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Medina-González, N. Eiró-Díaz, J.M. Fernández-Gómez, L. Ovidio-González, A. Jalón-Monzón, J. Casas-Nebra, S. Escaf-Barmadah" "autores" => array:7 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Medina-González" ] 1 => array:2 [ "nombre" => "N." "apellidos" => "Eiró-Díaz" ] 2 => array:2 [ "nombre" => "J.M." "apellidos" => "Fernández-Gómez" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Ovidio-González" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Jalón-Monzón" ] 5 => array:2 [ "nombre" => "J." "apellidos" => "Casas-Nebra" ] 6 => array:2 [ "nombre" => "S." 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Subirá-Ríos, F. Herranz-Amo, M. Moralejo-Gárate, J. Caño-Velasco, G. Bueno-Chomón, E. Rodríguez-Fernández, G. Barbas-Bernardos, C. Hernández-Fernández" "autores" => array:8 [ 0 => array:2 [ "nombre" => "D." "apellidos" => "Subirá-Ríos" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Herranz-Amo" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Moralejo-Gárate" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Caño-Velasco" ] 4 => array:2 [ "nombre" => "G." "apellidos" => "Bueno-Chomón" ] 5 => array:2 [ "nombre" => "E." "apellidos" => "Rodríguez-Fernández" ] 6 => array:2 [ "nombre" => "G." "apellidos" => "Barbas-Bernardos" ] 7 => array:2 [ "nombre" => "C." "apellidos" => "Hernández-Fernández" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210480619301391" "doi" => "10.1016/j.acuro.2019.07.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210480619301391?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578619301441?idApp=UINPBA00004N" "url" => "/21735786/0000004400000002/v1_202003050904/S2173578619301441/v1_202003050904/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "The endless evolution of laparoscopic approach" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "59" "paginaFinal" => "61" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "C. Hernández Fernández" "autores" => array:1 [ 0 => array:3 [ "nombre" => "C." "apellidos" => "Hernández Fernández" "email" => array:1 [ 0 => "carloshfdez@me.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Urología, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La continua evolución del abordaje laparoscópico" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Most approaches performed at urological surgeries were described throughout the 19th century. During the 20th century, scientific forum discussions were limited to elucidating which of the available approaches was the most appropriate for a given condition. For this reason, it was also crucial to have information about the complications implied by these approaches, as well as the ways to avoid them or solve them. Undoubtedly, the phrase “the greater the surgeon, the bigger the incision,” was clearly evident in many Urology Services.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Meanwhile, slowly but steadily, percutaneous endoscopic access to the abdominal cavity began its journey. “laparoscopy” is the result of an evolution in which, for almost a century, different factors were implemented: the desire for direct visualization of the internal organs of the abdomen without the inherent need for large incisions, the technological development of the classical endoscopic instruments used by the urologist, and the appearance of long, thin instruments which can be manipulated remotely. In fact, it was Kelling who, in 1901, described cystoscopic visualization of the abdomen, (previously developed by Nitze) through a small abdominal incision. In 1910, Jacobaeus coined the term “laparoscopy” for the first time to refer to the visualization of the intraperitoneal space using, not only the introduction of an endoscopic vision system through minimal access to the abdominal cavity, but also air insufflation to provide an improved inspection of this anatomical region. Shortly after, Zollikofer (1925) advocates the use of CO<span class="elsevierStyleInf">2</span> to achieve the necessary abdominal distension, decreasing the probability of embolic events observed with air, while limiting the risk of explosion.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Concerning the use of laparoscopic approach in our specialty, we owe John Wickham (godfather of the concept of “minimally invasive surgery”) the retroperitoneoscopic ureteral stone removal. The “extraordinarily complex” remark that he grants to this intervention is noteworthy.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Certainly, the true milestone of laparoscopic access in Urology occurs in 1991, when Ralph Clayman<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> published his first experience with transperitoneal access to perform a radical nephrectomy. From this moment, the interest in these approaches begins to grow among the urological community, and its incorporation in some Urology Services gradually takes place.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The course of laparoscopic history in Spain has run parallel. Thus, in 1976, Páramo et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> communicate for the first time the success in endoscopic visualization of cryptorchid testes; in 1991, Sánchez de Badajoz et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> perform the surgical correction of a varicocele; the following year, Rioja Sanz et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> achieve a transperitoneal nephrectomy and in 1994, Hernández Fernández et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> accomplish a laparoscopic nephrectomy through a retroperitoneal access. The foundations of these approaches (retroperitoneum and peritoneal cavity) were laid during this period, as well as the patients' and the different entry ports’ positioning (optical and other necessary instruments).</p><p id="par0025" class="elsevierStylePara elsevierViewall">In a short time, the clear advantages provided by this type of access to the patient (less pain, bleeding and complications related to the surgical wound, as well as a faster recovery) were revealed. However, the numerous inconveniences which the urologist had to face when performing them (less movement freedom, loss of three-dimensional vision and no tactile sensation, among others) were also evident. In order to balance this equation, it was crucial for surgeons to understand the basic concepts of triangulation, to keep the minimum distance between trocars in order to avoid collisions, and properly systematize the number and diameter of ports to be used according to the surgical technique to be performed as well as the necessary instruments. Nakada et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> stand out in this regard. In 1997, they aimed to solve some of the difficulties described above (tactile sensation) with the description of “hand-assisted” surgery. This new alternative generated a renewed spirit in the urological group and in the industrial field, culminating in the appearance of different devices that allowed the surgeon’s non-dominant hand to be introduced into the surgical field (Gelport® [Applied medical], Lapdisc® [Dexteriti], etc.). The acquired experience allowed the overcoming of the learning curve and the simplification of purely laparoscopic processes, with hand-assisted procedures gradually falling into disuse, except for live donor nephrectomy.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Pursuing for innovation, surgical instrument manufacturers developed 2 potential improvements at the beginning of the 21st century: port miniaturization and single port. In both cases, the sales arguments were the same: more aesthetic incisions and less need for postoperative analgesia. On the contrary, urologists were facing new technical difficulties: crossing and collision of the instruments in the abdomen, mirror imaging, poor visualization of anatomical structures and worse aspiration, among others. The laparo-endoscopic single site surgery (LESS) single-port approach was rapidly added to natural orifice transluminal endoscopic surgery (NOTES) technique, and the presence of publications about this type of procedures (as well as of their acronyms) increased in the literature. This fact triggered the need for a consensus meeting to unify the terminology used in 2008.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The conclusions reached during this meeting were unanimous: greater technical complexity with a slight decrease in postoperative analgesia and, without a doubt, reduced scarring. Although some critical voices argued that the potential advantages of these approaches did not justify the clearly increased surgical difficulty and, consequently, higher complications risks (severe in some cases), time has demonstrated that this was not the right direction.</p><p id="par0035" class="elsevierStylePara elsevierViewall">However, at the same time that these alternatives were explored, robotic-assisted laparoscopy, or “robotic surgery”, was establishing in different Urology Services around the world. Thus, the group led by Menon systematized its use in radical prostatectomy.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Interestingly, this new technical variant required a greater number and caliber of trocars. In contrast to the single port approach, it did not base its benefits on aesthetic or analgesic improvements, but on an implemented three-dimensional vision, higher precision based on the increased number of freedom degrees and, above all, on a more natural and faster learning process. Even surgeons without previous laparoscopic experience were able to carry out techniques of certain complexity with shorter learning curves.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Gradually, robotic surgery has broadened its scope of action. Even though its urological indication was only radical prostatectomy, it is currently being used for a host of techniques which practically cover the entire anatomical spectrum of our specialty.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the same way that the development of endoscopy promoted the arrival and fulfillment of laparoscopy, the evolution of the latter has contributed to significant modifications and improvements in robotic surgery. For example, the diameter of the trocars has been reduced from 12 to 8 mm, and the miniaturization of laparoscopic equipment even handles 5 mm optics. Despite this, the greatest advance that we are assisting in robotic surgery may be the introduction of 4 arms through a single port, dealing with the obvious greater complexity experienced with its implantation in laparoscopy. Already in 2009, BJU International published an interesting article questioning the role of robotic assistance as the axis on which the definitive impulse of the single port will gravitate.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Subsequently, a systemic review of the scientific evidence published until 2013<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and a meta-analysis in this regard<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> conclude that, although operative times are significantly longer, improvements in pain reduction and need for analgesics, rapid recovery and return to usual activity, and aesthetic improvement, are evident. On the contrary, technological development is unstoppable. The surgical skills achieved by the urologist with these approaches are already showing reduced operative times, which in fact are a reflection of previous experience. There is one more positive aspect: the use of the same single-entry port can even address two anatomical regions such as pelvic and lumbar. In these cases, the configuration of the robotic laparoscopic arms can make it difficult or sometimes impossible to complete surgery with a single approach. The single port and the introduction of the four robotic elements will facilitate these techniques, without increasing operative times or requiring the relocation of trocars or robotic arms.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Finally, just as endoscopy facilitated the appearance of laparoscopy, its evolution has led to the development of robotic approaches performed through one small diameter incision without lengthening the learning curves or increasing the potential surgical risk for the benefit of our patients.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Hernández Fernández C. La continua evolución del abordaje laparoscópico. 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Journal Information
Vol. 44. Issue 2.
Pages 59-61 (March 2020)
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Vol. 44. Issue 2.
Pages 59-61 (March 2020)
Editorial
The endless evolution of laparoscopic approach
La continua evolución del abordaje laparoscópico
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C. Hernández Fernández
Servicio de Urología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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