Fig. 34.1
This figure identifies one of the first modified R-LESS attempts at port placement (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2008–2017. All Rights Reserved)
Since R-LESS surgery is still emerging and, to a certain degree, in its infancy as a surgical technique. Few studies have reported on the overall complication rates as in comparison to conventional laparoscopy (CL) . Reported complication rate for R-LESS ranges from 0% in small studies [4] to 18.8% [5] postoperatively. Several studies have set out to classify and categorize these various complications, namely these are divided into intraoperative, early postoperative, and late postoperative. The Clavien-Dindo standardized grading system is commonly used to report postoperative complications. Early complications were defined as occurrence within 90 days and late complications were referred to as an occurrence after this period of time. This chapter will outline and review the reported R-LESS studies and the specific experienced complications during these procedures (Table 34.1).
Table 34.1
Reports of various single site procedures and complications experienced
N | Procedure(s) | Complications | Type of complication | |
|---|---|---|---|---|
2009: Kaouk [4] | 3 | Radical prostatectomy, pyeloplasty, radical nephrectomy | None | N/A |
2009: Stein [12] | 4 | Pyeloplasty (2), radical nephrectomy (1), partial nephrectomy (1) | Anemia (1) | Clavien 2 |
2010: White [13] | 20 | Radical prostatectomy | Single port added (2), ileus (1), PE (1), anemia (1) | Intraoperative conversion, postoperative Clavien 1–2 |
2010: White [14] | 47 | Radical nephrectomy, partial nephrectomy, nephroureterectomy, radical cystoprostatectomy , radical prostatectomy, simple prostatectomy, ureteric reimplantation, pyeloplasty, sacrocolpopexy | Conversion to standard robotics (3), single port added (3) | Intraoperative conversion |
2011: Han [15] | 14 | Partial nephrectomy (14) | Conversion to mini open incision (2) | Intraoperative conversion |
2011: Lee [16] | 68 | Partial nephrectomy (51), nephroureterectomy (12), radical nephrectomy(2), adrenalectomy (2), simple nephrectomy (1) | Bleeding/anemia requiring transfusion (9), conversion (3), renal vein injury (1), ureteral injury(1) serosal bowel injury (1) | Intraoperative transfusion and suturing of injured structures |
2011: White [8] | 10 | Radical nephrectomy (10) | Skin infection (1) | Postoperative Clavien (1) |
2012: White [7] | 50 | Renal surgery (24), pelvic surgery (26) | Converted to CL (4), single port added (6), rectal injury (1), postoperative (8) | Intraoperative (11) postoperative Clavien grade 1–4 |
2012: Olweny [17] | 10 | Pyeloplasty (10) | Urine leak(1) | Postoperative Clavien grade 3a |
2012: Cestari [18] | 9 | Pyeloplasty (9) | Pyrexia (1) | Postoperative Clavien grade 2 |
2012: Fareed [19] | 9 | Suprapubic transvesical enucleation of the prostate (9) | Intraoperative bleeding (2), clot retention, DVT(1), UTI (1), MI(1) | Intraoperative (2), postoperative Clavien 2–4 |
2013: Mathieu [20] | 6 | Pyeloplasty (6) | None | N/A |
2013: Komnios [21] | 78 | Partial nephrectomy (78) | Bleeding/anemia (7), radical conversion (2), urinary leak (2), retroperitoneal bleed (1) | Intraoperative bleeding, postoperative Clavien 1–3b |
2014: Shin [5] | 79 | Partial nephrectomy (79) | Open radical conversion due to renal vein injury (1), ureteric injury (1), renal vein injury (1), hemorrhage requiring transfusion (9), pyrexia (1), clot retention (1), pneumonia (1), urine leak (1), embolization (1), hydronephrosis (1) | Intraoperative (3), postoperative Clavien 2–3(15) |
2014: Kaouk [9] | 19 | Radical prostatectomy(11), radical nephrectomy(2), partial nephrectomy(4), simple nephrectomy(2) | Anastomotic leak(1), urinary tract infection(2), umbilical scar abscess(1), bladder neck stricture(1), bleeding(1), anemia(1), perinephric hematoma(1) | Postoperative Clavien grade 1-3b |
Intraoperative Complications
During R-LESS cases, mechanical instrumentation and procedural movement is quite hindered and cumbersome due to the lack of operative space available in attempt to triangulate the instruments through the single port. When attempting to retract, dissect, or advance in the surgical procedure, working under such constraints becomes the main culprit of injury as it may be difficult to continuously visualize every instrument tip during procedural dissection. To minimize the risk of injury, blind advancement and movement of instruments should be avoided.
Bowel Injury
Bowel injury can be subcategorized into injury related to insufflation, mechanical injury by instrumentation, thermal injury, and injury related to trocar/port placement. Most commonly, access and insufflation to the peritoneal cavity is carried out with a Veress needle in R-LESS in the same fashion that occurs during CL. In patients with extensive history of prior abdominal surgeries, the risk of enteric injury during a Veress needle placement is increased and therefore it has been recommended that the placement of the Veress needle should be at least three finger breaths away from an incisional scar. Early identification of bowel injury is paramount and can often be recognized by a sudden increase of insufflation pressure after the CO2 has been connected. If a bowel injury is noted, immediate desufflation and, depending on the injury, a general surgery intraoperative consultation is in order. Only a serosal bowel injury and a rectal injury have been documented in literature thus far during R-LESS urological procedures [6, 7]. Both were managed by over sewing the serosa without need for an additional port placement or management.
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