Laparoendoscopic single-site surgery in gynaecology: A new frontier in minimally invasive surgery.

LESS surgery represents the next step forward in minimally invasive techniques; however, many questions must be answered and research must be performed to support the general application of LESS. There is definite patient interest, especially among women, as demonstrated by patients opting for single-port rather than multiport access surgeries; however, further research is need to answer the fundamental question of whether LESS shows any objective, reproducible benefit over conventional laparoscopy. There is agreement that these techniques provide improved cosmesis; however, standardized measures have not yet been employed to scientifically verify these findings. While this apparent benefit is important, the true indicator for the widespread acceptance of LESS will be whether or not these procedures demonstrates reduced pain, perioperative morbidity and convalescence thus justifying the increased technical demands and arguably more costly technology (when compared with conventional laparoscopy). Preliminary comparative studies indicate that LESS outcomes are at least equivalent to those of conventional laparoscopy, and in several studies LESS has shown improved pain profiles, decreased home oral narcotic requirements and faster return to work. It is likely that as the learning curve is overcome and large prospective studies are completed, that these questions will be addressed and more definitively answered.[ 41 ]

LESS procedures are typically performed via one of two approaches. The first is single-site surgery, where two or more conventional ports are placed through a single-incision. The second approach utilises a single, multichannel device, through which multiple instruments and optics are passed. The access point for these surgeries is typically the umbilicus, although less cosmetic extra-umbilical incisions may occasionally be necessary to complete the surgery. Improvements in access devices, optics and instrumentation have driven the dissemination of this new format of laparoscopic surgery.

Instrument crowding may occur due to several instruments being passed though a multichannel, single-port. Instruments may easily clash with one another or with the laparoscope, all of which are passed through the same surgical fulcrum. Conventional laparoscopes have a large extracorporeal profile with a light cable perpendicular to the telescope. Due to this latter feature, if the conventional laparoscope is utilised for LESS instrument clashing may be exacerbated. One method, however, to minimize this problem is by using a lower profile camera system. One system that is currently available is the rotatable 30°Visera EndoEYE laparoscope (Olympus America Inc, Center Valley, PA; Figure 5 ), which has the unique feature of a video laparoscope integrated with a coaxial light cable in line with the shaft of the telescope. The Olympus EndoEYE is currently the only laparoscope offering this unique feature, and it is available in 5-mm size in 0° and 30° configurations. It is also available with a flexible actively deflectable tip. Other special optics that may facilitate LESS surgery include a 45° telescope (Stryker), which has a coaxial, right-angle light guide adapter to help minimize sword fighting. SILS Port (Covidien, Mansfi eld, MA).

Initially, during the 1960s and 1970s, the application of laparoscopic surgery in gynaecology was restricted to diagnostic cases and tubal procedures such as sterilisation.[ 18 – 20 ] The first reported case of laparoscopic organ resection was not until 1975, when Tarasconi, a Brazilian obstetrician/gynaecologist, preformed an endoscopic salpingectomy with these techniques.[ 22 ] As laparoscopic techniques evolved, gynaecologists began to perform the more complex cases of the specialty with these minimally invasive techniques. The use of LESS surgery in gynaecology evolved similarly, with initial utilisation for straightforward tubal ligations. For example, Wheeless et al .[ 23 ] performed thousands of tubal ligations using a single-puncture laparoscope with an offset eyepiece. Utilising this technique for more complex gynaecological surgery was first described by Pelosi, who performed a single-incision laparoscopic hysterectomy with bilateral salpingo-oophorectomy in 1991.[ 24 ] This method, however, was not popularized for another 15 years due to numerous procedural obstacles.

Although several patient and surgical factors can make minimally invasive surgery more challenging, variables such as obesity, previous abdominal surgeries and a diagnosis of early-stage gynaecological cancer), do not necessarily preclude the performance of LESS.[ 11 13 15 ] However, women who have had more than two previous midline vertical laparotomies, a prior panniculectomy or who do not possess a native umbilicus, or who have a diagnosis of advanced malignancy may not be suitable candidates for single-port laparoscopic surgery. Patient selection should initially be geared towards simple cases, as learning these ergonomically challenging techniques may be less technically demanding in these cases. Enrolling in a training/ simulation course is also helpful in order to become familiar with the newer LESS technologies. Both practicing techniques in a dry lab setting or working with and/or observing a more experienced LESS surgeon is also helpful when beginning to use LESS techniques. Further data is needed to clarify the optimal patient candidacy for this novel laparoscopic approach.

In examining LESS techniques for gynaecological malignancies, several advantages may be proposed. Many women with breast or gynaecological cancers may perceive a benefit of LESS specific to their body image following surgery. Moreover, fewer incisions may result in faster recovery periods and a more timely administration of adjuvant therapies when required. More data is needed in order to support or refute these theories. There have been several reports from our research group demonstrating feasibility, safety and reproducibility of the LESS approach for treatment of select early-stage endometrial or ovarian cancers, pelvic masses, precancerous conditions and for risk-reducing salpingo-oophorectomy in women at high risk for ovarian cancer.[ 10 13 ] Furthermore, a recently report by Escobar et al . demonstrated that more complicated procedures, such as pelvic and para-aortic lymphadenectomy were also feasible and safe to perform with LESS techniques. These procedures produced comparable nodal counts to open or conventional laparoscopic surgery.[ 39 ] One limitation of LESS for nodal dissection was that visceral and truncal adiposity limited the access to the left para-aortic nodal region, and therefore, this procedure may be difficult to perform in morbidly obese woman utilising single-port techniques. One possible solution to this limitation is to position the patient in a lateral position with the left flank elevated (as is done with transperitoneal laparoscopic left nephrectomy procedures) in order to facilitate exposure of the left para-aortic lymph nodes to the level of the renal vessels. Further research is needed to determine if this positioning could provide adequate exposure in these patients. In a retrospective review of 74 LESS cases performed on a gynaecological oncology service, a variety of procedures were performed (including endometrial cancer staging and excision of complex pelvic masses). This study showed that perioperative complications were low (3.5%) and pain scores were excellent.[ 13 ] A Pearson product-moment correlation demonstrated a significant linear relationship between the operating time and number of cases for cancer staging (r=-0.71, n=26, P < 0.001) and non-staging procedures (r=-0.78, n=48, P < 0.002). This statistic revealed that approximately 20 cases were required to achieve stable decreased operative times, again supporting a learning curve for complex LESS procedures that is similar to that of conventional laparoscopic cases. Finally, LESS surgery may also be done via the da Vinci surgical system robotic platform through a GelPort or other similar single-port device.[ 11 40 ] Our group was the first to report on a robotic LESS gynaecological procedure utilising the S system. The newer technology of the generation SI da Vinci robotics (Intuitive Surgical) will have a specific single-port adapation that will allow for more facility with LESS. This may alleviate some of the challenging ergonomic issues associated with conventional LESS. The da Vinci single-port adaptation is currently undergoing FDA approval and will reportedly be available in 2011. This merger of single-port and robotics technology will further expand the use and feasibility of single-port surgery and is therefore eagerly anticipated.

Potential advantages of single-port over conventional multiport laparoscopy include superior cosmesis from a relatively hidden umbilical scar, a possible decrease in morbidity related to visceraland vascular injury during trocar placement, as well as risk reduction of postoperative wound infection, hernia formation and elimination of multiple trocar site closures. Studies have also suggested that women who undergo LESS report improved postoperative pain profiles when compared with those receiving conventional laparoscopic surgery.[ 25 ] This may be due to the utilisation of the umbilicus as the single site of the incision, as it is one of the thinnest regions on the abdominal wall, containing few blood vessels, muscle or nerves.

Laparoendoscopic single-site surgery is the latest innovation in minimally invasive surgery and appears to be feasible and safe to perform for a variety of gynecologic conditions. This approach may result in a “scarless” effect, because the healed incision remains concealed at the base of the navel. While initial series in the urological, general surgery and gynaecological literature have demonstrated the safety, aesthetic superiority and potentially improved pain profile of a single-port approach when compared with conventional laparoscopy, these early findings must be further validated. The routine application of LESS in gynaecology not only requires evaluation of safety but also of cost-effectiveness, and these studies must all be performed in larger, prospective studies to definitively answer questions regarding the clinical and economic impact of this novel surgical approach. More detailed data is also needed to further describe the learning curve and the optimal environment for trainees and surgeons to become skilled in LESS procedures. These additional research initiatives will help to drive advances in minimally invasive surgical techniques and technology, in order to continue to provide better outcomes for our surgical patients.

LESS surgery can be performed through a variety of access devices. Conventional, low profile ports of different lengths can help to minimize limitation of movement by the surgeon(s) due to the extracorporeal interaction of the instruments and camera (known as “sword fighting”). Technological developments have produced multichannel single-port devices as well.[ 26 – 29 ] The prototype access system is the TriPort (Advanced Surgical Concepts, Wicklow, Ireland). This is a Food and Drug Administration-approved device with 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 each accommodate one 12-mm and two 5-mm instruments within the same working space. The port comes in various sizes, ranging from 10 to 30 mm, and can be selected according to the size of the fascial incision. More recently, the Quad-Port, which has four working channels [ Figure 1 ] has been introduced. This port can accomodate one 15-, one 12-, and two 5-mm ports; or four 12-mm ports. While the TriPort can be placed by either an open approach or after insufflation with an introducer, the Quad-Port must be placed by an open-access technique. Quad Port (Advanced Surgical Concepts, Wicklow, Ireland). Another port that has also been used successfully for LESS procedures is the Uni-X Single-Port Access Laparoscopic system (PNavel systems, Cleveland, OH). This port has three working channels for 5-mm instruments, and it is placed by an open access technique, requiring stitches to secure it to the fascia. The GelPort or newer generation GelPoint (Applied Medical, Rancho Santa Margarita, CA) devices consist of a combination of the rigid ring of the Alexis ® wound retractor with a Gelseal ® cap which maintains pneumoperitoneum during multiple instrument exchanges.[ 27 28 ] Unlike the aforementioned ports, this system allows for the introduction of ports or instruments of varying shapes and sizes directly through the gel [ Figure 2 ]. This device can also be placed into a larger incision, allowing the surgeon to take advantage of the entire fascial incision required during extirpative procedures, and represents an efficient port for tissue removal. The disadvantage of this port can, however, is that it may balloon out during insufflation causing the instruments to be pushed further from the operative field and the fulcrum to be less stable than the other multichannel ports described. Gelpoint (Applied Medical Systems, Rancho Santa Margarita, CA). The SILS ™ Port Multiple Instrument Access Port (Covidien ® , Mansfield, MA) is another multi-instrument access port that allows up to three laparoscopicinstruments (three 5-mm cannulas or two 5-mm and one 12-mm cannula) to be used simultaneously through separate flexiblechannels [ Figure 3 ]. This port allows for adjustment of the cannula positions within the flexible port, and there is a separate channel that allows for CO 2 insufflation. The port must be inserted through an open access technique. Finally, the latest port to be approved is the Single-Site Laparoscopy Access System (Ethicon Endosurgery, Cincinnati, OH) which was introduced on the market in 2010 [ Figure 4 ]. Two 5-mm seals and one 15-mm seal enable use of a wide range of instrumentation. The advantages of this system include the use of a morcellator through the larger port; the integrated, low-profile system obviates the need for trocars; and the outer seal cap allows for 360° of rotation and reportedly facilitates specimen removal. EndoEYE Deflecting Tip Laparoscope (Olympus America Inc, Center Valley, PA). Single Site Laparoscopy Access System (Ethicon Endosurgery, Cincinatti, OH). Two of the biggest caveats that limit use of the LESS technique are instrument crowding and lack of triangulation. Many surgeons are accustomed to the tenet of triangulation, due to the use of conventional laparoscopy, and this practice can be approximated to some degree by utilising special single-port instrumentation, including flexible and/or articulating instruments. These instruments allow for intracorporeal triangulation, rather than the extracorporeal triangulation utilised in traditional laparoscopy. Those instruments currently available as articulating devices includegraspers, shears, endoshears, needle-drivers, and hook electrocautery. Several companies have designed a comprehensive spectrum of these articulating instruments. At this stage in development, bulk and technical challenge pose major obstacles in using articulating instruments.

Laparoscopy has become the standard treatment for many gynaecological conditions. Numerous studies have demonstrated that utilising laparoscopy for various benign and malignant gynaecological diseases results in shorter hospital stays, improved quality of life and improved surgical outcomes when compared with open abdominal surgery.[ 1 – 3 ] Laparoendoscopic single-site surgery (LESS), also known as single-port surgery, is a novel, rapidly-advancing minimally invasive technique. LESS improves the cosmetic benefits of minimally invasive surgery by providing only one incision, which also minimizes the potential morbidity associated with multiple incisions. Data from the general surgery and urology literature has demonstrated technical feasibility and reproducibility of this technique when utilised for a variety of procedures, including cholecystectomy, appendectomy, nephrectomy and hemicolectomy.[ 4 – 9 ] These early reports indicate that LESS is a promising surgical innovation that results not only in improved cosmesis, but also, in many cases, a shorter convalescence period and decreased postoperative analgesia requirements when compared with patients treated with conventional laparoscopic approaches. Single-incision surgery has been performed anecdotally for decades in gynaecology; however, the first surgery employing LESS techniques was not described in the literature until 2008. Since that time, the interest in this surgical approach has grown exponentially. Several publications in the gynaecology literature have demonstrated preliminary feasibility, safety and reproducibility of LESS in the treatment of both benign and oncological female conditions.[ 10 – 20 ] The recent surge in the number and variety of LESS cases has been facilitated by the introduction of new instrumentation and access devices. In addition, innovative approaches to single-site surgery and utilisation of both new and existing robotic platforms have further improved and advanced single-site surgery.