Transumbilical laparoendoscopic single-site surgery of simple nephrectomy of nonfunctioning kidney: a two-year experience

Background： Laparoendoscopic single-site surgery （LESS） may serve as a potential alternative to conventional laparoscopy and is developing quickly, but still in its infancy. The study is to present our two-year experience in transumbilical LESS simple nephrectomy （LESS-SN） for non-functioning kidney, in an effort to evaluate its feasibility, clinical outcomes and potential advantages. Methods： From December 2008 to December 2010, a total of 11 patients with body mass index （BMI）≤30 underwent transumbilical TriPortTM LESS-SN by a single experienced urologist at our institution. The indications for nephrectomy included nonfunctioning kidney associated with ureteropelvic junction stricture （n=l）, ureteral calculi （n=6）, tuberculosis （n=3）, and ureteral stricture （n=l）. Patient demographics perioperative and follow-up data were prospectively collected and analyzed. Results： Ten procedures were successfully completed with one patient converted to open surgery due to uncontrollable bleeding. The mean operative time was 189.2 （ranging 100-320 min） with an estimated blood loss of 204.5 （ranging 50-1 000 ml）. There were two complications of bleeding （1- intra-, 1- post-）. The mean hospitalization after surgery was 7.9 d （ranging 4-17 d） With a regular follow-up of 1, 6, 12, and 24 months after surgery, all patients remained symptom-free with an intra-umbilical scar. Conclusion： Transumbilical LESS simple nephrectomy for nonfunctioning kidney can be accomplished with favorable surgical outcomes and a superiority of cosmesis. However, cases with chronic inflammation are not suitable for initial up-take and should only be attempted by the very experienced laparoscopist.

Robotic laparoendoscopic single-site surgery(R-LESS) ：current status in urology

Laparoendoscopic single-site surgery(LESS)is technically challenging;it can reduces instrument triangulation and robust retraction and is associated with a steep learning curve.The instruments of the daVinci  surgical system(Intuitive Surgical)are designed with seven degrees of motion mimicing the dexterity of the human hand and wrist.This inherent feature of the robotic arm provides superior ergonomics when performing LESS,especially for complex reconstructive surgery.This review analyzes the evidence supporting current and future application of robotic technology in the field of urologic LESS.

Transumbilical laparoendoscopic single-site surgery(LESS) partial nephrectomy:a median follow-up of 2 years

Objective:Nephron-sparing surgery(NSS) for small renal masses offers a similar functional and oncological outcome to that of radical surgery.Laparoendoscopic single-site surgery(LESS) emerges as an advanced alternative for reduced invasiveness and improves cosmesis;LESS is developing quickly and its indications have been expanded,but still in its infancy.The aim of this paper is to report our preliminary experience in transumbilical LESS partial nephrectomy(LESS-PN),so as to assess its utility, safety and efficacy.Methods:From August 2009 to October 2010,3 patients underwent transumbilical LESS-PN via a novel multi-channel TriPort by a single experienced urologist in our institution.Patient demographics,perioperative and follow-up data were prospectively collected and analyzed.Results:All the three procedures were successfully completed.A 5-mm ancillary trocar was utilized in all 3 cases.The mean operative duration was 226.3(210-254 min) with an estimated blood loss of 56.7 ml (20-100 ml).Mean warm ischemia time was 35.7 min(19-48 min).One patient was transfused due to postoperative bleeding. The recovery was uneventful and mean length of postoperative stay was 13 days(12-14 days).At the latest follow-up,all patients remained symptom-free and had normal renal function without evidence of recurrence,and they were delighted for a hidden transumbilical scar.Conclusion:Transumbilical LESS-PN is a feasible and safe procedure albeit extremely technically challenging.Surgical outcomes at a median follow-up of 2 years are promising,while currently it should be reserved for highly selected patients with favorable tumor anatomy and performed by a very experienced laparoscopic surgeon.

A Comparison between Laparoendoscopic Single-Site and Conventional Laparoscopic Renal Stone Removal Surgery: A Study of Application in Two Cases

Aim: To present our initial experience of applying laparoendoscopic single-site surgery (LESS) nephrolithotomy in the treatment of renal calculi. Methods: In August 2010 and April 2012, the LESS nephrolithotomy technique was applied to treat two patients with a renal calculus. One patient had a calculus measuring 5 × 3 cm, and the second patient's measured 3 × 3 cm. Both patients underwent general anesthesia. The operations were performed through a retroperitoneal approach with a single-port instrument inserted through the retroperitoneal incision. The standard laparoscopic retroperitoneal technique was performed, and the calculi were removed by incising the area of the thin renal cortex and the renal pelvis, respectively. The operating time, estimated blood loss, intraoperative complications, other complications, drainage time, and post-operative hospital stay were recorded. Results: Both procedures were completed successfully. No additional trocars were added. No conversion to standard laparoscopic or open surgery was needed. The operating times were 130 min and 120 min, and the estimated blood losses were 40 mL and 30 mL. There were no intraoperative complications. The wound drainage times were 3 d and 2 d, respectively and the post-operative hospital stays were 8 d and 7 d, respectively. There was no secondary bleeding or wound infection. Follow-up times were 2 years and 3 months, respectively. No incidence of hydronephrosis was recorded. Conclusions: LESS nephrolithotomy is safe and feasible for treating kidney calculi. It can be applied in patients with large renal calculi and regionally thin renal parenchyma.

Synchronous bilateral laparoendoscopic single-site urological surgeries via the umbilicus:a report of 2 cases

Objective： To describe two cases of bilateral transumbilical laparoendoscopic single-site（LESS） surgeries in a single operative session and assess the safety, feasibility and efficacy. Methods： One patient underwent right ureterolithotomy and left varicocelectomy, and the patient was performed with right simple nephrectomy for nonfunctioning kidney due to ureteral calculus and left ureterolithotomy using a novel multichannel TriPortTM via a single 2-3 cm transumbilical incision Results： The right-side ureterolithotomy and left-side varicocelectomy were finished in 229 minutes, with a total estimated blood loss of 50 hal. The right-side simple nephrectomy and left-side ureterolithotomy in the other patient were finished in 340 minutes, with a total estimated blood loss of 100 ml. There were no major complications. At the latest follow-up, both patients remained symptom-free and there were no evidences of recurrence. Both of them were delighted for the single scarConclusion： Synchronous LESS urologic procedure via a single umbilical incision is technically feasible, safe and efficacious with a promising potential

Laparoendoscopic single-site distal pancreatectomy in pigs

AIM: To explore the technique for laparoendoscopic single-site distal pancreatectomy.

Initial experience of laparoendoscopic single-site radical prostatectomy with a novel purpose-built robotic system

Objective This prospective single-arm clinical trial aimed to evaluated the feasibility and safety of the application of the SHURUI system(Beijing Surgerii Technology Co.,Ltd.,Beijing,China),a novel purpose-built robotic system,in single-port robotic radical prostatectomy.Methods Sixteen patients diagnosed with prostate cancer were prospectively enrolled in and underwent robotic radical prostatectomy from October 2021 to August 2022 by the SHURUI single-port robotic surgical system.The demographic and baseline data,surgical,oncological,and functional outcomes as well as follow-up data were recorded.Results The mean operative time was 226.3(standard deviation[SD]52.0)min,and the mean console time was 183.4(SD 48.3)min,with the mean estimated blood loss of 116.3(SD 90.0)mL.The mean length of postoperative hospital stay was 4.50(SD 0.97)days.Two patients had postoperative complications(Clavien-Dindo Grade II),and both patients improved after conservative treatment.All patients’postoperative prostate-specific antigen levels decreased to below 0.2 ng/mL 1 month after discharge.The mean prostate-specific antigen level further decreased to a mean of 0.0219(SD 0.0641)ng/mL 6 months after surgery.Thirty days postoperatively,12 out of 16 patients reported using no more than one urinary pad per day,and all patients reported satisfactory urinary control without the need for pads 6 months after surgery.Conclusion The SHURUI system is safe and feasible in performing radical prostatectomy via both transperitoneal and extraperitoneal approaches.Tumor control and urinary continence were satisfying for patients enrolled in.The next phase involves conducting a large-scale,multicenter randomized controlled trial to thoroughly assess the effectiveness and safety of the new technology in a broader population.

Duplicated inferior vena cava in a patient undergoing right transumbilical laparoendoscopic single-site (LESS) radical nephrectomy

LaparoEndoscopic Single-site(LESS) renal surgery emerging as a potential alternative to conventional laparoscopy,is technically challenging and the major vascular anomaly may increase the risk of intraoperative haemorrhage.Herein,we present a case of right transumbilical LESS radical nephrectomy which was successfully performed in the presence of double inferior vena cava and duplicated the standard laparoscopic techniques.Most importantly,to bring such an aberrant vascular anatomy to the attention of laparoscopic,especially LESS surgeons with high resolution pictorial illustrations.

Laparoendoscopic Single-Site Combined Hysterectomy and Nephrectomy in Deep Infiltrating Endometriosis

Within the advance ports and instruments, laparoendoscopic single-site (LESS) surgery has been increasingly used among gynaecologic surgeons. In addition, advanced port systems have enabled to perform concomitant surgical procedures via transumbilical incision. However, combined surgical operations are rarely reported in the literature, particularly in gynaecology. This case report presents a 42-year-old woman who undergo concomitant LESS hysterectomy and nephrectomy due to deep infiltrating endometriosis (DIE) and end stage renal disease. The operation is performed in approximately 3 hours without any complications, and the patient is discharged on postoperative third day. This case demonstrates that complex concomitant operations even in a patient with DIE can be performed using a LESS surgical approach.

Laparoendoscopic single site,laparoscopic or open surgery for adrenal tumors:Selecting the optimal approach

Numerous surgical modalities are available to treat adrenal lesions. Minimally-invasive approaches for adrenalectomy are indicated in most circumstances, and new evidence continues to be accumulated. In this context, current indications for open surgical adrenalectomy(OS-A), minimally-invasive adrenalectomy(MI-A), and laparoendoscopic single-site adrenalectomy(LESS-A) remain unclear. A comprehensive Englishlanguage literature review was performed using MEDLINE/Pub MED to identify articles and guidelines pertinent to the surgical management of adrenal tumors. A comprehensive chart review was performed for three illustrative cases. Clinical recommendations were generated based on relevant literature and the expertise of the investigator group. MI-A offers advantages over OS-A in properly selected patients, who experience fewer complications, lower blood loss, and shorter hospital stays. Robot-assisted laparoscopic and retroperitoneoscopic adrenalectomy may offer advantages over transperitoneal surgery, and LESS-A may be an even less-invasive option that will require further evaluation. MI-A remains the surgical treatment of choice for most adrenal lesions. Tumor size and stage are the primary indications for selecting alternative treatment modalities. OS-A remains the gold standard for large tumors(> 10 cm) and suspected or known advanced stage malignancy. LESS-A appears to be an appropriate initial approach for small tumors(< 4-5 cm), including pheochromocytoma and isolated adrenal metastases.

Robotic single-site supracervical hysterectomy with manual morcellation:Preliminary experience

AIM To evaluate the feasibility,safety and peri-and postoperative outcomes of robotic single-site supracervical hysterectomy(RSSSH) for benign gynecologic disease.METHODS We report 3 patients who received RSSSH for adenomyosis of the uterus from November 2015 to April 2016.We evaluated the feasibility,safety and outcomes among these patients.RESULTS The mean surgical time was 244 min and the estimated blood loss was 216 mL,with no blood transfusion necessitated.The docking time was shortened gradually from 30 to 10 min.We spent 148 min on console operation.Manual morcel ation time was also short,ranging from 5 to 10 min.The mean hospital stay was 5 d.Lower VAS pain score was also noted.There is no complication during or after surgery.CONCLUSION RSSSH is feasible and safe,incurs less postoperative pain and gives good cosmetic appearance.The technique of inbag,manual morcellation can avoid tumor dissemination.

Single-site laparoscopic partial nephrectomy: Where are we going?

AIM:To review an evolution of laparoscopic surgery,there has been a growing interest in laparoendoscopic single-site surgery(LESS).METHODS:A comprehensive electronic literature search was conducted using PubM ed database to identify all publications relating to LESS-partial nephrectomy(PN).The research includes articles published from April 2008 to January 2014.We focused our attention only on articles in which were cited the single-site surgical technique(laparoscopic and robotic),tumour stage and grade,mean tumour size,intraoperative variables,blood loss and transfusion rate,length of postoperative stay and complication rates,Clavien classification,positive of surgical margins,pain assessment at discharge.RESULTS:A total of 9 studies were collected with 221patients included.The mean patients age was 62 years.The mean tumor size was 2.35 cm with a mean operative time of 181 min(range 111-270 min)and 58.3%were done by robot.The mean ischemia time was 23.6min.The 25.8%of patients underwent an unclamp LESS-PN.Mean estimated blood loss was 296 mL and median length of hospital stay was 4 d.The rate of severe post-operative complications(≥Clavien gradeⅢ)was 5.4%.Not all surgical series of LESS-PN or Robotic-LESS-PN shows conversion in Multiport Laparoscopic or Open Surgery.Regarding oncologic outcomes,surgical margins were positive 4%of patients(9/221),no distant or port-site metastases were recorded.CONCLUSION:LESS-PN and RLESS-PN are feasible and associated with reduced postoperative pain,shorter median hospital stay,shorter recovery time,and better cosmetic satisfaction without compromising surgical and oncological safety.

Single-incision laparoscopic surgery to treat hepatopancreatobiliary cancer:A technical review

Single-incision laparoscopic surgery(SILS),or laparoendoscopic single-site surgery,was launched to minimize incisional traumatic effects in the 1990s.Minor SILS,such as cholecystectomies,have been gaining in popularity over the past few decades.Its application in complicated hepatopancreatobiliary(HPB)surgeries,however,has made slow progress due to instrumental and technical limitations,costs,and safety concerns.While minimally invasive abdominal surgery is pushing the boundaries,advanced laparoscopic HPB surgeries have been shown to be comparable to open operations in terms of patient and oncologic safety,including hepatectomies,distal pancreatectomies(DP),and pancreaticoduodenectomies(PD).In contrast,advanced SILS for HPB malignancy has only been reported in a few small case series.Most of the procedures involved minor liver resections and DP;major hepatectomies were rarely described.Singleincision laparoscopic PD has not yet been reported.We herein review the published SILS for HPB cancer in the literature and our three-year experience focusing on the technical aspects.

Single-incision laparoscopic surgery for biliary tract disease

Single-incision laparoscopic surgery(SILS), or laparoendoscopic single-site surgery, has been employed in various fields to minimize traumatic effects over the last two decades. Single-incision laparoscopic cholecystectomy(SILC) has been the most frequently studied SILS to date. Hundreds of studies on SILC have failed to present conclusive results. Most randomized controlled trials(RCTs) have been small in scale and have been conducted under ideal operative conditions. The role of SILC in complicated scenarios remains uncertain. As common bile duct exploration(CBDE) methods have been used for more than one hundred years, laparoscopic CBDE(LCBDE) has emerged as an effective, demanding, and infrequent technique employed during the laparoscopic era. Likewise, laparoscopic biliary-enteric anastomosis is difficult to carry out, with only a few studies have been published on the approach. The application of SILS to CBDE and biliary-enteric anastomosis is extremely rare, and such innovative procedures are only carried out by a number of specialized groups across the globe. Herein we present a thorough and detailed analysis of SILC in terms of operative techniques, training and learning curves, safety and efficacy levels, recovery trends, and costs by reviewing RCTs conducted over the past three years and two recently updated meta-analyses. All existing literature on single-incision LCBDE and singleincision laparoscopic hepaticojejunostomy has been reviewed to describe these two demanding techniques.

Transurethral assistant transumbilical laparoendoscopic single-site radical prostatectomy

The laparoendoscopic single-site （LESS） technique is the latest technical innovation in laparoscopic surgery to undergo exponential development in urology. This study undertaken to illustrate our initial experience LESS radical prostatectomy （RP） and analyze early outcomes. Nineteen patients diagnosed with prostate cancer underwent LESS-RP in our institute. The patients were divided into two groups： conventional LESS and transurethral assistant LESS. Preoperative, perioperative, postoperative, pathologic, and functional outcomes data were assessed. With the help of a transurethral assistant, the mean operation and anastomosis time were decreased markedly. No focal positive margins were encountered. No prostate-specific antigen recurrence was detected 1 month postoperatively. Complete continence recovery （no pad） was observed in 32% of the patients at 1 month after the operation. No intraoperative and postoperative complications were reported, LESS-RP is a feasible and effective surgical procedure for treatment of prostate cancer. Moreover, transurethral assistant LESS could reduce the difficulty of LESS-RP and shorten the operation time.

Comparison of surgical effect and postoperative patient experience between laparoendoscopic single-site and conventional laparoscopic varicocelectomy, a systematic.review and meta-analysis

The present meta-analysis was conducted to compare the clinical effect and patient experience of laparoendoscopic single-site varicocelectomy （LESSV） and conventional laparoscopic varicocelectomy. The candidate studies were included after literature search of database Cochrane Library, PubMed, EMBASE, and MEDLINE. Related information on essential data and outcome measures was extracted from the eligible studies by two independent authors, and a meta-analysis was conducted using STATA 12.0 software. Subgroup analyses were conducted by study design （RCT and non-RCT）. The odds ratio （OR） or standardized mean difference （SMD） and their 95% confidence intervals （95% CIs） were used to estimate the outcome measures. Seven articles were included in our meta-analysis. The results indicated that patient who had undergone LESSV had a shorter duration of back to work （overall： SMD = -1.454, 95% Ch -2.502m0.405, P= 0.007; non-RCT： SMD = -2.906, 95% Ch -3.796-2.017, P= 0.000; and RCT： SMD = -0.841, 95% Ch -1.393-0.289, P = 0.003） and less pain experience at 3 h or 6 h （SMD = -0.447, 95% Ch -0.754-0.139, P = 0.004）, day 1 （SMD = -0.477, 95% Ch -0.905-0.05, P = 0.029）, and day 2 （SMD = -0.612, 95% Ch -1.099-0.125, P= 0.014） postoperatively based on RCT studies. However, the meta-analyses based on operation time, clinical effect （improvement of semen quality and scrotal pain relief）, and complications （hydrocele and recurrence） yielded nonsignificant results. In conclusion, LESSV had a rapid recovery and less pain experience over conventional laparoscopic varicocelectomy. However, there was no statistically significant difference between the two varicocelectomy techniques in terms of the clinical effect and the incidence of hydrocele and varicocele recurrence. More high-quality studies are warranted for a comprehensive conclusion.

Laparoendoscopic single-site radical prostatectomy： technique and initial outcomes

Background Laparoendoscopic single-site surgery radical prostatectomy （LESS-RP） is a challenging urological procedure and needs to be further evaluated. This study was undertaken to illustrate the safety and initial results of pure LESS-RP with conventional available instruments.

Natural orifice transluminal endoscopic surgery and localized resection for colorectal neoplasia

Modern methods of surgical intervention have the potential to provide effective,definitive management of early stage colorectal neoplasia by truly minimally invasive means.Margin-free clearance of early colonic neoplasia from within the intestinal lumen can already now be effected by endoscopic submucosal dissection in the colon and transluminal endoscopic microsurgery(TEM) in the rectum.Natural orifice transluminal endoscopic surgery(NOTES) offers the potential for providing transmural,full thickness excision as TEM does but at sites in the colon proximal to the rectum.The next conceptual advance required to make this practice an effective reality lies in evolving surgical regional staging strategies to effectively partner localized resective approaches and allow their deployment as definitive curative therapy.As the most compelling modality for nodal status ascertainment in the absence of lymphatic basin excision for other malignant disease processes,it seems timely to reconsider sentinel node biopsy in cancer of the colon and rectum.Whether by this means or indeed any other,such an ability to confidently identify patients with node negative disease would allow nascent innovative techniques flourish as definitive management for confined(N0) T1 and T2 cancers and so allow the application of available advanced technology for clinical benefit.Conversely,the development of a specific clinical niche for NOTES(whether,as here,for full thickness localized colonic excision or nodal staging alone) would greatly benefit the evolution and incorporation of this surgical strategy into clinical care paradigms.

Preliminary experience with transperitoneal laparoendoscopic single-site radical nephrectomy using a home-made single-port device in China

Background Laparoendoscopic single-site （LESS） surgery represents a technique to further reduce morbidity and scarring associated with surgery.We present our preliminary experience with transperitoneal LESS radical nephrectomy （RN） using a home-made single-port device in China.Methods From July 2010 to November 2011,eleven patients with renal tumor not greater than T2 underwent LESS-RN by an experienced laparoscopic surgeon.A home-made single-port device was used through a 5-cm umbilical incision.A combination of standard and articulating laparoscopic instruments was used.The sequence of steps of LESS-RN was similar to transperitoneal laparoscopic RN.Patient characteristics,perioperative variables and postoperative outcomes were recorded and analyzed.Results Except for two transperitoneal laparoscopic conversions and one hand-assisted laparoscopic conversion,the other procedures were completed successfully without conversion to open surgery.The mean operative time was 224.5 （155-297） minutes,estimated blood loss was 270.9 （50-900） ml,and hospital stay was 10.4 （5-15） days.The mean visual analog pain scale （VAPS） on the first postoperative day was 4.0/10.Final pathological analysis revealed renal cell carcinoma in all cases with a stage distribution of three T1a,five T1b,and three T2a tumors.With the mean followup period of 21.4 （12-28） months,all patients were alive without evidence of tumor recurrence or metastasis,and were satisfied with the appearance of the scars.Conclusion Transperitoneal LESS-RN using a home-made single-port device is technically feasible and safe in a selected group of patients （low body mass index and stage tumor） and has excellent cosmetic results.Although preliminary oncologic outcome is not compromised,the long-term evaluation of these patients is awaited.

Towards the Holy Grail: What can we do for truly scarless surgery?

The work of Muhe and Mouret in the late 1980s,paved the way for mainstream laparoscopic procedures and it rapidly became the mainstream method for many intra-abdominal procedures.Natural orifice transluminal surgery(NOTES)and Laparo-endoscopic single-site surgery(LESS)are very exciting new modalities in the field of minimally invasive surgery which work for further reducing the scars of standard laparoscopy and towards scarless surgery.However,according to objective assessment of the literatures,there is no clearly demonstrated benefit of NOTES(LESS),even cosmesis is poorly supported and had mixed results in the available data.NOTES(LESS)is far from the truly scarless surgery.Towards the Holy Grail,we have developed several techniques of creating nonvisible scar and named them as"Scar-hidden Endoscopic Surgery".With the rapid development of science and technology,we believe that minimally invasive surgery over the next2 decades will continue to bring remarkable change and realize truly scarless surgery even we may not be able to imagine what lies ahead.