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OBJECTIVE To quantify the volume of hidden blood loss (HBL) between conventional laparoscopic surgery (CLS) and laparoendoscopic single-site surgery (LESS) for ovarian cyst and to explore its risk factors. METHODS A total of 310 patients who underwent CLS or LESS were enrolled in this study. The Nadler formula and Gross formula were used to calculate each patient's estimated blood volume and total blood loss, multiple linear regression analysis was applied to identify the risk factors. RESULTS The HBL in LESS was more than in CLS (P = 0.000). Operative time (p = 0.015), pre-hematocrit (P = 0.002), pre-hemoglobin (P = 0.015), and pelvic adhesions (P = 0.037) were positively correlated with HBL in CLS. Intraoperative bleeding (P = 0.026), operative time (P = 0.000), pre-hematocrit (P = 0.042), CA125 (P = 0.047), and cyst volume (P = 0.012) were independent risk factors for HBL in LESS. CONCLUSION A large amount of HBL occurs in ovarian cystectomy surgery and cannot be ignored in clinical work; fully and correctly understanding HBL and exploring its causes can ensure the safety and improve the prognosis of patients.

Background: The National Aeronautics and Space Administration Task Load Index (NASA-TLX) a nd Surgery Task Load Index (SURG-TLX) are two subjective workload m easurement instruments. Both instruments provide unweighted andweightedworkload measurements. Weighted TLX m easures have seldomly been used byresearchers typically becauseof its high correlation with unweighted TLX a nd addedexperimentaltime to collect pairwise weightings. Therefore, theaim of thestudy wa s to compare weighted TLX scores with unweighted TLX scores and each’s sensitivity for demographic and experimentalfactors. Methods: Two simulated la paroscopic single site surgery tasks were completedusing four surgicalmethods by 25 participants. Pearson correlations, principle componentanalyses and mixed effect models were used to compare the unweightedandweighted TLXscores across tasks a nd methods. Results: There was a high correlation(r > 0.950, p < 0.001) betweentheunweighted TLXscores and the weighted TLX scores. The weighted TLX scores showed better sensitivity to both demographic and experimental factors for both TLX instruments. Conclusion: The overall weighted NASA-TLX and SURG-TLX scores differed from their respective unweighted scores even with a high correlation. The weighted TLXshowed potentialto better discriminate subjective workloadfor single-site ta sks. Future research is needed to identify and validatea more streamlinedweightingmethodparticularly for complex experimental taskslike single-site surgery.

Study Objective To evaluate and report preliminary data after the use of an internal grasper and magnetic anchoring guidance system (MAGS) to allow free movement and optimal triangulation in the abdominal cavity during gynecologic laparoendoscopic single-site surgery (LESS). Design A prospective, single-center case series. Setting The First Affiliated Hospital of Xi'an Jiaotong University. Patients Eighteen female patients underwent MAGS-assisted LESS with an internal grasper. Interventions A single surgeon performed MAGS-assisted LESS on patients with benign gynecologic diseases while documenting operative time, device insertion time, surgeon assessment of technical adaptation, patient-evaluated pain and cosmetic outcomes, adverse events, and blood loss. Measurements and Main Results Eighteen patients underwent transumbilical MAGS-assisted LESS using an internal grasper from November 1, 2019, to December 31, 2019. The mean operative time and insertion time were 98.7 minutes and 1 minute, respectively. The use of MAGS was easily mastered by the surgeon and considered consistently useful in overcoming the limitations of LESS. The patients reported average pain scores of 4.8, 2.3, and 0.5 immediately, 24 hours, and 1 week after surgery, respectively. All patients expressed satisfaction with the postoperative cosmetic results. No serious complications were observed. The mean blood loss was 43.6 mL. Conclusion MAGS-assisted LESS is easy to deploy and use for benign gynecologic disease and seems to result in positive outcomes. Larger randomized controlled trials are warranted.

Surgical techniques for robot-assisted partial nephrectomy are driven by the aims of simplifying the most challenging surgical steps, maximizing functional and oncologic outcomes, and consistently pushing the envelope on possibilities. Over the past several years, we have seen an emergence in not only innovation in surgical technique, and robotic platforms, but integration of a variety of imaging techniques. We believe with developing robotic expertise, practicing urologists will continue to push the envelope in nephron preservation and complication-free recovery.

Background: A tubo-ovarian abscess is a potential late complication after hymenectomy for imperforate hymen, especially when complicated with hematosalpinx. Laparoendoscopic single-site (LESS) surg...

Highlights • First report of multiple procedures performed through single site. • Complex single site surgery performed without the use of port assistive device. • Cosmetically superior procedure. • Single incision multiport. • Reduced post operative pain, reduced length of hospital stay and cost effective., Introduction Single site surgery is rapidly gaining popularity for its cosmetic benefits. However it requires immense technical skill due to its challenging ergonomics.We have reported here a case where multiple surgeries have been performed through the same single site,without the usage of special devices.This article has been reported in line with the SCARE criteria [1]. Presentation of case A 45-year-old obese lady presented with symptomatic cholelithiasis and a para umbilical hernia. She underwent uneventful trans umbilical, single site laparoscopic cholecystectomy, sleeve gastrectomy and paraumbilical hernia repair. Discussion This article is being published as it is the first reported from the Middle East. Recent development of laparoscopy was represented with introduction of the concept of scarless surgery using Natural Orifice Transluminal Endoscopic Surgery (NOTES), or its Transumbilical counterpart (NOTUS). Unfortunately,these two approaches have not been widely reported, probably due to the need for specialized instruments, learning curve, and prolonged surgery time [2]. Conclusion This single case report is to indicate that it is technically possible and cosmetically appealing to perform such a complex surgery.

Aim The purpose of this study was to report on 626 cases of successful robotic single-site (RSS) surgeries to address various types of gynecologic disease and to evaluate the outcomes and learning curve inherent to RSS surgery in the gynecology field. Methods A total of 626 cases of RSS surgeries were performed by 3 gynecologic surgeons at Ewha Womans University Medical Center, Robot Surgery Center from November 2014 to January 2018 were collected retrospectively. All of the patients' charts were reviewed, and the clinical characteristics and surgical variables were analyzed. Results Among the total of 626 cases, there were 220 cases of RSS myomectomy (RSSM), 182 cases of RSS hysterectomy (RSSH), 195 of RSS adnexectomy, 24 of RSS sacrocolpopexy (RSS SCP) and 5 were classified as other RSS surgeries. The patient's mean age was 38.98 ± 10.07 years. There was 3.99 ± 2.15 min of mean docking time and 117.78 ± 51.18 min of mean operating time. The surgical variables were analyzed annually. The total operating time was seen to decrease significantly according to each period. The docking time declined significantly and gradually after 1 year. We also analyzed each of the surgical types by time. The operating time of RSSH, RSSM, RSS adnexectomy and RSS SCP fell over time. The tendency found was for operating time to decline sharply following the first 10 cases. When we analyzed the data at annual intervals, the operating time was most significantly less and stable following the first year. There were a few intraoperative or perioperative complications in 16 cases (2.6%). Conclusion Robotic single-site surgery is a feasible and safe procedure for treating various kinds of gynecologic diseases. The learning curve was approximately 10 cases of RSS surgery in gynecologic disease, having a greater amount of experience at performing RSS surgery was revealed to be key to achieving better surgical outcomes.

Background: A gossypiboma is a pseudotumor caused by a foreign-body reaction developing around inadvertently retained surgical materials in the body. Although advancements in surgical techniques an...

OBJECTIVE This study examined the feasibility of robotic laparoendoscopic single-site surgery (LESS) for the treatment of adolescent endometriosis (n = 36). Additionally, we assessed a novel technique known as butterfly resection for severe cases. METHODS This was a retrospective study of women from 12 to 21 years old who received therapeutic robotic LESS for symptomatic endometriosis by a single experienced surgeon. RESULTS There were 32 cases of peritoneal and four cases of deep infiltrating endometriosis (DIE). Focal resection was performed in 9/32 peritoneal and all DIE cases; butterfly resection was performed in the remaining 23/32 peritoneal. At 3 months, 16/23 had complete resolution of pelvic pain in the butterfly group versus 10/13 in the focal group (P = 0.64). CONCLUSION Robotic LESS produces safe outcomes with low complication rates. Butterfly resection may be considered for extensive lesions, with similar levels of pain relief compared to traditional focal resection techniques. CAPSULE Single-site robotic surgery produces safe outcomes with low complication rates in adolescents with endometriosis, with techniques customized based on disease severity.

Background: Laparoendoscopic single site surgery (LESS) is feasible for more complex procedure types, but the technical challenges and learning curve posed by LESS makes traditional multi-incision laparoscopy still the preferred technique. The aims of this study were to understand the restricted mobility and positional requirements of these more complex procedures and to generate innovative instrument designs to overcome these restrictions. Methods: A two-phase study was conducted where three lightly-embalmed (fresh tissue) cadavers were utilized to estimate in vivo mobility restriction and positional requirements. These data were combined to quantifying instrument force and positional requirements to develop a novel design for a LESS-specific grasper. Results: The LESS-specific has an ergonomic curved axial handle and locking mechanism that enables surgeons to relax their grip without the grasper releasing. Conclusion: Further design adaptations are needed to optimize the size, angles, and curvature of the tool, as well as to add two points of articulation for rapid intracorporeal adjustment.

Introduction: Urachal remnants are relatively rare. Generally, urachal remnants are detected in young people, and the removed specimen is small, comprising a good indication for laparoscopic surgery. Laparoendoscopic single-site surgery (LESS) for urachal remnants is considered to be safe and result in an excellent cosmetic outcome. Therefore, we report our single-center experience with LESS for urachal remnants. Methods: We retrospectively reviewed 30 patients with urachal remnants who underwent LESS from January 2011 to December 2017. The patients’ characteristics, surgical data, postoperative pain, and cosmetic assessment results were retrospectively collected and analyzed. Results: Mean total operative time was 151 min, mean pneumoperitoneal surgery time was 83 min, and mean estimated blood loss was 5.0 mL. All patients were started on an oral diet and began ambulating on postoperative day 1. Mean hospital stay was 5.5 days. LESS was completed successfully in all patients, with no conversion to conventional or open surgery. Conclusions: LESS is a viable option for the surgical treatment of urachal remnants. This technique may result in less pain than conventional techniques. Further accumulation of surgical outcomes (especially regarding safety and cosmesis) is required for LESS to become an established treatment for urachal remnants.

BACKGROUND Cataract and Primary Open Angle Glaucoma (POAG) are the leading causes of painless progressive loss of vision in the world. Surgery is the most productive and cost-effective treatment for patients suffering from Cataract and POAG. As the incidence and prevalence of Cataract with POAG is on the rise, the requirement of more skilful surgeons specialized in combined surgery is the need of the hour. The objectives of this study were- 1) to develop a simple and effective technique in surgical treatment for cataract and glaucoma. 2) to make it easier to transform from being a cataract surgeon alone to a combined cataract and glaucoma surgeon. 3) To compare the outcome of single site cataract surgery and trabeculectomy over two site surgery. MATERIALS AND METHODS Over two-years period, 30 patients diagnosed as cataract with primary open angle glaucoma underwent single site or two site combined small incision cataract surgery and trabeculectomy and were subjected to IOP measurement before and after surgery. The mean Intraocular pressure before and after surgery was compared to arrive at the results. Intra-operative and immediate post-operative complications are noted. Filtering bleb formation is noted. RESULTS Reduction of mean IOP by 5.7 mmHg (22%) in the single site surgery group compared to simple trabeculectomy and two site surgery was seen. No significant intra-operative and post-operative complications were experienced in single site surgery. Filtering bleb formation is seen in all cases who underwent single site surgery in the immediate post-operative period. CONCLUSION The single site combined small incision cataract surgery and trabeculectomy is an effective, easier and less time-consuming technique that can be mastered by every sutureless cataract surgeon.

To evaluate the surgical outcomes of single-site laparoscopic percutaneous extraperitoneal closure (SLPEC) and modified transumbilical two-port laparoscopic suturing (M-TTLS) of the hernia sac for the treatment of pediatric inguinal hernia (PIH) and determine whether one approach was superior to another.From January 2014 to June 2017, a total of 599 children had undergone SLPEC or M-TTLS in our department. SLPEC and M-TTLS were the most frequently performed single-site laparoscopic procedures for PIH in our department, which represented the extraperitoneal and intraperitoneal approaches, respectively. All patients were followed up at the out-patients' clinics and the medical records were reviewed with respect to all operative outcomes.There were 412 patients undergoing SLPEC and 187 patients undergoing M-TTLS, of which 358 hernias were on the right side, 172 on the left and 69 bilaterally. Two hundred and thirty-one unilateral hernias with contralateral patent processus vaginalis underwent contralateral repair at the same session. Mean operation time was 10.81 minutes in unilateral repair and 17.00 minutes in bilateral repairs, respectively. The perioperative complications included minor extraperitoneal hematoma in four (0.44%) patients, recurrence in one (0.11%), hydrocele in five (0.56%), and contralateral metachronous inguinal hernia in three (1.00%). No other complication developed in either group. There was no significant difference of complications between the two approaches except for the longer operation time in M-TTLS.Both SLPEC and M-TTLS were the safe and effective methods for PIH. The complications were comparable for M-TTLS and SLPEC, but operation time was significantly longer in M-TTLS than in SLPEC.

Objective To report the first case series of robotic single-site (RSS) surgery via the da Vinci Si Surgical System for mature cyst teratoma cystectomy in China. Materials and methods The study was devised as a retrospective study in a single medical center. Five patients with mature cyst teratomas requested a minimally invasive surgical treatment. These patients were treated with RSS surgery for mature cyst teratoma between January 2014 and January 2015. RSS mature cyst teratoma cystectomies were performed with the da Vinci single-site platform in the Hainan branch of PLA General Hospital. Data regarding patient characteristics, surgical approach, and perioperative clinical outcomes were collected and analyzed in a retrospective study. Results All RSS procedures were completed successfully in the five patients. No instrument failure was noted during the procedures. The median operating time was 65 minutes (range 45-100 minutes). The median docking time was 20 minutes (range 18-28 minutes). No instrument failure was noted during any surgical procedures. The median blood loss was 30 mL (range 10-70 mL). No patient had massive intraoperative bleeding nor required a transfusion. No extra trocar was placed during the surgery. None of the patients had bladder or rectal injury. The median length of stay in hospital was 2.8 days. All patients were followed up until 6 months postoperatively, and no surgical complication occurred. Conclusion RSS mature cyst teratoma cystectomy using the wristed semirigid instrumentation is feasible. Randomized controlled trials with a larger number of patients and longer postoperative follow-up should be conducted to further evaluate the effect of this therapeutic strategy.

Objective: To compare perioperative outcomes of robotic single-site (RSS) surgery with conventional single-port laparoendoscopic surgery for the treatment of advanced-stage endometriosis. ...

Objective In gynecological oncology surgery, pelvic lymphadenectomy and para-aortic lymphadenectomy is a critical surgical staging procedure. Multiple methods have been used to perform lymphadenectomy. Compared with multiport laparoscopy, the central incision of transumbilical laparoendoscopic single-site surgery (TU-LESS) provides equal access to the para-aortic and bilateral obturator region [1]. And it is accepted that extraperitoneal approach is ideal for lymphadenectomy, which avoids intestinal disturbance and reduce intra-abdominal adhesion [2]. Therefore, we developed TU-LESS extraperitoneal approach for lymphadenectomy, which combined the benefits of these aforementioned methods. Methods This study was approved by the Ethics Committee of West China Second University Hospital of Sichuan University (No. 150). A video is applied to demonstrate each steps for this specific technique. Step 1: Create TU-LESS intraperitoneal approach. Step 2: Pinpoint the peritoneal position. Step 3: Insert the port and create retroperitoneal pneumonia. Step 4: Remove lymph nodes through TU-LESS extraperitoneal approach. Step 5: Operate intraperitoneal surgery. Results This micro-invasive approach reduces the risk of direct bowel injury, adhesion formation, wound complications. For gynecologic cancer patients, especially for the advanced cervical cancer, this micro-invasive approach not only provide accurate staging but also achieve enhanced recovery following surgery, thus patients could receive subsequent adjuvant radio/chemotherapy on time. Conclusion TU-LESS extraperitoneal approach is an innovative method for lymphadenectomy.

To analyze and draw the learning curve of laparoendoscopic single-site surgery (LESS) in various benign gynecological diseases, so as to provide a reference for applying this cutting-edge technique.A retrospective analysis of LESS was conducted. Factors influencing the LESS learning process were assessed using Cox's proportional hazards regression. The cumulative sum (CUSUM) value and the learning curve were calculated and visualized based on operation time (OT), blood loss (BL), conventional laparoscopic surgery (CLS), conversion rate (CV), and complications (CP). The CUSUM value was defined as the sum of CUSUMA total of 445 cases, including adnexectomies (The learning curve of LESS for benign gynecological diseases indicates a stepwise process, during which the surgeon's CLS experience is the key, especially in ovarian cystectomy and myomectomy. For the training of young gynecologists, CLS should be emphasized in the early stage, and LESS should be introduced gradually.

Since their introduction in the surgical field, single-access laparoendoscopic surgery and robotic surgery platforms have evolved significantly through the years. Their combination brought to the surface unique abilities and potential for completing successfully robotic single-site operations that have proved to be extremely challenging even for laparoendoscopic surgeons with mass experience. Lately, robotic single-site approach has been utilized successfully in a gradually expanding list of operations, ranging from demanding fields of abdominal surgery such as hepatobiliary pancreatic surgery to other surgical specialties such as urology and gynecology. In this chapter, we present an overview of robotic single-site surgery with emphasis on the historical evolution of this technology, the available platforms, and the published evidence in the literature.

The development of single-site laparoscopic surgery (SIL) is attributed to the first decade of the current century by the majority of surgeons. However, the idea to gain access to the abdominal cavity through one incision dates back to 1902, when the German surgeon Georg Kelling performed the first one-port laparoscopy in dogs [1]. It was a Swedish gastroenterologist, namely Hans Christian Jacobaeus, who did the first single-port laparoscopy in humans in 1910 [2]. For reasons of technical and general medical limitations, including but not restricted to the lack of sufficient anesthesiology, it took until the final two decades of the last century for minimally invasive surgery to be accepted as a matter of clinical routine. Again, technical limitations mandated the use of multiple incisions, at least for therapeutic indications. The concept of SIL was then adopted by gynecologists for tubal sterilization using a single incision and a specially adapted instrument [3]. Further surgical and technical developments allowed modified adaptation of the SIL concept in more demanding procedures. Again, gynecologists pioneered the field with the first SIL hysterectomy [4] as well as the first SIL appendectomy in 1991 [5]. At that time, the concept did not meet with great enthusiasm on the part of general surgeons, and so our predecessors either developed extraumbilical one-trocar techniques [6] or gradually reduced the number of incisions for appendectomy by applying a transumbilical laparoscopically assisted technique [7]. The first case series of SIL cholecystectomies using a technique that was similar to what we now know as SIL was published by Navarra and colleagues in 1997 [8]. It took another 10 years for surgeons around the globe to become comfortable with this “new” idea, and subsequently the concept gained momentum and a majority of surgeons busied themselves with this technique. The synonyms of the SIL concept are given in Table 30.1. The number of performed procedures and published reports exploded within a few years and peaked in 2012 and 2013 (Fig. 30.1; publications). The technique spread to all surgical subdivisions and new applications were created.

Introduction Laparoendoscopic single-site surgery (LESS) can reduce the limited invasiveness of conventional laparoscopy while providing superior cosmetic results. Robotic single-site surgery (RSSS) can overcome this shortcoming to a certain extent. Aim To evaluate the advantages of RSSS in treating early-stage endometrial cancer by comparing RSSS with LESS. Material and methods From January 2018 to August 2018, patients diagnosed with endometrial cancer from endometrial curettage and imaging studies were selected for this prospective cohort study, with 22 undergoing RSSS and 18 undergoing LESS. All surgical procedures were performed using the conventional da Vinci Si surgical system with the Lagiport single port or a conventional laparoendoscopic instrument with the Lagiport single port. Operative time was recorded electronically. Intraoperative parameters and postoperative parameters were recorded and further analyzed. Results The operation was successfully completed, and a pure single-point approach was adopted. There were no laparotomy or intraoperative complications. Compared with the LESS group, the RSSS group had significantly longer pre-surgical time, significantly lower median operation time, significantly lower median blood loss, and significantly lower vaginal cuff closure time. The median length of hospital stay in the RSSS group was significantly lower than that in the LESS group. There was no significant difference in the incidence of early and late complications between the two groups. No recurrence events were observed in either the RSSS or the LESS group. Conclusions RSSS is feasible and safe in patients with early-stage endometrial cancer. RSSS can reduce operating time, blood loss and length of hospital stay compared with LESS.

Partial nephrectomy (PN) is the standard procedure for most patients with localized renal cancer. Laparoscopy has become the preferred surgical approach to target this cancer, but the steep learning curve with laparoscopic PN (LPN) remains a concern. In LPN intracorporeal suturing, the operation time is further extended even under robot assistance, a step which prolongs warm ischemic time. Herein, we shared our experience to reduce the warm ischemia time, which allows surgeons to perform LPN more easily by using a combination of hemostatic agents to safely control parenchymal bleeding. Between 2015 and 2018, we enrolled 52 patients who underwent LPN in our hospital. Single-site sutureless LPN and traditional suture methods were performed in 33 and 19 patients, respectively. Preoperative, intra-operative, and postoperative variables were recorded. Renal function was evaluated by estimated glomerular filtration rate (eGFR) pre- and postoperatively. The average warm ischemia time (sutureless vs. suture group, 11.8 &plusmn, 3.9 vs. 21.2 &plusmn, 7.2 min, p &lt, 0.001) and the operation time (167.9 &plusmn, 37.5 vs. 193.7 &plusmn, 42.5 min, p = 0.035) were significantly shorter in the sutureless group. In the sutureless group, only 2 patients suffered from massive urinary leakage (&gt, 200 mL/day) from the Jackson Pratt drainage tube, but the leakage spontaneously decreased within 7 days after surgery. eGFR and serum hemoglobin were not found to be significantly different pre- and postoperatively. All tumors were removed without a positive surgical margin. All patients were alive without recurrent tumors at mean postoperative follow-ups of 29.3 &plusmn, 12.2 months. Single-site sutureless LPN is a feasible surgical method for most patients with small exophytic renal cancer with excellent cosmetic results without affecting oncological results.

INTRODUCTION AND OBJECTIVE:To compare the efficacy of suprapubic-assisted laparoendoscopic single-site surgery (SA-LESS) and open ureterovesical reimplantation using insertion method, and to evalua...

Objectives To compare suprapubic-assisted laparoendoscopic single-site surgery nephrectomy with standard laparoscopic nephrectomy. Methods A retrospective case-control study comparing three surgeons' experience with 122 suprapubic-assisted laparoendoscopic single-site surgery nephrectomy and 107 standard laparoscopic nephrectomy was carried out. Operative time, estimated blood loss, intraoperative complications, intraoperative conversion, postoperative bowel recovery, postoperative analgesics, postoperative visual analog pain scale score, postoperative length of stay, days before going back to work, postoperative complications and Patient Scar Assessment Questionnaire were compared after propensity score matching. Results A total of 97 matched pairs were obtained after propensity score matching. There were no statistically significant differences between the suprapubic-assisted laparoendoscopic single-site surgery nephrectomy and standard laparoscopic nephrectomy groups with respect to operative time, estimated blood loss, intraoperative complications, intraoperative conversion, postoperative bowel recovery, length of stay and postoperative complications. Suprapubic-assisted laparoendoscopic single-site surgery nephrectomy group had decreased postoperative analgesics (20.9 vs 23.5, P = 0.04), visual analog pain scale score at 24 h (4.28 vs 5.28, P = 0.000), visual analog pain scale score at discharge (1.01 vs 1.47, P = 0.000), days before going back to work (28.4 vs 31.9, P = 0.000) and Patient Scar Assessment Questionnaire score (34.0 vs 42.0, P = 0.000), compared with the standard laparoscopic nephrectomy group. Conclusions Suprapubic-assisted laparoendoscopic single-site surgery nephrectomy and standard laparoscopic nephrectomy are equivalent in terms of the safety and efficacy. However, suprapubic-assisted laparoendoscopic single-site surgery nephrectomy confers less postoperative pain, fewer days before going back to work and better cosmetic result when compared with standard laparoscopic nephrectomy.

Laparoendoscopic single-site surgery (LESS) is a surgical approach that takes the best of minimally invasive surgery and can give the benefit of nearly scarless surgery. The approach poses unique challenges for the most experienced of laparoscopic surgeons, but has demonstrated ability to reduce hospital costs, post-operative pain and narcotic requirement, and even in one series, decrease operative time. Although only retrospective reviews are available, there is no evidence of increased risks or complications associated with LESS pediatric urological surgery. We review technical approaches, supplies, equipment, and considerations for performing LESS surgery in pediatric urology and review published literature on multiple applications.

Introduction Currently, polypropylene materials are used widely for the treatment of various urogynecologic disorders. This type of treatment can be complicated, although rarely, with erosions of the polypropylene implants into the bladder or the urethra. There is no established treatment for such complications. We present our experience in transvesical laparoendoscopic single-site surgery (T-LESS) removal of eroded materials, and a review of the literature in this field. Materials and methods From June 2015 to May 2017 eight females, with an average age of 66.5 years (range 55–80 years), were referred to our Center because of the erosion of polypropylene material in the bladder, after anti-incontinence or pelvic organ prolapse treatment. Patients were diagnosed with ultrasound and cystoscopy. Seven bladder erosions and one bladder and urethral penetration were found. Patients were qualified for removal with the T-LESS approach. The Tri-Port + disposable set and standard laparoscopic instruments were used. The eroded materials were dissected and cut away, and the defects of the bladder wall were closed with barbed sutures. The peri-operative efficacy and safety of the method were assessed, and the patients were scheduled for follow-up visits at 6 weeks and every 3 months thereafter. The patients were offered a cystoscopic exam during the 7–10 month period after the operation. Results The procedures were completed successfully in all patients. No blood loss or complications were observed. The mean operative time was 54.5 min, and the average hospital stay was 30 h. During a follow-up at 11 months, all patients were cured, except for one who presented urethral erosion. Conclusions The T-LESS technique for removal of eroded meshes is a safe and effective method. The precise access to the bladder minimizes morbidity, and suturing the bladder wall defects may reduce the risk of recurrence.

Objectives To determine the feasibility and safety of performing transvesical laparoendoscopic single-site surgery (T-LESS) in patients with medium-size, hard stones or multiple stones with high burden. Methods In this case series study, 12 patients (11 males and one female) with a mean age of 66.8 years were operated on from February 2016 to May 2017 due to bladder calculi, using the T-LESS approach with a single-port device (Tri-Port + , Olympus, Germany). Indications for this procedure were hard, medium-size, solitary stones after previous unsuccessful endoscopic lithotripsy or the presence of multiple high-burden stones. In two patients, additional procedures (diverticulectomy or a ureterocele incision) were performed simultaneously. Results All stones were removed intact. No serious complications were observed. The mean operative time was 46 min and the postoperative hospital stay was 22 h. The mean diameter of the largest stone and the mean stone volume of each case were 24 mm and 11 cm3, respectively. At the mean follow-up time of 15 months, there was significant improvement of the symptoms. Conclusions The T-LESS technique is an efficient, safe and minimally invasive procedure for intact bladder stone removal in selected patients. The method avoids the risk of urethral injury. Nevertheless, further investigation is needed to assess the wider applicability of the procedure.

Purpose. New laparoscopic devices are being continuously developed to overcome some of the technical and ergonomic limitations of laparoendoscopic single-site (LESS) surgery. This study aims to assess the surgeon’s surgical performance and ergonomics during the use of a handheld, robotic-driven, articulating laparoscopic instrument during LESS surgery. Methods. Seven right-handed experienced surgeons took part in this study. A set of basic suturing tasks and digestive and urological procedures in a porcine model were performed. Surgeons used both a conventional laparoscopic needle holder and a robotic device. The learning curve, execution time, and precision using the surgical needle were assessed. The surgeon’s posture was analyzed using a motion tracking system and a data glove. Results. After the training period, execution time on the intracorporeal suturing was significantly shorter using the conventional needle holder. The precision was higher using the conventional instrument in the horizontal plane, but the number of attempts to position the needle was lower using the robotic device (1.625 ± 0.250 vs 1.188 ± 0.375 attempts). The extension of the elbow (134.681 ± 14.35° vs 120.631 ± 13.134°) and the flexion of the shoulder (26.122 ± 7.411° vs 18.475 ± 14.166°) were significantly lower using the robotic instrument. The wrist posture using the robotic device was ergonomically acceptable during both surgical procedures. Conclusions. Results show a positive learning curve in ergonomics and surgical performance using the robotic instrument during LESS surgery. This instrument improves the surgeon’s body posture and the needle positioning errors. The use of the robotic instrument is feasible and safe during LESS partial nephrectomy and sigmoidectomy procedures.

Study Objective Demonstrate contained tissue extraction technique of a large presumed benign ovarian mass. Design Surgical video. Setting Outpatient laparoscopic single site surgery. Patients or Participants Single surgical case of a 41-year-old with a large dermoid tumor of the right ovary. Interventions Total laparoscopic hysterectomy and salpingoophorectomy. Video obtained of the salpingoophorectomy with containment and extraction technique. Measurements and Main Results Containment and extraction of a large dermoid tumor. Conclusion Contained tissue extraction within an inflated bag is useful for large presumed benign ovarian masses.

Laparoendoscopic single-site surgery (LESS) for laparoscopic inguinal hernia repair (IHR) offers the potential for excellent cosmetic outcomes and maximization of the inherent advantages of minimally invasive surgery. LESS IHR is associated with a steep learning curve, which is attributable to both the IHR technique itself and the single-site technique. The technical obstacles in the single-site technique may be mitigated by employing certain maneuvers and strategies that minimize clashing between instruments and improve freedom of movement. The current literature consistently points out the inherent challenges in LESS IHR, with its longer operative time compared to that of conventional laparoscopic IHR. LESS IHR performed by capable operators has comparable complication rates, duration of hospital stay, and incidence of recurrence as conventional laparoscopic IHR. LESS IHR is both feasible and safe. Given its excellent cosmetic outcome, it is likely to be sought by younger patients who are concerned with scar formation. The use of robotics may bypass the technical challenges in LESS, but cost considerations in their usage will likely persist.

Minimally invasive surgery continues to transform the field of gynecologic oncology and has now become the standard of care for many early-stage malignancies. The proven benefits of minimally invasive surgery are driving the rapid introduction and dissemination of novel technologies and the increasing ability to perform even the most complex procedures less invasively. In this article, we will review the current literature on traditional multiport laparoscopy, robotic-assisted laparoscopy, laparoendoscopic single-site surgery as well as robotic-assisted laparoendoscopic single-site surgery, with a specific focus on their role in the treatment of gynecologic malignancies.

Introduction Umbilical laparoendoscopic single-site (LESS) surgery is an increasingly used modality for treating renal masses. We present a prospective comparison between LESS renal surgery and conventional laparoscopy. Material and method A comparative paired study was conducted that evaluated the surgical results and complications of patients with renal neoplasia treated with LESS surgery (n = 49) or multiport laparoscopy (n = 53). The LESS approach was performed with reusable material placed in the navel and double-rotation curved instruments. An additional 3.5-mm port was employed in 69.4% of the cases. We assessed demographic data, the type of technique (nephrectomy, partial nephrectomy and nephroureterectomy), surgical time, blood loss, hemoglobin, need for transfusion, number and severity of complications (Clavien-Dindo), hospital stay, histological data and prognosis. Results There were no differences in follow-up, age, sex, body mass index, preoperative hemoglobin levels or type of surgery. Conversion occurred in 2 cases (1 in each group). The surgical time was equivalent (p = 0.6). Intraoperative transfusion (p = 0.03) and blood loss (p Conclusions Umbilical LESS surgery with reusable platform enables various surgical techniques to be performed when treating renal masses, with time consumption and safety comparable to conventional laparoscopy. The LESS approach is advantageous in terms of blood loss and hospital stay.

The creation of the da Vinci Single-Site© Surgical Platform (DVSSP) allowed robotic surgery to perform single portal procedures. Due to the characteristics of the robotic single-site system, the triangulation of the instruments was optimized, facilitating the execution of the movements. For this, the care in the placement of the portal have fundamental importance. In overweight and patients with obesity, the subcutaneous can impede the ideal positioning of the portal, affecting the movement of the robotic arms and creating discomfort for the surgeon and bringing risks to the patient. Three points are made for subcutaneous reduction, allowing better adaptation of the device. This technique is performed in all patients with obesity submitted to single-site robotic surgery at our service. It is a simple, fast, and low-cost method, allowing more safety to patient and comfort for the surgeon.

Objective: This study was to introduce the modified mini-laparoscopic adrenalectomy and investigate the advantage of operative time, cosmetic effect, and pain reduction by comparing the mo...

Introduction: Tissue retraction during minimally invasive surgery has been achieved to date with patient positioning or additional instrumentation. The Levita™ Magnetic Surgical System (Sa...

Objective: To share our experience of transition from multiport to single-site robotic surgery for benign gynecological conditions as well as to assess the selection criteria of candidates for robotic single-site supracervical hysterectomy (RSSH). Materials and methods: A retrospective review was conducted on patients undergoing robotic supracervical hysterectomy by a single surgeon in a single institute between June 2014 and December 2017. Patients who underwent additional procedures along with supracervical hysterectomy and who had unexpectant corpus malignancy proved pathologically were excluded from comparisons between patients undergoing RSSH and robotic multiport supracervical hysterectomy (RMSH). Results: Between June 2014 and December 2017, we accomplished 26 RSSH and 57 RMSH. There were no conversions, intraoperative complications, and readmissions within 30 days after surgery. In the RSSH group, the mean uterine weight was 264.6 ± 140.9 g with mean docking time of 15.8 ± 5.5 min, mean console time of 61.1 ± 35.6 min and mean operative time of 140.3 ± 34.4 min. In comparison to the RMSH group, the percentage of overweight/obese patients was lower (p = 0.018) and the uterine size was smaller (p

Background: Minimally invasive surgery is currently a preferred treatment for symptomatic ovarian cyst(s), with single-site techniques, such as transumbilical laparoendoscopic single-site surgery (TU-LESS) and transvaginal laparoendoscopic single-site surgery (TV-LESS), gaining increasing popularity. Although both methods have delivered positive outcomes, there is currently limited literature directly comparing TU-LESS and TV-LESS. Objectives: This study had two primary objectives: (1) to evaluate the safety and feasibility of TV-LESS and TU-LESS for the treatment of ovarian cysts and (2) to compare the surgical and postoperative outcomes of the two procedures. Method: This was a prospective observational clinical analysis of 81 patients with a diagnosis of benign ovarian cyst with indication for TV-LESS or TU-LESS. Surgeries were performed at a tertiary hospital between February 1, 2018 and January 31, 2020. Patients were divided into TV-LESS (n = 40) and TU-LESS groups (n = 40), with one excluded due to severe pelvic adhesive disease. Demographics, operation outcomes, and follow-up details were compared. Results: All 80 patients underwent uncomplicated procedures. The two groups were demographically matched (except age), with no difference in operation time, intra-operative blood loss, hemoglobin loss, and hospitalization costs (P > 0.05). However, TV-LESS patients had significantly faster time to ambulation (P