Laparoendoscopic single‐site surgery: current clinical experience

摘要

Laparoendoscopic single-site surgery (LESS) uses a single skin incision, often concealed, to perform procedures with minimal scarring. Nearly all laparoscopic and robotic procedures in urology have been successfully performed using this approach. Despite being derived from similar minimally invasive principles, the performance of single-site surgery differs from the basic tenets of laparoscopic surgery. Triangulation is a key factor during standard laparoscopic surgery to provide the surgeon with an ergonomic means to perform dissection and suturing. Single port surgery defies this most basic tenet of laparoscopy and, not surprisingly, procedures can be quite difficult and movements inefficient with straight, non-articulating laparoscopic instruments (Fig. 1). An additional principle of laparoscopic surgery, placement of additional ports freely, would still be recommended if necessary, but by definition the number of additional port sites is severely limited if single port surgery is carried out successfully. Articulating instruments and flexible tip laparoscope being used through a single port platform. Several questions surround the widespread adoption of these new techniques. The first is whether there are benefits of LESS procedures compared to standard laparoscopic or robotic surgery. LESS is in its infancy and studies comparing it to laparoscopy are few with small case-control studies. Aesthetic advantages are easily recognizable but symptomatic benefits and oncological and reconstructive success rates have yet to be determined (Fig. 2). Another critical factor for successful adoption of LESS will be the development of instrumentation and surgical platforms to optimize ergonomics for performance of these procedures. Several single port devices have been developed but modification and optimization of these platforms is ongoing. Just as critical is the development of instrumentation, e.g. bent or articulating, which allows the surgeon to perform tasks safely, meticulously and comfortably. Robotic applications with smoother articulation and greater surgeon comfort hold promise for LESS procedures. Single umbilical scar after LESS ileal interposition. Undoubtedly, these procedures are more physically and conceptually challenging at this point in time; it is necessary to note that the single-site approach represents a technical paradigm shift which will require an evolution in instrumentation and adequate time for training to allow for widespread adoption. Initial reports of single incision surgery appeared in paediatric and general surgery literature. In 1998, Esposito [1] reported 25 consecutive paediatric appendectomy procedures using a single 10-mm subumbilical port. A laparoscope with a 5-mm channel was inserted through the single port as an instrument through the laparoscope was used to grasp the appendix and bring it out of the incision. Standard open techniques were then used to perform the appendectomy. Operative time averaged 25 min and no intraoperative or postoperative complications were noted. Piskun and Rajpal [2] in 1999 reported laparoscopic cholecystectomy in 10 patients through a single transumbilical incision. Two 5-mm ports were placed through the transumbilical incision and two percutaneous holding stitches were used for retraction of the gallbladder. All patients were discharged within 24 h of surgery. The initial two LESS urological cases, simple nephrectomy and ureterolithotomy, were reported by Ranéet al. [3] in abstract form at the 2007 World Congress of Endourology. Subsequently, Raman et al. [4] reported single umbilical incision nephrectomy in four pigs (eight renal units) and three humans (two non-functioning kidneys and one renal mass). They used three standard 5-mm laparoscopic ports through a single umbilical incision for the majority of the dissection. One of the trocars was exchanged for a 12-mm port for transection of the hilar vessels with an endovascular stapler. The human procedures were