Individual intraumbilical 5mm port placement suitable for LESS pyeloplasty. Low profile trocars with small heads allow the ports to be placed very close to each other while reducing external clashing of the ports themselves during surgery

External view of LESS renal surgery. Note how close the instruments and camera are to each other, which can produce significant ergonomic challenges for the surgeon and assistant

Articulating laparoscopic grasper and endoscope used for LESS surgery. Also demonstrated is the proximal crossing of the instruments, which occurs inside the abdominal cavity

Marking the 2-3cm incision site for the insertion of a purpose-built LESS port device. The umbilicus can be everted and the incision concealed within the folds of the umbilicus itself to maximize the cosmetic outcome

Entering the abdomen with an open approach through the small incision. The fascia can be tagged with suture to help elevated the abdominal wall to insert the port and for ease of closure at the end of the case

Placement of the Alexis retractor portion of a GelPOINT ® access device (Applied Medical, Rancho Santa Margarita, CA. One of the rings of the retractor has already been placed within the incision and the external ring is folded in on itself to tighten the device into place on the abdominal wall

The GelPOINT ® device locked into place in position for surgery. It is helpful to place the ports through the gel dome before attachment. We find that a diamond configuration of ports reduces instrument and robotic arm conflict. Here we have placed two 5mm robotic trocars at the sides of the “diamond shape,” while 10mm standard laparoscopic ports (one for the robotic camera and one for the assistant to pass suture through) are at the top and bottom