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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.

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.

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.

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 preferred surgical approach for many gynecologic oncology procedures is now laparoscopy. Reduced morbidity, shorter hospitalization and a more rapid recovery have been associated with minimally invasive surgical approaches when compared to laparotomy. Incisional morbidity, including vascular and viscous injury, postoperative hernia, infection, and pain remain significant concerns. Use of fewer and smaller incisions during laparoscopy may be expected to further minimize these risks. Laparoendoscopic single-site surgery (LESS), or single incision laparoscopy, describes the use of one small skin incision to complete laparoscopic surgical procedures. Recent advances in instrumentation have allowed increasingly complex procedures in gynecologic cancer patients to be completed. This review will serve as an update in regards to implementation of LESS in gynecologic oncology. Technical challenges encountered during performance of LESS as well as strategies to overcome these challenges will be discussed.

Objective Perform a comparative analysis of the outcomes of conventional laparoscopic adrenalectomy (LC) and the newly introduced laparo-endoscopic single-site surgery (LESS) over ten years. Material and method We retrospectively reviewed the experience of a single surgeon from our medical center with laparoscopic adrenalectomy, either through LC or LESS, with 75 patients between August 2005 and June 2015. Here we describe: age, sex, size, lateralization, preoperative diagnosis, total operating time, intraoperative bleeding, conversion to open surgery, mean hospital stay, intra- and postoperative complications and histopathology report. We used Fischer's and the Chi-squared tests to compare categorical data and Student's t-test for a comparison of the means with a normal distribution. Statistical significance was determined when p

Study Objective To provide a basic introduction to Laparoendoscopic Single-Site surgery (LESS) for the gynecologist including basic set up, concepts, and tips. Design Video submission created. Setting The operating room set up and procedure was recorded. Patients or Participants One patient involved in all video demonstrated. Interventions Laparoendoscopic Single-Site (LESS) Surgery recorded. Measurements and Main Results Laparoendoscopic Single-Site (LESS) procedure was recorded. Conclusion After reviewing the video presented you will have basic instructions including tips and tricks to performing single-site surgery.

Video Objective Pectopexy is the most effective procedure to treat pelvic organ prolapse and can be used as an alternative to sacrocolpopexy. The minimally invasive access for pectopexy is divided into single-port and multi-port with or without robotic assistance. Transumbilical natural orifice transluminal endoscopic surgery (transumbilical laparoendoscopic single site surgery, transumbilical LESS) is an emerging minimally invasive approach, which reduces abdominal incision and enhances aesthetics. Pectopexy is an ingenious combination of the two approaches, which achieves a good clinical effect. These advantages outweigh the difficulties in learning the new technique. Our purpose was to show the surgical skills of the transumbilical LESS. Setting Xinxiang City Central Hospital Gynecologic Oncology, China Interventions Transumbilical single-site laparoendoscopic pectopexy was performed, which was a combination of laparoendoscopic and single-site surgeries. Conclusion Transumbilical LESS allows the surgeon to perform iliopectineal ligament after accessing the entire abdomen via a single port. This procedure can achieve a good clinical effect.

Objective The aim was to assess the feasibility and outcomes of pediatric urological laparoendoscopic single site (LESS) surgery. Materials and methods A retrospective review was performed of all children who underwent LESS surgery at a single pediatric institution from September 2010 to July 2013. Patient demographics, intraoperative details, narcotic usage, and complications were reviewed. The umbilicus was used as the surgical site in all cases. All procedures were performed with a flexible tip laparoscope, a multichannel port, standard 3- or 5-mm laparoscopic instrumentation, and articulating instruments. Results Sixty-one patients (50 male, 11 female) were identified. Procedures included 18 orchidopexies, 15 nephrectomies, 11 varicocelectomies, nine nephroureterectomies, four partial nephrectomies, one ureterectomy, one ureterolithotomy, one orchiectomy, and one utricle excision. The ureterolithotomy was converted to open surgery for failure to progress. The utricle excision was converted to conventional laparoscopy by adding one accessory port and one skin puncture because of the close proximity of the vas deferens to the utricle. Intraoperative complications included one vas deferens injury during orchidopexy in a postpubertal male. Postoperative complications occurred in six patients: five grade II and one grade IIIb. Conclusions Pediatric urological LESS procedures are technically feasible, safe, and effective. Further evaluation is warranted to better define its role in pediatric urological surgery.

This is to describe a case of a morbidly obese (BMI = 40) female with retrocaval ureter treated with laparoendoscopic single-site surgery. A JJ stent was positioned. A 2 cm umbilical access was created. A single port platform was positioned. The entire ureter was mobilized posterior to the vena cava and transected where the dilated portion ended. The distal ureter was repositioned lateral to the inferior vena cava. Anastomosis was done. A 3 mm trocar was used to assist suturing. At 4-month follow-up, CT revealed no evidence of obstruction of the right kidney and the patient was symptomless. Although challenging, in a morbidly obese patient, LESS repair for retrocaval ureter is feasible.

Many access devices have been developed for laparoendoscopic single-site surgery (LESS) during recent years. However, investigations are needed to determine which port is most suitable for this relatively new technique. The aim of this study was to evaluate commonly used ports using mechanical approaches in a training simulator. Any port that required less force and shorter surgery times had superior maneuverability.The following three commercially available access devices were evaluated: Multi-ports, TriPort, and single-incision laparoscopic surgery (SILS) Port. A LESS mechanical evaluation platform was developed to investigate the forces that acted on the instruments in the ports while moving along horizontal and vertical axes. In addition, a strain-force measurement system was used to compare the average load on the ports when performing standard maneuvers. Additionally, the task completion time was recorded when the maneuvers in these ports were completed.During the horizontal displacement of the instrument, the traction forces of the Multi-ports were lower than those of the SILS Port, which were lower than those of the TriPort. The average traction forces were significantly different in pairwise multiple comparisons (P0.05). When the instrument was inserted into the ports, the vertical friction forces of the Multi-ports were the lowest and those of the TriPort were the highest. On extraction of the instrument, the friction forces of the Multi-ports remained the lowest, followed by those of the TriPort and SILS Port. There were statistically significant results among all the devices (P0.05). The average load required to perform the task was less for the SILS Port than that for the TriPort (P0.05). Similarly, the average load for the Multi-ports was significantly less than that for the TriPort (P0.001). The participants who used the Multi-ports had significantly faster task times than those who used the SILS Port or TriPort (P0.005).Compared with the TriPort and SILS Port, the Multi-ports was associated with the least average load and the shortest task performance times in a training simulator. This study demonstrates that the Multi-ports may offer superior maneuverability for LESS.

Objectives: To assess the learning curve and safety of laparoendoscopic single-site (LESS) surgery of gynecological surgeries. Materials and methods: Sixty-three women who underwent LESS surgery by a single experienced laparoscopic surgeon from February 2011 to August 2011 were included. Commercialized single-incision laparoscopic surgery homemade ports were used, along with conventional straight instruments. The learning curve has been defined as the additional surgical time with respect to surgical order of LESS surgery, which has been estimated using a smooth function in a linear model with generalized least squares, with some adjustments made due to influencing factors of the operations. Results: All women completed LESS surgeries without the need for ancillary ports, except for two laparotomy conversions due to incidental ovarian malignancy. Three women, one with a gastrointestinal stromal tumor, one with laparoscopic myomectomy, and one who had been receiving simultaneous hysteroscopic myomectomy, were excluded. Of the 58 women included, 39 underwent adnexal surgeries and 19 underwent hysterectomies. Complications occurred with one woman who required a blood transfusion during the procedure. Surgical time was longer in bilateral cystectomy compared with unilateral cystectomy and unilateral/bilateral salpingo-oophorectomy (110.6 ± 51.1 minutes vs. 73.0 ± 26.3 minutes and 66.3 ± 26.9 minutes; p

Background Laparoendoscopic single-site (LESS) surgery has been shown to be a well-tolerated alternative for the placement of an adjustable gastric band. To date, only small series have suggested that this approach may provide potential clinical benefits over standard multiport laparoscopy. The objective of this study was to compare the outcomes of patients undergoing LESS adjustable gastric banding (LESS-AGB) and a cohort of patients undergoing standard multiport laparoscopic adjustable gastric banding (LAGB). Methods A total of 206 patients underwent placement of an adjustable gastric band. Of these, 106 patients underwent LESS-AGB and were compared with a demographically similar cohort of 100 patients who underwent standard LAGB. Data collected included operative time, parenteral and oral narcotic consumption, duration of patient controlled analgesia (PCA) device, subjective pain scores using the 0–10 numeric pain intensity scale, and length of stay. Unpaired t test was used for analysis. Results Compared with multiport LAGB patients, LESS-AGB patients reported significantly less pain at the first postoperative hour ( P = .012), twelfth postoperative hour ( P = .017), and twenty-fourth postoperative hour ( P = .012), and consumed fewer oral analgesic tablets ( P = .012). Operative times were significantly longer in the LESS-AGB group ( P = .029). No significant differences were seen in duration of PCA, parenteral narcotic consumption, or length of stay. One LESS-AGB case required conversion to multiport laparoscopy. Complication rates were similar between the 2 groups. Conclusion LESS-AGB is associated with less pain and less oral analgesic consumption than multiport LAGB. Given these clinical advantages and superior cosmetic results, laparoendoscopic single-site surgery may be an attractive alternative approach for patients considering LAGB. (Surg Obes Relat Dis 2013;0;000–00.) © 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Context Laparoscopic surgery in urology is considered to be an important advance, although it is not exempt from some morbidity associated to the use of multiple trocars and specifically to the extraction of the specimen. In order to decrease this morbidity and improve esthetics, other techniques are being developed, such as natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS). It is aimed to review the current status of laparoendoscopic single site surgery in urology. Acquisition of evidence A nonsystematic review has been carried out by means of the bibliographic search using the terms LESS and Urology from 2007 to 2012. The current LESS experience in urology is described, and its principal indications and the different single site devices and instruments available on the market are described. Synthesis of evidence LESS surgery arose as one more step in the constant evolution of minimally invasive surgery in an attempt to improve esthetics, reduce surgical trauma and decrease pain and the post-operative complications associated to the conventional laparoscopy with multiple trocars. Since it was first described in 2007, the experience has been increasing exponentially and the LESS technique, whether assisted or not by robot, is becoming consolidated for a large spectrum of urological indications (both in oncological and reconstructive surgery) on a much greater scale than the NOTES technique. Even though most of the existing data are not randomized and very rarely comparative, with the selection bias that this represents, it seems clear that the esthetic benefit and analgesic control associated to the LESS surgery is real and reproducible. The complications associated to it are greater in cases of major oncology surgery and are due more to the technique itself then to the approach. Conclusions Although the real benefit of the LESS surgery in urology cannot be appropriately quantified, the cosmetic improvement, less pain and greater patient satisfaction with their wound are clear. Appropriate training in this type of procedures in centers having large volumes and the continuous technical improvements in the instrumental development by the biomedical industry has resulted in the fact that the transumbilical LESS technique in urology has been born to stay.

Background Laparoendoscopic single-site (LESS) surgery can be performed without apparent scarring, while maintaining the salutary benefits of conventional laparoscopic surgery. The purpose of this study was to compare patients' preoperative and postoperative perceptions of LESS surgery. Methods Before and after undergoing LESS surgery, 120 patients were given questionnaires; their responses were assimilated and analyzed. Results Of 120 patients, 62% were female (age, 52 ± 16.6 y), and 54% had prior abdominal surgery. Preoperatively, women and older patients reported heightened appearance dissatisfaction. Preoperatively, most patients would not accept more risk, pain, surgery/recovery times, and/or costs than associated with standard laparoscopy. Postoperatively, patients reported increased satisfaction in their overall and abdominal region appearance. Satisfaction was noted by 92%; satisfaction was related significantly to scar appearance and cosmesis. Conclusions Preoperatively, patients were most concerned with safety; postoperatively, patients' concerns shifted to cosmetic outcome. LESS surgery provides an opportunity for improved patient satisfaction.

Context Radical cystectomy with orthotopic derivation is one of the most complex urological techniques, although laparoscopic surgery has made this procedure increasingly less invasive. Objective To provide an updated review of the single port approach to carry out radical surgery due to bladder cancer. Evidence acquisition A comprehensive review of the literature was performed using Medline and Embase to discover the accumulated experience of the viability of carrying out laparoendoscopic radical cystectomy, pelvic lymphadenectomy and orthotopic neobladder using the LESS (laparoendoscopic single site surgery) approach. Our experience with this approach is also presented and the technique used with the reusable KeyPort® system developed by Richard Wolf is described. Evidence synthesis Radical treatment of bladder cancer is possible in men and women using a single port and even performance of ileal neobladder, as reconstructive procedure in these patients. The surgical technique, post-operative cares and result obtained in our center are described. The accumulated experience worldwide describes 25 cases of radical cystectomy performed using different single port systems, 14 of them with orthotopic intestinal neobladder. Conclusion The KeyPort® umbilical cystectomy constitutes in our setting the least possible invasive alternative to efficiently treat muscle-invasive bladder cancer, with excellent esthetic result, minimum post-operative pain and short hospital stay. The umbilical scar decreases the analgesic requirements and it ends up being practically invisible. This supposes an important step in the development of the minimally invasive surgery for bladder cancer.

To assess the feasibility, safety, and efficacy of transperitoneal laparoendoscopic single-site (LESS) adrenalectomy and determine whether it shows any objective advantage compared with standard laparoscopy.From August 2009 to May 2011, 13 transperitoneal LESS adrenalectomies were performed through a 2-3-cm skin incision using the TriPort access system. This cohort was compared with a contemporary 1:2 matched-pair group of 26 patients undergoing standard laparoscopic adrenalectomy by the same urologist. The perioperative outcomes, including cosmetic satisfaction scores, were statistically analyzed.The 2 groups were comparable with respect to patient demographics, estimated blood loss, and postoperative hospitalization (P.05). The LESS procedures had a longer mean operative time (148.5 vs 112.9 minutes, P = .032) but a significantly lower postoperative visual analog pain scale score (2.3 vs 3.7, P = .001), fewer patients requiring analgesics (30.8% vs 73.1%, P = .011), and an earlier resumption of oral intake (21.6 vs 26.0 hours, P = .002). The mean length of the scar in the LESS group was much smaller (2.3 vs 5.9 cm, P.0001) with a statistically significant greater mean cosmetic satisfaction score (9.5 vs 9.1, P = .042).The perioperative outcomes of transperitoneal LESS adrenalectomy for small adrenal tumors were comparable to those with the standard laparoscopic approach. It also provides better postoperative pain control, faster recovery of bowel function, and better cosmetic satisfaction than standard laparoscopy, albeit with a longer operative time.

Objective Nephron-sparing surgery (NSS) for small renal masses offers a similar functional and oncological outcome to that of radical surgery. Laparoendoscopic single-site surgery(LESS) emerges as an advanced alternative for reduced invasiveness and improves cosmesis; LESS is developing quickly and its indications have been expanded, but still in its infancy. The aim of this paper is to report our preliminary experience in transumbilical LESS partial nephrectomy (LESS-PN), so as to assess its utility, safety and efficacy. Methods From August 2009 to October 2010, 3 patients underwent transumbilical LESS-PN via a novel multi-channel TriPort by a single experienced urologist in our institution. Patient demographics, perioperative and follow-up data were prospectively collected and analyzed. Results All the three procedures were successfully completed. A 5-mm ancillary trocar was utilized in all 3 cases. The mean operative duration was 226.3 (210–254 min) with an estimated blood loss of 56.7 ml (20–100 ml). Mean warm ischemia time was 35.7 min (19–48 min). One patient was transfused due to postoperative bleeding. The recovery was uneventful and mean length of postoperative stay was 13 days (12–14 days). At the latest follow-up, all patients remained symptom-free and had normal renal function without evidence of recurrence, and they were delighted for a hidden transumbilical scar. Conclusion Transumbilical LESS-PN is a feasible and safe procedure albeit extremely technically challenging. Surgical outcomes at a median follow-up of 2 years are promising, while currently it should be reserved for highly selected patients with favorable tumor anatomy and performed by a very experienced laparoscopic surgeon.

Until the mid-1980s, cholecystectomy was performed through a generous right upper abdominal incision. After the early reports from Europe and the United States on the safety and feasibility of laparoscopic cholecystectomy, the minimally invasive revolution began. This revolution has continued to the current time, where surgeons are attempting to perform minimally invasive procedures with less or no visible scarring. Cholecystectomy is ideally suited for the single-site umbilical laparoscopic approach to obviate the need for epigastric and supraumbilical incisions. This article will describe the single-site umbilical laparoscopic cholecystectomy, which has been performed at Children's Mercy Hospital since 2009. Also, the literature concerning this approach in adults and in children will be discussed. Finally, a prospective randomized trial comparing the single-site cholecystectomy with the traditional 4-port laparoscopic cholecystectomy will also be described.

OBJECTIVES To define clinical scenarios in urology for which laparoendoscopic single-site surgery (LESS) is indicated and likely to be successful. We report a series of LESS nephrectomies and compare patient characteristics with traditional laparoscopic nephrectomies performed during the same time period. METHODS We retrospectively reviewed all laparoscopic nephrectomies (conventional or LESS) performed by a single surgeon at our institution since our initial LESS cases in August 2007. Patients were not randomized; instead the surgeon used clinical judgment to decide with the patient which procedure should be performed. Factors that may have influenced this decision were retrospectively analyzed. RESULTS Of all minimally invasive nephrectomies, 47% were performed using LESS technique (30/64). One conversion from LESS to standard laparoscopy occurred. Patients undergoing LESS had a smaller median age (47 vs 63.5 years, P = .004), body mass index (24.4 vs 28.4, P = .001), tumor size in nephrectomies performed for suspected malignancy (4 cm vs 6 cm, P = .043), and hospital length of stay (42.7 vs 46.1 hours, P = .006). LESS patients were also more likely to be undergoing a nephrectomy for a benign indication (50% vs 15%, P = .006). The complication rate for LESS and conventional laparoscopy was 13% (4/30) and 15% (5/34), respectively, with similar distributions across Clavien grades. CONCLUSIONS With appropriate patient selection, almost 50% of minimally invasive nephrectomies can be performed using LESS with similar complication rates and outcomes compared with traditional laparoscopy. Younger, thinner patients with nononcological indications or smaller tumors are prime candidates for LESS nephrectomy.

Laparo-endoscopic single site surgery (LESS) is a relatively new technique that has been described in recent medical literature to be feasible in the management of benign gynaecological conditions. However, the use of this technique in the management of gynaecological cancers is still controversial. In this case report, we describe the first single port laparoscopic pelvic lymphadenectomy performed in Singapore. This involved a patient who was diagnosed with endometrial cancer after a vaginal hysterectomy for uterovaginal prolapse.

OBJECTIVES To describe novel robotic laparoendoscopic single-site surgery (R-LESS) instruments, and present the initial laboratory experience in urology. METHODS The VeSPA surgical instruments (Intuitive Surgical, Sunnyvale, CA) were designed to be used with the DaVinci Si surgical system. A multichannel port and curved cannulae were inserted through a single 3.5-cm umbilical incision. The port allowed 1 scope, 2 robotic instruments, and a 5- to 12-mm assistant instrument. Four pyeloplasties (right 2, left 2), 4 partial nephrectomies (right 2, left 2), and 8 nephrectomies (right 4, left 4) were performed in 4 female farm pigs (mean weight, 34.5 kg). Technical feasibility and efficiency were assessed in addition to perioperative outcomes. RESULTS All 16 R-LESS procedures were performed successfully without the addition of laparoscopic ports or open conversion. Mean total operative time was 110 minutes (range, 82-127), and mean blood loss was 20 mL (range, 10-100). Mean warm ischemia time for partial nephrectomy was 14.8 minutes (range, 12-20). There were no intraoperative complications. No robotic system failures occurred, and robotic instrument clashing was found to be minimal. One needle driver malfunctioned and assistant movement was limited. CONCLUSIONS R-LESS kidney surgery using the VeSPA instruments is feasible and efficient in the porcine model. The system offers a wide range of motion, instrument and scope stability, improved ergonomics, and minimal instrument clashing. Although preliminary experience is encouraging, further refinements are expected to optimize urological applications of this robotic technology.

Transumbilical laparoendoscopic single-site (LESS) surgery is a recent advancement in minimally invasive surgery. However, this procedure usually requires a specialized multichannel port for introducing the laparoscope and instruments under pneumoperitoneum. In an isobaric procedure, a wound retractor alone can conveniently be used for transumbilical single-site access. Fourteen isobaric LESS adnexal surgeries including 1 emergency procedure with adnexal torsion were performed using multiple instruments inserted through the wound retractor. No extraumbilical incisions or conversion to standard multiple-port laparoscopic surgery were required. Port-related complications were not noted, and the cosmetic results were excellent. A wound retractor offers safe and reliable access for isobaric LESS adnexal surgery as an alternative to the current specialized port systems.

Herein, we describe a surgical approach for management of a pregnant woman with an ovarian tumor using laparoendoscopic single-site surgery with exteriorization. We assessed both the feasibility and cosmetic outcome. The operation lasted 25 minutes, and the estimated blood loss was negligible. No perioperative or postoperative complications developed, and the patient was discharged on postoperative day 2.

Background Laparoendoscopic single-site surgery (LESS) allows for the performance of major urologic procedures with a single small incision and minimal scarring. The da Vinci Surgical System provides advantages of easy articulation and improved ergonomics; however, an ideal platform for these procedures has not been identified. Objective To evaluate the GelPort laparoscopic system as an access platform for robotic LESS (R-LESS) procedures. Design, setting, and participants Since April 2008, 11 R-LESS procedures have been completed successfully in a single institutional referral center. For the last four consecutive cases, the GelPort has been used as an access platform through a 2.5–5-cm umbilical incision. Intervention R-LESS cases performed with the GelPort included pyeloplasty ( n =2), radical nephrectomy ( n =1), and partial nephrectomy ( n =1). Measurements Perioperative data were obtained for all patients including demographic data, operative indications, operative records, length of stay, complications, and pathologic analysis. Results and limitations For both pyeloplasty cases, average operative time (OR time) was 235min and estimated blood loss (EBL) was 38cm 3 . For the patient undergoing radical nephrectomy for a 5.1-cm renal tumor, OR time was 200min and EBL was 250cm 3 . The final patient underwent partial nephrectomy without renal hilar clamping for an 11-cm angiomyolipoma with OR time of 180min and EBL of 600cm 3 . All R-LESS procedures attempted with the GelPort were completed successfully and without complication. Average length of hospital stay was 1.75 d (range: 1–2). The partial nephrectomy patient required transfusion of 1 U of packed red blood cells. Conclusions Use of the GelPort as an access platform for R-LESS procedures provides adequate spacing and flexibility of port placement and acceptable access to the surgical field for the assistant, especially during procedures that require a specimen extraction incision. Additional platform and instrumentation development will likely simplify R-LESS procedures further as experience grows.

Objectives To present the initial clinical experience with laparoendoscopic single-site (LESS) radical nephrectomy and nephroureterectomy performed completely through a Pfannenstiel incision. Methods Two patients underwent a single-site nephrectomy and nephroureterectomy for the diagnosis of an enhancing renal parenchymal mass and a renal pelvic mass, respectively. In both cases, a 7.5-cm Pfannenstiel incision was made and GelPort was inserted. Trocars were placed through the access port, and nephrectomy was performed using standard and bariatric length laparoscopic instruments. Distal ureter was resected through the Pfannenstiel incision for nephroureterectomy. No additional ports were used as both procedures were completed via the Pfannenstiel approach. Results The procedures were completed in 187 and 409 minutes, respectively, without complication. Blood loss was estimated at 50 and 200 mL, respectively. Postoperatively, the patients required minimal analgesia. Patients were discharged on postoperative days 2 and 4, respectively. Conclusions LESS nephrectomy and nephroureterectomy using only a Pfannenstiel incision are technically feasible and reproducible in human beings if performed by surgeons with standard laparoscopic skills. Using standard and bariatric length laparoscopic instruments, the procedures were performed without complication, with minimal blood loss and minimal variance from standard laparoscopic techniques. We anticipate that this approach can be incorporated by the urologist adept at laparoscopic surgery and provides a practical application of LESS surgery for extirpative procedures.

Laparoendoscopic single site (LESS) surgery is a recently coined term that refers to a group of techniques that perform laparoscopic intervention through a single abdominal incision often hidden within the umbilicus. The relative ease and swiftness of early success of LESS surgery is in large part because of the familiarity of current practitioners with advanced laparoscopic techniques and the advent of several technologic advances in the areas of instrumentation, camera systems, and access devices. As ongoing advancements in instrumentation and future robotics platforms are incorporated, the scope and application of LESS surgery is likely to expand. Ultimately, prospective studies that compare the safety and effectiveness of this new approach with the standard conventional laparoscopic approach will determine the future role in surgical practice.

Over the past few decades, advancements in minimally invasive surgery techniques have made surgical management of gastroesophageal reflux diseases increasingly popular. More recently, the field of minimally invasive surgery has experienced a natural evolution towards a reduction in the invasiveness of surgery and even in the number of abdominal access incisions. In fact, single site/access approaches have been successfully applied to a number of common minimally invasive surgery procedures including cholecystectomy, hysterectomy, colectomy, bariatric and even anti-reflux surgery. However, there is very little published data on the application of this technique in anti-reflux surgery. We present a brief review of available data as well as a summary of our experiences with this innovative approach to minimally invasive foregut surgery.