Year
Procedure
Approach
References
2006
Appendectomy
Transgastric
Rao & Reddy [13]
2007
Cholecystectomy
Transvaginal
Zorron et al. [14]
2008
Colectomy
Transvaginal
Lacy et al. [15]
2008
Peritoneoscopy
Transgastric
Hazey et al. [16]
2008
Peritoneoscopy
Transvaginal
Zorron et al. [17]
2008
Appendectomy
Transvaginal
Palanivelu et al. [18]
2008
Gastrectomy
Transvaginal
Ramos et al. [19]
2009
Cholecystectomy
Transgastric
Auyang et al. [20]
2009
Nephrectomy
Transvaginal
Kaouk et al. [12]
2009
Splenectomy
Transvaginal
Targarona et al. [21]
2010
Gastric banding
Transvaginal
Michalik et al. [22]
2010
Incisional hernia repair
Transvaginal
Jacobsen et al. [23]
2011
Gastric mass resection
Transgastric
Willingham et al. [24]
One notable milestone in the inception and development of NOTES was the recognition that the adaptation of this novel surgical approach must be performed in a safe, structured and carefully monitored fashion. A summit was held in 2005 with members from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the American Society for Gastrointestinal Endoscopy (ASGE) collaborating to determine the appropriate pathway for the safe and responsible development and evaluation of NOTES. This culminated in the publication of a white paper which set out the challenges and goals for NOTES, as well as a roadmap for addressing them [25]. An organization called the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) was formed to lead this effort, and to manage a registry of trials and human procedures in the field. A second white paper was published in 2011, reporting on progress made [26]. The uptake of NOTES has remained largely experimental, and numerous challenges continue to prevent widespread adoption of this surgical approach. It remains an exciting but challenging area for future development and progress.
LESS
While modern single-site laparoscopy is considered relatively new, the origins of laparoscopy were in fact in single-site procedures. In 1961 Platteborse described access to the abdominal cavity with a 12 mm trocar and a working channel [27], allowing biopsies of the liver and gall bladder. Around the same time Steptoe began gynaecological laparoscopic procedures [28], which would culminate in his collaboration with Edwards and the birth of in-vitro fertilisation. Using his technique of access, a series of 25 laparoscopic sterilisations was subsequently carried out at Johns Hopkins Hospital by Wheeless in 1969 [29].
As interest in laparoscopy grew it became apparent that multiple instruments and ports would be necessary to achieve the required retraction and triangulation in more complex procedures, as well as to reduce the potential for instrument clashes. The progression to multi-port laparoscopy enabled the technique to emerge as not only a viable alternative to traditional methods of open surgery, but eventually as the preferred surgical approach in many procedures today. There was still, however, interest in single-port surgery by some pioneers. Notably, the American gynaecologist Pelosi, who performed the first major extirpative single-site procedure in 1991—a hysterectomy with bilateral salpingo-oophrectomy via a single transumbilical port [30]. His group subsequently reported a supracervical hysterectomy and the earliest series of single-port appendectomies [31, 32]. In 1997 Navarra published his report of a single-port laparoscopic cholecystectomy [33]. Over the next decade, the indication and complexity of reported cases increased. Emergency procedures such as salpingectomy for ectopic pregnancy were carried out and described as “feasible and safe” by Ghezzi et al. in 2005 [34]. A series of paediatric procedures was reported by Cobellis et al. in 2006, where a single 10 mm transumbilical trocar was used to identify a Meckel’s diverticulum and bring it to the skin, where the diverticulum was excised [35].
Single-port urological procedures were first described in the early twenty-first century. Hirano et al. reported a series of single-port adrenalectomies in 2005 [36]. These were performed using a large (4 cm) port inserted into the retroperitoneum, with no gas insufflation. However, significant complications were reported, including fulminant hepatitis, pulmonary embolism and death. The first successful laparo-endoscopic single-site urological procedure (a simple nephrectomy in a 36 year old man) was presented by Rane et al. at the World Congress of Endourology in 2007 [37]. A multichannel port (the R-port, Advanced Surgical Concepts, Wicklow, Ireland) was used via a single flank incision to insert a 5 mm telescope, two further 5 mm instruments and a 10 mm clip applier. The same group subsequently reported successful ureterolithotomy, orchidopexy and orchiectomy [37]. Raman et al. reported a series of nephrectomies in 2007, utilising multiple trocars and articulating instruments via a single umbilical incision [38]. These were performed for both benign as well as malignant disease. Radical nephrectomies as well as pyeloplasties were reported by Desai et al. in 2008, this time using custom-designed curved instruments and the R-port; a supplementary 2 mm needle port was also used [39].
The range and complexity of single-port urological procedures grew rapidly. Kaouk et al. reported laparoscopic renal cryoablation, wedge renal biopsy and sacrocolpopexy in 2008, and further experiences with LESS reconstructive procedures were reported including dismembered pyeloplasty, ureteral reimplantation with psoas hitch, ileal ureter construction and urteroneocystostomy [40, 41]. A series of live donor nephrectomies via a LESS approach was reported in 2008 by Gill et al., with no complications and excellent graft outcome [42]. This was followed by highly complex extirpative procedures successfully performed via a LESS approach, including radical prostatectomy and radical cystectomy with pelvic lymph node dissection [43, 44] (Table 21.2).
Table 21.2
Highlights of Laparoendoscopic Single-Site Surgery (LESS) procedures
Year | Procedure | Approach | References |
---|---|---|---|
1969 | Tubal ligation | Single transumbilical trocar | Wheeless [29] |
1991 | Hysterectomy with bilateralsalpingo-oophorectomy | Single transumbilical trocar | Pelosi et al. [30] |
1992 | Supracervical hysterectomy with bilateral salpingo-oophorectomy | Single transumbilical trocar | Pelosi et al. [31] |
1992 | Appendectomy | Single transumbilical trocar | Pelosi et al. [32] |
1997 | Cholecystectomy | Single transumbilical trocar | Navarra et al. [33] |
2001 | Ovarian cystectomy | Single transumbilical trocar | Kosumi et al. [45] |
2005 | Salpingectomy for ectopic pregnancy | Single transumbilical trocar | Ghezzi et al. [34] |
2005 | Retroperitoneal adrenalectomy | Single retroperitoneal port. Noinsufflation used | Hirano et al. [36] |
2006 | Meckel’s diverticulectomy | Single transumbilical trocar | Cobellis et al. [35] |
2007 | Simple nephrectomy, radical nephrectomy | Single transumbilical incision, multiple ports | Raman et al. [38] |
2007 | Simple nephrectomy | Single port through a flank incision | Rane et al. [37] |
2008 | Orchidectomy, orchidopexy, ureterolithotomy | Transumbilical R-port | Rane et al. [37] |
2008 | Simple nephrectomy | Single transumbilical port | Desai et al. [39] |
2008 | Pyeloplasty | Transumbilical port and 2 mm needle port | Desai et al. [39] |
2008 | Renal cryotherapy, radical nephrectomy, wedgekidney biopsy, sacrocolpopexy | Single transumbilical port | Kaouk et al. [40] |
2008 | Live donor nephrectomy | Transumbilical port and 2 mm needle port | Gill et al. [42] |
2008 | Paediatric varicocelectomy | Single transumbilical trocar | Kaouk et al. [46] |
2008 | Radical prostatectomy | Single transumbilical port | Kaouk et al. [43] |
2008 | Transvesical simple prostatectomy | Single port introduced percutaneously through the bladder | Desai et al. [47] |
2008 | Transvesical robotic radical prostatectomy (cadaveric)
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