Nomenclature

Various terminologies and acronyms have been used to describe surgical procedures that perform laparoscopic surgery through a single incision or surgical site ( Box 1 ). To standardize terminology with regard to scientific communications and performance of clinical trials, LESS was proposed as a common nomenclature by a consortium comprised of experts from various surgical specialties. This term has also been endorsed by the Urologic NOTES Working Group in a recent communication. By combining these terms into a universal language, search engines can be applied more efficiently to the developing literature to promote the fast dissemination of ideas and results.

Development and evolution of laparoendoscopic single-site surgery

The concept of LESS surgery has been around for many years and has been used across many surgical specialties. Gynecologists using a single-puncture laparoscope with an offset eyepiece have performed tens of thousands of tubal ligations through the years. More recently, single-incision techniques have been reported in the general surgery literature for insertion of peritoneal dialysis catheters in children using only an umbilical port for the laparoscope and retroperitoneoscopic adrenalectomies using a large 4.5-cm trocar without insufflation. A search of the historical literature produces many such published reports of what are now termed as LESS procedures.

Natural orifice transluminal endoscopic surgery (NOTES) was first described in 2003 and has a similar philosophical basis as LESS surgery in terms of reduced morbidity and cosmetic appeal. There have been many reports of animal studies exploring various NOTES techniques, largely in the porcine model. These are typically performed with flexible endoscopes with integral working channels for passage and manipulation of instruments introduced by way of the mouth, vagina, or rectum. Despite the relatively extensive laboratory experience, reported clinical cases remain few because of the unfamiliarity with instrumentation and optics. Most of the reported NOTES animal cases by urologists have been undertaken using a hybrid NOTES technique, using an additional 12-mm port in the umbilicus to aid in the surgery. In contrast to the less familiar NOTES approaches, LESS procedures reduce the morbidity and improve on the cosmesis of laparoscopic surgery using more familiar laparoscopic instrumentation with equivalent results.

Since the initial reports of clinical successes, there have been a large number and variety of LESS surgeries reported in urology. The potential reasons for LESS gaining popularity in the future are multifactorial. Urologists are more familiar with surgery through the abdominal wall than they are approaching structures through a hollow viscus. With the use of more familiar instruments, the learning curve with LESS may be shorter. The cosmetic benefits are maintained when a single umbilical incision is used because this can easily be hidden with careful closure.

LESS procedures are typically performed by a variation of one of two approaches. The first is single-site surgery, where more than one port, conventional or otherwise, can be used through common incision site. The second involves single-port surgery, where a single device, through which multiple instruments and optics can be passed, is used to access the peritoneal cavity. The access point for these surgeries may be in the umbilicus, an existing cicatrix on the abdomen, or extraumbilical; although this may be less cosmetic, at times it is necessary to complete the surgery.

Development and evolution of laparoendoscopic single-site surgery

The concept of LESS surgery has been around for many years and has been used across many surgical specialties. Gynecologists using a single-puncture laparoscope with an offset eyepiece have performed tens of thousands of tubal ligations through the years. More recently, single-incision techniques have been reported in the general surgery literature for insertion of peritoneal dialysis catheters in children using only an umbilical port for the laparoscope and retroperitoneoscopic adrenalectomies using a large 4.5-cm trocar without insufflation. A search of the historical literature produces many such published reports of what are now termed as LESS procedures.

Natural orifice transluminal endoscopic surgery (NOTES) was first described in 2003 and has a similar philosophical basis as LESS surgery in terms of reduced morbidity and cosmetic appeal. There have been many reports of animal studies exploring various NOTES techniques, largely in the porcine model. These are typically performed with flexible endoscopes with integral working channels for passage and manipulation of instruments introduced by way of the mouth, vagina, or rectum. Despite the relatively extensive laboratory experience, reported clinical cases remain few because of the unfamiliarity with instrumentation and optics. Most of the reported NOTES animal cases by urologists have been undertaken using a hybrid NOTES technique, using an additional 12-mm port in the umbilicus to aid in the surgery. In contrast to the less familiar NOTES approaches, LESS procedures reduce the morbidity and improve on the cosmesis of laparoscopic surgery using more familiar laparoscopic instrumentation with equivalent results.

Since the initial reports of clinical successes, there have been a large number and variety of LESS surgeries reported in urology. The potential reasons for LESS gaining popularity in the future are multifactorial. Urologists are more familiar with surgery through the abdominal wall than they are approaching structures through a hollow viscus. With the use of more familiar instruments, the learning curve with LESS may be shorter. The cosmetic benefits are maintained when a single umbilical incision is used because this can easily be hidden with careful closure.

LESS procedures are typically performed by a variation of one of two approaches. The first is single-site surgery, where more than one port, conventional or otherwise, can be used through common incision site. The second involves single-port surgery, where a single device, through which multiple instruments and optics can be passed, is used to access the peritoneal cavity. The access point for these surgeries may be in the umbilicus, an existing cicatrix on the abdomen, or extraumbilical; although this may be less cosmetic, at times it is necessary to complete the surgery.

Instruments and technology

Improvements in access devices, optics, and instrumentation have driven the dissemination of this new format of laparoscopic surgery. A brief description of the various new devices that have been used follows ( Table 1 ).

Access Devices

LESS surgery can be carried out through a variety of access devices. Conventional, albeit low-profile, laparoscopic trocars may be used in single-site surgery. Ports with a low external profile and of varying lengths are favored for these procedures to minimize the extracorporeal interaction of the devices causing limitation of movement internally. In addition, there have been reports of using shortened ports in the same way to reduce the intra-abdominal profile of the cannulae.

Specific access devices used in single-port surgery allow multiple instruments to be passed through them at the same time. The best-known and most commonly used access system is the TriPort (Advanced Surgical Concepts, Wicklow, Ireland) ( Fig. 1 ). This Food and Drug Administration–approved device has two components: a retracting component, which consists of an inner and outer ring with a double-barreled plastic sleeve; and a multichannel valve, which has three valves made of a unique elastomeric material. These valves accommodate one 12-mm and two 5-mm instruments within the same working space. The size of the port is variable according to the size of the fascial incision and can range from 10 to 30 mm depending to the surgery to be carried out. There is a variation of this device called the QuadPort, which has four working channels. It comes in two variations depending on the application for which it is intended (one 15-, one 12-, and two 5-mm ports; or four 12-mm ports). This device can be placed into incisions up to 50 mm in length and is useful for extirpative procedures in which a specimen needs to be removed. Both devices have a separate insufflation port through the valve housing; the valve housings can be removed to facilitate removal of a specimen through the retracting component. The TriPort can be placed by an open approach or after insufflation with an introducer, whereas the QuadPort must be placed with an open access technique.

The TriPort applied to a model abdominal wall ( A ) and as viewed from above ( B ). Note the presence of three working channels and an insufflation port.

The Uni-X Single Port Access Laparoscopic system (PNavel systems, Cleveland, Ohio), which has three working channels for 5-mm instruments, has also been used successfully for performing LESS procedures. It is placed by an open access technique and requires stitches to secure it in place to the fascia.

The use of a GelPort (Applied Medical, Rancho Santa Margarita, California) device by inserting three conventional laparoscopic ports through it to do a radical nephrectomy has been reported. The advantage of this system is that it allows for the introduction of ports or instruments of varying shapes and sizes in different configurations directly through the gel. It can be placed into a larger incision allowing the surgeon to take advantage of the entire fascial incision required during extirpative procedures, such as radical and donor nephrectomy. The port can, however, balloon out during insufflation causing the instruments to be pushed further from the operative field and the fulcrum to be less stable than is seen with the purpose-designed multichannel ports.

Other single-port devices are still in various stages of commercialization and there have been no published reports using these devices.

Instruments

The primary problems while doing LESS are loss of the triangulation, which is present with conventional laparoscopy, and the “chopsticks” effect with clashing of the closely situated instruments ( Fig. 2 ). These can be overcome to some extent by using special instrumentation. Desai and colleagues and Rane and colleagues described the use of prototype fixed-shaft bent instruments to facilitate single-port surgery. Similar prototype instruments were also developed by PNavel systems for use with the Uni-X device. Various newer actively articulating instruments are available. These companies have made a full spectrum of instruments available including endo-shears, needle drivers, graspers, and hook electrocauteries in these articulating series. In contrast to instruments with a fixed curve, actively articulating instruments can be inserted through rigid trocars. Although these instruments are useful in overcoming issues of triangulation, they continue to lack sufficient strength to provide robust retraction and dissection.

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