasive approaches.

The best option: Umbilical LESS radical nephrectomy with vaginal extraction.

INTRODUCTION: Umbilical laparoendoscopic single-site (LESS) surgery represents an excellent alternative to laparoscopic or robotic multiport surgery. LESS surgery offers faster recovery, less postoperative pain and optimal cosmetic results. The reusable nature of its instruments also has significant economic advantages. PATIENT AND METHOD: We present a 34-year-old patient with a solid mesorenal lesion measuring 8 cm in the left kidney treated with pure LESS radical nephrectomy assisted by vaginal extraction of the specimen. The umbilical approach using a single-site multichannel KeyPort (Richard Wolf GmbH, Knittlingen, Germany) with DuoRotate curved instruments allows for minimum crushing and fewer spatial conflicts. Its perfect umbilical adaptation provides a hermetic system. The instrument's double rotation provides considerable movement precision. Vaginal extraction avoids damage to the abdominal wall and the need for widening the umbilical incision. RESULTS: After the placement of the device and triangulation of the clips, we proceeded to operate on posterior parietal peritoneum. The descending colon was mobilized to access the retroperitoneum and dissect the renal hilum. Hem-o-lok clips were placed on the artery and vein, which were subsequently sectioned. The specimen was inserted into a laparoscopic bag. Under direct vision, we placed a 15-mm trocar through the bottom of the vaginal posterior fornix to facilitate the extraction of the bag's thread. The incision was widened with the fingers, and the specimen was extracted, closing the vagina from the perineum with visualization from the navel. Abdominal drainage was not employed. The surgical time was 180 min. The patient was discharged the following day without needing analgesia. A year later, the patient was disease-free and had no complications. CONCLUSIONS: Umbilical LESS radical nephrectomy with vaginal extraction is feasible in selected cases. The procedure is oncologically safe, avoids scars and facilitates early recovery. From a practical point of view, this approach greatly simplifies natural orifice transluminal endoscopic surgery (NOTES) and enables a minimally invasive equivalent result.

Robotic single port cholecystectomy (R-LESS-C): experience in 36 patients.

BACKGROUND: Laparoendoscopic single-site surgery (LESS) has emerged as a result of a search for "pain-less" and "scar-less" surgery. Laparoendoscopic single-site cholecystectomy (LESS-C) is probably the most common application in general surgery, although it harbors certain limitations. It was proposed that the da Vinci Single-Site (Si) robotic system may overcome some of the difficulties experienced during LESS, providing three dimensional views and the ability to work in a right-handed fashion. Thirty-six robotic single port cholecystectomies (R-LESS-C) performed with the da Vinci Si robotic system are evaluated in this paper MATERIALS AND METHODS: R-LESS-C performed in 36 patients were reviewed. The data related to the perioperative period (i.e., anesthesia time, operation time, docking time, and console time) was recorded prospectively, whereas the hospitalization period, postoperative visual analogue scale (VAS) pain scores were collected retrospectively. RESULTS: A total number of 36 patients, with a mean age of 40.1 years (21-64 years), underwent R-LESS-C. There were five men and 31 women. The mean anesthesia and operation times were 79.3 minutes (45-130 minutes) and 61.8 minutes (34-110 minutes), respectively. The mean docking time was 9.8 minutes (4-30 minutes) and the mean console time was 24.9 minutes (7-60 minutes). The mean hospital stay was 1.05 days (1-2 days) and the mean pain score (VAS) was 3.6 (2-8) in the first 24 hours. Incisional hernia was recorded in one patient. CONCLUSION: R-LESS-C can be performed reliably with acceptable operative times and safety. The da Vinci Si robotic system may ease LESS-C. Two issues should be considered for routine use: expensive resources are needed and the incidence of incisional hernia may increase.

[Laparoendoscopic single-site surgery in gynecology: the situation in 2013]. / La laparoscopie par incision unique en gynécologie : état des lieux en 2013.

BACKGROUND: Single-incision laparoscopic surgery (SILS) is a recent technic of minimally invasive surgery that arouses a growing interest due to its potential benefits in terms of pain and cosmetic. However, in gynecology as well as in other surgical specialties, preliminary results seem to be controversial. Its feasibility and interest by comparison with conventional laparoscopy (CL) have not been confirmed by randomized multicenter studies. OBJECTIVES: Compare in gynecological surgery, feasibility and surgical outcomes (conversion rate and complications, postoperative pain, duration of surgery, length of hospital stay, appearance and cost) between SILS and CL. PATIENTS AND METHODS: For this, a review of the literature from a PUBMED and Medline databases was conducted. The clinical cases and series with fewer than 10 patients were excluded. Eligible data were compared and analyzed. RESULTS: A total of 46 studies including five prospective randomized were studied in gynecology. Conversion rates and complications appear identical to those of the CL. The learning curve is also comparable. The technique is not standardized and some ergonomic problems are described. Operating time and duration of hospitalization seems to be comparable. The postoperative pain assessment found conflicting results. The cosmetic results are in favor of the single incision laparoscopy. Finally, the cost is higher. CONCLUSIONS: According to the literature, the single incision laparoscopy seems feasible and safe, with better cosmetic results. But the cost is increased and associated with no benefit in terms of pain, operating time and duration of hospitalization. Beyond cosmetics results, further randomized studies are needed to identify a possible benefit.