INTRODUCTION: The laparoendoscopic single-site (LESS) technique has advantages over multi-site surgery that include better cosmesis, less incisional pain, and the ability to convert to standard multiport surgery, if needed. A steep learning curve makes the procedure prohibitive for trainees in many centers. To simplify this learning curve, we adopted a bridging technique that includes an incisional LESS (iLESS) approach using a GelPort device (Applied Medical Resources Corp; Rancho Santa Margarita, CA, USA). We describe the iLESS technique and report our initial experiences.
METHOD: The iLESS surgical technique is illustrated on a centrally-located 5 cm right renal mass in a 54-year-old female patient with a poorly functioning right kidney. A single-port supraumbilical nephrectomy was conducted using the GelPort device. The device was inserted through an 8 cm supraumbilical incision. Procedures are fully described and compared with the LESS technique.
RESULTS: The procedure was technically successful. The total operative duration was 2.2 hours, the estimated blood loss was 70 mL, and the hospital stay was 3 days. There were no complications during or after surgery. The total analgesia requirement was 30 mg of morphine. Visual analog pain scores were 7/10 and 2/10 at 1 and 2 days after surgery, respectively.
CONCLUSIONS: The iLESS nephrectomy is technically feasible using standard laparoscopic instruments. Selected patients should have a low body mass index and an anterior abdominal wall thickness of < 6 cm. We expect this procedure to help bridge the gap between standard laparoscopy and LESS, because the GelPort device simulates a modified type of laparoendoscopic single-site surgery. Rigid or flexible instruments are used selectively to provide a smooth learning curve.
Ahmed Al-Sameraaii, Edward Latif, Peter Aslan
Submitted March 20, 2011 - Accepted for Publication June 13, 2011
KEYWORDS: Incisional laparoendoscopic single site; iLESS; Supraumbilical; Single port; Laparoscopic surgery; Gelport
CORRESPONDENCE: Dr. Ahmed Al-Sameraaii, Department of Urology, Hurstville Private Hospital, 37 Gloucester Road, Hurstville, NSW 2220, Sydney, Australia ().
CITATION: UroToday Int J. 2011 Aug;4(4):art51. doi:10.3834/uij.1944-5784.2011.08.07.
ABBREVIATIONS AND ACRONYMS: GIA, gastrointestinal anastomosis; iLESS, incisional laparoendoscopic single-site; LESS, laparoendoscopic single-site.
INTRODUCTION
Laparoendoscopic single-site (LESS) surgery is an area of active progress for abdominal surgery and urology [1,2,3,4]. A number of advantages over multi-site laparoscopic surgery have been proposed, including better cosmesis, less incisional pain, and the ability to convert to standard multiport surgery, if needed [3]. Single-incision nephrectomy has been well described; a number of reports of single-incision donor nephrectomies and other urologic applications have been published [1,5].
The primary disadvantages of LESS are the restricted degrees of freedom of movement, the need for articulated instruments, the number of ports that that can be used, and the proximity of the instruments to each other during the operation. All of these issues increase the complexity and technical challenges of the operation. Further difficulties can be related to the technique of port placement and utilization during single-incision laparoscopic surgery.
The LESS technique requires special instruments to overcome the lack of triangulation, crowding, and limited mobility. A steep learning curve remains prohibitive for trainees in many centers, despite a high volume of cases. To simplify this learning curve, we adopted a bridging technique for the skilled urologist that includes an incisional LESS (iLESS) approach where a GelPort device (Applied Medical Resources Corp; Rancho Santa Margarita, CA, USA) can first be inserted [6]. The purpose of the present report is to describe the method of establishing single-site access using the GelPort and standard instruments in a teaching hospital, as a learning tool toward LESS surgery.
METHOD
We will illustrate the surgical technique on a 54-year-old female patient with a body mass index of 22.3 kg/m2 and a small, poorly functioning right kidney. Contrast computed tomography revealed a centrally located heterogeneous 5 cm mass.
Surgical Instruments
The following standard instruments are used in most cases of iLESS: (1) standard 10 mm endolaparoscope with 30° lens; (2) Metzenbaum monopolar scissors; (3) bipolar laparoscopic forceps; (4) 5 mm laparoscopic Babcock. An articulating forceps is optional in iLESS, unlike the pure LESS technique where their use is essential to overcome the articulation/triangulation problem.
The GelPort is a sterile, disposable, hand-access device that is intended for single use. It is approved by the United States Food and Drug Administration. The device consists of a: (1) wound-protecting sheath, (2) wound-retractor double ring, and (3) unique gel-seal cap. The wound-protecting sheath is designed to protect incisions and soft tissues from malignant and infectious exposure; it also provides a flexible fulcrum for the iLESS method. The wound-retractor ring facilitates organ removal while minimizing the incision size. The gel-seal cap enables unlimited exchange of both the hand and instruments while maintaining the pneumoperitoneum.
Surgical Technique
Under general anesthesia, the patient was catheterized and placed laterally with a 15° bed flexion. The left axilla and pressure points were all supported and the right arm was stabilized on an arm flyer.
Single access was achieved with the GelPort, as described previously [6,7]. The patients selected for this procedure should have a low body mass index and an anterior abdominal wall thickness of < 6 cm. For port insertion, the bed is tilted to a gentle supine position. A mini-laparotomy (midline umbilical or supraumbilical) is performed and the GelPort is applied (see Figure 1, Figure 2, Figure 3). The 3 ports are placed at a maximum distance from each other within the GelPort, as allowed by the GelPort diameter (7-8 cm) and the outer ring.
The right hemicolon is dissected in the standard manner by incising the peritoneal reflection at the line of Toldt. If additional retraction is required on the right side, a single 5 mm port or a 2 mm miniport can be utilized to elevate the liver edge with a grasping forceps at the lateral edge of the right hemidiaphragm; this is all done through a 2-5 mm stab incision.
The gonadal vessels are identified medial to the ureter. The right hand scissors or Legasure can effectively dissect the tissues around the ureter (the ureter has been elevated with the right-hand laparoscopic Babcock instrument). Unlike the pure LESS technique, the approach with iLESS does not include early division or damage to the ureter, thus resembling the standard laparoscopic approach.
Effective triangulation was obtained in this case; when inadequate, the malleable instrument can be substituted. The gonadal veins are dissected and secured with clips or controlled effectively with the Legasure.
The hilum is then effectively dissected, and adequate exposure of the suprahilar tissues is obtained. We prefer to use the Legasure or harmonic scalpel instrument for this part, to address the adrenal vein region and soft tissue above the renal vein. In most cases, the renal vein is visible before the artery and almost always lies at a more anterior plane.
Full exposure of the suprarenal gland area and tissue can be cleared with the Legasure, with good hemostasis. The psoas muscle is preferably viewed from both suprahilar and infrahilar views before addressing the renal vein.
Once the renal vein is exposed, it is carefully dissected ventrally and posteriorly. An artery branch may be identified cranial to the renal vein; another branch may be identified at a lower level toward the lower pole. The main renal artery may not be visible because it is located cranially and posteriorly to the main renal vein. The renal artery can be secured with 2 small Hem-o-Lok or titanium clips, with 3 clips positioned toward the aorta and 2 clips toward the kidney. The surgeon can also use a gastrointestinal anastomosis (GIA) staple to address the renal artery and vein, either separately or en masse. The stapler tip must be clearly visible beyond the renal vein (with no intervening staples) before complete division. The renal vein should only be clipped after ensuring that all arteries are clipped; the renal vein should not be clipped along with the renal artery. Renal mobilization can be completed, leaving the lateral attachment.
A standard 15 mm large bag can be introduced through the GelPort. In the present case, the specimen was brought into the bag with the help of 2 forceps. The incision was effective in delivering the specimen for inspection. We did not need to further extend the 8 cm incision for specimen extirpation.
RESULTS
The procedure was technically successful with a single supraumbilical skin incision. The total operative duration was 2.2 hours. The estimated blood loss was 70 mL, and the hospital stay was 3 days. There were no complications during or after surgery. The total analgesia requirement was 30 mg of morphine. Visual analog pain scores were 7/10 and 2/10 at 1 and 2 days after surgery, respectively.
DISCUSSION
Laparoscopic surgery has allowed the performance of several major urologic operations through small incisions. Procedures performed through solitary abdominal incisions for traditional laparoscopic surgery are under extensive evaluation [8]. LESS surgeries for nephrectomy, pyeloplasty, and even donor nephrectomy have recently been performed [1,3]. Although laparoscopic procedures have several advantages over their open surgical counterparts, the advantages of single-site surgery over conventional laparoscopic techniques are still unproven [5]. Limited port-related morbidity and better cosmetic outcome have been proposed as advantages of LESS without adequate documentation [9].
With LESS surgical techniques rapidly evolving, several new reticulating forceps have been designed and marketed. The entries for Triport (Olympus America; Center Valley, PA, USA) and Quadraport (LAGIS; Taichung County, Taiwan) access systems allow the simultaneous passage of up to 4 instruments during laparoscopic surgery.
A number of methods have been described for port access to perform LESS, including multiple fascial punctures through 1 skin incision, the use of additional transabdominal sutures or miniports to stabilize the target organ [4], and the use of novel port access devices such as the Triport. To further overcome the technical challenges for LESS and the hilar control, different instruments that provide angulations and small-profile trocars have been developed.
A single 12 mm, articulating GIA staple is effective for the renal vein, because it provides 3 titanium lines of hemostasis on each side. There were no reported cases of arteriovenous (AV) fistula in a large series [10].
Unfortunately, problems remain with the LESS procedures. The cost of the single-use instruments is high. Lack of triangulation between the standard instruments in the ports causes clashing, and the procedure is not ergonomic. Deflected-tip single-use instruments (eg, Laparo-Angle, Cambridge Endoscopic Devices; Framingham, MA, USA) are essential in LESS surgery, adding to the total cost for most cases.
Most hospitals are familiar with the GelPort, which is utilized in the majority of hand-assisted laparoscopic surgeries. The device allows the introduction of different sized instruments as well as the insertion of different ports at its full circumference. The procedure provides adequate triangulation and a flexible fulcrum (Figure 4). However, it remains suitable only for select patients with a favorable body habitus and with tumors of a suitable size and location for such an approach. The surgeon can then decide when to introduce the deflected tip instruments and how to utilize them for the difficult cases.
CONCLUSIONS
The iLESS surgery is technically feasible for most standard applications in urology in select patients. With proper patient choice and improvement in instrumentation and technology, the role of LESS in minimally invasive urology is likely to expand and the overall cost of surgery should be reduced. Our novel technique describes using the GelPort device. We expect this procedure to help bridge the gap between standard laparoscopy and LESS, because the device simulates a modified type of laparoendoscopic single-site surgery. Rigid or flexible instruments are used selectively to allow a smooth learning curve. We plan to use it for our trainees in the future.
Conflict of Interest: none declared.
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