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 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.

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.

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.

Overview of single-port laparoscopic surgery for colorectal cancers: Past, present, and the future

Single-port laparoscopic surgery (SPLS) is implemented through a tailored minimal single incision through which a number of laparoscopic instruments access. Introduction of operation-customized port system, utilization of a camera without a separate external light, and instruments with different lengths has brought the favorable environment for SPLS. However, performing SPLS still creates several hardships compared to multiport laparoscopic surgery; a single-port system inevitably leads to clashing of surgical instruments due to crowding. To overcome such difficulties, investigators has developed novel concepts and maneuvers, including the concept of inverse triangulation and the maneuvers of pivoting, spreading out dissection, hanging suture, and transluminal traction. The final destination of SPLS is expected to be a completely seamless operation, maximizing the minimal invasiveness. Specimen extraction through the umbilicus can undermine cosmesis by inducing a larger incision. Therefore, hybrid laparoscopic technique, which combined laparoscopic surgical technique with natural orifice specimen extraction (NOSE) - i.e., transvaginal or transanal route-, has been developed. SPLS and NOSE seemed to be the best combination in pursuit of minimal invasiveness. In the near future, robotic SPLS with natural orifice transluminal endoscopic surgery’s way of specimen extraction seems to be pursued. It is expected to provide a completely or nearly complete seamless operation regardless of location of the lesion in the abdomen.

Technical and instrumental prerequisites for single-port laparoscopic solo surgery:state of art

With the aid of advanced surgical techniques and instruments, single-port laparoscopic surgery(SPLS) can be accomplished with just two surgical members: an operator and a camera assistant. Under these circumstances, the reasonable replacement of a human camera assistant by a mechanical camera holder has resulted in a new surgical procedure termed singleport solo surgery(SPSS). In SPSS, the fixation and coordinated movement of a camera held by mechanicaldevices provides fixed and stable operative images that are under the control of the operator. Therefore, SPSS primarily benefits from the provision of the operator's eye-to-hand coordination. Because SPSS is an intuitive modification of SPLS, the indications for SPSS are the same as those for SPLS. Though SPSS necessitates more actions than the surgery with a human assistant, these difficulties seem to be easily overcome by the greater provision of static operative images and the need for less lens cleaning and repositioning of the camera. When the operation is expected to be difficult and demanding, the SPSS process could be assisted by the addition of another instrument holder besides the camera holder.

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.

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.

Modified technical protocol for single-port laparoscopic appendectomy using needle-type grasping forceps for acute simple appendicitis:A case report

BACKGROUND Because of the mild inflammatory status in acute uncomplicated appendicitis,our team developed a novel technical protocol for single-port laparoscopic appendec-tomy using needle-type grasping forceps(SLAN)and achieved positive clinical outcomes.However,the intraoperative procedure lacked stability and fluency due to a series of problems highlighted by the small incision design of the proto-col(only 1 cm long).Therefore,there is a growing clinical demand to further opti-mize the SLAN protocol.CASE SUMMARY An adult male patient was admitted for persistent right lower abdominal pain with preoperative computed tomography findings suggestive of appendicitis accompanied by localized peritonitis.A modified technical protocol for SLAN based on minimally invasive surgical principles was used,and the patient was confirmed to have acute simple appendicitis by postoperative pathological ana-lysis.Postoperative recovery was uneventful,and no postoperative complications,such as incision infection or severe incision pain,were observed.The patient was discharged successfully on postoperative day 2.CONCLUSION The modified technical protocol of SLAN may be a new minimally invasive surgical alternative for patients with acute simple appendicitis.

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.

Recent advances in uniportal video-assisted thoracoscopic surgery

Thanks to the recent improvements in video-assisted thoracoscopic techniques （VATS） and anesthetic procedures, a great deal of complex lung resections can be performed avoiding open surgery. The experience gained through VATS techniques, enhancement of the surgical instruments ,improvement of high definition cameras and avoidance of intubated general anesthesia have been the greatest advances to minimize the trauma to the patient. Uniportal VATS for major resections has become a revolution in the treatment of lung pathologies since initially described 4 years ago. The huge number of surgical videos posted on specialized websites, live surgery events and experimental courses has contributed to the rapid learning of uniportal major thoracoscopic surgery during the last years. The future of the thoracic surgery is based on evolution of surgical procedures and anesthetic techniques to try to reduce the trauma to the patient. Further development of new technologies probably will focus on sealing devices for all vessels and fissure, refined staplers and instruments, improvements in 3D systems or wireless cameras, and robotic surgery. As thoracoscopic techniques continue to evolve exponentially, we can see the emergence of new approaches in the anesthetical and the perioperative management of these patients. Advances in anesthesia include lobectomies performed without the employment of general anesthesia, through maintaining spontaneous ventilation, and with minimally sedated patients. Uniportal VATS resections under spontaneous ventilation probably represent the least invasive approach to operate lung cancer.

Single-port transperitoneal robotic-assisted laparoscopic radical prostatectomy (spRALP): Initial experience

Objective:To assess the feasibility of single-port transperitoneal robotic-assisted laparoscopic radical prostatectomy(spRALP)and discuss its surgical technique.Methods:A 60-year-old male was admitted with an elevated prostate-specific antigen(PSA)level of 13.89 ng/mL and confirmed with prostate cancer on biopsy showing three of 22 positive cores with a Gleason score of 3þ4=7.Multiparametric magnetic resonance(MR)and bone scintigraphy showed organ-confined disease.spRALP was performed using da Vinci Si HD surgical system,with access of a quadri-channel laparoscopic port placed supraumbilically.Two drainage tubes were placed before wound closure.The surgical procedure was largely in consistence with a conventional robotic-assisted laparoscopic radical prostatectomy.Results:The surgery was successfully carried out with a duration of 152 min and an estimated blood loss of 100 mL.The patient was discharged on postoperative Day 4 after removal of both pelvic drainage tubes.Foley catheter was removed on postoperative Day 14.No major complications were encountered.Postoperative pathology showed a Gleason score of 3þ4=7 with no extraprostatic extension and negative surgical margins.Conclusion:Single-port robotic prostatectomy is feasible using the currently available robotic instruments in most Chinese robotic urological centers.Meticulous preoperative planning and careful patient selection are mandatory.Further studies concerning perioperative complications and pentafecta outcome compared with the conventional multi-port robotic prostatectomy is required.

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-port versus multi-port cholecystectomy for patients with acute cholecystitis: a retrospective comparative analysis

BACKGROUND: Trans-umbilical single-port laparoscopic cholecystectomy for chronic gallbladder disease is becoming increasingly accepted worldwide. But so far, no reports exist about the challenging single-port surgery for acute cholecystitis. The objective of this study was to describe our experience with single-port cholecystectomy in comparison to the conventional laparoscopic technique. METHODS: Between August 2008 and March 2010, 73 patients with symptomatic gallbladder disease and histopathological signs of acute cholecystitis underwent laparoscopic cholecystec- tomy at our institution. Thirty-six patients were operated on with the single-port technique (SP group) and the data were compared with a control group of 37 patients who were treated with the multi-port technique (MP group). RESULTS: The mean age in the SP group was 61.5 (range 21-81) years and in the MP group was 60 (range 21-94) (P=0.712). Gender, ASA status and BMI were not significantly different. The number of white blood cells was different before [SP: 9.2 (range 2.8-78.4); MP: 13.2 (range 4.4-28.6); P=0.001] and after the operation [SP: 7.8 (range 3.5-184.8); MP: 11.1 (range 5-20.8); P=0.002]. Mean operating time was 88 (range 34-174) minutes in the SP group vs 94 (range 39-209) minutes in the MP group (P=0.147). Four patients (5%) required conversion to an open procedure (SP: 1; MP: 3; P=0.320). During the follow- up period of 332 (range 29-570) days in the SP group and 428 (range 111-619) days in the MP group (P=0.044), eleven (15%) patients developed postoperative complications (P=0.745) and two patients in the SP group required reoperation (P=0.154). CONCLUSIONS: Trans-umbilical single-port cholecystectomy for beginning acute cholecystitis is feasible and the complicationrate is comparable with the standard multi-port operation. In spite of our good results, these operations are difficult to perform and should only be done in high-volume centers for laparoscopic surgery with experience in single-port surgery.

New trends in colorectal surgery: Single port and natural orifice techniques

Single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) have rapidly gained pace worldwide, potentially replacing conventional laparoscopic surgery (CLS) as the preferred colorectal surgery technique. Currently available data mainly consist of retrospective series analyzed in four meta-analyses. Despite conflicting results and lack of an objective comparison, SILS appears to offer cosmetic advantages over CLS. However, due to conflicting results and marked heterogeneity, present data fail to show significant differences in terms of operative time, postoperative morbidity profiles, port-site complications rates, oncological appropriateness, duration of hospitalization or cost when comparing SILS with conventional laparoscopy for colorectal procedures. The application of “pure” NOTES in humans remains limited to case reports because of unresolved issues concerning the ideal access site, distant organ reach, spatial orientation and viscera closure. Alternatively, minilaparoscopy-assisted natural orifice surgery techniques are being developed. The transanal “down-to-up” total mesorectum excision has been derived for transanal endoscopic microsurgery (TEM) and represents the most encouraging NOTES-derived technique. Preliminary experiences demonstrate good oncological and functional short-term outcomes. Large-scale randomized controlled trials are now mandatory to confirm the long-term SILS results and validate transanal TEM for the application of NOTES in humans.

Present laparoscopic surgery for colorectal cancer in Japan

In many clinical studies,laparoscopic surgery(LS) for colon cancer has been shown to be less invasive than open surgery(OS) while maintaining similar safety.Furthermore,there are no significant differences between LS and OS in long-term outcomes.Thus,LS has been accepted as one of the standard treatments for colon cancer.In the treatments of rectal cancer as well,LS has achieved favorable outcomes,with many reports showing long-term outcomes comparable to those of OS.Furthermore,the magnification in laparoscopy improves visualization in the pelvic cavity and facilitates precise manipulation,as well as providing excellent educational effects.For these reasons,rectal cancer has seemed to be well indicated for LS,as has been colon cancer.The indication for LS in the treatment of locally advanced rectal cancer,which is relatively unresectable(e.g.,cancer invading other organs),remains an open issue.In recent years,new techniques such as singleport and robotic surgery have begun to be introduced for LS.Presently,various clinical studies in our country as well as in most Western countries have demonstrated that LS,with these new techniques,are gradually showing long-term outcomes.

Single-port technique evolution and current practice in urologic procedures

Different groups described the single-port surgery since its first report in laparoscopic procedures.However,the acceptance of this technique among urologists,even after the robotic approach,was reduced in the past years.Therefore,to overcome the challenges related to the single-port surgery,a new robotic platform named da Vinci SP was created with exclusive single port technology.We performed a non-systematic literature review regarding the single port technique in urologic surgeries since the first laparoscopic report until the da Vinci SP robotic platform.Three different periods were described(laparoscopy,robotic,and da Vinci SP),and we focused in our experience with this new single port robot.We selected different articles and summarized the information regarding the use of single-site surgery in laparoscopic procedures and the challenges of this approach.We also reported the experience of different groups using the single port robotic technique and some recent reports of the da Vinci SP approach.In our experience with this new console,we described some critical points related to our radical prostatectomy technique and the lessons learned during the introduction of this novel platform.Previous single-site procedures described some common challenges that limited the technique expansion.However,our experience with the da Vinci SP described feasible and safe procedures with acceptable intraoperative outcomes.The introduction of this platform is recent in the market,and the literature still lacks a high level of evidence describing the long-term outcomes of this new technology.

Single port laparoscopic liver surgery:A minireview

Nowadays,the trend is to perform surgeries with"scarless"incisions.In light of this,the single-port laparoscopic surgery(SPLS)technique is rapidly becoming widespread due to its lack of invasiveness and its cosmetic advantages,as the only entry point is usually hidden in the umbilicus.The interest in"scarless"liver resections did not grow as rapidly as the interest in other scarless surgeries.Hepatopancreatobiliary surgeons are reluctant to operate a malignant lesion through a narrowincision with limited exposure.There are concerns over adverse oncological outcomes for single-port laparoscopic liver resections(SPL-LR)for hepatocellular carcinoma or metastatic colorectal cancer.In addition,getting familiar with using the operating instruments through a narrow incision with limited exposure is very challenging.In this article,we reviewed the published literature to describe history,indications,contraindications,ideal patients for new beginners,technical difficulty,advantages,disadvantages,oncological concern and the future of SPL-LR.

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.