Is single port laparoscopy SPL positioned to be more successful than using the natural orifice transluminal endoscopic surgery NOTES approach? Is there any substantial advantage of SPL or NOTES over conventional laparoscopy and robotics? Are retention suture t-anchors to the lateral parietal peritoneum improving the SPL access for scarless single port transumbilical
nephrectomy and pyeloplasty?
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…In the last two decades there has been a change in surgical practice, with the increasing incorporation of minimally invasive laparoscopic/robotic procedures. Minimally invasive surgery aims to provide effective treatment of surgical diseases inside a body cavity, while decreasing access-related morbidity. The advantages of excellent visualization, decreased blood loss, less postoperative pain, quicker recovery, and superior cosmesis, coupled with oncological outcomes comparable to the open counterpart, have now been repeatedly reported for a wide array of minimally invasive procedures across many surgical specialities.
With increasing levels of comfort in the laparoscopic environment, there have been continuing attempts to further decrease access-related morbidity. This includes the incorporation of needlescopic instruments…, natural orifice transluminal endoscopic surgery (NOTES)…and single port laparoscopy (SPL)… We earlier reported partial incorporation of 1.9-mm needlescopic instrumentation in laparoscopic urological surgery…These instruments can be passed through 2 mm needlescopic Veress needle ports that are about the diameter of a 16 G angiocath needle. The 2-mm trocars can be inserted with no need for a skin incision, do not require formal closure, and are associated with negligible scarring or pain.
There has been a recent interest in the use of NOTES for nephrectomy in an animal model; NOTES completely avoids abdominal wall incisions and attendant scarring. Therefore, the abdominal wall remains unviolated; however, intra-abdominal scarring is expected to be the same, as it depends on mobilization of the target organ, its adjacent viscera and parieties. In addition, NOTES is associated with the unique issue of achieving reliable closure of the iatrogenically created, controlled opening in the hollow organ of access, i.e. stomach, colon, vagina. As such, water-tight repair of the viscus of access is mandatory. SPL involves the introduction of special multichannel access devices that allow laparoscopic surgery through one incision. By contrast with NOTES, a single port of laparoscopic entry into the abdomen is created, which can be cosmetically concealed, when appropriate, within the umbilicus. The R-Port is one such unique single-access device that is an offshoot of the design for hand-assist laparoscopic surgery. A few features of the R-Port design make it articularly suitable for SPL. The R-port uses a pulley and ring system that tightly cinches the abdominal wall in a self-retaining fashion, and creates an effective self-retaining seal for insufflation with no need for tacking sutures. The entire mechanism is flexible and therefore allows the passage of instruments with an exaggerated curve that cannot be inserted through conventional rigid laparoscopic ports. There is no internal profile, thereby allowing greater freedom of instruments. This feature is critical with SPL, as all instruments are closely ‘packed’ together, and the ability to constantly realign instruments relative to each other is of paramount importance. Purpose-designed curved, bent and/or articulating instruments are inserted through the two to four inlets of this single port device to perform the laparoscopic procedure.
By contrast with NOTES, no deliberate viscerotomy is created, eliminating the need for this often difficult visceral closure, and potential complications thereof, such as leakage from a gastrotomy or colotomy. Also, locating the single port within the umbilicus eliminates any visible scarring. Advocates of NOTES and SPL also argue that the potential for intra-abdominal adhesions will be decreased. However, this remains unconfirmed and to us, doubtful. Thus we report, to our knowledge, the first clinical report of a totally ‘scarless’ nephrectomy and pyeloplasty with the incision completely concealed within the umbilicus, using a single-access trocar with no extra-umbilical incisions. The procedures were technically successful, albeit taking longer than expected for their traditional laparoscopic counterparts.
Certain technical caveats of SPL require consideration. The parallel and close lie of the right- and left-hand instrument shafts tends to result in ‘crowding’ of the laparoscope and instruments. Although this problem is partly offset by the prototype instruments that have varying curvatures or bends in the shaft, dissection through a single port is more difficult than in conventional multi-port laparoscopy. To overcome this, the instrument shafts are frequently crossed at the point of entry into the valve, such that the external right-hand instrument becomes the left instrument internally, and vice-versa. As such, intraoperative dissection might sometimes be done with the left hand, requiring ambidexterity on the part of the surgeon. For right-sided renal surgery, we were able to achieve necessary retraction of the liver by selective use of a 5-mm grasper inserted through the third inlet of the Triport, and maintained in place by the first assistant. Fixed tissue retraction of the kidney and perirenal fat was achieved by retention sutures anchored to the lateral parietal peritoneum. Absence of a separate venting channel for intra-abdominal smoke slows the procedure somewhat.
Selective use of 2 mm needlescopic instruments facilitates SPL, especially intracorporeal suturing, which is otherwise hampered by the loss of triangulation. This 2 mm Minisite port does not require a skin incision for introduction, and thus requires no formal closure. We previously reported that use of needlescopic ports has no cosmetic sequelae and does not increase the morbidity.
Currently single port procedures are somewhat cumbersome, and additional work remains before these techniques achieve the level of standardization that is now established for conventional laparoscopy. Robust flexible articulating instruments and high-illumination, high-magnification flexible endoscopes, as well as free-standing insertable retractors, will need to be developed. Combining the two methods of NOTES and SPL, such that a tri-lumen single port can be used through a natural orifice (vagina), could maximize the benefits of the two techniques. Introducing robotically controlled flexible instruments inserted through the single port might be the ultimate answer to facilitate technical performance. Is there any substantial advantage of SPL or NOTES over conventional laparoscopy and robotics? There might be an apparent psychological and cosmetic benefit, and decreased postoperative pain, but much work remains to address these issues and determine their true role in minimally invasive surgery.
In conclusion, we report the initial experience of organ-ablative and reconstructive renal surgery using a single transumbilical port. No extra-umbilical incisions were used; both procedures were completed successfully within a reasonable time, with no complications, and the patients recovered quickly. We think that continuing advances in single port technology will improve in the near-term…