• Our aim is to provide free detailed comprehensive manual for urologic surgical procedures. This site should serve as a valuable reference for urologic residents and medical students in training.

  • Single Site Surgery

    ABOUT THE AUTHOR

    David Canes, MD

    David Canes, MD, is the medical director of the Lahey Institute of Urology at Parkland Medical Center. He is fellowship-trained in advanced laparoscopic and robotic urology, and has been involved in more than 350 robotic urologic procedures using the da Vinci® Surgical System. Dr. Canes has helped other surgeons learn the technique of robotic prostatectomy both regionally and abroad.

    Dr. Canes attended medical school at the Weill Medical College of Cornell University and went on to complete a six-year Urology residency training program at Lahey Clinic Medical Center. Following residency, Dr. Canes pursued additional subspecialty fellowship training at the Glickman Urological and Kidney Institute of Cleveland Clinic, a world-renowned center for minimally invasive surgery. Under the mentorship of Mihir Desai, MD, and Inderbir Gill, MD, MCh, he specialized in advanced laparoscopy, robotic surgery and endourology. Subsequently, Dr. Canes was recruited to join the staff at the Institute of Urology at Lahey Clinic.

    INTRODUCTION

    As an attempt to further reduce morbidity and enhance the cosmetic appeal of minimally invasive surgery, Laparo-endoscopic single site (LESS) surgery has made its initial foreys into urologic laparoscopy.1  In this technique, the general idea is to consolidate the point of access including the camera and all working instruments into one single site.   The typical entry site has been the umbilicus, using one of several commercially access systems, or alternative home-made devices.2  Within a surprisingly short period of time, clinical reports have demonstrated at least the feasibility of LESS for a wide range of procedures.

    Laparoscopic surgery is a well-established alternative to open surgery.  In general, the benefits of laparoscopy on postoperative pain, cosmesis, hospital stay, and convalescence are widely recognized. The magnitude of benefit of laparoscopy over open surgery differs substantially by procedure. For instance, profound differences are seen for adrenalectomy because the open incision is so large to gain access to the deeply obscured target organ, while the benefit is more hotly debated for radical cystectomy and urinary diversion where significant morbidity comes from the unavoidable bowel work.

    Current efforts are aimed at further reducing the morbidity associated with minimally invasive surgery.  To this end, two recent innovations are being developed either pure or hybrid: (1) NOTES (natural orifice translumenal endoscopic surgery whereby intraperitoneal access is gained through the mouth, anus, vagina, or urethra and the viscus-of-entry is perforated to reach the surgical target and (2) LESS where the surgical scar is virtually concealed within the umbilicus.  The most recently accepted acronym is LESS.3 This chapter seeks to place LESS in its historical context both outside and within the urologic arena, review current instrumentation, and describe in detail the technique for LESS nephrectomy.

    BACKGROUND

    Any rational effort to reduce morbidity while maintaining high surgical standards are valuable.  Indirect evidence for potential benefits of LESS and NOTES already exists.  For instance, there is some evidence that a reduction in port size decreases operative morbidity.4  Mostafa et al compared patients undergoing needlescopic versus conventional laparoscopic appendectomy.5  The needlescopic group had shorter hospital stay (1.3 vs 3.2 days), reduced narcotic requirements, and faster return to work (8 vs 17 days).  In a randomized prospective comparison of conventional laparoscopic cholecystectomy versus the same procedure using downsized trocars (3.5mm), Bisgaard et al detected less incisional pain in the first postoperative week.6

    Notwithstanding biases associated with the small studies mentioned, if decreasing the size and/or number of ports decreases morbidity, the effect of restricting access to the umbilicus only (LESS), or removing transabdominal incisions completely (NOTES), warrants further investigation.  With each procedure, the possibility of inserting additional ports as necessary always exists, and therefore no safety compromise would be expected.

    LESS: GYNECOLOGY AND GENERAL SURGERY HISTORY

    In what could be considered the first LESS surgery, Clifford Wheeless, a gynecologist at Johns Hopkins, published his technique of “single incision” laparoscopic tubal ligation in 1969.7  Two years later, he reported on 85 patients who had been sterilized using his outpatient surgical technique.8  After infiltrating the umbilicus with local anesthetic, through a 1 cm incision along the inferior umbilical ridge, he established CO2 insufflation, and inserted a laparoscope with an offset eyepiece.  The fallopian tubes were brought into view by external manupulation of a  tenaculum inserted through the vagina. Through the working channel, a biopsy forceps was used to grasp and cauterize each fallopian tube.  In a subsequent update, Wheeless reported on 3600 cases, 2600 of whom had one incision tubal ligation.9  In 1977, Singh recognized the cosmetic benefits of this technique having performed over 1000 single-trocar tubal sterilization procedures.10  He used an 8mm intraumbilical incision, stating, “(w)ound healing is so satisfactory that no scar is grossly visible postoperatively.”

    In 1991, Pelosi et al reported a total hysterectomy with bilateral salpingo-oophorectomy, using a single-puncture technique, the first complex extirpative procedure of its kind11. The following year Pelosi reported supracervical hysterectomy for benign uterine disease in four patients, calling the technique “mini-laparocopy.”12  Similar to the tubal sterilization technique, they used a laparoscope with an offset eyepiece, passing standard laparoscopic instruments down a 5mm working channel.  Dissection was accomplished primarly via blunt maneuvers, hydrodissection, bipolar and monopolar electrocautery, all with concomitant uterine manipulation by with an intrauterine cannula.  The umbilical incision was extended to 3cm for specimen extraction. In their discussion, the authors comment on their theoretical impression of advantages: simplicity, lower cost, decreased trocar-site related complications, improved cosmesis, and ability to convert to standard laparoscopy or open surgery when required.

    Pelosi, who pioneered single-port pelvic surgery, reported the first series (n=25) of single-trocar appendectomy in 1992.13  D’Alessio et al followed in 2001 with a large series of 116 patients undergoing single-port (using a standard 11mm Hasson trocar) transumbilical laparoscopic assisted appendectomy (TULAA).14  The authors commented on the aesthetic aspect of the procedure, noting, “the transumbilical incision is practically invisible.” Additional trocars were required in 28 cases (19%), and open conversion was required in 6 (4%).  A standard 11mm Hasson trocar was used.  The appendix was grasped and delivered through the umbilical incision using a grasper through the 5mm working channel of a laparoscope, and the appendectomy performed extracorporeally.  Mean operative time was 35 minutes.  The single-trocar group returned to normal activity at 7 days, compared with 10 days for the multiple trocar group, and 14 for the open surgical cases.

    Published experience with single-port appendectomy was multi-institutional.  In 2007, Ates reported single-port appendectomy in 35 patients.15 In an additional 3 patients (8%), a second trocar was required because of adhesions and retrocecal appendiceal position.  In 33 patients, they describe using a specialized trocar with dual 5mm working channels (Applied Medical, Rancho Santa Margarita, Calif).  In two, a laparoscope with an offset eyepiece and 6mm working channel (Karl Storz) was employed.   A percutaneous appendiceal sling suture through the mesoappendix provided countertraction, taking over the role usually reserved for a second instrument through an additional trocar.  The base of the appendix was ligated and sutured intracorporeally.

    The first transumbilical cholecystectomy was reported in 1999.16  Through a single intraumbilical incision, two separate 5mm trocars were placed.  Two intra-abdominal stay sutures, one through the gallbladder dome and the other through its neck, facilitated surgical manipulation.  The 5mm fasciotomies were joined for specimen extraction.  No extraumbilical incisions were required.  The authors supported their technique by pointing to a “low threshold for the conversion of the transumbilical to a standard laparoscopic cholecystectomy.”  The procedure was successfully completed without intraoperative complication in 10 patients.

    Single-port ovarian cystectomy in a two-month old was reported in 2001.17  This 6cm cyst was accessible through a single 10mm umbilical trocar, grasped through the working channel of a Wolf cerebral endoscope, and delivered to the umbilical incision  where the procedure was essentially performed open surgically. The cyst was aspirated, decorticated, and delivered into the peritoneal cavity.  The authors make note of the “almost undetectable scar.”

    Other relatively simple procedures have been reported using a single transumbilical access site.  Laparoscopic salpingectomy through a single umbilical trocar was reported in 2005.18 Similar to the cases of appendectomy mentioned above, these 10 cases of salpingectomy were facilitated by placing a percutaneous sling suture through the affected tube, suspending the fallopian tube by extracoporeal suture manipulation, obviating the need for a second trocar.  An external uterine manipulator was also required. In 2007, Meckel’s diverticulectomy was reported in 9 patients using a single port approach, with a mean operative time of 70 minutes,19 however the intestinal segment was brought out through the umbilical incision and bowel work performed extracorporeally.  The initial grasping of the ileum required coaxial movements alongside the camera. A wide fasciotomy beneath the skin incision allowed for exterior bowel work without vascular congestion.

    Application of a single trocar to direct placement of intra-peritoneal drains has been described, although morbidity data is lacking.  Blessing described a single-trocar technique for placement of a peritoneal dialysis catheter in 2005.20  The presence of the tube requires a separate extraumbilical incision for tube tunneling, but the laparoscopic view allows verification of tip position in the pelvis, a prerequisite for adequate long term functioning. Goitein et al described laparoscopically assisted ventroculoperitoneal shunt placement in 2006,21 avoiding the typical small midline laparotomy incision.  Through a periumbilical 5mm trocar with laparoscope, the peritoneal cavity was inspected to choose an ideal site for catheter insertion.  The introducer/dilator was passed under laparoscopic vision, and the tip guided towards the pelvis.  Of the 10 cases performed, an additional trocar for adhesiolysis was placed in 3 patients.

    LESS IN UROLOGY

    Access devices

    In general, access can be accomplished by placing multiple standard laparoscopic trocars through separate but adjacent fascial puncture sites within one incision,22 or use one of a multitude of purpose-built multichannel single port devices.  One of the first of these devices, the R-port (Advanced Surgical Concepts, Wicklow, Ireland), was later modified to be the currently available TriportTM (ASC/Olympus, NY).  This device consists of two components: (1) a fascial retractor containing an inner and outer ring with intervening plastic sleeve and (2) a multichannel valve (one 12mm, two 5mm). Each is covered with a thermoplastic elastomer which maintains a tight seal, while allowing the smooth introduction of instruments and accessories.  This dual construction allows the cap to be removed, leaving the retractor in place and therefore facilitating either specimen removal or exterior bowel work, as the particular indication dictates.  A more recent modification is the QuadportTM (ASC/Olympus, NY), which allows simultaneous use of one 5mm, two 10mm, and one 15mm instrument.

    The technique for placing the TriportTM is as follows: After making a vertical intraumbilical incision and releasing dermis from the fascia, a 2 cm fasciotomy is made in an open or Hasson fashion.  The inner ring is loaded within a non-bladed introducer which deploys the inner ring intraperitoneally.  Slack is removed whereby the taught plastic sleeve effectively tents open the fasciotomy, and tightly approximates the rings to create an effective seal.  Once deployed, the retractor is reminiscent of a miniature hand port to which the multivalve cap with insufflation inlet is attached.

    Another alternative is the GelPortTM (Applied Medical). This device is akin to a small hand-port (sits in a 2-7 cm fasciotomy), through which the surgeon can place three trocars at any desired location. The self-sealing gel allows removal and repositioning without loss of pneumoperitoneum. The main ergonomic advantage is increased spacing between working instruments, potentially minimizing clashing. Currently, other options for integrated ports abound, including the X-cone (Storz), SILS port (Covidien), and Airseal (Surgiquest).  Each device has its own advantages and limitations, and use is determined largely by surgeon preference.  Use of a commercially available port is not mandatory, as the use of a surgical glove to fashion an inexpensive multichannel port has been well described.2

    Instruments

    As a general rule, the majority of LESS procedures can be performed using standard laparoscopic instrumentation.  However, many surgeons prefer to move their nondominant hand away from the dominant dissecting hand.  To accomplish this, an articulating or pre-bent instrument is used as an adjunct. Examples of articulating instrumentse include the RealHandTM (Novare Surgical Systems, Cupertino, CA), or the AutonomyTM Laparo-angleTM (Cambridge-Endo, Framingham, MA), and the Roticulator (Covidien).

    The laparoscopic camera deserves specific mention. Since extracorporeal instrument crowding is a significant obstacle, limiting camera bulk outside the body is advantageous.  In this regard, the Endoeye camera (Olympus Orangeburg, NY), with its in-line integrated light and camera source, is ideal.  The Endoeye is available either as a rigid lens or articulating at the tip.  By no means is this the only choice for LESS, and other camera options have been nicely reviewed by Autorino et al.23

    Early Clinical Applications

    Zeltser et al reported single-trocar nephrectomy using novel magnetically anchored instruments each deployed through the 15mm umbilical portal of entry in a porcine model.24  Magnetic couplers were fixed across the relatively thin porcine abdominal wall. Both a camera and a robotic cautery arm were employed, with each of these hard wired to external guidance systems, and the light was provided by fiberoptic cables surrounding the umbilical trocar itself.  Standard laparoscopic graspers and the vascular stapler were manipulated through the umbilical trocar, and tissue dissection accomplished with the robotic arm.  The specimen was extracted through the solitary umbilical incision.  As of this writing, the use of magnetically anchored instruments to facilitate urologic LESS procedures has not been reported in humans, however the lack of histological damage with prolonged coupling across the abdominal wall has been demonstrated.25

    The first two cases of single-port surgery in urology worldwide were reported by Rane and Rao et al, in abstract form, at the 2007 World Congress of Endourology meeting in Cancun, Mexico.26  This contained the first report of single-port non-transumbilical simple nephrectomy, using an R-port at the flank with retroperitoneoscopic approach.  The patient was a 36 year old man with a small nonfunctioning right kidney.  The second case was a laparoscopic transperitoneal ureterolithotomy for an impacted 2.5 cm proximal ureteral stone, accessed exclusively via an intraumbilical R-port.

    Raman reported the first single-incision transumbilical nephrectomy.22 Following an initial porcine feasibility study, three human nephrectomies were performed, one for a 4.5 cm renal cell carcinoma, and the others for benign nonfunction, with a mean operative time of 133 minutes.  Through a single umbilical incision, three adjacent conventional trocars (one 12mm, two 5mm) were placed.  The hilum was transected using an endovascular stapler through the 12mm port.  On the right side (nephrectomy for carcinoma), static liver retraction required an extraumbilical skin incision for a 3mm instrument.

    In 2007, Desai et al reported the first single-port transumbilical nephrectomy.27  Access was through an R-port, vision using a 5mm 30 degree Endoeye camera, as well as curved and standard laparoscopic grasping instruments.  The transperitoneal left nephrectomy, performed for benign non-functioning kidney after failed pyeloplasty, was performed without any extraumbilical skin incisions in 3.6 hours.  This same report described single-port transumbilical pyeloplasty for primary right UPJ obstruction.  A 2mm needlescopic grasper was used through a Veres Minisite port (USSC, Norfolk, CT) which had been used to establish pneumoperitoneum.  A 5mm atraumatic grasper placed through one of the three R-port inlets was used for liver retraction as needed.  The umbilical incision was used to exteriorize a penrose drain at the conclusion of the case.

    In another early series, Kaouk reported 7 patients undergoing single-port transumbilical urologic laparoscopic procedures28 including renal cryotherapy (n=2), wedge kidney biopsy (n=1), and sacrocolpopexy (n=4).  The Uni-X Single Port was used for access, and no extraumbilical incisions were made. For this series, standard laparoscopic instruments, a flexible 5mm endoscope (Olympus Surgical, Orangeburg, NY), and bent laparoscopic instruments (Pnavel Systems) were used.  Three additional patients underwent extraumbilical skin incisions: retroperitoneoscopic cryotherapy (n=2) with incision at the tip of the 12th rib, and radical nephrectomy (n=1) with a 12mm trocar placed through a standard Gibson incision for various intraoperative manipulations and ultimate specimen extraction.

    Gill et al reported the initial 4 patients undergoing LESS live donor nephrectomy.29 A 2 mm Veres needle port, inserted via skin needle-puncture to create pneumoperitoneum, was used to selectively insert a needlescopic grasper for tissue retraction.  Excellent donor vascular and tissue dissection could be performed, and a quality donor kidney was retrieved trans-umbilically after pre-entrapment; median umbilical incision length was 4 cm.  In all four patients, no conversion to standard laparoscopy was required, and no intraoperative complications were observed.  Median operating time was 3.3 hours, blood loss was 50cc, warm ischemia time was 6.2 minutes, and hospital stay was 3 days.  One patient had 2 left renal arteries; each was controlled individually.  Median length of harvested renal artery was 3.3cm, renal vein was 4cm, and ureter was 15 cm. All allografts functioned immediately upon transplantation, with early nadir serum creatinine being in the 0.9-1.8mg/dL.

    Complex reconstructive LESS urologic procedures have also been performed, including ileal ureteral interposition, bilateral single session pyeloplasty, and psoas hitch ureteroneocystostomy.30 In addition, complex extirpative procedures requiring reconstruction have been accomplished, including LESS partial nephrectomy, simple and radical prostatectomy, and radical cystectomy with extended pelvic lymphadenectomy.31-35

    LESS vs STANDARD LAPAROSCOPY: COMPARATIVE STUDIES

    Comparative studies of LESS to standard laparoscopy have been retrospective to date. Prospective studies oare ongoing, but have yet to be published.  In general, the common thread among these studies is the equivalence of in-hospital perioperative measures. For example, the UT Southwestern group reported a retrospective case-control comparison between patients undergoing standard laparoscopic nephrectomy (n=22), and patients undergoing LESS nephrectomy (n=11).36  There was no difference as regards operative time, hemoglobin drop, analgesic use, length of stay, or complication rate.  Blood loss was lower in the LESS group. Using an identical study design, the same group reported a comparison of 14 LESS pyeloplasties to 28 standard laparoscopic pyeloplasties.37  Again, postoperative measures were equivalent, including length of stay, analgesic requirements, and complication rates.  Operative times and blood loss were shorter in the LESS group, perhaps because of heavy attending involvement at this tertiary referral teaching institution.

    Canes et al reported a retrospective matched pair comparison between patients undergoing LESS donor nephrectomy to standard laparoscopic donor nephrectomy (n-17 in each group).38 Similar to other studies, perioperative measures were identical (operative time, blood loss, length of stay, analgesic requirements, and visual analog pain scores.  Warm ischemia time was longer in the LESS group, and allograft function was comparable.  When postoperative measures of convalescence were evaluated, the LESS patients reported fewer days on pain medication, days off work, and days to complete physical recovery.  The authors conceded that the patients may have modeled their subjective recollection of events to match the fact that they had received this new, cutting edge procedure (patients obviously not blinded to their procedure).

    Another retrospective comparison of donor nephrectomy came from Kavoussi’s group in 2010.39  For LESS, this group prefers a Pfannensteil access site, and they presented a matched comparison of 6 patients in each group.  The groups were statistically identical with regard to operative time, warm ischemia time, estimated blood loss, length of stay, analgesic requirements, and visual analog pain scores. Finally, Jeong et al reported a retrospective matched case-control study of LESS (n=9) vs standard (n=17) laparoscopic adrenalectomy.40 Once again, no significant difference was apparent between groups when analyzing perioperative parameters including operative time, blood loss, hospital stay, analgesic use, and complication rates.

    The sum total of comparative published work to date is that the exact benefit of LESS over conventional laparoscopy needs to be further investigated in a prospective fashion.  If su­ch a benefit exists, it may be subtle and not revealed by comparing standard perioperative measures.  More sensitive quality of life questionnaires or cosmesis scales may be required, and remain to be elucidated.  As of this writing, no definitive benefit beyond cosmesis exisits, and some may rightfully challenge the cosmetic benefit, since this has not been formally evaluated.

    TECHNICAL CHALLENGES

    Wide spacing of trocars for triangulation is the basis of conventional laparoscopy.  Instrument triangulation allows proper tissue retraction, which is essential for precise dissection along anatomical tissue planes.  Placing several parallel instruments makes triangulation more difficult.  Using at least one flexible or curved instrument offsets the shafts sufficiently to accomplish some degree of triangulation.  As previously mentioned, many surgeons prefer to use a conventional (straight) instrument in their dominant hand, and a flexible/curved instrument in the nondominant hand. Often this requires counterintuitive movements on the outside, where the instruments may cross each other.  While generally frowned upon during standard laparoscopy, crossing instruments are frequently necessary in single-port access surgery.

    Fixation or sling sutures can be used to recreate retraction normally accomplished by an additional assistant trocar.  These can either be static intra-abdominal sutures affixed to the parietal peritoneum, or percutaneous sutures grasped and manipulated outside the body. These techniques have proved useful in the general surgical literature for salpingectomy,17 appendectomy,14 and cholecystectomy15 as discussed.  In the case of pyeloplasty, suturing the lateral cut edge of Gerota’s fascia to the lateral abdominal wall is another example of securing wide exposure of the operative field without adding ports.

     External crowding and clashing of instruments is the most salient and frustrating aspect of the learning curve for these procedures.  One must choose instruments which will set the stage for success.  For one, the instrument profile should be as slim as possible.  A primary advantage of using the Olympus EndoEye camera system is its streamlined profile whereas the standard laparoscopic light cable enters the lens at 90°, and its interaction with adjacent instruments is severely limiting, even prohibitive.

    Using different length instruments can further mitigate external crowding.  This prevents the bulkiest portion of each instrument from lining up and hitting the adjacent instrument handle.  For instance, using a standard laparoscopic grasper and a bariatric suction cannula, which is longer than the standard length lap instruments, minimizes crowding to some degree.  In addition, a skilled camera operator anticipates clashing, and chooses an alternate camera angle which, like a pair of scissors opening, moves the camera away from the active surgical instruments.

    During standard laparoscopy, when the camera lines up with the shaft of a working instrument, depth perception is lost.  This can become an issue during single-port surgery.  The surgeon must become accustomed viewing angles that would otherwise seem suboptimal during standard laparoscopy.  The flexible tip endoscope ameliorates this to some degree.

    IMPACT OF LESS ON STANDARD LAPAROSCOPY

    Single port laparoscopy has had a positive effect on standard laparoscopy.  Even with flexible instrumentation LESS is technically more challenging than straight laparoscopy.  However, we are still in the initial learning curve.  This struggle has brought to light various superfluous aspects of standard laparoscopy, and seems to have facilitated these cases as well.  For example, instead of placing ancillary assistant ports for upper tract surgery by routine, one may substitute a retraction suture, or discover that lateral retraction in a given case is unnecessary.

    TECHNIQUE: LESS NEPHRECTOMY

    The patient undergoes preoperative bowel preparation, and is given antibiotic prophylaxis in a manner unchanged from the standard laparoscopic approach.  A foley catheter is placed sterilely.   The patient is positioned in a modified flank position, with the operative side up, as per standard for upper tract laparoscopy (figure 1).

    Figure 1. Patient positioning for LESS right simple nephrectomy.

    After a sterile prep and drape, a vertical intraumbilical incision is made. This differs form the circum-umbilical incision to which most are accustomed. The rationale is that the predominance of the scar will disappear into the umbilical cicatrix with postoperative healing. The key is for the assistant to grasp the cut skin edges as they dive down into the umbilicus, tenting them up into view. Once the skin incision is made, it will become clear that the central umbilical skin is tethered to the rectus fascia. These skin flaps are raised, exposing the fascia cleanly in the midline (figure 2).

    Figure 2. Skin flaps raised, intraumbilical incision.

    Often, even in patients with no clinical umbilical fascial hernia defect, a small knuckle of fat can be seen where the umbilicus was tethered.  This serves as a perfect entry point for a right angle clamp, and the fasciotomy can be easily made in this manner.  The size of the fasciotomy will depend on the proprietary device chosen by the surgeon (the purpose here is not to advocate one over another).  The peritoneum is incised, and the abdominal cavity entered sharply. Alternatively, if one prefers adjacent conventional trocars, a sufficient area of fascia is cleared for their sequential introduction.  For the sake of this discussion, we will assume that three inlets are available (2x 5mm, 1x 10mm).

    The surgeon employs a flexible grasper in the left hand, and standard laparoscopic monopolar enabled shears in the right hand.  The colon is medialized along a plane between Gerota’s fascia and the mesocolon.  Grasping an appendix epiploica with the left hand will put the colon on enough stretch to efficiently dissect akin to standard laparoscopy.  The camera assistant has a dual role: provide an appropriate camera image, and keep the camera handle away from the surgeon’s working hands.  On the left side, the dissection continues to mobilize the spleen and tail of pancreas completely off the kidney, such that they fall away passively (not requiring active retraction). Placing the patient in slight Trendelenberg may keep the reflected spleen out of the way.  On the right side, liver retraction is a challenge.  Either use a 2-3mm subxiphoid static liver retraction port (additional needlescopic instrument still considered LESS according to consortium consensus), or use a fourth inlet (e.g. Quadport), and have the camera assistant retract the liver when upper pole dissection is being performed.

    Incise Gerota’s fascia to enter the retroperitoneum, at the lower pole medial to the expected location of the ureter.  The ureter is reflected off the psoas muscle at the level of the lower pole.  One the left, keep the gonadal vein packet with the ureter, on the right allow the gonadal vein to stay medial to avoid inadvertent avulsion from the inferior vena cava.  In both cases, grasping the lateral cut edge of Gerota’s fascia with a flexible grasper and then arching the retractor in a shape akin to casting a fishing line brings the left hand out of the way extracorporeally, puts tissue on tension, and allows the straight right hand laparoscopic instrument to dissect comfortably.  Using this technique, the plane is carried cephalad to the hilum.

    At this point, place a lateral retraction suture, using a 6 inch 2-0 vicryl suture with an SH needle, with a knot and Hem-o-lock clip (Teleflex Medical) at the distal end.  Pass the suture through the lateral cut edge of gerota’s fascia, and then through the parietal peritoneum of the lateral abdominal wall.  Pulling the suture will create lateral tension, duplicating this task normally delegated to a 5mm lateral assistant trocar.  Use another clip to fix the suture in place.  As the dissection proceeds, the tissue will no longer be on tension, and the suture can be tightened, or additional ones placed as the situation dictates.  The stitch allows the LESS dissection to become “two handed” as opposed to the predominantly “one-handed” dissection that this operation often requires.

    As the hilar dissection continues, the author’s preference is to switch from a monopolar shears to hook electrocautery in the right hand.  This portion proceeds the same as standard laparoscopic nephrectomy.  The renal artery and vein are skeletonized, and controlled individually whenever possible.  In the accompanying video, in this particular case the diminutive single renal artery was directly behind the vein and en-bloc ligation with a vascular stapler was performed.  In addition, a needlescopic grasper was introduced through a separate puncture site for further safety during hilar control.  This maneuver may not be necessary in all cases, but is certainly recommended during the learning curve.

    The upper pole is separated from the adrenal gland, if adrenal-sparing surgery is indicated.  The Instruments will be dictated by surgeon preference (monopolar and bipolar energey, harmonic scalpel, vascular stapler, clips and scissors, etc).  Remaining circumferential attachments of the kidney are released, and the ureter divided between clips or stapled per surgeon preference.  Again, the presence of a 12mm inlet or trocar depending on the access device is mandatory, as many of the instruments necessary for this procedure, particularly the endoGIA stapler, require this size for insertion.

    The 15mm endocatch bag is often not possible to introduce.  A workaround is as follows: (1) detatch the endocatch bag and drawstring from the deployment device along its perforations.  Take a lubricious 0.038 glidewire and pass it all the way around the mouth of the bag (in the same seam as the drawstring.  Roll the bag up and introduce it through the 12mm inlet/trocar, keeping the ends of the glidewire extracorporeal.  When the bag is introduced, the memory of the glidewire will cause the bag to spring open, and the specimen is entrapped.  The glidewire is withdrawn and the bag cinched closed.  Depending on the surgical indications (i.e. benign vs malignant disease), the mouth of the bag can be brought through the fasciotomy for morcellation.

    The nephrectomy bed is reinspected for hemostasis, the peritoneal cavity is desufflated, and the single-port device is removed.  The fasciotomy, subcutaneous tissue, and skin are closed (figure 3).

    Figure 3. Appearance of closed umbilical wound at the time of surgery.

    The surgeon must keep in mind that the varied indications for simple nephrectomy include numerous pathologies with the final common pathway if intense perinephric inflammation and scar (obstruction with recurrent infections, xanthogranulomatous pyelonephritis, etc).  The threshold to add trocars and thereby transition to standard laparoscopy must be low.

    CONCLUSIONS

    As with many surgical advances, one can find historical origins of these seemingly new techniques being rediscovered. The same is true for LESS, our gynecology colleagues paved the way almost 40 years ago, having performed thousands of what essentially were LESS tubal ligations. Concomitant uterine manipulation via the vaginal natural orifice facilitated these early operations. Without mainstream standard laparoscopy to bolster its existence, however, decades passed before single port surgery resurfaced in published series.

    After the pioneering efforts in single-port gynecologic surgery, such procedures took little foothold.  Instrumentation to perform complex maneuvers intracorporeally did not exist.  This accounts for several reports of single port surgery which can best be regarded as hybrid reports, in which the pathologic target organ was exteriorized through the umbilicus and extracorporeal open surgery performed.13,16,18  It would take several decades before flexible instrumentation caught up with the surgical concept.

    Currently, while the cosmetic benefit is apparent, the true impact of LESS on perioperative pain and morbidity are not known.  Patient attitudes about scar-free surgery have also not been quantified.  The incremental benefit in morbidity is not likely to match that seen with the jump from open to conventional laparoscopic surgery.  This, however, is no justification for accepting the status quo.  Flexible multichannel robotic systems, and stand-alone deployable miniature robots are not far off.  When these technologies become widely available, both LESS and NOTES procedures will advance even further. Currently, careful case selection is paramount such that these procedures can be explored safely, with a low threshold to convert to standard laparoscopy as indicated for safety and quality of care. Ongoing refinement in technique and instrumentation is likely to expand its future role.

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