Laparoendoscopic single-site (LESS) bilateral nephrectomy in the pretransplant pediatric population

Laparoendoscopic single-site simultaneous bilateral nephrectomy: first reported case series

Bilateral renal tumors in patients on dialysis are usually managed with bilateral nephrectomy. With traditional laparoscopy, this procedure requires the insertion of multiple trocars. Laparoendoscopic single-site surgery (LESS) uses a single umbilical incision to insert multiple instruments and is also employed for extraction of specimens. This technique appears especially useful for bilateral nephrectomy, since many access ports can be spared. We describe 5 cases of simultaneous bilateral radical nephrectomies performed at a single academic institution. We had no intraoperative complications and a mean operating time of 155 minutes. Four patients could be resected using this approach; one case was converted to a traditional laparoscopy. One case had a postoperative complication. We believe this technique is feasible, and can be accomplished with acceptable morbidity and ade-quate operative time.

Laparoendoscopic Single-Site (LESS) Surgery in Pediatric Urology: A 4-Year Experience

Objective

The aim of the study was to assess the feasibility and outcomes of pediatric urological laparoendoscopic single-site (LESS) surgery.

Materials and Methods

We retrospectively collected charts of all patients who underwent LESS procedures in our department from January 2013 to December 2016. Data included demographic characteristics, type of procedures, intraoperative details, hospital stay, and complications. The umbilicus was used as the surgical site in all cases. All procedures were performed with a homemade glove port and standard straight 3- or 5-mm laparoscopic instruments.

Results

Seventy-three patients (55 males, 18 females) were identifed. Procedures included 46 orchidop-exies, 21 pyeloplasties, 8 varicocelectomies, 3 nephrecto-mies, 3 nephroureterectomies, 3 orchiectomies, and 1 renal hydatid cyst treatment. Median operative time for the entire cohort was 47 min (range 26-156 min). There was no signifcant intraoperative blood loss. No conversion to conventional laparoscopy or open surgery was needed. All patients required paracetamol postoperatively. The mean follow-up was 18 months. Two patients had testicular atrophy after a Fowler-Stephens procedure and 1 patient had testicular reascension. Cosmetic results were excellent. Forty-five (62.5%) patients were discharged on the day of surgery.

Conclusion

Our study demonstrated that LESS surgery using our glove port technique and conventional laparoscopic instruments is a feasible and safe technique for the surgical management of various pediatric urological conditions.

Laparoendoscopic single-site surgery (LESS) for major urological procedures in the pediatric population: A systematic review

BACKGROUND

Improvements in laparoscopic surgery have led to the introduction of laparoendoscopic single-site surgery (LESS) as an alternative to conventional laparoscopy conferring a number of possible advantages. In this review, we aim to elucidate the aspects of LESS for major urological procedures in the pediatric population.

MATERIALS AND METHODS

An in-depth search of the literature was performed in the databases of PubMed and Scopus, for studies investigating the technical aspects and clinical outcomes of partial nephrectomies, nephrectomies, nephroureterectomies, varicocelectomies and pyeloplasties in children. Data on parameters such as operation time, instrumentation, perioperative complications, hospital stay and follow up period were collected and further analyzed cumulatively.

RESULTS

Twenty nine studies met the inclusion criteria incorporating 386 patients who underwent 401 procedures. There were no major intraoperative complications, with only 19 patients (4.73%) facing postoperative complications. No perioperative deaths were reported.

CONCLUSIONS

In the hands of experienced surgeons LESS seems a feasible, efficient and less invasive alternative to standard laparoscopy in the field of pediatric urology. There is an eminent need of well-designed randomized controlled trials comparing the two techniques.

Laparoendoscopic single-site surgery (LESS) for the treatment of different urologic pathologies in pediatrics: single-center single-surgeon experience

INTRODUCTION

Recently LESS has been reported as a valid minimally option for treatment of some urologic pathologies in pediatrics. However, the initial reports of pediatric LESS are still limited to case reports and initial case series. This may be due to the inherent technical difficulty of LESS and the currently available LESS instruments. In this report, we present the largest case series of pediatric LESS for treatment of different urologic pathologies in pediatrics.

MATERIALS AND METHODS

Included in this study are children who had LESS during the period of January 2011 to June 2013. Both Olympus TriPort (Olympus, New York, USA and Advance Surgical Concept, Wicklow, Ireland) and Covedien SILS access port (Covedien, Chicopec, Massachusetts, USA) were used and were inserted through the umbilicus. Exclusion criteria included children less than 3 years old, history of previous transperitoneal abdominal surgery, malignant indications, and complex urogenital congenital anomalies. All LESS procedures were done by a single experienced laparoscopist and data were reviewed retrospectively.

RESULTS

Twenty-two children had 39 LESS procedures without conversion to conventional laparoscopy or open surgery. No intraoperative or postoperative complications were reported and no extra-port was added in any of the patients. The following table shows the mean age, operative time, hospital stay, VAS as well as the overall mean of different LESS procedures. In all patients the umbilical scar was invisible and all patients and their parents had high wound satisfaction. At a mean follow up of 18.6 ± 6.4 months, all patients with UPJO had successful repair.

DISCUSSION

Our study included 13 boys with undescended testis who were managed in different ways according to the length of spermatic vessels and the size of the testis. One of the arguments against LESS management of undescended testis is that it requires a 2.5-cm incision, which is collectively larger than a 5-mm camera and two 3-mm working ports of conventional laparoscopy. However, the Triport access can be inserted through a 12-15-mm single umbilical incision without any additional openings in the abdomen as required with conventional laparoscopy which may increase the risk of internal organ injury and other port-related complications. Our results of five LESS varicocelectomies correlate with reports in the literature; regarding the operative time and hospital stay. LESS pediatric nephrectomy has been reported by many authors and our results correlates with that have been published. Compared with conventional laparoscopic nephrectomy, LESS nephrectomy seems to have shorter operative time and hospital stay. Although both cases of LESS nephrectomy were on the right side, we did not add any extra-ports which could be related to technical modifications during the surgery as well as the experience of the surgeon. To date, few data are available about LESS pyeloplasty in pediatrics. Our study included three patients who had left LESS pyeloplasties. In these patients, no extra-port was added. Despite of the technical difficulty of intracorporeal suturing during LESS, LESS pyeloplasty seems to be feasible with adequate training. Our patients had short hospital stay, low VAS at discharge, received a low dose of NSAID as postoperative analgesic and in all cases there was high wound satisfaction. One of the limitations of the current study could be the selection criteria of the patients, with children younger than 3 years and children who may be more technically difficult, being excluded. Furthermore, the number of patients in some indications is small and more patients are required to give solid conclusions and detect possible complications.

CONCLUSIONS

Our study demonstrates the technical feasibility and safety of LESS for both ablative and reconstructive pathologies in pediatrics. However, more applications including a larger scale of pediatric patients as well as prospective comparative studies with conventional laparoscopy, are necessary.

Minimally invasive surgery in the management of abdominal tumors in children

The application of minimally invasive surgical techniques to pediatric abdominal tumors is a controversial application towards the surgical management of childhood cancer. Although general pediatric surgeons practice minimally invasive surgery techniques in a vast array of abdominal cases, its role in pediatric oncology is still developing, with no consensus in North America about its use for pediatric solid abdominal tumors. The purposes of this article are to review the current literature about the use of minimally invasive surgery in pediatric abdominal oncology and to examine established indications, procedures and technologic advances.

Single-incision endoscopy-assisted ileocecal resection

BACKGROUND

Minimally invasive laparoscopic surgery was widely performed for colectomies. In recent years, as a new approach, the sigmoid colon or rectum is removed through the anus, minimizing the need for skin incisions. However, the resected ileocecal portion or the right side of the colon may be difficult to remove from the anus. Therefore, it usually needs to be removed using a skin incision, which typically restricts the size of the tissue. In these cases, we applied a less-invasive single-incision endoscopy-assisted colectomy to avoid forceps interference and reduce the port size required for the energy device. In this study, we introduce an ideal single-incision technique.

METHODS

We performed surgeries on 3 patients with cecal or proximal ascending colon cancer (1 early and 2 advanced cases). Under general anesthesia, we initially made a right pararectal incision (3 to 5 cm), which was dependent on the tumor size and fixed a GelPort (Applied Medical, Orange County, CA) and inserted 12- and 5-mm trocars. Through the 12-mm trocar, we inserted a gastrointestinal scope for dissecting the ileocecal area from the retroperitoneum using a hook knife, similar to the endoscopic submucosal dissection technique. After mobilization, all other maneuvers were performed by an open method.

RESULTS

The mean surgery time was 185 minutes. There were no major complications among the patients.

DISCUSSION

This single-incision endoscopy-assisted dissection needs no additional suction, irrigation, or electrocoagulator and is a realistic and idealistic technique at present. Transvaginal and transanal retrieval methods are still controversial.

CONCLUSION

We believe that this endoscopic technique may be essential for advancement to minimally invasive laparoscopic surgery toward natural orifice transluminal endoscopic surgery.

Single-incision pediatric endosurgery: a systematic review

BACKGROUND

Single-incision pediatric endosurgery (SIPES) is defined as minimally invasive surgery performed through a unique incision in the abdomen, chest, or retroperitoneum. Several publications exist, but no previous systematic review has been made to evaluate the real benefits of this approach in terms of feasibility and clinical outcomes.

MATERIALS AND METHODS

We performed an electronic search in PubMed up to March 2012 with the terms "single AND incision OR site OR port OR trocar AND children" including related articles and obtained 197 articles. After applying our inclusion criteria, 78 articles were reviewed.

RESULTS

We identified prospective controlled trials (n=1), case-control studies (n=12), case series (n=49), and case reports (n=16). In total, 4212 patients had been operated on by SIPES and were separated by systems: gastrointestinal (n=2888), urologic (n=390), gynecologic (n=27), other abdominal (n=874), and thoracic (n=33) procedures. The most common procedure was SIPES appendectomy, and a unique prospective controlled trial supports its safety and effectiveness. Technically demanding surgeries such as hepatojejunostomy and colonic surgeries were described. Multichannel ports and multiple ports, standard and articulated instruments, transparietal instruments, retraction sutures, and magnets were used. Operative times, length of stay, and complications similar to standard laparoscopic surgery were described. A low conversion rate (to a reduced port, standard laparoscopy and open procedures) was also mentioned. No comparable measure for pain and cosmesis assessment was used.

CONCLUSIONS

A wide experience in SIPES and feasibility has already been described with good clinical outcomes and low rate of conversion. Appendectomy is the unique procedure in which SIPES has been demonstrated to be safe and effective. It is pending the execution of prospective controlled trials for other operations to demonstrate, with objective evidence, the real benefits of this less invasive approach.