| BackgroundSurgery is an important means of medical therapy. It is a double-edged sword, which can heal the disease while cause trauma to the patient. The pursuit for "non-invasive" and perfect cosmetic results is the instinct drive for development of minimally invasive surgery. It was not until 1987 that Mouret successfully underwent laparoscopic cholecystectomy, which opened a new chapter of minimally invasive surgery. Laparoscopy has many advantages, for instance, small incision, cosmetic result, less tissue injury, less bleeding, faster recovery, clear operative field and precise manipulation compared to open surgery. So laparoscopy was widely accepted by doctors and patients. Laparoscopic techniques have dramatically changed minimally invasive surgical landscape and gained rapid development in urology and other specialties throughout the world. In 1991, Clayman successfully underwent the first laparoscopic nephrectomy, which introduced laparoscopic technique into the field of urology.In 21st century, as science and technology improve, surgeons continue to carry out exploration and innovation in laparoscopic technology. To further decrease associated surgical morbidity and improve cosmetic outcomes, some scholars have proposed'scar-free'surgery, therefore, natural orifice transluminal endoscopic surgery (NOTES) was developed. NOTES means undergoing intra-abdominal surgery via natural orifice (stomach, vagina, rectum or bladder). Although NOTES seems to be a promising new innovation and animal experiments have achieved some success, there are still some problems couldn't be solved by then, such as, cost-performance ratio between damage to health natural orifice and abdominal wall, how to close natural orifice incision effectively and reliably, principles and processes of short-and long-term rehabilitation for natural orifice injury, abdominal incision infection related to NOTES, difficult to make use of conventional laparoscopic techniques and instruments during NOTES procedure, NOTES flexible endoscope is too long and too much bending that increases difficulty for operation and so on. Thus, NOTES is still at clinical trial stage.To propose reasonable'scar-free'surgery, scholars turned to the bellybutton. Umbilicus is the only inherent physical scar, to make a small umbilical incision, the scar concealed within the umbilicus postoperatively. Thus, laparoendoscopic single-site surgery (LESS) came into being. In 1992, Pelosi et al reported initial laparoscopic appendectomy via the single umbilical incision, then in 1997 Navarra et al reported the first single umbilical port access laparoscopic cholecystectomy. It was not until 2007 that single-incision laparoscopic was introduced into urological field. Rane et al reported first two cases of single port laparoscopic urologic surgery at world congress of endourology, Cancum, Mexico in 2007. Since then many doctors have represented their experience with simple nephrectomy, radical nephrectomy, pyeloplasty, simple prostatectomy via bladder and live donor nephrectomy using single-port laparoscopic technique. It is widely recognized that LESS has good cosmetic outcomes. As with any new and emerging field there is confusion about the nomenclature and terminology used to describe the procedures and techniques. In July of 2008, a multidisciplinary consortium of experts (the LaparoEndoscopic Single-Site Surgery Consortium for Assessment and Research [LESSCAR]) met then determined'laparoendoscopic single-site surgery'(LESS) was both scientifically accurate and colloquially appropriate name for single-incision laparoscopic surgery.As the role of LESS continues to expand, some problems emerged, such as, it is difficult to achieve triangulation, one of the fundamental concepts of conventional laparoscopic surgery. Good exposure couldn't be achieved during procedure. Does LESS provide safe and effective outcomes to patient?Objectives1. To design and supply multi-lumen single port for LESS clinical practice and simulator training according to LESS technique requirements.2. To develop and supply specialized instruments for LESS which can help rebuild triangulation and reduce devices collision.3. To carry out LESS urological surgery and verify the feasibility, safety, clinical effectiveness as well.Methods1. To design and supply multi-channel single port for LESS. After simulator training experiment the qualified LESS port was used for further clinical practice.2. To develop specially designed instruments for LESS by modifying conventional laparoscopic instruments, which can help reestablishment of triangulation and reduction of devices collision.3. To carry out various LESS urological surgeries, such as, unroofing of renal cyst, varicocelectomy and radical cystectomy, with conventional laparoscopic instruments and single multi-channel ports provided by manufacturers or homemade. Operation time, estimated blood loss, clinical effect and complications were observed to verify feasibility, safety of application of LESS in urological field.Results1. The designed three-channel single port trocar is size-fit and easy manipulation. Elastic rubber makes insertion of trocar into abdominal cavity easily and the waist part of trocar fits the incision well which results in good air tightness. The homemade three-channel single port can be used for real laparoendoscopic single-site surgery such as unroofing of renal cyst, varicocelectomy.2. LESS apparatus can be achieved by improving standard laparoscopic instruments based on the technical characteristics of LESS. There are some innovations can be adopted in design of new LESS instruments:a. working length increased; b. proximal bend laterally; c. distal bend medially; d. distal semi-circular curved; e. joint at handle knot. Two or more points can be improved at the same time. 3. Conversion:There were a total of 22 patients enrolled in the study,14 varicocelectomy,5 unroofing of renal cyst and 2 radical cystectomy. Conversion to conventional laparoscopic surgery required in 1 patient, the remaining 21 cases were successfully completed. The case required surgical conversion is renal cyst located in the left dorsal renal upper pole, after 2 hours dissection good exposure couldn't be achieved, so we decided to add 2 extra trocars, one under the subcostal margin and the other at iliac fossa, then the operation was successfully completed at last.4. The shortest operation time was 35 minutes (LESS left varicocelectomy), the longest operation time was 330 minutes (LESS radical cystectomy, time for construction of neobladder was excluded). The mean operation time for LESS unroofing of renal cyst, varicocelecomy and radical cystectomy were 109min(range 60-175min),68.6min(range 35-125min) and 305min (range 240-330 min), respectively. The mean estimated blood loss for LESS unroofing of renal cyst, varicocelecomy and radical cystectomy were 38ml (range 5-100ml),8.2ml (range 5-20ml),550ml (range 500ml and 600ml), respectively. No severe bleeding happened.2 LESS radical cystectomy patients needed 400ml and 600ml transfusion, No need of transfusion for the remaining patients. The mean postoperative hospital stay for LESS unroofing of renal cyst, varicocelecomy and radical cystectomy were 6.3 days (range 3-9 days),5.3 days (range 2-15 days) and 43 days (range 37-49 days), respectively.5. Clinical efficacy:No complain of pain was seen in any unroofing of renal cyst or varicocelectomy case.2 patients of LESS radical cystectomy have pain two days postoperatively, but no need for additional analgesic. Patients with LESS unroofing of renal cyst and varicocelectomy regained self-ambulation 1 day after operation, restored the diet 2 days after operation. The resumption of peristalsis, restoration of the normal diet happened at 3,9 days respectively after operation in patients with LESS radical cystectomy. The incision scar was hidden within umbilicus in 5 patients with LESS unroofing of renal cyst and 14 patients with LESS varicocelectomy. 'Scar-free surgery'was achieved, and those patients were satisfied with incision cosmetic appearance. LESS radical cystectomy left 7-cm long incision scar at lower abdomen. The capacity of renal cyst cavity was significantly reduced postoperatively compared to that preoperative in all 6 patients. The back pain was relieved postoperative in 2 patients. Of 14 cases varicocele patients,4 with abnormal sperm before surgery, the quality of sperm improved 3 months after operation. No local tumor recurrence and distant metastasis were observed 3 months postoperatively in 2 LESS radical cystecomy cases. Short term follow-up showed normal biochemistry, basically continence during daytime while 1-2 pads were needed during night. Urodynamic tests showed reservoir capacity was about 280ml, residual urine volume 10ml, maximum flow rate 11.1ml/s. IVU showed normal renal function without dilation of bilateral ureters.6. Complication:In all 22 cases, left side acute epididymitis was detected 2 days after LESS varicocelectomy in one patient, after anti-infective intensive therapy the patient was discharged 15 days postoperatively. One patient with LESS radical cystectomy was observed incision fat necrosis and mental abnormality, treated by local dressing, anti-inflammatory and sedation. The remaining 20 patients recovered uneventfully without complications, such as incisional hernia, visceral injury.7. At the beginning of carrying out single-port surgery, operating time was quite long due to lack of experience and specialized instruments. As the experience and equipment improved, operation proficiency increased significantly with shorter operation time.Conclusions1. Ideal single port trocar should meet the 6 requirements:small diameter, multi-channel, safe, reliable, easy manipulation, good air-tightness and fixed firmly. This study designed three-channel single port trocar made of elastic rubber met all requirements.2. Develop working length increased and proximal laterally curved or distal medially curved instruments by modifying conventional laparoscopic instruments based on technical characteristics of LESS operation. Newly designed apparatus could overcome devices collision problem and rebuild laparoscopic operation triangulation. 3. Based on the study which included 22 patients underwent laparoendoscopic single-site surgery with low morbidity, it is proved that application of LESS in urological clinical is technically feasible. Short-term follow-up showed good clinical efficacy. Long-term follow-up need to be carry out to determine efficiency especially cancer control efficacy of LESS.4. The rich experience of conventional laparoscopic surgery is the foundation of performing laparoendoscopic single-site surgery, especially in difficult surgery. Since 2000, we have dedicated to the application and promotion of laparoscopic techniques. In August 1,2002 we performed first laparoscopic radical cystectomy, since then more than 100 laparoscopic radical cystectomies have been completed, including some cases with history of partial cystectomy or nephroureterectomy. With rich experience of conventional laparoscopic surgery, we could successfully perform LESS cystectomy all by ourselves.5. It is feasible to perform LESS operation with conventional laparoscopic instruments, even radical cystectomy. In two cases of LESS radical cystectomy, we used the following traditional laparoscopic apparatus:atraumatic grasping forceps, scissors, harmonic scalpel, and bipolar forceps. Despite the crowding of instruments and'mirror manipulation', we performed surgery successfully.6. Prebent or flexible instruments could make great help to LESS operation. We compared the conventional laparoscopic instruments and prebent and flexible devices during LESS unroofing of renal cyst and varicocelectomy, we preferred prebent and flexible instruments in LESS procedure, due to easy rebuild of triangulation and reduction of equipments swordfight and mirror manipulation. But force applied to the instrument tip dissipates along the flexible portion of the shaft limiting some maneuvers during blunt dissection. After several attempts, we chose conventional laparoscopic instruments on the dominant hand, prebent instruments on the other. Thus, prebent equipment is in charge of traction and exposure while conventional equipment of the main manipulation, such as cutting and coagulation, in this way, we took advantage of both types of instruments.7. Skilled assistants are very important during LESS procedure. Differences between LESS surgery and conventional laparoscopic surgery included instruments crowding and difficulty in building'operation triangulation'. How to find a suitable location and angle for placement of endoscope in a crowded space is challenging.8. The incision scar hidden within the umbilical folds after LESS especially for transumbilical LESS (U-LESS) operations, thus scar-free surgery was achieved with good cosmetic outcomes.9. Learning curve issues always happen when someone learns a new techniques. As numbers of cases increased and the accumulation of experience, the operation time will gradually reduced. The learning curve will be overcome.10. The risk of LESS associated complication and conversion rate were quite low in selective patients. In our study of 22 patients, Conversion to conventional laparoscopic surgery required in 1 patient with renal cyst, the remaining 21 cases were successfully completed. Left side acute epididymitis was detected 2 days after LESS varicocelectomy in one patient, with anti-infective intensive therapy the patient was discharged 15 days postoperatively. One patient with LESS radical cystectomy was observed incision fat necrosis and mental abnormality. Postoperative complications prolonged hospital stay.11. LESS in urology is in its infancy. Further refinements in instrumentation and operative techniques will be required before it can be widely accepted. Before use in the broader population, prospective, randomized studies are required to determine the true benefit and utility of this novel surgical approach compared with current alternatives. Patients might benefit from this new technology.
|
PDF Full Text Request