Umbilical and periumbilical

The majority of urologic upper tract LESS surgery is approached via an umbilical single‐site access. Published reports of LESS have used all of the wide variety of access modalities available, both commercially manufactured and “homemade” designs created by surgeons using already available devices [1, 5, 8, 9] (Table 121.1). The umbilical trocar site is most often employed as it provides the opportunity to conceal incisions/scars. Multiport trocars, GelPort™/GelPoint Advanced™ devices (Applied Medical, Rancho Santa Margarita, CA, USA), or a clustered series of low‐profile trocars can be employed within the umbilicus. Multiport trocar placement at the umbilicus requires a single incision, ranging from 2 to 5 cm to accommodate the chosen trocar (Figure 121.1). Use of separate low‐profile trocars allows for more independent mobility and use of reusable devices, also using an incision ranging from 2 to 3 cm at the umbilicus (Figure 121.2).

Compared with conventional laparoscopy, during LESS surgery the laparoscope and working instruments are in much closer proximity to one another due to the nature of single‐site access. This can necessitate the use of flexible scopes and/or instruments to avoid clashing and to allow for triangulation. The umbilical port site allows for adequate access to the upper tract urologic organs with the use of regular length instrumentation, in most cases.

When treating obese patients, lateralization of the centrally located single incision toward the side of intended surgery may be necessary to offset length limitations of the operating instruments. The surgeon must consider whether this lateralized incision, no longer “hidden” within the umbilicus, still offers potential cosmetic advantages to the patient on a case‐by‐case basis. Alternatively, a retroperitoneoscopic LESS approach can be employed. Lateralization of the single site of access is akin to the lateralization of trocars employed during conventional laparoscopy in this patient population. Typically, this maintains the midpoint of the incision at the craniocaudal level of the umbilicus, but simply shifts it laterally toward the targeted kidney or adrenal gland, providing improved visualization with the laparoscope and simpler reach with the working instruments. Considerations when employing this modification in trocar placement include: the risk of developing incisional hernias, anatomic approach to traversing versus splitting muscle layers, as well as postoperative pain and cosmesis.

Operative approach

A suprapubic approach has been reported for LESS simple, radical, and donor nephrectomy, as well as LESS nephroureterectomy. In selected patients, a cosmetic advantage may be obtained by concealing the single incision below the waistline. A small, or “mini‐Pfannenstiel,” incision is employed that ranges between 5 and 8 cm in size. The size of the incision should allow for specimen extraction, but be as small as possible to optimize cosmesis. Access can be gained with a multiport device (Figure 121.3) or using independently inserted, low‐profile trocars [6, 10–12].

The suprapubic approach has more theoretical advantage in cases that require a sizable incision for specimen extraction, such as simple, radical, or donor nephrectomy or nephroureterectomy, in contrast to purely reconstructive surgery (e.g. LESS pyeloplasty) or surgery requiring extraction of small specimens (e.g. LESS cyst decortication or LESS partial nephrectomy). To allow for full access and ability to dissect circumferentially around the upper pole and posterolateral attachments of the kidney, it is useful to have bariatric and articulating laparoscopic instruments available.

Another approach gaining traction within recent years is single‐incision triangulated umbilical surgery (SITUS). Retraction of the single umbilical incision allows the entry of several spaced working ports. Instrumentation is straight, standard laparosopic as spacing of the trocars allows triangulation of the target tissue.

Use of accessory and needlescopic trocars

Although even complex reconstructive LESS procedures, such as pyeloplasty and partial nephrectomy, can be performed with no accessory points of entry [6], the use of accessory trocars or 1.9 mm needlescopic instruments has been reported extensively in the early experience of LESS. These added instruments act as an adjunct to the single‐site approach and provide for instrument triangulation and added retraction, or can assist with intracorporeal suturing and knot tying. Accessory ports create a bridge between conventional laparoscopy and LESS, as surgeons learn LESS surgery. These ports play a critical role in challenging cases in which triangulation for adequate retraction and dissection is not adequately achieved with single‐site access and available instrumentation.

With minimal to no morbidity, needlescopic instruments have been reported to enhance surgeon confidence and ensure patient safety during the diffusion of this new and challenging technique [4]. As experience with LESS increases and surgeons progress along the learning curve, the use of accessory trocars for assistance in triangulation and retraction will likely decrease. However, there will likely always remain an important role for accessory trocars or needlescopic instruments for more complex surgical cases. Moreover, additional access is always preferable to any compromise in safety or efficacy. Accessory trocars measuring from 5 to 12 mm in diameter have been reported. These are used by some urologists during LESS donor nephrectomy to allow for the expeditious and safe maneuvers necessary to limit the warm ischemia time of the renal allograft specimens. They also are adjuncts to LESS for complex reconstructive procedures or in patients with anatomic challenges requiring extensive adhesiolysis or body habitus limiting instrument flexibility. The site of accessory trocar placement can also be used as the location for drain placement at the culmination of the case.

LESS nephrectomy

LESS nephrectomy can be performed for both “simple” nephrectomy and radical nephrectomy, for benign and malignant pathologies, respectively. Although done for differing indications, LESS nephrectomy has similar principles and maneuvers to conventional laparoscopic nephrectomy, with slight surgeon‐specific modifications to overcome the novel challenges of the single‐site approach of the operation [13].

The first laparoscopic extirpative surgery in urology was the laparoscopic nephrectomy reported in 1991, and this is now a relatively straightforward case often undertaken by new trainees prior to more complex renal surgeries [14]. Since the first LESS nephrectomy was reported in 2007 by Rane et al., the number has soared and remains the most common LESS urologic surgery performed [15]. A simple nephrectomy for non‐oncologic indications allows for morcellation of the resection specimen. The most common location for trocar placement is at the umbilicus, and morcellation obviates the need to extend the umbilical trocar site incision, maximizing the cosmetic outcome [16]. However, extension of the incision is warranted in radical nephrectomies and nephroureterectomies to allow for passage of the entire kidney specimen intact for pathologic examination and appropriate staging without compromising the oncologic efficacy of the surgery.

Rane et al. described their initial experience with five LESS simple nephrectomies [16]. Their indications for simple nephrectomy included chronic reflux, recurrent infections, longstanding ureteropelvic junction obstruction, stone disease, and ureteral strictures, leading to poorly functioning symptomatic kidneys. In these cases of benign renal pathology, morcellation allows for an operative scar to be hidden within the anatomic folds of the umbilicus.

Since this report of LESS simple nephrectomies, other groups have reported LESS radical nephrectomy with adequate pathologic outcomes [5, 17, 18]. LESS radical nephrectomy has been reported through umbilical access as well as through a Pfannenstiel incision. In both circumstances, the incision is commonly 4–8 cm in length for purposes of specimen extraction, unless morcellation is employed. Despite requiring a larger extraction site, LESS radical nephrectomy still requires fewer incisions compared to conventional laparoscopy, and the incision is at least partially hidden within the umbilicus or within the skin creases of the suprapubic region, depending upon approach utilized.

In a series comparing LESS simple and radical nephrectomy to conventional laparoscopic nephrectomy, Raman et al. reported equivalent operative time, postoperative analgesic use, length of hospitalization, and rate of complications. Although the LESS cohort was found to have a lower recorded estimated blood loss, the change in hemoglobin concentration across the two patient groups was not statistically significant [17]. This was followed by a randomized controlled trial comparing LESS versus conventional multiport laparoscopic nephrectomy that demonstrated lower visual analog pain scores and decreased analgesic requirements for LESS surgery [19].

More recently, a similar study comparing patients with cT1–2 renal cell carcinoma showed superior postoperative Quality of Recovery‐40 (QoR‐40) questionnaire scores in the LESS group. Four out of five assessed dimensions were significantly improved in the LESS group; including emotional state, physical comfort, psychological support, and physical independence. Interestingly, pain was equivalent in the conventional laparoscopy and LESS groups [20]. Larger retrospective reviews have concluded LESS nephrectomy to have no significant differences in outcomes compared to the gold standard laparoscopic approach [21, 22]. A systematic review and meta‐analysis of 25 retrospective studies showed that LESS nephrectomy is associated with longer operating time as well as a higher conversion to open rate compared with conventional laparoscopic nephrectomy. LESS was shown to offer advantages in terms of reduced postoperative pain, lower analgesic requirement, shorter length of stay, shorter recovery time, and better cosmetic satisfaction. Overall, there was no difference in terms of perioperative complication outcomes [23].

LESS partial nephrectomy

Partial nephrectomy remains a challenging operation even when performed by multiport laparoscopy. However, in selected patients, LESS partial nephrectomy has been demonstrated to be feasible and safe. LESS partial nephrectomy has been described without accessory trocars, technically replicating the conventional laparoscopic technique with careful hilar dissection for complete pedicle control, identification and excision of the tumor, and various hemostatic techniques coupled with the renorrhaphy (see Video 121.1) [5]. In efforts to minimize warm ischemia time and provide a hemostatic renorrhaphy, a 2 mm needlescopic accessory port is utilized by some experts for intracorporeal suturing [24]. As demonstrated by surgeons who have reported their experience with LESS partial nephrectomy, it is critical to convert to conventional laparoscopy in cases of limited exposure of the tumor resection site or when hemostasis is prohibitively challenging via a strict LESS approach.

Indications for conventional laparoscopic partial nephrectomy are expanding and now include resection of selected T1b tumors, central or hilar tumors, and multifocal tumors within the same kidney [25]. Currently, LESS surgery has been largely reserved for the strictest indications. In the renal LESS series reported to date, LESS partial nephrectomy was performed in a highly select patient population with ideal body habitus, limited prior abdominal surgery, and favorable tumor size and location.

A retrospective multi‐institutional series analysis of a 190 cases was performed examining LESS partial nephrectomy and the resultant renal function as well as the short‐term oncological outcomes. When hilar clamping was utilized, a significant increase in serum creatinine concentration and a significant decrease in estimated glomerular filtration rate (eGFR) were observed postoperatively and at six months. The degree of functional loss was correlated with the length of warm ischemia. The overall postoperative complication rate was 14.7%. Overall, survival rates were comparable to those following conventional laparoscopic partial nephrectomy. Furthermore, the authors found on univariate analysis that the robotic platform is a positive predictor for complication outcomes (predicts a complication is less likely to occur). On multivariate analysis, a low Padua Prediction Score was the only positive predictor for complications. It was concluded that the robotic platform can be a feasible and effective modality in terms of renal function and oncological control that may be likely to reduce postoperative complications [26].

When comparing robotic LESS to conventional robotic partial nephrectomy, one group found the robotic platform to have an increased warm ischemia time as well as total operative time but no significant differences in negative surgical margin rate, postoperative renal function, or complication rate. They also noted that the visual analog pain scale scores at discharge were significantly lower in the robotic cohort [27]

Related posts:

1: Perioperative Considerations Radiation Safety During Diagnosis and Treatment Cryotherapy of the Prostate Bipolar Vaporization of the Prostate Patient Preparation and Operating Room Setup for Laparoscopic and Robotic Surgery Pelvic Lymphadenectomy

Stay updated, free articles. Join our Telegram channel

Join