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Laparoendoscopic single-site totally extraperitoneal (LESS-TEP) hernioplasty emerged in 2009, and various studies have been performed. However, no significant difference between LESS-TEP hernioplasty and conventional three-port totally extraperitoneal (TEP) hernioplasty has been found. We evaluated the benefits, safety, and feasibility of moving the incision downward to the suprapubic area when performing LESS-TEP hernioplasty. LESS-TEP hernioplasty with a suprapubic incision was performed in 21 patients at the Central Hospital of Shantou, China, from 1 May to 31 August 2019. The patient demographics, hernia type and site, operation time, estimated blood loss, length of surgical incision, defect and mesh areas, conversion to conventional TEP hernioplasty, and postoperative pain scale score were prospectively collected. Only regular laparoscopic instruments were used during surgery. Among 21 patients with hernias (male/female = 19:2), 12 had left inguinal hernias, 8 had right inguinal hernias, and 1 had bilateral inguinal hernias. The mean operative time was 93 min (range, 50–150 min). The mean estimated blood loss was 6.7 ml (range, 5–20 ml). No patients underwent conversion to conventional TEP hernioplasty or developed intraoperative complications. The mean postoperative pain scale score was 2.28 (range, 0–6). The mean hospital stay was 2.28 days (range, 1–6 days). Postoperative fever occurred in one patient and was managed successfully with supportive treatment. LESS-TEP hernioplasty with a suprapubic incision is safe and feasible because of better cosmetic outcomes, potential earlier convalescence, less interference among laparoscopic instruments, and broader indications. The learning curve is considered acceptable. [ABSTRACT FROM AUTHOR]

In the field of minimally invasive surgery, there is a constant drive to devise and execute the most minimally invasive surgeries possible. By the very nature of laparoscopy and robotic surgery, what one can accomplish with several ports of a given size will invariably be studied and attempted with fewer ports and with ports of smaller sizes. After researching the literature, we were not able to find any single port hysterectomies performed through a port size of smaller than 15 mm. We were able to perform, described here, a technique for performing laparoscopic hysterectomy through a single port of only 11 mm in diameter. We illustrate the technique in the accompanying video and believe the technique to be safe and reproducible. [ABSTRACT FROM AUTHOR]

Radical perineal prostatectomy (RPP) has been revived with the advent of single-port (SP) robotic surgery. However, its interest and precise role need to be evaluated and better defined. To describe in detail the technique of SP-RPP and compare initial perioperative outcomes with those of multiport robot-assisted transperitoneal radical prostatectomy (MP-RARP). From October 2018 to June 2020, perioperative data of 26 consecutive patients who underwent SP-RPP for localized prostate cancer (PCa) in a single institution were prospectively entered into an institutional review board–approved database. Data of 86 consecutive patients treated from September 2017 to September 2018 with MP-RARP by the same surgeon, before the beginning of the SP experience, were used as comparators. SP-RPP was performed using the SP robotic platform (Intuitive Surgical, Sunnyvale, CA, USA) according to the technique described in the supplementary video. Demographics, and intra- and postoperative data were analyzed in a matched-paired design with a 1:1 ratio on the following factors: age at surgery, prostate-specific antigen level, preoperative Gleason score, and history of abdominal surgery. After matching, baseline characteristics were comparable except for the rate of prior laparotomy, which was higher in the SP-RPP group (52% vs 8%, p < 0.001). In the SP-RPP group, 84% of the patients had a high risk and an unfavorable intermediate risk of positive surgical margins (PSMs) versus 57% in the MP-RARP group (p = 0.03). While the rate of nonlimited PSMs (ie, >3 mm) was higher in the SP-RPP group (38.5% vs 7.7%, p < 0.01), the number of patients with biochemical recurrence at 1 yr was comparable between SP-RPP and MP-RARP (1 vs 3, p = 0.3). SP-RPP is a complex procedure for patients with a complex surgical history and high-risk localized PCa with limited alternative therapeutic options. Our study suggests that patients with high-risk localized prostate cancer and limited treatment options due to a complex abdominal surgical history (ie, frozen pelvis) may be suitable candidates for single-port radical perineal prostatectomy. Single-port radical perineal prostatectomy is a feasible but challenging procedure for patients with complex surgical history (ie, frozen pelvis) and high-risk localized prostate cancer who have limited alternative therapeutic options. [ABSTRACT FROM AUTHOR]

Background: Usually laparoscopy is performed by means of a 2-dimensional (2D) image system and multiport approach. To overcome the lack of depth perception, new 3-dimensional (3D) systems are arising with the added advantage of providing stereoscopic vision. To further reduce surgery-related trauma, there are new minimally invasive surgical techniques being developed, such as LESS (laparoendoscopic single-site) surgery. The aim of this study was to compare 2D and 3D laparoscopic systems in LESS surgical procedures.Materials and Methods: All participants were selected from different levels of experience in laparoscopic surgery-10 novices, 7 intermediates, and 10 experts were included. None of the participants had had previous experience in LESS surgery. Participants were chosen randomly to begin their experience with either the 2D or 3D laparoscopic system. The exercise consisted of performing an ex vivo pork cholecystectomy through a SILS port with the assistance of a fixed distance laparoscope. Errors, time, and participants' preference were recorded. Statistical analysis of time and errors between groups was conducted with a Student's t test (using independent samples) and the Mann-Whitney test.Results: In all 3 groups, the average time with the 2D system was significantly reduced after having used the 3D system ( P < .05). In the postexercise questionnaire, two thirds of participants showed a preference for using the 3D system.Conclusion: This study suggests that the 3D system may improve the learning curve and that learning from the 3D system is transferable to the 2D environment. Additionally, the majority of participants prefer 3D equipment. [ABSTRACT FROM AUTHOR]

Objectives To define the learning curve of laparoendoscopic single-site surgery (LESS) of an experienced laparoscopist. Patients and methods Patients who had LESS, since its implementation in December 2009 until December 2014, were retrospectively analysed. Procedures were divided into groups of 10 and scored according to the European Scoring System for Laparoscopic Operations in Urology. Different LESS indications were done by one experienced laparoscopist. Technical feasibility, surgical safety, outcome, as well as the number of patients required to achieve professional competence were assessed. Results In all, 179 patients were included, with mean (SD) age of 36.3 (17.5) years and 25.4% of the patients had had previous surgeries. Upper urinary tract procedures were done in 65.9% of patients and 54.7% of the procedures were extirpative. Both transperitoneal and retroperitoneal LESS were performed in 92.8% and 7.2% of the patients, respectively. The intraoperative and postoperative complication rates were 2.2% and 5.6% (Clavien–Dindo Grade II 3.9% and IIIa 1.7%), respectively. In all, 75% of intraoperative complications and all conversions were reported during the first 30 LESS procedures; despite the significantly higher difficulty score in the subsequent LESS procedures. One 5-mm extra port, conversion to conventional laparoscopy and open surgery was reported in 14%, 1.7%, and 1.1% of the cases, respectively. At mean (SD) follow-up of 39.7 (11.4) months, all the patients that underwent reconstructive LESS procedures but one were successful. Conclusion In experienced hands, at least 30 LESS procedures are required to achieve professional competence. Although difficult, both conversion and complication rates of LESS are low in experienced hands. [ABSTRACT FROM AUTHOR]

The objective was to give a general overview of common complications and rates reported in the current literature during performance of a variety of urologic procedures using laparo-endoscopic single-site surgery or LESS. A search of published reports using Pubmed and MEDLINE was performed with the following search terms: laparo-endoscopic single-site surgery, LESS or laparo-endoscopic single-site surgery complications within the date range of 2005--2011. Studies that were deemed appropriate and relevant to the current symposium were chosen for review. Overall complication rates were reported as ranging between 10% and 25%. In general, reconstructive procedures had consistently higher rates of complications than their extirpative/ablative counterparts (27% vs. 8%). There remain insufficient data to comment on differences in the rates or types of complications related to variations in the approach (transperitoneal vs. retroperitoneal), site of surgery (upper tract vs. lower tract) or specific technique used (instruments, access devices, robotic platforms, etc.). Complication rates associated with LESS in urology appear only slightly higher than with conventional laparoscopy. However, with proper patient selection and careful application of these techniques, proofs of concept and technical feasibility have been shown in several series. There continues to be a need for more standardization of the technique and reporting as well as more collaborative efforts to fully address questions of safety and efficacy of these new procedures.

Minimal access surgery is rapidly expanding and currently single-port surgery is at the forefront of laparoscopy. Operating through a single port is technically demanding but through advances in camera design and instrument design, it is now gaining popularity. It offers minimal scar surgery as well as decreased postoperative pain and swift recovery. Here we present a case of bilateral simultaneous single-port laparoscopic nephrectomy (LESS) laparoendoscopic single site surgery in a 51-year-old man. Illustrating that LESS can be used by surgeons with laparoscopic skills outside of a few major international centers.

Background: Sleeve gastrectomy has become an established primary bariatric surgical technique. Its relatively lower complexity has made it eligible to be performed by single-incision laparoscopy (single-incision laparoscopic sleeve gastrectomy, SILSG). The aim of this paper is to present our SILSG technique and surgical outcomes and demonstrate that SILSG is a safe and feasible procedure using conventional laparoscopic instruments. Methods: All patients who underwent SILSG since December 2012 in our institution were analyzed. The operative technique involved creation of a transumbilical incision and the introduction of a GelPoint device with four trocars. Rigid instruments were used in all patients. Gastric transection was performed 4 cm proximal to the pylorus and calibrated with a 36-Fr bougie. Hemostasis of the staple line was achieved with metallic clips. Results: A total of 74 patients underwent SILSG. Their mean age and body mass index were 34.2 ± 9.2 years and 34.0 ± 3.2 kg/m (range 30.0-42.7 kg/m), respectively. The mean operative time was 48 ± 10 min. No reoperations or deaths occurred. One patient developed portal vein thrombosis. The mean length of hospital stay was 2.4 ± 2.0 days. The cosmetic result was satisfactory in all patients. Conclusions: SILSG is a safe and feasible procedure when performed with the technique described herein. This technique allows for the use of conventional laparoscopic instruments and reasonable operative times. The main benefit of the procedure is an excellent cosmetic result with virtually no visible scars. [ABSTRACT FROM AUTHOR]

Background In patients with localized high-risk prostate cancer awaiting radiation therapy, pelvic lymphadenectomy (PL) is a reliable minimally invasive staging procedure. We compared outcomes after laparoendoscopic single site PL (LESSPL) with those after conventional multiport laparoscopic PL (MLPL). Methods A retrospective case-control study was carried out at the authors' center. For LESSPL the reusable X-Cone single port was combined with straight and prebent laparoscopic instruments and an additional 3 mm needlescopic grasper. MLPL was performed via four trocars of different sizes using standard laparoscopic instruments. Results Patients who underwent either LESSPL (n = 20) or MLPL (n = 97) between January 2008 and July 2013, were included in the study. Demographic data were comparable between groups. Patients in the LESSPL group tended to be older and had a significantly higher ASA score. The mean operating time was 172.4 ± 34.1 min for LESSPL and 116.6 ± 40.1 min for MLPL (P < .001). During LESSPL, no conversion to MLPL was necessary. An average of 12 lymph nodes per patient was retrieved, with no significant difference between study groups. Postoperative pain scores were similar between groups. The hospital stay was 2.3 ± 0.7 days after LESSPL and 3.1 ± 1.2 days after MLPL (P = .01). Two days postoperatively, significantly more patients after LESSPL than after MLPL recovered their normal physical activity (P < .001). Six months postoperatively, no complications were registered in the LESSPL group and cosmetic results were excellent. Conclusions In the present study, shorter hospitalization and quicker postoperative recovery were major benefits of LESSPL over MLPL. In patients with localized prostate cancer, staging LESS pelvic lymphadenectomy may be a safe alternative to conventional multiport laparoscopy. [ABSTRACT FROM AUTHOR]

Purpose: To describe the surgical technique and to report the midterm outcomes of laparoendoscopic single-site radical prostatectomy (LESS-RP) with a homemade single-port device. Methods: Between August 2009 and October 2011, 20 LESS-RP procedures were performed in a single center by a high-volume surgeon. The surgical methods are outlined in the paper. Preoperative, perioperative, pathologic, midterm oncological, and functional outcomes data were analyzed. Results: On average, patients were 66.1 years old, had a mean body mass index of 24.4 kg/m, and a mean prostate-specific antigen (PSA) value of 12.2 ng/ml. No conversion was required; however, a single additional 5-mm port was required in one case. The mean operative time was 248 min; mean estimated blood loss was 94 ml. The mean visual analog pain score at day 3 was 1.5 out of 10, and the mean hospital stay was 15.4 day. Pathology showed one focal positive margin (5 %) in a T3a patient, and mean Gleason score was 6.7. There were a total of four Clavien grade 2 complications. The median follow-up was 22.8 month (range 12-36 month). No PSA recurrence was detected during follow-up period; the potency rate after bilateral neurovascular bundle preservation was 60 % (3/5). Complete continence recovery (no pad) was observed in 85 % of the patients at 1 year, in 90 % at 2 years, and in all three patients at 3 years. Conclusions: LESS-RP is technically feasible and safe, with excellent cosmesis, low postoperative pain levels, and acceptable midterm oncological, and functional outcomes. Comparative investigation to conventional LRP is needed. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To describe the characteristics of 35 myomas in 28 patients who underwent laparoendoscopic single-site myomectomy (LESS-M). Study design: Retrospective analysis of 28 patients who underwent LESS-M at Samsung Medical Center from January 2009 to January 2013. Results: The median age of 28 patients was 34 years (range: 27–61) and median body mass index was 21.9 (range: 17.3–28.5). The median number of extracted myomas was one (range: 1–4) and the largest myoma diameter was 6cm (range: 2–15). The total number of extracted myomas was 35 and the types of extracted myoma were subserosal (16 myomas, 45.7%), intramural (nine myomas, 25.7%) and intraligamentary (seven myomas, 20%). In subserosal and intramural myoma, 21 myomas were located at the anterior wall and four myomas were located at the posterior wall of the uterus. Median operation time was 131min (range: 35–232). Estimated intraoperative blood loss was 65mL (range: 20–300), hemoglobin change was 2g/dL (range: 0.5–2.9) and hospital stay was 3 days (range: 1–4). There was no conversion to laparotomy but in one patient (3.6%), LESS-M converted to two-port laparoscopic myomectomy. There was no blood transfusion during and after operation. Intraoperative and postoperative complications did not occur. Conclusion: Careful selection of patients considering the type and location of myomas is important for successful LESS-M. Myomas located in the anterior wall, subserosal or intraligamentary myomas are appropriate for LESS-M. [Copyright &y& Elsevier]

Background: This study aimed to compare laparoendoscopic single-site varicocelectomy (LESSV) with multiport laparoscopic varicocelectomy (MLV) in terms of intraoperative parameters and postoperative outcomes. Methods: A retrospective case-control study investigated 10 male adolescents and 89 adults who underwent either LESSV or MLV at the authors' center. The reusable X-Cone single port was inserted transumbilically. A 5-mm 30° telescope was used together with a straight and a prebent laparoscopic instrument. The MLV procedure was performed using two 5-mm ports and one 10-mm port. Results: Between January 2009 and November 2012, 20 patients underwent LESSV and 79 patients underwent MLV. The demographic data were comparable between the two groups. The mean operating time was 59.1 ± 15.5 min for LESSV and 51.2 ± 14.4 min for MLV ( P = 0.04). In the LESSV group, no conversion to MLV was necessary. The hospital stay was 1.6 ± 0.7 days in the LESSV group versus 1.8 ± 0.5 days in the MLV group ( P = 0.17). The postoperative pain scores did differ between the two groups. By day 2, significantly more patients in the LESSV group than in the MLV group fully recovered their normal physical activity ( P = 0.02). Comparison of pre- and postoperative values showed relief of testicular pain and improvement of semen parameters for the majority of the patients. The overall incidence of complications was distributed equally between the two groups as follows: paresthesia of the upper thigh (8 %), wound infection (5 %), epididymitis (3 %) and hydrocele (4 %). All the patients in the LESSV group were fully satisfied with their cosmetic results compared with only 76 % of the patients in the MLV group ( P = 0.01). Conclusions: The LESSV procedure performed with the reusable X-Cone is as safe and efficient as MLV. After LESSV, the parameters measuring postoperative patient satisfaction are significantly improved. Given its reusable components, including prebent laparoscopic instruments, the X-Cone platform is a cost-effective alternative to disposable or homemade single ports. [ABSTRACT FROM AUTHOR]

Objective: To compare surgical outcomes and complications between single-port access (SPA) and multi-port access (MPA) laparoscopy-assisted vaginal hysterectomy (LAVH). Study design: A retrospective review of medical records was performed in patients who underwent LAVH for non-malignant gynaecological diseases at Eun Hospital between April 2010 and April 2012. One hundred and twenty women underwent SPA LAVH using a transumbilical three-channel single-port system and 130 women underwent conventional MPA LAVH. Surgical outcomes and complications were compared between the two groups. Results: The outcomes of the SPA-LAVH group vs. the conventional MPA-LAVH group were as follows: mean±standard deviation total operative time (73.1±24.3 vs. 70.3±22.1min, p =0.349), largest dimension of uterus (10.7±2.3 vs. 10.8±2.8cm, p =0.847), weight of extirpated uterus (311±185 vs. 339±234g, p =0.298) and change in haemoglobin (1.7±0.8 vs. 2.0±0.9g/dl, p =0.025). The incidence of complications was similar in each group (20 vs. 16 patients, p =0.327). Unplanned intra-operative laparotomy was not necessary in either group, and there were no cases of bowel injury or main vessel injury in either group. In total, there were three bladder injuries: one in the SPA-LAVH group and two in the MPA-LAVH group. The postoperative course was uneventful in most patients, but six patients had a transient paralytic ileus (four in the SPA-LAVH group and two in the MPA-LAVH group) and 10 patients had a pelvic haematoma (five in each group), all of whom recovered following conservative management. Port-related complications were rare, but one patient in the SPA-LAVH group had a port-site umbilical hernia. Conclusion: Use of SPA and MPA LAVH has similar results in terms of surgical outcomes and complications. [ABSTRACT FROM AUTHOR]

Abstract: Background: Laparoendoscopic single-site surgery (LESS) has emerged as a natural progression from standard laparoscopy aiming to further minimize the morbidity of urologic procedures. Objective: To describe our technique and report the surgical and functional outcomes of unclamped LESS partial nephrectomy (PN) in the treatment of small renal masses (SRMs). Design, setting, and participants: Prospective evaluation of pre- and postoperative variables of patients undergoing the LESS-PN without ischemia between 2009 and 2012. The indications were single exophytic SRMs. Surgical procedure: Unclamped LESS-PN was performed through a transperitoneal approach. A pararectal Hasson access technique was preferred. Single-port access was achieved via different single-port devices. A combination of straight and articulating laparoscopic instruments was used. The tumor was excised using bipolar scissors during normal renal perfusion. Hemostasis was achieved by bipolar electrocautery, parenchymal stitches, and hemostatic agents. Outcome measurements and statistical analysis: Demographic, operative, postoperative, and pathologic outcomes data were recorded and analyzed. Results and limitations: A total of 21 LESS-PN were performed (operative time: 111±41min; blood loss: 196±195ml: tumor size: 2.0±0.3cm). Neither conversion to open surgery nor transfusions occurred. Three patients required conversion to standard laparoscopy. Postoperatively, three complications (Clavien grades 2, 3a, and 4) were recorded. Pathologic examination revealed 14 clear cell carcinomas, four renal cysts, two oncocytomas, and one angiomyolipoma. Hospital stay was 4.4±1.9 d. At the last follow-up (mean: 17±11.5 mo), no port-site, local, or distant recurrences were detected. No significant variation in serum creatinine and estimated glomerular filtration rate was observed. Subjective scar evaluation indicated 66% of patients were very satisfied/enthusiastic. Study limitations include the small sample size, the lack of a control group, the short follow-up period, and the arbitrary measure of patient''s scar perception. Conclusions: Unclamped LESS-PN for selected SRMs is a safe and feasible procedure providing favorable postoperative outcomes and ensuring high levels of subjective, cosmetic satisfaction. [Copyright &y& Elsevier]

The objective was to give a general overview of common complications and rates reported in the current literature during performance of a variety of urologic procedures using laparo-endoscopic single-site surgery or LESS. A search of published reports using Pubmed and MEDLINE was performed with the following search terms: laparo-endoscopic single-site surgery, LESS or laparo-endoscopic single-site surgery complications within the date range of 2005-2011. Studies that were deemed appropriate and relevant to the current symposium were chosen for review. Overall complication rates were reported as ranging between 10% and 25%. In general, reconstructive procedures had consistently higher rates of complications than their extirpative/ablative counterparts (27% vs. 8%). There remain insufficient data to comment on differences in the rates or types of complications related to variations in the approach (transperitoneal vs. retroperitoneal), site of surgery (upper tract vs. lower tract) or specific technique used (instruments, access devices, robotic platforms, etc.). Complication rates associated with LESS in urology appear only slightly higher than with conventional laparoscopy. However, with proper patient selection and careful application of these techniques, proofs of concept and technical feasibility have been shown in several series. There continues to be a need for more standardization of the technique and reporting as well as more collaborative efforts to fully address questions of safety and efficacy of these new procedures. [ABSTRACT FROM AUTHOR]

Background: Laparoendoscopic single-site surgery (LESS) has emerged as a technique that uses a natural scar, the umbilicus, within which a multiple-entry portal is placed into a 3.0-4.0-cm single incision to perform operations. The objective of this study was to compare incision size, wound complications, and postoperative pain of LESS compared with those of laparoscopic cholecystectomy (LC). Methods: A prospective randomized controlled study was conducted between January and June 2011 at two university hospitals in Rio de Janeiro, Brazil. Fifty-seven patients were randomly assigned to undergo laparoscopic or LESS cholecystectomy. Skin and aponeurosis wound sizes were recorded. A 10-point visual analog scale (VAS) was used to assess pain at postoperative hours 3 and 24. Healing and wound complications were assessed at follow-up. Results: A total of 57 patients, 53 women and 4 men with a mean age of 48.7 years, were randomly assigned to undergo LESS ( n = 28) or LC ( n = 29). The mean length of the umbilical skin incision was 4.0 cm (range = 2.1-5.8) in LESS and 2.7 cm (1.5-5.1) in LC ( p < .0001). The mean internal aponeurosis diameter was 3.5 cm (2.0-5.5) in LESS and 2.3 cm (1.2-3.5) in LC ( p < .0001). The mean operative time was 60.3 min (32-128) for LESS and 51.3 min (25-120) for LC ( p = 0.11). Gallbladder perforation at detachment occurred in 15.69 % of the LESS cases and in 5.88 % of the LC cases ( p = 0.028). The mean VAS score for pain at hour 3 was 2.0 points (0-7) for the LESS group and 4.0 (0-10) for the LC group ( p = 0.07), and at postoperative hour 24 it was 0.3 points (0-6) for LESS and 2.3 (0-10) for LC ( p = 0.03). There were no significant differences in wound complications. Incisional hernias were not found in either group. Conclusions: The LESS single-port (SP) operations demand a bigger incision than LC surgery. However, there were no differences in healing, wound infections, and hernia development. We found a tendency of less postoperative pain associated with LESS/SP than with LC. [ABSTRACT FROM AUTHOR]

Abstract: Background: Laparoendoscopic single-site (LESS) radical prostatectomy (RP) has been performed through different approaches. A new DuoRotate manual system developed by Richard Wolf (KeyPort; Richard Wolf GmbH, Knittlingen, Germany) can be applied to RP. Objectives: Our aim was to describe the surgical technique and report early outcomes of KeyPort LESS-RP to determine if this procedure is feasible and safe. Design, setting, and participants: Prospective study performed between October 2011 and January 2012 to standardize LESS-RP. A total of 31 procedures were performed (10 with and 21 without neurovascular preservation, 8 with and 23 without pelvic lymph node dissection). Surgical procedure: LESS-RP was performed using the methods outlined in the manuscript. All patients underwent LESS RP by the same surgical team. Access was achieved via a tri-channel reusable KeyPort and one 3.5-mm extra port to facilitate urethrovesical anastomosis and drainage extraction. Outcome measurements and statistical analysis: Preoperative, perioperative, and pathologic outcomes data are presented. Results and limitations: The mean age of the patients was 64 yr; mean body mass index: 30.7kg/m2; mean prostate-specific antigen level: 7 ng/ml; mean operative time: 207min; and mean estimated blood loss: 258ml. The average length of stay was 2.9 d and visual analog pain score (range: 0 [no pain] to 10) at day 2 was 1.2. Five focal positive margins (16.7%) were encountered (4.4% for pT2 and 57.1% for pT3). Five cases (16.7%) were pT2a, 3 (10%) were pT2b, 15 (50%) were pT2c, and 7 (23.3%) were pT3a. Lymph node dissection results were negative in all patients. Major complications occurred in two patients (6.5%) (hypercapnia with respiratory acidosis and rectourethral fistula) and minor complications in four (12.9%) (atrial fibrillation, orchitis, transfusion, and vomiting). No case required additional analgesia. Incision was totally hidden in the umbilicus. Study limitations included short follow-up (mean: 20.2±4.1 wk), premature functional data, and absence of a comparative cohort. Conclusions: The KeyPort system allows performance of umbilical RP with few complications, a low positive-margin rate, excellent aesthetic results, and very low postoperative pain levels. [Copyright &y& Elsevier]

Introduction: The conventional laparoscopic surgery is now paving way to the new technologies including robotic and laparoscopic single-site surgery (LESS). We present our updated experience on LESS radical nephrectomy (LESS-RN). Patients and methods: The data from patients undergoing LESS-RN in our two institutions were reviewed along with various clinical and pathological parameters. Results: Between 2008 and 2011, 42 LESS-RN were performed (right = 22, left = 20) with mean (range) age and BMI of 63.7 (33-86) years and 25.1 (18-38.6) kg/m, respectively. In addition to the instruments in the single port, one extra 3-mm needlescopic instrument was required in 19 patients (right = 17, left = 2). In three patients, two additional 5-mm trocars and instruments were required. None required open conversion. The recorded adverse events include one bowel injury (intraoperative closure without the need for stoma), one postoperative bleeding requiring blood transfusion, one prolonged ileus, and one deep venous thrombosis. The resected specimens revealed pT1a ( n = 3), pT1b ( n = 33), pT2a ( n = 4), and pT3b ( n = 2) tumors. The finding of pT3b was incidental rather than planned procedure. None of the patients had positive margins. Conclusion: LESS-RN has proven to be feasible and safe. Beyond cosmesis, further advantages of this approach need to be addressed by randomized trials. [ABSTRACT FROM AUTHOR]

Introduction: We present the first human case of laparo-endoscopic single-site sigmoidectomy with transanal natural orifice specimen extraction.Discussion: This technical achievement is a new step toward pure colorectal Natural Orifices Transluminal Endoscopic Surgery. It is the product of a gradual development with critical steps being conceived and standardised in years of experimental and clinical procedures. [ABSTRACT FROM AUTHOR]

Abstract: Background: Recent reports have suggested that robotic laparoendoscopic single-site surgery (R-LESS) is feasible, yet comparative studies to conventional laparoscopy are lacking. Objective: To report our early experience with R-LESS radical nephrectomy (RN). Design, setting, and participants: A retrospective review of R-LESS RN data was performed between May 2008 and November 2010. A total of 10 procedures were performed and subsequently matched to 10 conventional laparoscopic RN procedures (controls). The control group was matched with respect to patient age, body mass index (BMI), American Society of Anesthesiologists score, surgical indication, and tumor size. Surgical procedure: R-LESS RN was performed using methods outlined in the manuscript and . All patients underwent R-LESS RN by a single surgeon. Single-port access was achieved via two commercially available multichannel ports, and robotic trocars were inserted either through separate fascial stabs or through the port, depending on the type used. The da Vinci S and da Vinci-Si Surgical Systems (Intuitive Surgical, Sunnyvale, CA, USA) with pediatric and standard instruments were used. Measurements: Preoperative, perioperative, pathologic, and functional outcomes data were analyzed. Results and limitations: The mean patient age was 64.0 yr of age for both groups, and BMI was 29.2kg/m2. There was no difference between R-LESS and conventional laparoscopy cases in median operative time, estimated blood loss, visual analogue scale, or complication rate. The R-LESS group had a lower median narcotic requirement during hospital admission (25.3 morphine equivalents vs 37.5 morphine equivalents; p =0.049) and a shorter length of stay (2.5 d vs 3.0 d; p =0.03). Study limitations include the small sample size, short follow-up period, and all the inherent biases introduced by a retrospective study design. Conclusions: R-LESS RN offers comparable perioperative outcomes to conventional laparoscopic RN. Prospective comparison is needed to definitively establish the position of R-LESS in minimally invasive urologic surgery. [Copyright &y& Elsevier]

OBJECTIVE: • To present complications and rates of conversion from LESS to conventional laparoscopy (CL) at the time of upper tract LESS urologic procedures. PATIENTS AND METHODS: • Patients undergoing LESS upper tract procedures between September, 2007 and November, 2008 ( n = 125) were identified at six high-volume academic centers pioneering urologic LESS procedures. All LESS procedures were performed transperitoneally via a single umbilical incision using either adjacent conventional trocars or a dedicated single-site accessdevice. Reconstructive procedures incorporating a single planned 2 mm accessory needle port were included as LESS procedures and were not consideredconversions. • Patients, undergoing LESS procedures requiring conversion to CL with the placement of additional ports were identified. Conversion was defined as the placement of additional 5 or 10/12 mm ports beyond the primary incision. In each case the operative reports were reviewed, the reason for conversion was determined, and the number and types of additional ports and complications were noted. RESULTS: • Upper tract LESS procedures were performed in 125 patients comprising 13.3% of the total 937 laparoscopic procedures performed at the participating institutions during this time period. Conversion to CL was necessary in 7 patients (5.6%) undergoing LESS requiring the addition of 2– 5 ports. • Reasons for conversion included:facilitate dissection in 3 (43%), facilitate reconstruction in 3 (43%), and control of bleeding in 1 (14%). All attempted LESS cases were completed laparoscopically without need for open conversion. • Complications occurred in 15.2% of patients undergoing LESS surgery. Three of the 7 patients that required conversion to CL developed postoperative complications (Clavien grade II in two and IIIa in one). • Limitations of this study included the inability to standardize LESS patient selection criteria, instrumentation andsurgical technique as well as the lack of available complete data from a CL control group for comparison. CONCLUSION: • LESS surgery is technically feasible for a variety of upper urinary tract reconstructive and ablative procedures, although it appears to be associated with higher rates of complications than in mature CL series. Conversion to CL occurs infrequently and may be a reflection of stringent patient selection. [ABSTRACT FROM AUTHOR]

Laparoendoscopic single-site surgery (LESS) is a novel technique that aims to perform abdominal surgery through a single incision. Various access techniques and ports exist. This review will attempt to describe the currently available ports as well as highlight their advantages and disadvantages. [ABSTRACT FROM AUTHOR]

OBJECTIVE We evaluated the feasibility and the potential advantages of a modification of the single-port laparoscopic radical prostatectomy using a periumbilical multichannel port plus a second port placed in the left fossa with the aim of having an adequate working angle during the most critical steps of the procedure. PATIENTS AND METHODS Between March and September 2009 we operated on five patients with early-stage prostate cancer (T1c) and a normal body mass index ( < 25). The procedure was carried out with a specially-designed multichannel trocar which contains two 5mm and one 10mm ports plus a 5mm port placed in the left iliac fossa in order to have an adequate working angle. The first two patients received a nerve sparing radical prostatectomy. RESULTS All cases were completed successfully in a mean operative time of 225 minutes (range 210-250) with blood losses of less than 100ml. All patients were discharged from the hospital in 3rd postoperative day and the catheter was always removed seven days from surgery. No intraoperative complications occurred. The pathological tumour stage revealed pT2bNo prostate cancer in all five cases without positive surgical margins. After a mean follow-up of 4 months (range 1-7) all patients have an undetectable prostate-specific antigen level and no postoperative early major complications. The first two patients were fully continent respectively after 3 and 8 weeks after surgery, the third patient uses one safety pad after three month from surgery. The last two patients have a moderate incontinence and are currently under rehabilitation. Regarding potency the first patient had intercourses without any therapies after two months from surgery while the second one (6 months follow up) has partial penile tumescence using oral vardenafil. CONCLUSION Two ports laparoscopic radical prostatectomy is feasible in very selected cases. However, our pilot study should be still considered a technical report and the limits of the technique must still be defined in a larger population and by other investigators. [ABSTRACT FROM AUTHOR]

Abstract: The objective of this article was to review the published literature on laparoendoscopic single-site surgery (LESS) in gynecology and to present current advances in instruments used in LESS surgery. Inasmuch as LESS surgery is relatively new, the current literature on use of this technique in gynecology is somewhat limited. Sixteen articles were available for the literature review: 10 case series, 2 comparative studies, 3 case reports, and 1 surgical technique demonstration. In recent years, however, improvements in traditional laparoscopic techniques and availability of more advanced instruments has made single-incision laparoscopy more feasible and safer for the patient. There is increasing interest in LESS surgery both as an alternative to traditional laparoscopy and as an adjunct to robotic surgery when performing complicated procedures through a single incision. Although LESS surgery provides another option in the arena of minimally invasive gynecologic surgery, the ultimate role of this approach remains to be determined. [ABSTRACT FROM AUTHOR]

Abstract: Background: Laparoendoscopic single-site (LESS) surgery is challenging. To help overcome current technical and ergonomic limitations, the da Vinci robotic platform can be applied to LESS. Objectives: Our aim was to describe the surgical technique and to report the early outcomes of robotic LESS (R-LESS) radical prostatectomy (RP). Design, setting, and participants: A retrospective review of prospectively captured R-LESS RP data was performed between May 2008 and May 2010. A total of 20 procedures were scheduled (12 with and 8 without pelvic lymph node dissection). Surgical procedure: R-LESS prostatectomy was performed using the methods outlined in the paper and in the supplemental video material. Interventions: All patients underwent R-LESS RP by one high-volume surgeon. Single-port access was achieved via a commercially available multichannel port. The da Vinci S and da Vinci Si surgical platform was used with pediatric and standard instruments. Measurements: Preoperative, perioperative, pathologic, and functional outcomes data were analyzed. Results and limitations: The mean age was 60.4 yr; body mass index was 25.4kg/m2. The mean operative time was 189.5min; estimated blood loss was 142.0ml. The average length of stay was 2.7 d, and the visual analog pain score at discharge was 1.4 of 10. Four focal positive margins were encountered, with two occurring during the first three cases. Pathology revealed a Gleason score of 3+3 in 3 patients, 3+4 in 11 patients, 4+3 in 4 patients, and 4+4 in 2 patients. There were a total of four complications according to the Clavien system including one grade 1, two grade 2, and one grade 4. The median follow-up has been 4 mo (range: 1–24 mo). Study limitations include the small sample size, the short follow-up, and the lack of comparative cohort. Conclusions: The R-LESS RP is technically feasible and reduces some of the difficulties encountered with conventional LESS RP. [Copyright &y& Elsevier]

Laparoscopic surgery is frequently used in urology and the introduction of the da Vinci surgical system has served to further increase the demand for these procedures. Yet, laparoscopy is not without its drawbacks including port site complications, such as bleeding, hernia, internal organ damage and scarring. To further decrease morbidity of standard laparoscopy, newer techniques such as laparoendoscopic single-site surgery (LESS) are currently being investigated. LESS is technically challenging and reduces instrument triangulation and robust retraction, and is associated with a steep learning curve. To help overcome current limitations we have introduced the da Vinci surgical system to LESS and report our experience with robotic laparoendoscopic single-site surgery. [ABSTRACT FROM AUTHOR]

Abstract: Background: Laparoendoscopic single-site surgery (LESS) allows for the performance of major urologic procedures with a single small incision and minimal scarring. The da Vinci Surgical System provides advantages of easy articulation and improved ergonomics; however, an ideal platform for these procedures has not been identified. Objective: To evaluate the GelPort laparoscopic system as an access platform for robotic LESS (R-LESS) procedures. Design, setting, and participants: Since April 2008, 11 R-LESS procedures have been completed successfully in a single institutional referral center. For the last four consecutive cases, the GelPort has been used as an access platform through a 2.5–5-cm umbilical incision. Intervention: R-LESS cases performed with the GelPort included pyeloplasty (n =2), radical nephrectomy (n =1), and partial nephrectomy (n =1). Measurements: Perioperative data were obtained for all patients including demographic data, operative indications, operative records, length of stay, complications, and pathologic analysis. Results and limitations: For both pyeloplasty cases, average operative time (OR time) was 235min and estimated blood loss (EBL) was 38cm3. For the patient undergoing radical nephrectomy for a 5.1-cm renal tumor, OR time was 200min and EBL was 250cm3. The final patient underwent partial nephrectomy without renal hilar clamping for an 11-cm angiomyolipoma with OR time of 180min and EBL of 600cm3. All R-LESS procedures attempted with the GelPort were completed successfully and without complication. Average length of hospital stay was 1.75 d (range: 1–2). The partial nephrectomy patient required transfusion of 1 U of packed red blood cells. Conclusions: Use of the GelPort as an access platform for R-LESS procedures provides adequate spacing and flexibility of port placement and acceptable access to the surgical field for the assistant, especially during procedures that require a specimen extraction incision. Additional platform and instrumentation development will likely simplify R-LESS procedures further as experience grows. [Copyright &y& Elsevier]

Currently, over 80% of radical prostatectomies have been performed with the da Vinci Surgical System. In order to improve the aesthetic outlook and decrease the morbidity of the operation, the new da Vinci Single Port (SP) system was developed in 2018. However, one major problem is the SP system is still not available in most countries. We aim to present our initial experience and show the safety and feasibility of the single-site robotic-assisted radical prostatectomy (LESS-RP) using the da Vinci Single-Site platform. From June 2017 to January 2020, 120 patients with localized prostate cancer (stage T1–T3b) at Kaohsiung Medical University Hospital were included in this study. We describe our technique and report our initial results of LESS-RP using the da Vinci Si robotic system. Preoperative, intraoperative and postoperative patient variables were recorded. Prostate-specific antigen (PSA)-free survival was also analyzed. A total of 120 patients were enrolled in the study. The median age of patients was 68 years (IQR 63–71), with a median body mass index of 25 kg/m2 (IQR 23–27). The median PSA value before operation was 10.7 ng/mL (IQR 7.9–21.1). The median setup time for creat-ing the extraperitoneal space and ports document was 25 min (IQR 18–34). The median robotic console time and operation time were 135 min (IQR 110–161) and 225 min (IQR 197–274), respectively. Median blood loss was 365 mL (IQR 200–600). There were 11 (9.2%) patients who experienced complications (Clavien–Dindo classification Gr II). The me-dian catheter duration was 8 days (IQR 7–9), with a median of 10 days (IQR 7–11) of hospital stay. The PSA free-survival rate was 86% at a median 19 months (IQR 6–28) of follow up. Robotic radical prostatectomy using the da Vinci Single-Site platform system is safe and feasible, with acceptable outcomes. [ABSTRACT FROM AUTHOR]

Objective: Because minimally invasive hysterectomy has become increasingly performed by gynecologic surgeons, strategies to further improve outcomes have emerged, including innovations in surgical approach. We sought to evaluate the intraoperative and perioperative outcomes and success rates of laparoendoscopic single-site surgery (LESS) and vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy in comparison with those of conventional multiport laparoscopic (MPL) hysterectomy.Data Sources: A librarian-led search of PubMed, Scopus, CINAHL, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials was performed for case-control, retrospective cohort, and randomized controlled trials through May 2020.Methods Of Study Selection: The inclusion criterion was publications comparing LESS or vNOTES hysterectomy with conventional MPL hysterectomy for the management of benign or malignant gynecologic disease. Four authors reviewed the abstracts and selected studies for full-text review. The manuscripts were reviewed, separately, by 2 authors for final inclusion and assessment of bias using either the risk-of-bias assessment tool or the Newcastle-Ottawa scale. Any disagreement was resolved by discussion with, or arbitration by, a third reviewer. The titles of 2259 articles were screened, and 108 articles were chosen for abstract screening. Full-text screening resulted in 29 studies eligible for inclusion.Tabulation, Integration, and Results: Extracted data were placed into REDCap (Vanderbilt University, Nashville, TN), and MPL hysterectomy was compared with single-port hysterectomy using meta-analysis models. The outcomes included estimated blood loss (EBL); operative (OP) time; transfusion; length of hospital stay (LOS); conversion to laparotomy; visual analog scale pain scores at 12 hours, 24 hours, and 48 hours; any complications; and 7 subcategories of complications. Random-effects models were built for continuous outcomes and binary outcomes, and the results are reported as standardized mean difference (SMD) or odds ratio (OR) and their corresponding 95% confidence intervals, respectively. Meta-analysis could not be performed for vNOTES vs MPL, given that only 3 studies met the eligibility criteria. When LESS and MPL were compared, there was a shorter OP time for MPL (SMD = -0.2577, p <.001) and lower rate of transfusion (OR = 0.1697, p <.001), without a significant difference in EBL (SMD = -0.0243, p = .689). There was a nonsignificant trend toward higher risk of conversion to laparotomy in the MPL group (OR = 2.5871, p = .078). Pain scores were no different 12 or 24 hours postoperatively but were significantly higher at 48 hours postoperatively (SMD = 0.1861, p = .035) in the MPL group. There were no differences in overall or individual complications between the LESS and MPL groups. In the vNOTES comparison, 2 studies demonstrated shorter OP times, with reduced LOS and no difference in complications.Conclusion: In this meta-analysis, we identified that LESS hysterectomy has comparable and low overall rates of complications and conversion to laparotomy compared with MPL. Notably, the OP time seems longer, and the pain scores at 48 hours may be lower with LESS hysterectomy than with MPL hysterectomy. Limited data suggest that vNOTES hysterectomy may have shorter OP times and improved EBL, transfusion rates, LOS, and pain scores compared with MPL hysterectomy, but further study is needed. There remains a deficit in high-quality data to understand the differences in cosmesis among these surgical approaches. The quality of data for this analysis seems to be low to moderate. [ABSTRACT FROM AUTHOR]

Minimal access surgery is rapidly expanding and currently single-port surgery is at the forefront of laparoscopy. Operating through a single port is technically demanding but through advances in camera design and instrument design, it is now gaining popularity. It offers minimal scar surgery as well as decreased postoperative pain and swift recovery. Here we present a case of bilateral simultaneous single-port laparoscopic nephrectomy (LESS) laparoendoscopic single site surgery in a 51-year-old man. Illustrating that LESS can be used by surgeons with laparoscopic skills outside of a few major international centers. [ABSTRACT FROM AUTHOR]