Single‐incision multiport

Single‐incision multiport LESS surgery describes a single‐skin incision with multiple standard low‐profile laparoscopic trocars in separate fascial incisions (Figure 120.1a). Benefits include access to readily available products with potential downsides of external clashing. In 2007, Raman et al. described using this technique in a pig model, with subsequent successful completion in three humans [6]. Additional reports since that time have described this technique with transperitoneal LESS donor nephrectomy [7].

Homemade

Prior to the introduction of dedicated single‐port devices, many clinicians created their own LESS ports. A popular method uses an Alexis® retractor and a surgical glove. Ports are placed through the fingers of the glove and secured with suture (Figure 120.1b) [8]. Benefits to using this system include flexibility in port placement, as well as the ability to use standard laparoscopic instruments given the potential wide range of motion [8]. Issues utilizing this type of system include lack of rigidity and port stability, as well as tearing of the glove requiring the need to stop the operation and redo the port [8–10].

TriPort+/TriPort15™/QuadPort+™ (Advanced Surgical Concepts, Bray, Ireland)

The first LESS port on the market, originally called the R‐Port™ and subsequently the TriPort, was used in the first reported LESS nephrectomy [2] and the first R‐LESS series [4]. Advanced Surgical Concepts now has three current configurations utilizing this technology: TriPort+, TriPort15, and QuadPort+. Models are currently distributed by Olympus (Tokyo, Japan). Each port has an internal anchoring ring that is placed through a Hasson incision with a blunt trocar and secures the device to the parietal peritoneum. An outer ring cinches down over a plastic sleeve to create a tight seal on the abdominal wall. The excess sleeve is excised prior to securing the port cap. The ports are built into the cap, and allow the passage of curved instruments due to their flexibility.

Both TriPort + and TriPort15 models are used with fascial incisions 12–25 mm and can accommodate abdominal walls up to 10 cm thick. They have two insufflation and/or ventilation ports, with the main difference being the working channels. The TriPort + has three 5 mm ports and one 5–10 mm port (Figure 120.1c) and the TriPort15 has two 5 mm ports and one 5–15 mm port (Figure 120.1d).

With the ability to accommodate the same abdominal wall thickness of 10 cm, the QuadPort + is for fascial incisions between 25 and 60 mm. It has two 5 mm ports, two 5–10 mm ports, and one 5–15 mm port, as well as two insufflation and/or ventilation ports (Figure 120.1e).

TriPort has shown broad utilization in the literature. In pediatric urology, it has been used for ochidopexy [11], varicocelectomy [12], simple nephrectomy [11, 13], and pyeloplasty [11, 13].

For adult transperitoneal LESS surgery, reports include partial nephrectomy [14, 15], radical nephrectomy [16], donor nephrectomy [17], adrenalectomy [18], vesicovaginal fistula repair [19], bladder diverticulectomy [20], and pyeloplasty [12]. Extraperitoneal LESS usage with TriPort has included cyst decortication [21], adrenalectomy [22], and radical prostatectomy [23]. More limited reports depict use of the TriPort to transvesically remove mesh [24, 25] and perform a bladder diverticulectomy [26].

Early R‐LESS reports describe placing one robotic arm alongside the TriPort, but through the same skin incision, to limit instrument clashing. This technique has been utilized for radical prostatectomy, pyeloplasty, radical nephrectomy, and partial nephrectomy [4, 27].

SILS port (Covidien, Dublin, Ireland)

The SILS port is a flexible foam port that is placed via Hasson technique through an approximate 2.0 cm fascial incision (Figure 120.1f). The low‐profile design can mold to the incision tightly to limit gas leakage, but due to its relatively fixed size cannot accept a large range of fasical incision sizes or abdominal wall thicknesses. The three different models (SILSPT5TA, SILSPT12TA, and SILSPT15TA) each accommodate three trocars at a time, with the first two being 5 mm, and the last trocar either 5 mm, 5–12 mm, or 5–15 mm, respectively. There is also a separate insufflation/ventilation port, and one of the 5 mm ports has a side hole for additional insufflation/ventilation if needed.

Reports have described using the SILS port for pediatric cases [11], including simple nephrectomies [28]. In the adult literature, the SILS port has been utilized for transperitoneal LESS donor nephrectomy [7], varicocelectomy [29], and adrenalectomy [30], as well as retroperitoneal LESS adrenalectomy [31].

Because of its low‐profile design and to prevent external clashing of instruments, adaptations to use the SILS port for R‐LESS involve adjacently placed robotic ports through the same skin incision, essentially robotic single‐site surgery [32]. This has been completed in patients undergoing robotic prostatectomy [33] and in select radical nephrectomy cases [34].

GelPOINT/GelPOINT Mini (Applied Medical, Rancho Santa Margarita, CA, USA)

This system is based on an Alexis® wound retractor and is an evolution of the GelPort system. The device comes in two sizes, GelPOINT (incisions 1.5–7.0 cm, Figure 120.1 g) and GelPOINT Mini (incisions 1.5–3.0 cm, Figure 120.1 h). The retractor is placed through a Hasson incision and cinched to the abdominal wall. A GelSeal® cap is secured to the retractor, forming a tight seal and preventing gas leakage. Both systems incorporate three 5–10 mm sleeves and one 5–12 mm sleeve. The sleeves, which function as ports, are placed through the cap in a customizable configuration. In addition, two insufflation and/or venting ports are available on the cap. Benefits of these systems include the ability to move the ports in a number of configurations to prevent external and internal clashing. This has made this system ideal for R‐LESS adoption, and is currently in use at the author’s institution. To perform, robotic 5 mm flared trocars are predocked onto the robot arms and clutched through the sleeves.

Pediatric LESS reports using GelPOINT include transperitoneal nephrectomy, nephroureterectomy, partial nephrectomy, renal cyst decortication, gonadectomy, Malone antegrade continence enema, calyceal diverticulectomy, and ovarian detorsion with cystectomy [35]. Pediatric retroperitoneal LESS nephrectomy has also been reported [36].

Adult LESS procedures include transperitoneal nephrectomy [37] and donor nephrectomy [7, 38–41], and retroperitoneal nephrectomy [42], partial nephrectomy [43], and donor nephrectomy [44].

R‐LESS procedures have included pyeloplasty [45], partial nephrectomy [45], and radical nephrectomy [34, 45]. In addition, GelPOINT Mini was used to perform the first R‐LESS perineal prostatectomy [46].

OCTO™ Port V2 (DalimSurgnet, Seoul, Korea)

The OCTO Port V2 is a two‐piece device, consisting of a wound retractor and a port cap (Figure 120.1i). The wound retractor comes in three sizes: 1.5–3.0 cm, 3.5–5.0 cm, and a deeper 3.5–5.0 cm for thicker abdominal walls. An inner ring is placed through a Hasson incision, and secured by stretching the externalized silicone around the external ring. The port cap comes with either three (one 5 mm and two 5–12 mm) or four (two 5 mm and two 5–12 mm) built‐in ports. In addition, each four‐port cap can be in one of two configurations: (i) 5 mm ports on opposite sides and (ii) 5 mm ports on the same side, giving multiple different options depending on surgeon preference and the operation performed. The port caps are made of silicone, making them flexible during laparoscopy and allowing passage of curved instruments. After securing to the wound retractor, the port cap can rotate 360°, allowing for versatility in instrument position. There are also two smoke filtering systems and a separate insufflation port.

Notable OCTO Port use in the literature includes transperitoneal LESS radical nephrectomies in humans [47] and partial nephrectomies in a porcine model [48].

X‐Cone, Endocone, S‐Port™ (Karl Storz, Tuttlingen, Germany)

The X‐Cone is a reusable single‐port device that consists of two metal halves that secure together to form a 2.5 cm cone (Figure 120.1j). A fascial incision of approximately 2.0 cm is used, and the two halves are inserted separately before securing in place. The silicone sealing assembly with built‐in ports is secured on top of the cone. The port configuration is four 5 mm ports and one 5–12 mm port. There are two additional adapters for insufflation and/or venting.

The Endocone is a 3.4 cm multilumen reusable port with six 3–5 mm channels, one 5–12 mm channel, and one 5–15 mm channel (Figure 120.1 k). It has a separate insufflation port, and is placed through a 3.0–5.0 cm fascial incision using the Hasson technique.

The S‐Port consists of single‐use wound retractors and an attachment cap that has an insufflation port. Once secured to the wound retractor, either the X‐Cone or Endocone seal cap can be secured on top for variations in port placement.

Reports in pediatric urology have included transperitoneal LESS nephroureterectomy [49], nephrectomy, and orchidopexy [50].

Reports in adult urology have described using the X‐Cone to perform transperitoneal LESS staging lymphadenectomy in patients with high‐risk prostate cancer [51], varicocelectomy [52], radical nephrectomy, partial nephrectomy, pyeloplasty, and renal cyst ablation [53].

Greco et al. utilized the Endocone to perform LESS transperitoneal radical nephrectomy in 33 patients [54].

Single‐Site™ port (Intuitive Surgical Inc., Sunnyvale, CA, USA)

The Single‐Site port is the first platform designed specifically for R‐LESS with the da Vinci® Si Surgical System (Figure 120.1 l). The flexible port is placed through a 1.5 cm fascial incision and has access for the 8.5 mm robotic endoscope, two 5 mm curved robotic cannulae, a 5–10 mm assistant port, and an insufflation port. The curved cannulae are designed to recreate triangulation and are used specifically with Intuitive semirigid instruments (described later).

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