Single port sigmoidectomy in an experimental model with survival

Comparison of efficacy between robotic and open hepatectomy: a systematic review and meta-analysis of propensity score-matched studies

This meta-analysis evaluates and contrasts the diagnosis and perioperative results involving RLR (robotic liver resection) and open OLR (open liver resection). The researcher used systematic search criteria of databases including MEDLINE, PubMed, Google Scholar, and the Cochrane Library for relevant literature published between January 2000 and January 2025. Eight non-randomized controlled trials were included, each using propensity score matching (PSM), involving 1192 patients. Among them, 557 patients received robotic laparoscopic resection (RLR), while 635 patients underwent open laparoscopic resection (OLR). Undergoing RLR was found to lead to longer surgical times, according to the analysis; however, patients undergoing RLR experienced notably shorter hospital stays compared to those undergoing open liver resection. No significant variations were noted regarding blood loss between the groups, incidence of bile leakage, complication rates, R0 resection margins, or 90-day mortality. RLR demonstrates surgical results similar to those of OLR. Key advantages include shorter hospitalization times and lower complication rates.

Minimally Invasive Rectal Surgery: Current Status and Future Perspectives in the Era of Digital Surgery

Over the past two decades, minimally invasive approaches in rectal surgery have changed the landscape of surgical interventions, impacting both malignant and benign pathologies. The dynamic nature of rectal cancer treatment owes much to innovations in surgical techniques, reflected in the expanding literature on available treatment modalities. Local excision, facilitated by minimally invasive surgery, offers curative potential for patients with early T1 rectal cancers and favorable pathologic features. For more complex cases, laparoscopic and robotic surgery have demonstrated significant efficacy and provided precise, durable outcomes while reducing perioperative morbidity and enhancing postoperative recovery. Additionally, advancements in imaging, surgical instrumentation, and enhanced recovery protocols have further optimized patient care. The integration of multidisciplinary care has also emerged as a cornerstone of treatment, emphasizing collaboration among surgeons, oncologists, and radiologists to deliver personalized, evidence-based care. This narrative review aims to elucidate current minimally invasive surgical techniques and approaches for rectal pathologies, spanning benign and malignant conditions, while also exploring future directions in the field, including the potential role of artificial intelligence and next-generation robotic platforms.

Comparative assessment of safety and efficacy between the AirSeal system and conventional insufflation system in robot-assisted laparoscopic radical prostatectomy: a systematic review and meta-analysis

This meta-analysis aimed to compare perioperative outcome measures between the AirSeal system and conventional insufflation system in robot-assisted laparoscopic prostatectomy. Up to May 2024, comprehensive searches were conducted across various prominent databases worldwide, such as PubMed, Embase, and Google Scholar, focusing solely on English-language materials. Reviews and protocols devoid of published data were excluded, along with conference abstracts and articles unrelated to the study's aims. Primary outcome measures encompassed operative duration and hospitalization length, while secondary outcome measures included estimated blood loss and complications. The meta-analysis included five cohort studies, encompassing a total of 1503 patients. In comparison to the conventional insufflation system group, the AirSeal group displayed shorter operative times (WMD - 15.62, 95% CI - 21.87 to - 9.37; p < 0.00001) and reduced hospital stays (WMD - 0.45, 95% CI - 0.60 to - 0.30; p < 0.00001). Fewer major complications (OR 0.15, 95% CI 0.03 to 0.66; p = 0.01). Notably, there were no significant differences observed in estimated blood loss or overall complications between the two groups. Compared to conventional insufflation systems, employing the AirSeal system in robot-assisted laparoscopic radical prostatectomy appears to potentially decrease operative time and hospital length of stay without a concurrent rise in estimated blood loss or complication rates.

Clinical Outcomes of Reduced-Port Laparoscopic Surgery for Patients With Sigmoid Colon Cancer: Surgery With 1 Surgeon and 1 Camera Operator

Purpose

This study compared the perioperative clinical outcomes of reduced-port laparoscopic surgery (RPLS) with those of conventional multiport laparoscopic surgery (MPLS) for patients with sigmoid colon cancer and investigated the safety and feasibility of RPLS performed by 1 surgeon and 1 camera operator.

Methods

From the beginning of 2010 until the end of 2014, 605 patients underwent a colectomy for sigmoid colon cancer. We compared the characteristics, postoperative outcomes, and pathologic results for the patients who underwent RPLS and for the patients who underwent MPLS. We also compared the clinical outcomes of single-incision laparoscopic surgery (SILS) and 3-port laparoscopic surgery.

Results

Of the 115 patients in the RPLS group, 59 underwent SILS and 56 underwent 3-port laparoscopic surgery. The MPLS group included 490 patients. The RPLS group had shorter operating time (137.4 ± 43.2 minutes vs. 155.5 ± 47.9 minutes, P < 0.001) and shorter incision length (5.3 ± 2.2 cm vs. 7.8 ± 1.2 cm, P < 0.001) than the MPLS group. In analyses of SILS and 3-port laparoscopic surgery, the SILS group showed younger age, longer operating time, and shorter incision length than the 3-port surgery group and exhibited a more advanced T stage, more lymphatic invasion, and larger tumor size.

Conclusion

RPLS performed by 1 surgeon and 1 camera operator appears to be a feasible and safe surgical option for the treatment of patients with sigmoid colon cancer, showing comparable clinical outcomes with shorter operation time and shorter incision length than MPLS. SILS can be applied to patients with favorable tumor characteristics.

COMPARISON BETWEEN INCIDENCE OF INCISIONAL HERNIA IN LAPAROSCOPIC CHOLECYSTECTOMY AND BY SINGLE PORT

Background:

Surgeries with single port access have been gaining ground among surgeons who seek minimally invasive procedures. Although this technique uses only one access, the incision is larger when compared to laparoscopic cholecystectomy and this fact can lead to a higher incidence of incisional hernias.

Aim:

To compare the incidence of incisional hernia after laparoscopic cholecystectomy and by single port.

Methods:

A total of 57 patients were randomly divided into two groups and submitted to conventional laparoscopic cholecystectomy (n=29) and laparoscopic cholecystectomy by single access (n=28). The patients were followed up and reviewed in a 40.4 month follow-up for identification of incisional hernias.

Results:

Follow-up showed 21,4% of incisional hernia in single port group and 3.57% in conventional technique.

Conclusions:

There was a higher incidence of late incisional hernia in patients submitted to single port access cholecystectomy compared to conventional laparoscopic cholecystectomy.

Low pressure gynecological laparoscopy (7mmHg) with AirSeal® System versus a standard insufflation (15mmHg): A pilot study in 60 patients

OBJECTIVES

To evaluate feasibility of performing benign gynecologic pathology low pressure (7mmHg) laparoscopy (LPL) with AirSeal^® system and to study benefits in terms of postoperative pain, when compared to a standard insufflation group (15mmHg).

MATERIALS AND METHODS

In this prospective randomized pilot study, 60 patients had laparoscopy for gynecologic benign pathology: 30 with 7mmHg and AirSeal system, and 30 with 15mmHg standard insufflator. The primary endpoint was incidence of shoulder pain. A postoperative questionnaire was completed by each patient to assess shoulder pain (Numeric Rating Scale [NRS], from 0 to 10) at H4, H8, H24, and consumption of morphinics was notified. During each procedure, anesthesia parameters were collected (peak airway pressure, systolic blood pressure, end tidal CO₂).

RESULTS

Laparoscopy was performed on 30 patients in AirSeal^®-LP group without need to increase pressure above 7mmHg, and no complication was reported. Incidence of shoulder pain was significantly lower in the AirSeal^®-LP group (23.3% vs. 73.3%, P<0.001). NRS shoulder pain was significantly lower in AirSeal^® LP group at hour 4, 8 and 24. Maximal values of ETCO₂, systolic blood pressure, and peak airway pressure were significantly lower in AirSeal^®-LP group.

CONCLUSION

LP (7mmHg) laparoscopy with AirSeal^® platform allows laparoscopic surgery with less postoperative shoulder pain. These results could facilitate the development of ambulatory laparoscopy.

Feasibility of transanal endoscopic total mesorectal excision for rectal cancer: results of a pilot study

Purpose

To evaluate the feasibility of transanal total mesorectal excision (TME) in patients with rectal cancer.

Methods

This study enrolled 12 patients with clinically node negative rectal cancer located 4–12 cm from the anal verge who underwent transanal endoscopic TME with the assistance of single port laparoscopic surgery between September 2013 and August 2014. The primary endpoint was TME quality; secondary endpoints included number of harvested lymph nodes and postoperative complications within 30 days (NCT01938027).

Results

The 12 patients included 7 males and 5 females, of median age 59 years and median body mass index 24.2 kg/m². Tumors were located on average 6.7 cm from the anal verge. Four patients (33.3%) received preoperative chemoradiotherapy. Median operating time was 195 minutes and median blood loss was 50 mL. There were no intraoperative complications and no conversions to open surgery. TME was complete or nearly complete in 11 patients (91.7%). Median distal resection and circumferential resection margins were 18.5 mm and 10 mm, respectively. Median number of harvested lymph nodes was 15. Median length of hospital stay was 9 days. There were no postoperative deaths. Six patients experienced minor postoperative complications, including urinary dysfunction in 2, transient ileus in 3, and wound abscess in 1.

Conclusion

This pilot study showed that high-quality TME was possible in most patients without serious complications. Transanal TME for patients with rectal cancer may be feasible and safe, but further investigations are necessary to evaluate its long-term functional and oncologic outcomes and to clarify its indications.

A Novel Procedure for Single-Incision Laparoscopic Cholecystectomy-The Teres Hanging Technique Combined with Fundus-First, Dome-Down Separation

BACKGROUND

Generally, single-incision laparoscopic cholecystectomy (SILC) requires the use of articulating devices or additional trocars because of the technical difficulties caused by the lack of ergonomics. We developed a novel procedure comprising mainly two simple ideas, "the teres hanging technique combined with fundus-first, dome-down separation," which mainly uses conventional rigid laparoscopic instruments. In this study, we demonstrated our technique and retrospectively evaluated the clinical outcomes.

SUBJECTS AND METHODS

Three trocars were set through a 2.0-cm transumbilical minilaparotomy that was covered with an EZ Access™ combined with a lap protector. To create an adequate surgical field, the teres ligament was laparoscopically hung up with a suture on a straight needle. The gall bladder was then dissected through the fundus to the neck using rigid laparoscopic instruments without any additional trocars. At our institution, 18 consecutive patients underwent SILC using our technique from January 2014 to August 2015. Each patient had a symptomatic gallbladder (GB) stone or polyp. All operations were performed by surgeons who had never performed SILC until this study.

RESULTS

In all operations, our technique was successfully completed without GB perforation or other intraoperative complications. Additional trocars or open laparotomy were not required. The median operation time was 79 minutes, and blood loss was negligible. No postoperative complications were encountered.

CONCLUSIONS

Our novel procedure is safe and feasible. Even for surgeons who have never performed SILC before, our technique may become a standard for benign GB disease without requiring the use of articulating devices or additional trocars.

Reduced-port laparoscopic surgery for a tumor-specific mesorectal excision in patients with colorectal cancer: initial experience with 20 consecutive cases

PURPOSE

Single-port plus one-port, reduced-port laparoscopic surgery (RPLS) may decrease collisions between laparoscopic instruments and the camera in a narrow, bony, pelvic cavity while maintaining the cosmetic advantages of single-incision laparoscopic surgery. The aim of this study is to describe our initial experience with and to assess the feasibility and safety of RPLS for tumor-specific mesorectal excisions (TSMEs) in patients with colorectal cancer.

METHODS

Between May 2010 and August 2012, RPLS for TSME was performed in 20 patients with colorectal cancer. A single port with four channels through an umbilical incision and an additional port in the right lower quadrant were used for RPLS.

RESULTS

The median operation time was 231 minutes (range, 160-347 minutes), and the estimated blood loss was 100 mL (range, 50-500 mL). We transected the rectum with one laparoscopic stapler in 17 cases (85%). The median time to soft diet was 4 days (range, 3-6 days), and the length of hospital stay was 7 days (range, 5-45 days). The median total number of lymph nodes harvested was 16 (range, 7-36), and circumferential resection margin involvement was found in 1 case (5%). Seven patients (35%) developed postoperative complications, and no mortalities occurred within 30 days. During the median follow-up period of 20 months (range, 12-40 months), liver metastasis occurred in 1 patient 10 months after surgery, and local recurrence was nonexistent.

CONCLUSION

RPLS for TSME in patients with colorectal cancer is technically feasible and safe without compromising oncologic safety. However, further studies comparing RPLS with a conventional, laparoscopic low-anterior resection are needed to prove the advantages of the RPLS procedure.

New trends in colorectal surgery: Single port and natural orifice techniques

Single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) have rapidly gained pace worldwide, potentially replacing conventional laparoscopic surgery (CLS) as the preferred colorectal surgery technique. Currently available data mainly consist of retrospective series analyzed in four meta-analyses. Despite conflicting results and lack of an objective comparison, SILS appears to offer cosmetic advantages over CLS. However, due to conflicting results and marked heterogeneity, present data fail to show significant differences in terms of operative time, postoperative morbidity profiles, port-site complications rates, oncological appropriateness, duration of hospitalization or cost when comparing SILS with conventional laparoscopy for colorectal procedures. The application of “pure” NOTES in humans remains limited to case reports because of unresolved issues concerning the ideal access site, distant organ reach, spatial orientation and viscera closure. Alternatively, minilaparoscopy-assisted natural orifice surgery techniques are being developed. The transanal “down-to-up” total mesorectum excision has been derived for transanal endoscopic microsurgery (TEM) and represents the most encouraging NOTES-derived technique. Preliminary experiences demonstrate good oncological and functional short-term outcomes. Large-scale randomized controlled trials are now mandatory to confirm the long-term SILS results and validate transanal TEM for the application of NOTES in humans.

Successful retrieval of a retained capsule endoscope with single incision laparoscopic surgery

Capsule endoscopy (CE) is commonly used for examining and diagnosing gastrointestinal disease, especially small bowel disease. Capsule retention is a well-known and significant complication of CE and requires surgical or endoscopic removal. Most reports described the retrieval of retained CE via laparotomy. We report a case of successful retrieval of the capsule using single incision laparoscopic surgery.

Prospective comparison between the AirSeal® System valve-less Trocar and a standard Versaport™ Plus V2 Trocar in robotic-assisted radical prostatectomy

BACKGROUND AND PURPOSE

To prospectively compare the AirSeal® System valve-less Trocar with a standard Versaport™ Plus V2 Trocar as assistant insufflating port in transperitoneal and extraperitoneal robotic-assisted radical prostatectomy (t-RARP/e-RARP).

PATIENTS AND METHODS

Two consecutive cohorts of patients undergoing RARP using either a 12 mm AirSeal valve-less Trocar (n=19 [14 t-RARP/5 e-RARP]) or a 12 mm Versaport Plus V2 Trocar (n=17 [11 t-RARP/6 e-RARP]) were prospectively evaluated. Age, body mass index, tumor characteristics, and surgical approach were similar in both cohorts. Besides relevant clinical data, episodes of pressure loss (<8 mm Hg), the number of necessary trocar manipulations, the frequency of camera cleaning, and overall carbon dioxide (CO2) consumption were recorded and compared.

RESULTS

Mean surgical time was 175 minutes in the AirSeal and 166 minutes in the Versaport group (p=0.55). Whereas in the AirSeal group, only one episode of pressure loss <8 mm Hg was observed; this occurred in mean 38 times in the Versaport group (p<0.0001). No trocar manipulations for specimen or needle retrieval were necessary in the AirSeal group in contrast to in mean 15 in the Versaport group (p<0.0001). Otherwise, no appreciable differences regarding overall operating time, blood loss, camera cleaning, or overall CO2 consumption were observed for the present study. Patient CO2 absorption was not evaluated.

CONCLUSIONS

In the present study, the AirSeal Trocar offered a more stable pneumocavity and facilitated specimen retrieval and needle extraction.

Minimally invasive surgical treatment of sigmoid diverticulitis

INTRODUCTION

Diverticular disease is very common in Western societies. However, there is a trend towards reducing indications for the surgical management of diverticulitis. Minimally invasive surgery offers many potential advantages to patients in the treatment of diverticulitis and may optimise surgical indications.

METHODS

A systematic literature review of minimally invasive techniques was carried out for the treatment of diverticulitis. The following techniques were reviewed: laparoscopic, single-port, natural orifice specimen extraction, natural orifice transluminal endoscopic surgery and laparoscopic lavage for the treatment of diverticulitis.

RESULTS

In total, 2,050 minimally invasive cases were reviewed. Of all the different minimally invasive techniques published regarding the management of diverticular disease, laparoscopic surgery is the only technique that has undergone the rigours of randomised controlled trials. The documented benefits are less blood loss, less pain and analgesic requirements, a reduction in major complications, a reduction in the frequency of drain usage, a reduction in the duration of postoperative ileus and shorter hospital stay. However, operative time does appear to be longer. It has also been demonstrated that elective laparoscopic surgery results in improved quality of life and social functioning.

CONCLUSION

Minimally invasive surgery for the treatment of diverticular disease appears feasible and safe. The result of future randomised trials will more clearly define the role each minimally invasive technique will play in the future.

The barrier-free trocar technique in three laparoscopic standard procedures

BACKGROUND:

Numerous technical and surgical innovations took place in laparoscopic surgery in the recent past. It is debatable whether single-access surgery or natural orifice surgery (NOS) will establish for several standard procedures. Most of the NOS-procedures are controversial and single-access surgery still has to prove its equality in controlled trials. In the intention to reduce the ingress incisons and to facilitate instrumentation, we decided to test the barrier-free AirSeal^®-trocar in clinical practice.

MATERIALS AND METHODS:

Laparoscopically we performed a cholecystectomy, gastric wedge-resection and a fundoplication using the barrier-free AirSeal^® 12-mm-trocar. This trocar works without any mechanical barrier so that via this trocar the use of two instruments is possible.

RESULTS:

All three operations were successful.

CONCLUSION:

Laparoscopic standard procedures are feasible using this barrier-free trocar without a higher degree of difficulty. Because of the facilitated instrumentation, it is possible to work more efficiently and to maintain the focus on the surgical field.

An original endoluminal magnetic anastomotic device allowing pure NOTES transgastric and transrectal sigmoidectomy in a porcine model: proof of concept

INTRODUCTION

While experimental natural orifice transluminal endoscopic surgery (NOTES) sigmoid colectomies have been reported, pure NOTES anastomoses are restricted by the limited reach of commercially available circular staplers. MAGNAMOSIS is a set of self-orienting magnetic rings that can be delivered endoluminally throughout the colon to generate a compression anastomosis. Aim. To assess the feasibility of a pure NOTES transrectal (TR) and transgastric (TG) approach to perform any segmental colectomy.

MATERIALS AND METHODS

One pig (50 kg) underwent the experimental procedure as follows: (a) creation of the TG access to the peritoneal cavity, (b) precise transluminal placement of the proximal MAGNAMOSIS ring, (c) creation of the TR access with the TEO and transrectal dissection of the sigmoid mesentery, (d) resection of the surgical specimen, (e) transrectal extraction of the specimen, (f) delivery and mating of the distal MAGNAMOSIS ring, and (g) closure of the TG and TR viscerotomies. The animal survived for 14 days at which time burst pressure and histology were performed.

RESULTS

A pure NOTES TR and TG segmental colectomy was performed in 139 minutes. The postoperative course was uneventful. The animal had a formed bowel movement including the magnetic rings on postoperative day 5. Endoscopic examination at postoperative day 14 revealed a patent anastomosis. Necropsy revealed no abscess or signs of peritonitis. Burst pressure was >198 mm Hg. The histology showed a sealed anastomosis with mild inflammation.

CONCLUSIONS

MAGNAMOSIS enabled a totally NOTES partial colectomy with combined TG and TR access. The flexible delivery options and low cost of manufacturing could make MAGNAMOSIS an attractive alternative to circular staplers.

Three-port laparoscopy-assisted colectomy for colorectal cancer using external traction with suspension suture

BACKGROUND

Laparoscopy-assisted colectomy is accepted as a standard procedure for colorectal resection. There have been many attempts to minimize the invasiveness of the procedure by reducing the number of operating ports and changing the specimen retrieval windows. Indeed, the invasiveness of laparoscopy-assisted colectomy has been minimized with these attempts; however, the technical challenges have increased. The technical challenges are related to lack of retraction and triangulation, which is necessary to expose the appropriate surgical field for safe surgery. A new technique based on retraction and triangulation with suspension suture traction for laparoscopy-assisted colorectal surgery is presented.

METHODS

Between September and November 2009, 24 laparoscopy-assisted colorectal resections for adenocarcinoma were performed through 3 ports with external traction with suspension suture. The surgical technique is described herein, and the intraoperative and postoperative courses of the patients were assessed.

RESULT

There were no intraoperative complications, and no need to convert to open surgery. All the resection margins were clear and the mean distance of proximal and distal margins was 11.4 and 4.8 cm, respectively. The median number of lymph nodes examined was 20.7. There were 2 cases of postoperative bleeding, but no cases of leakage or strictures at the anastomosis site.

CONCLUSIONS

This new, simple technique is feasible and safe. External suspension suture traction can create an appropriate operative field, allowing balanced traction and countertraction and meeting the needs for oncologic surgery. In addition, this technique can be applied to other types of laparoscopic surgery and will contribute to reducing the number of ports.

Transumbilical single-incision laparoscopic cholecystectomy with conventional instruments and ports: the way forward?

BACKGROUND

The quest for scarless surgery continues, but the goal remains elusive. The logical top contender was natural orifice surgery, but unfortunately even today it remains in infancy. Minilaparoscopy also did not generate much interest. In this scenario, transumbilical single-incision laparoscopy surgery holds promise, especially as far as cosmetics is concerned, and may be the ultimate answer.

METHODS

All the 240 patients were operated by the same surgeon through a transversely placed umbilical incision in the upper half of the umbilicus. Three conventional ports, 10, 5, and 5 mm, were introduced through the same skin incision but separate transfacial punctures. The instruments included 10- and 5-mm 30° rigid telescopes and rigid instruments as in standard laparoscopic cholecystectomy (SLC). Patients with acute cholecystitis and calculous pancreatitis were included, but those with choledocholithiasis were excluded. Results were compared with those with SLC.

RESULTS

Patients were predominately female, with an average age of 37.6 years. Ten patients had difficult gallbladders, 24 had acute cholecystitis, and 10 had calculous pancreatitis. The mean operating time was 25.8 minutes, compared with 18.4 minutes in SLC. Intracorporeal knotting was required in 2 patients. Conversion to SLC was required in 5 patients. Morrisons pouch drain was left in 1 patient. Injectable analgesic was required in 138 (57.5%) patients and infection was seen in 2 (0.8%) patients.

CONCLUSIONS

Transumbilical single-skin-incision laparoscopic cholecystectomy performed solely with conventional instruments is feasible, easy to learn, and probably the future of laparoscopic cholecystectomy.

Single-incision laparoscopic colectomy without using special articulating instruments: an initial experience

BACKGROUND

Single-incision laparoscopic colectomy (SILC) was introduced as a novel minimally invasive technique. The benefits of this technique include reducing number of the incision and cosmetic improvement. Unlike the conventional laparoscopic colectomy, majority of previously reported SILC need to be performed using special curved or articulated instruments. The purpose of this study is to demonstrate our initial experience of SILC, which could be performed using the standard laparoscopic instruments.

MATERIAL AND METHODS

Retrospective review of 14 patients who underwent SILC at Siriraj Hospital from May to December 2010, patient's demographic data, perioperative outcomes, early postoperative complications and pathological data were collected and analyzed.

RESULTS

The mean age of all patients was 60 years. The most common operation with SILC was sigmoidectomy (n = 9), followed by right hemicolectomy (n = 2), left hemicolectomy (n = 1), anterior resection (n = 1), and total colectomy (n = 1). The trocar insertion techniques were multi-fascial incision using regular port (n = 11) and GelPOINT(®) (n = 3). The mean operative time was 155 minutes (range 90-280) and the mean estimate blood loss was 32.1 mL (range 10-100). All patients were successfully operated without conversion. The mean length of hospital stay was 9 days (range 5-20). There was no mortality. The pathological results revealed colorectal cancer (n = 12), neoplastic polyp (n = 1) and Familial adenomatous polyposis (FAP) (n = 1). The mean number of lymph nodes retrieval was 16.6 (range 3-34).

CONCLUSION

SILC can successfully and safely be performed with standard laparoscopic instruments. This technique might be an alternative procedure to conventional laparoscopic colectomy with better cosmetic result.

Single incision laparoscopic surgery in general surgery: a review

Single incision laparoscopic surgery (SILS) is a rapidly developing field that may represent the future of laparoscopic surgery. The major advantage of SILS over standard laparoscopic surgery is in cosmesis, with surgery becoming essentially scarless if the incision is hidden within the umbilicus. Only one incision is required so the risk of potential complications like port site hernias, haematomas and wound infection is reduced. The trade-off for this is a technically more challenging procedure with different underlying principles to that of traditional laparoscopic surgery. A wide variety of new equipment has been developed to support SILS and the range of procedures that are amenable to the technique is increasing. To date most of the published data relating to SILS are in the form of case series, with the first large randomised controlled trials due to be completed by the end of 2012. The existing evidence suggests that SILS is similar to standard laparoscopic surgery in terms of complication rates, completion rates and post-operative pain scores. However, the duration of SILS is longer than equivalent laparoscopic procedures. This article discusses SILS with regard to its applications in general surgery and reviews the evidence currently available.

Original technique to close the transrectal viscerotomy access in a NOTES transrectal and transgastric segmental colectomy

Segmental colectomy is an ideal procedure for natural orifice transluminal endoscopic surgery (NOTES). Transanal endoscopic approaches have enabled rectosigmoid colectomy through a viscerotomy that is resected with the specimen. To extend NOTES segmental colectomy to the entire colon and beyond, a rectal viscerotomy will have to be safely and effectively closed at the end of the procedure. A new technique for rectal viscerotomy closure using a circular EEA hemorrhoid and prolapse stapler with DST series technology (Covidien) is described.

Laparo-endoscopic single-site (LESS) with transanal natural orifice specimen extraction (NOSE) sigmoidectomy: a new step before pure colorectal natural orifices transluminal endoscopic surgery (NOTES®)

INTRODUCTION

We present the first human case of laparo-endoscopic single-site sigmoidectomy with transanal natural orifice specimen extraction.

DISCUSSION

This technical achievement is a new step toward pure colorectal Natural Orifices Transluminal Endoscopic Surgery. It is the product of a gradual development with critical steps being conceived and standardised in years of experimental and clinical procedures.

Single-port access laparoscopic surgery for rectal cancer: initial experience with 10 cases

BACKGROUND

Single-port access laparoscopic surgery is emerging as a method to improve the morbidity and cosmetic benefits of conventional laparoscopic surgery and minimize the surgical trauma. However, the feasibility of this procedure in rectal surgery has not yet been determined.

OBJECTIVE

This study aimed to evaluate our initial experience using single-port access in laparoscopic rectal surgery.

DESIGN

This investigation was designed as a prospective clinical study.

SETTINGS

The study took place in a university hospital.

PATIENTS

Ten patients with nonmetastatic rectal cancer underwent rectal resections.

MAIN OUTCOME MEASURES

The main outcome measures are perioperative data including intraoperative and postoperative complications, pathological outcome, length of stay, and short-term follow-up.

RESULTS

The median age of the patients was 67 (range, 49-83) and the median body mass index was 23.5 kg/m (range, 20-25 kg/m). Six patients had previously had abdominal surgery. The operations were 6 low anterior resections (4 receiving diverting ileostomy), 2 anterior resections, 1 Hartmann procedure, and 1 abdominoperineal resection. The median operative time was 229 minutes (range, 185-318), and blood loss ranged from 0 to 100 mL. In 2 cases, it was necessary to add an extra 5-mm port to deal with intraoperative complications. The median hospital stay was 7 days (range, 4-14). There were no anastomotic leaks and no mortality. All of the resection margins were clear, and the circumferential resection margin was a median of 11 mm (range, 2.5-25). The median number of lymph nodes examined was 14 (range, 3-20).

LIMITATIONS

This study's limitations include the lack of registration of postoperative pain, immunological parameters, and long-term clinical and oncological outcome. The small sample size makes it difficult to ascertain complication and conversion rates.

CONCLUSIONS

Single-port access laparoscopic surgery for rectal cancer can be performed safely in slim patients with a small tumor. This technique can be an alternative option for selected patients in the hands of skilled laparoscopic surgeons. Prospective comparative studies are needed to determine the role for this technique approach in the future.

Minimally invasive single-site surgery for the digestive system: A technological review

Minimally Invasive Single Site (MISS) surgery is a better terminology to explain the novel concept of scarless surgery, which is increasingly making its way into clinical practice. But, there are some difficulties. We review the existing technologies for MISS surgery with regards to single-port devices, endoscope and camera, instruments, retractors and also the future perspectives for the evolution of MISS surgery. While we need to move ahead cautiously and wait for the development of appropriate technology, we believe that the "Ultimate form of Minimally Invasive Surgery" will be a hybrid form of MISS surgery and Natural Orifice Transluminal Endoscopic Surgery, complimented by technological innovations from the fields of robotics and computer-assisted surgery.

Minimal invasive single-site surgery in colorectal procedures: Current state of the art

BACKGROUND

Minimally invasive single-site (MISS) surgery has recently been applied to colorectal surgery. We aimed to assess the current state of the art and the adequacy of preliminary oncological results.

METHODS

We performed a systematic review of the literature using Pubmed, Medline, SCOPUS and Web of Science databases. Keywords used were "Single Port" or "Single-Incision" or "LaparoEndoscopic Single Site" or "SILS™" and "Colon" or "Colorectal" and "Surgery".

RESULTS

Twenty-nine articles on colorectal MISS surgery have been published from July 2008 to July 2010, presenting data on 149 patients. One study reported analgesic requirement. The final incision length ranged from 2.5 to 8 cm. Only two studies reported fascial incision length. There were two port site hernias in a series of 13 patients (15.38%). Two "fully laparoscopic" MISS procedures with preparation and achievement of the anastomosis completely intracorporeally are reported. Future site of ileostomy was used as the sole access for the procedures in three studies. Lymph node harvesting, resection margins and length of specimen were sufficient in oncological cases.

CONCLUSIONS

MISS colorectal surgery is a challenging procedure that seems to be safe and feasible, but the existing clinical evidence is limited. In selected cases, and especially when an ileostomy is planned, colorectal surgery may be an ideal indication for MISS surgery leading to a no-scar surgery. Despite preliminary oncological results showing the feasibility of MISS surgery, we want to stress the need to standardize the technique and carefully evaluate its application in oncosurgery under ethical committee control.

Single-incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy: a retrospective comparative study

BACKGROUND

Recent reports have suggested that single-incision laparoscopic cholecystectomy (SILC) is technically feasible. We present our initial retrospective comparative study between SILC and conventional laparoscopic cholecystectomy (CLC) with respect to perioperative outcomes.

METHODS

The authors reviewed 100 SILC and 100 CLC performed by a single surgeon from May 2009 to July 2010 at the Shengjing Hospital of China Medical University. All the procedures were completed by using the standard trocars and rigid laparoscopic instruments. Demographic data, operating time, estimated blood loss, analgesics requirements, days to oral food intake, and complications were compared.

RESULTS

Of the attempted SILC cases, 99 cases (99%) were successfully performed, with 1 case requiring three additional trocars for safe dissection because of existence of accessory bile duct. In the CLC group, all the procedures were successfully completed (three trocars) without conversion to open cholecystectomy. Compared with the CLC group, there was a lower mean estimated blood loss (17.9 ± 15.8 mL versus 27.5 ± 13.9 mL; P = .000) and analgesic requirement (10 versus 23; P = .024) in the SILC group. However, there was no difference between SILC and CLC in operating time (53.5 ± 24.0 minutes versus 49.2 ± 13.8 minutes; P = .163), days to oral food intake (1.8 ± 0.8 days versus 1.8 ± 0.7 days; P = .873), and postoperative complication rate (2% versus 0%; P = .155).

CONCLUSION

SILC is feasible using the standard trocars and rigid laparoscopic instruments, and it is an effective alternative to CLC in selected patients. However, further clinical studies are necessary to confirm its real benefits.

Laparoendoscopic single-site porcine nephrectomy using a novel valveless trocar system

BACKGROUND AND PURPOSE

The AirSeal™ access system is a novel laparoscopic trocar that uses airflow to create insufflation pressure without the need for a physical seal or valve. By eliminating all valve elements within the lumen of the canula, the port provides a platform that accommodates multiple instruments of any diameter, shape, or combination and is ideally suited for laparoendoscopic single-site surgery (LESS). We present our initial experience with valveless trocars in traditional urologic laparoscopic cases and a porcine LESS nephrectomy series.

MATERIALS AND METHODS

Nine transperitoneal LESS nephrectomies were performed in a live porcine model using the 27-mm oval valveless trocar. All working instruments were placed through the single port, and the specimen was extracted through the 4-cm port site.

RESULTS

All cases were completed without technical or operative complications. The porcine single-port nephrectomy (n=9) was successfully performed in a mean operative time of 24 minutes through the single 27-mm oval trocar. This accommodated a 5-mm laparoscope, multiple 5-mm instruments, the Endo GIA stapler, and the 15-mm Endocatch bag without loss of insufflation pressure. Condensation and smudging of the laparoscope were minimized, improving visualization and efficiency. The system allowed for use of suction without significant loss of insufflation pressure.

CONCLUSION

The initial experience with the AirSeal valveless trocar system in LESS is encouraging. This technology may offer significant benefits over traditional laparoscopic trocars and single -port platforms and appears particularly suited to facilitate LESS.

The role of single-incision laparoscopic surgery in abdominal and pelvic surgery: a systematic review

OBJECTIVE

This review aimed to determine the role of single-incision laparoscopic surgery (SILS) in abdominal and pelvic operations.

DATA SOURCES

The Medline, EMBASE, and PsycINFO databases were systematically searched until October 2009 using "single-incision laparoscopic surgery" and related terms as keywords. References from retrieved articles were reviewed to broaden the search

STUDY SELECTION

The study included case reports, case series, and empirical studies that reported SILS in abdominal and pelvic operations.

DATA EXTRACTION

Number of patients, type of instruments, operative time, blood loss, conversion rate, length of hospital stay, length of follow-up evaluation, and complications were extracted from the reviewed items

DATA SYNTHESIS

The review included 102 studies classified as level 4 evidence. Most of these studies investigated SILS in cholecystectomy (n=34), appendectomy (n=24), and nephrectomy (n=17). For these procedures, operative time, hospital stay, and complications were comparable with those of conventional laparoscopy. Conversion to conventional laparoscopy was seldom performed in cholecystectomy (range, 0-24%) and more frequent in appendectomy (range, 0-41%) and nephrectomy (range, 0-33%).

CONCLUSION

The potential benefits of SILS include superior cosmesis and possibly shorter operative time, lower costs, and a shortened time to full physical recovery. Careful case selection and a low threshold of conversion to conventional laparoscopic surgery are essential. Multicenter, randomized, prospective studies are needed to compare short- and long-term outcome measures against those of conventional laparoscopic surgery.

Fully laparoscopic colorectal anastomosis involving percutaneous endoluminal colonic anvil control (PECAC)

INTRODUCTION

A novel technique for secure placement of the anvil for mechanical stapled anastomosis in the proximal colon without exteriorization of the bowel is described.

METHODS

After standard laparoscopic segmental colonic mobilization, a needle-cannula from a percutaneous endoscopic gastrostomy kit is passed under direct endoscopic vision transparietally into the colon at the site intended for anvil placement. A wire passed through the cannula into the colon is then withdrawn endoscopically per ano. The stapler anvil is fixed to the wire and pulled back along the intestine before being positioned by traction through the needle puncture site. After distal specimen transection, a standard stapled anastomosis is performed.

RESULTS

The technique is illustrated in 2 patients undergoing laparoscopic sigmoidectomy by either a single port or a multiport procedure with transanal specimen extraction.

CONCLUSION

By positioning the anvil without colon exteriorization, this technique enables pure intraperitoneal colonic anastomoses that may advance natural orifice operating.

Single-incision laparoscopic surgery: a promising approach to sigmoidectomy for diverticular disease

BACKGROUND

Laparoscopic sigmoidectomy has become the standard procedure in elective surgery for recurrent diverticular disease. To realize further benefits of this minimal invasive procedure and to offer less postoperative pain, shorter recovery time, reduced complications, and improved cosmetic results, attempts are being made to minimize the number of necessary skin incisions for trocar positioning. One method is to use only one port for laparoscopic access to perform diverticular-related elective sigmoidectomies.

METHODS

Between 7 July and 4 August 2009, 10 consecutive patients were referred for partial left colon resection due to multiple episodes of diverticulitis. In all cases, access to the abdomen was achieved through a 2- to 2.5-cm single incision via the umbilicus followed by insertion of the single-incision laparoscopic surgery (SILS™) port system. Outcomes such as change in the procedural method, operative time, postoperative complications, and length of stay were recorded.

RESULTS

Of the 10 consecutive sigmoidectomies, 9 were performed successfully with the SILS™ procedure using only one incision in the umbilicus. No mortalities or major complications were noted. The median operating time was 120 min, and the median postoperative hospital stay was 7 days.

CONCLUSION

As an alternative to the standard laparoscopic procedure, single-incision laparoscopic sigmoidectomy via the umbilicus is technically feasible and effective. This attractive procedure aims to increase the patient's comfort further after abdominal surgery.

Single-access laparoscopic colectomy with a novel multiport device in sigmoid colectomy for colon cancer

PURPOSE

Laparoscopic-assisted colectomy is a common procedure for colorectal disease, and laparoscopic colectomy from a single access point is rapidly evolving. This report describes the use of single-access laparoscopic colectomy (SALC) with a novel multiport device in sigmoidectomy for colon cancer.

METHODS

Data were collected retrospectively on 5 patients who underwent the procedure for colon cancers in the period from November 2008 through January 2009. The abdomen was approached through a 3- to 4-cm incision via the umbilicus in every case. To ensure maintenance of the pneumoperitoneum, the procedure was performed with a specially developed multiport device enveloped by a glove containing 3 5-mm ports. In all 5 patients, the root of the inferior mesenteric artery was isolated and divided at the distal side where the left colic artery branched off.

RESULTS

The median total surgical time was 185 (range, 176-210) minutes. In all patients, surgical blood loss was slight (range, 0-20 mL). Only one patient required conversion into laparoscopic-assisted colectomy by the addition of 2 ports, because the location adjacent to the descending colon made it necessary to mobilize the splenic flexure. The median number of harvested lymph nodes was 17 (range, 12-24). No postoperative complications occurred. The postoperative hospital stay was 7 days for every patient.

CONCLUSIONS

Single-access laparoscopic sigmoidectomy seems to be feasible and safe when performed by experienced laparoscopic surgeons who are familiar with the unique principles of this procedure. Additional experience and continued investigations are warranted.

Robotic-assisted single-incision right colectomy: early experience

BACKGROUND

Application of laparoendoscopic single-site surgery (LESS) is increasing across surgical disciplines. In addition to the possibility of decreased postoperative pain, LESS offers better cosmesis with virtually 'scarless' surgeries, while avoiding the increased costs and complexity of natural orifice surgery. Instrument conflict minimization often requires the crossing of articulating instruments, which we believe can be more intuitively facilitated using the daVinci-S((R)) robotic system. We describe our early experience with three robotic single-incision right hemicolectomies.

METHODS

Three robotic single-incision right hemicolectomies were performed using the daVinci-S robotic system, utilizing a single 4 cm incision through or around the umbilicus. The procedure was performed using three robotic arms, a 12 mm camera and two 8 mm robotic ports. A medial to lateral approach was used and an extracorporeal resection and anastomosis was performed after undocking the robot.

RESULTS

There were no intraoperative or postoperative complications. Average operative time was 152 min. The first case was converted to non-robotic single-incision right hemicolectomy during mobilization of the ascending colon, due to uncontrollable air leakage around the ports. The second and third cases were successfully completed without air loss by purse-stringing sutures around each individual port and the use of the SILS() port, respectively.

CONCLUSIONS

Robotic-assisted single-incision right hemicolectomy can be successfully and safely performed using the daVinci-S robotic system. Several techniques may be employed to prevent the loss of pneumoperitoneum. We believe right hemicolectomy lends itself to single-site surgery because specimen extraction requires a 4 cm incision and may confer patient benefit, with decreased postoperative pain and improved cosmesis. By crossing the robotic instruments and reassigning control of the arms, the robot represents a means to help perform these procedures safely by allowing them to be performed in a more intuitive fashion.

Single-port laparoscopic cholecystectomy: initial experience

BACKGROUND

As surgeons embrace the concept of increasingly less invasive surgery, techniques using only a single small incision have begun to gain traction. Several commercially available products have emerged recently. The TriPort system and the SILS Port are single-port devices that allow the surgeon to perform laparoscopic surgery through a 2- to 3-cm periumbilical incision. This study aimed to ascertain whether these devices allow safe and reliable access for laparoscopic cholecystectomy.

METHODS

From March 2008 to June 2009, single-port laparoscopic cholecystectomy was attempted for 22 patients with an average age of 40 years (range, 23-73 years). The data collected prospectively after institutional review board approval included demographics, operative time, complications, and reasons for conversion to standard four-port laparoscopic surgery.

RESULTS

The operation was completed successfully for 21 of the 22 patients (15 women and 7 men) using five different techniques. The mean body mass index (BMI) of the patients was 32.7 kg/cm(2) (range, 22.3-46.1 kg/cm(2)). Three of the patients had previously undergone laparoscopic Roux-en-Y gastric bypass. The mean operative time was 80.8 min (range, 51-156 min). One patient experienced a Richter's hernia postoperatively, which required a reoperation and subsequent bowel resection. One patient required conversion to a standard four-port laparoscopic cholecystectomy because the articulating instrument could not reach the gallbladder from the umbilicus.

CONCLUSION

The results from the current series show single-port laparoscopic cholecystectomy to be a promising technique. A variety of patient demographics appear suited to this approach. The operative time in this series compares favorably with that for the standard four-port operation. The feasibility of single-port laparoscopic cholecystectomy is now established. However, routine application of this novel technique requires an evaluation of its safety and cost effectiveness in larger studies. In addition, its superiority over standard laparoscopic cholecystectomy in terms of postoperative pain, cosmesis, and overall patient satisfaction requires further study. Refinements in instrumentation will enable wider use of this novel minimally invasive approach.

[NOTES and other minimally invasive surgical techniques (hybrid NOTES, NOTUS, SPS, SILS), and their effect on surgical approaches]

A new surgical technique--called Natural Orifice Translumenal Endoscopic Surgery (NOTES)--evolved in 2004. Although numerous problems arose regarding this method--and most of them are unresolved yet--several new articles about the human application have been published. In order to find solutions of a certain extent, new techniques have been developed (hybrid NOTES, NOTUS, SPS, SLIS, etc). Although these could not eliminate difficulties completely, they do provide some solutions in many cases. It is very important for the surgeon of modern days to be familiar with these techniques and analyze them in a critically. Application of these methods requires a review of principles of surgery and flexible endoscopy. Although in many cases these are considered axioms, there data exist in literature of different management principles, as well. It is fundamental that critically review of the basic questions of NOTES (which natural orifice is the best, how to close the viscerotomy, how to avoid infection, who should carry out the NOTES surgery) is carried out in relation of the complications of the original 'gold standard' methods (e.g. frequency of infection or hernia after laparoscopy). Based on human data there is minimal postoperative pain after the NOTES procedure, and patients in general will leave the hospital on the same day. Is such a short postoperative stay enough and can we entirely dismiss drainage after cholecystectomy? Results of the human procedures are adequate to draw further conclusions regarding the new technique. Retrospective analysis of problems occurring during the evolution of laparoscopy can make it possible to avoid mistakes that can be made in the development of NOTES.

A comprehensive review of single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) techniques for cholecystectomy

INTRODUCTION

Surgery of the gallbladder has evolved tremendously over the last century. Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common laparoscopic procedure worldwide. In recent times, innovative techniques of natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS) have been applied in gallbladder removal as a step towards even more less-invasive procedures.

DISCUSSION

While NOTES and SILS represent the advent of essentially scarless surgery, limited applications of these technologies in human subjects exists. In this article, we present a comprehensive review of the potential benefits, limitations and risks of these novel techniques.

CONCLUSION

While much remains unknown and unanswered surrounding these procedures, it is clear that extensive research and development with regards to the ethics and the technical aspects of these procedures as well as randomized studies to compare them with traditional laparoscopy are essential.

Challenges and lessons learned from NOTES cholecystectomy initial experience: a stepwise approach from the laboratory to clinical application

BACKGROUND/PURPOSE

The initial idea behind natural orifice transluminal endoscopic surgery (NOTES) was that of an incisionless surgery. NOTES cholecystectomy is a good model of human ingenuity and technological advance. NOTES cholecystectomy in a human being was performed at our institution after extensive laboratory work in live pig models. In this process we gained helpful information related to NOTES cholecystectomy.

METHODS

More than 250 cholecystectomies in pigs have been performed. From May 2007 to November 2008 a total of 10 and 6 transvaginal and transgastric human cholecystectomies, respectively, have been performed.

RESULTS

The procedure was successful in all patients, with a mean operative time of 120 min. There were no intraoperative or postoperative complications. Patients recovered promptly after surgery and had minor postoperative pain. They were discharged on the second postoperative day.

CONCLUSIONS

The advantages of laparoscopy appeared to be enhanced by this approach: patients had minor postoperative pain and minimal scarring. This stepwise experience in the cholecystectomy procedure is an important first step in the development of methods and devices to enable the evaluation of potential incisionless NOTES surgery. Additional research and comparison studies are needed for further improvement in order to provide NOTES procedures to a wider range of patients.

Laparoscopic-assisted sigmoidectomy with transanal specimen extraction: a bridge to NOTES?

The combination of standard laparoscopy and specimen extraction through a natural orifice has the potential to decrease wound related complications. We describe the technical approach to laparoscopic sigmoidectomy in which the specimen is extracted transanally through a proctoscope. Laparoscopic-assisted sigmoidectomy with transanal specimen removal avoids an abdominal wall extraction incision and may be considered an alternative approach to conventional minimally invasive sigmoidectomy in patients with disease of the sigmoid or left colon.