Current state of single-port transumbilical surgery in urology: Challenges and applications | Actas Urológicas Españolas (English Edition)

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García-Mediero, P.M. Cabrera, F. Cáceres, E. Mateo, A. García-Tello, J.C. Angulo" "autores" => array:6 [ 0 => array:2 [ "nombre" => "J.M." "apellidos" => "García-Mediero" ] 1 => array:2 [ "nombre" => "P.M." "apellidos" => "Cabrera" ] 2 => array:2 [ "nombre" => "F." "apellidos" => "Cáceres" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Mateo" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "García-Tello" ] 5 => array:4 [ "nombre" => "J.C." 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The Alexis retraction system (B) is placed, to which the GelPoint disposable port (Applied Medical) (C) is coupled, which allows for the introduction of various instruments and conventional laparoscopic lens (D)." ] ] ] "textoCompleto" => "The evolution of minimally invasive surgeryFor many urological procedures, the laparoscopic access has proven effective in reducing postoperative morbidity, mean length of stay, and time of incorporation into working life, and in improving the esthetics of the scar, all without compromising the oncological and functional results of conventional open surgery.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> However, various complications associated to the use and disposal of trocars during laparoscopic surgery have been described.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>In order to reduce these complications and, therefore, decrease the morbidity of laparoscopic surgery and improve the esthetics, other techniques are being developed, such as laparoendoscopic surgery through natural orifices (Natural orifice transluminal endoscopic surgery [NOTES]) and laparoendoscopic single site surgery [LESS]).<a class="elsevierStyleCrossRef" href="#bib0015">3</a> NOTES, in its strictest sense, means not using any abdominal port. Thus, we avoid an external scar and its associated morbidity.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> The evident disadvantages of this type of surgery involve the complete loss of triangulation, partial loss of visibility, insufficient traction, and important conflict of space.The application of a 3.5-mm accessory port was not considered incompatible with the term NOTES, but a step further in the development of this technique and it has been called hybrid NOTES.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> The first series of NOTES was reported in 2004 by Kalloo et al. performing transgastric liver biopsies.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Several urological groups initially used a variety of terms, such as E-NOTES, SILS, OPUS, SPA, SPL, and SIL, to describe the technique now better known as LESS or laparoendoscopic single-site surgery.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>LESS presents all the advantages of NOTES, such as improved esthetics and decreased abdominal trauma, without the added difficulties of passing through a natural orifice (stomach, rectum, vagina, bladder).<a class="elsevierStyleCrossRef" href="#bib0040">8</a> Even so, access in LESS still requires skin incision. From a cosmetic point of view, the ideal approach in LESS is carried out transumbilically, either through a single-port access with several instrumentation channels, a single skin incision in which several separate ports are inserted, a single skin incision in which various ports are placed through various fascial incisions or even several small transumbilical incisions.The navel, due to its topographical situation, is one of the most suitable places for the practice of LESS, as it allows for access to both renal and retroperitoneal surgery, as well as to processes of the bony pelvis. Moreover, strictly speaking, it is an embryonic NOTES (E-NOTES), since the navel is a natural embryonic opening and the scar of an umbilical surgery can be completely hidden in the natural scar itself, which means surgery ‘without incision’,<a class="elsevierStyleCrossRef" href="#bib0045">9</a> or rather without apparent incision or with no incision visible. The aim of this paper is to assess the current and foreseeable future of urologic surgery ‘without incision’.Urologic surgery has always been in the first line of minimally invasive surgery in the last decades of the history of medicine. Transurethral resection, extracorporeal shock wave lithotripsy, retrograde intrarenal surgery, ureterorenoscopy, and percutaneous nephrolithotomy are some excellent examples of this evolution.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> The kidney tumors previously requiring high morbidity incisions, such as lumbotomy, are treated routinely in most centers by means of laparoscopy.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> It is not surprising, then, that the specialty that was better prepared to give impetus to these new minimally invasive techniques has been urology.Single-site urological transumbilical surgeryCurrently, the term LESS encompasses the concept of minimally invasive surgery performed laparoscopically through a single port placed by a single incision, using both conventional laparoscopic instruments and new instruments with a degree of deflection (curved) or flexible.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>The first description of a real LESS procedure was performed in the gynecological field around 1972 and it consisted of a tubal ligation. Through a 1-cm infraumbilical incision, a laparoscopy optic was inserted to identify and cauterize each fallopian tube.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> The cosmetic benefit of this technique led to the gynecologists to explore more complex procedures, including total hysterectomy with double adnexectomy in 1991.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> General surgeons also began to explore the benefits of this technique by performing appendectomies and cholecystectomies.<a class="elsevierStyleCrossRefs" href="#bib0070">14,15</a> In 1999, they developed a new variant to conduct cholecystectomies by a single skin incision and 2 fascial ones, enabling them to accommodate two 5-mm trocars through the same incision.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>The first case of LESS urological surgery described in humans was performed through a flank incision, through which, and through an R-Port® single port (Advance Surgical Concepts, Wicklow, Ireland) nephrectomy of an atrophic kidney was completed.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> The first transumbilical urological procedure with LESS was described by Ramal et al. in 2007, performing a nephrectomy through a single incision but with multiple trocars.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> The experience has increased exponentially and the LESS technique with the new single-port devices, either disposable or reusable, is emerging as an excellent choice for a wide range of urological indications.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>One option is to practice radical nephrectomy through a 7-cm pararectal incision by means of a single GelPort® port (Applied Medical, Rancho Santa Margarita, USA).<a class="elsevierStyleCrossRef" href="#bib0095">19</a> The Pfannenstiel incision has also been explored for radical nephrectomies and nephroureterectomies by means of a GelPort®.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> These accesses have shown viable options to umbilical incision; however, most of the single-port urological experience was made through the navel because this wound is much less invasive, it means a lower impact of the umbilical aponeurotic midline incision, and prevents muscle injury, which significantly reduces the incision pain and the morbidity associated with it.However, as with many new surgical platforms, LESS has faced significant ergonomic challenges, some of which are still present. Most problems are avoided with a specific training program and they are lessened with practice and with the proper knowledge of the instruments.<a class="elsevierStyleCrossRef" href="#bib0105">21</a>In conventional laparoscopy, the arrangement of several trocars allows for correct triangulation to exert traction–countertraction tissues, avoiding the intracorporeal clushing of the instruments. The clushing, both intra-and extracorporeal, is the main problem with this technique (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The technical and equipment challenges have been very effectively described by Sawyer and Ponsky,<a class="elsevierStyleCrossRef" href="#bib0110">22</a> who emphasize rapid innovation and at the same time highlight the difficulties inherent to the technique, among which are the limitation of a reduced visual field in which all the instruments are in parallel.In fact, at the beginning of this technique, the surgeons performed the procedure with conventional laparoscopic instruments through a single skin incision accompanied by several fascial incisions.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>. Articulated clamps, endobag, and standard endoclips were used, along with a 5-mm and 45° rigid optic. A significant clushing of intra and extracorporeal instruments and a significant learning curve were described. Adrenalectomy was also carried out through a 2-cm skin incision and various fascial ones, which came together to remove the piece.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> The authors had in this case limited maneuverability, with tearing of the fascia, lack of vision, and difficulty for vascular control.With the aim to overcome these difficulties, we have developed new platforms that rely on a single skin and fascial incision, with the potential to accommodate up to 3 or 4 instruments simultaneously (Triport®, QuadPort®, Advance Surgical Concepts). Another solution under the same philosophy is to carry out a single skin and fascial incision to allow for the introduction of several instruments using the Alexis system associated to GelPoint Advance Access Platform (Applied Medical, Rancho Santa Margarita, CA, USA), which allows for the use of conventional laparoscopic instruments by conveniently distancing the instruments from the surgical field, thus facilitating triangulation (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). However, this device has the disadvantage of its disposable character due to the economic implications that this entails.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>A newly developed device is KeyPort® (Richard Wolf GmBH, Knittlingen, Germany). It is a reusable device with 3 channels and with a suitable ergonomic shape for its optimal transumbilical placement, with perfect attachment to the aponeurosis, without the need for anchorage points or to use other self-retention systems. Moreover, it has 3 channels that permit the introduction of both rigid instruments and with different degrees of rotation and deflection<a class="elsevierStyleCrossRef" href="#bib0045">9</a> (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The reusable nature of this device involves a great advantage in economic terms. In addition, the working instruments designed for this system are Duo-Rotate; that is, they incorporate an intelligent double rotation system which allows for high precision and versatility of movement, as well as the correct traction of the tissues.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>The use of minilaparoscopy accessory ports (3–3.5mm) is the ideal complement to LESS, facilitating angulation and performing the sutures with minimum cosmetic impact.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> This assistance has been postulated as a bridge to save the step of conventional laparoscopy to LESS. In certain procedures, it may be necessary to place minilaparoscopy instruments without a trocar for liver retraction or puppet sutures for bladder or colon retraction.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Such assistance does not usually leave a scar.Trading houses and available devicesKarl StorzThis house has 2 devices marketed for single port surgery, X-Cone, and EndoCone (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The first consists of 2 half metallic frames and a silicone sealing unit with 4 inlets. Storz recommends using an instrument with curved distal end and a straight instrument in combination with a 5.5-mm extra-long optic, with an angle of 30° and a length of 50cm. The insertion procedure is more complicated than other devices. In case of performing too large an incision, there is a loss of gas and if, conversely, it is smaller, a muscle tear can occur by bringing the half frames together. The instrumental change is quick and easy, but the maximum diameter is 13mm. In order to remove the piece, it is necessary to withdraw the complete sealing unit. The second model is comprised by only 2 pieces: an EndoCone trocar sheath without obturator and a cap provided with various holes6 for the passage of instruments and 2 for optic. It is often used in combination with non-rotatable curved instruments (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). It is easily introduced, although it has no blunt obturator to ensure safe introduction. The management and exchange of the instruments are quick and easy, and it also makes it possible to work with up to 15mm. It is a stable platform without pneumoperitoneum leakages. Due to its robustness, the durability is great, although it may prove heavy and unbalanced.<elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia>CovidienThis company pioneered the single port with the SILS-Port® system (Single Incision Laparoscopic Surgery Port). It is an expendable device composed of a cellular plastic base with 3 channels for the introduction of rigid trocars, although it also offers special disposable rotatable and adjustable instruments (Roticulator) that are managed intuitively but with the drawback that the jaws always remain in the same position (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The introduction of the device is quite simple if we are helped with a curved forceps. The exchange of the instruments is quick and easy, being able to work with instruments of up to 15mm. The platform is stable, although pneumoperitoneum leaks can occur, especially when applied with robot-assisted surgery. For the extraction of the piece, we have to completely remove the port.OlympusOlympus has 2 single-use systems marketed, TriPort® and QuadPort® (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The first one has 3 valves for 5-mm instruments and a 10-mm valve, together with a connector for CO2 insufflation and another one for fume extraction. The system is introduced through a special applicator and is fixed around the navel with the aid of a sleeve system. This sleeve serves as a working channel and to protect the wound. TriPort® has two 5-mm accesses and a 15-mm one. QuadPort® has 4 channels (5, 10, 12, and 15mm). The greatest accesses can be adapted for 5-mm instruments through the corresponding sealing caps. This company also has curved specific instruments for single-use LESS (HiQLS), which are introduced with the help of a special trocar. The management and change of tools are quick and easy as it is a stable system, without gas leak. Removing the cap, any surgical piece can be safely and easily extracted, without removing the entire device. Its disposable nature implies a high cost.Applied MedicalThe most flexible solution in single-port surgery is probably the single-use GelPoint system, with sleeve-separator system (Alexis) similar to the Olympus one and a gel cap (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 4</a>). This gel cap makes it possible to place several trocars of any size at any point of the gel pad, so that the instruments can be introduced to achieve the most favorable angle for triangulation. All the Applied Medical instruments are fungible, some of which are pre-curved (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). The introduction of the device is carried out in 2 steps: first the sleeve is inserted with the help of a flexible insertion ring, and then the GelPoint cap is placed. The management and exchange of the instruments is very simple and quick, and the free selection of diameters and positions of the trocars allows for great freedom of movement. It is a very stable system, with no loss of gas. Removing the gel cap, we can extract any surgical specimen safely and easily.DaLim SurginetThis South Korean company has presented one of the latest disposable systems in the field of single-port systems, OctoPort® (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). It is a fungible platform consisting of a flexible silicone funnel system that holds the system firmly to the abdominal cover. Then, adapters are applied as needed. Large sealing caps (10–15mm) are set to the desired diameter of the instrument by means of smaller caps or changing their position. This manufacturer does not offer special instruments for LESS. The insertion of the device is done in several steps, first, we insert the base of the silicone ring, then the silicone ring, and finally the cover is fixed. The management of the instruments is quick and easy thanks to the adapter-reducer and the flexible sealing caps. The system is stable, without loss of pneumoperitoneum. Removing the cap, we extract the surgical piece.Richard WolfThe latest system to be marketed is the KeyPort® by Richard Wolf, a reusable system which consists of 3 parts: trocar sheath, trocar, and silicone sealing unit with 3 inlets with valves (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>). The sheath has 2 thread pitches that facilitate umbilical insertion and that, in turn, give stability to the system preventing a gas leak. The tip of the distal end of the trocar is blunt and atraumatic. The obturation unit has a valved inlet for 5-mm instruments, another one for 5–15-mm instruments, and a third one for the passage of the optic. It also presents a connector for CO2 insufflation. The 3 main inlets are equipped with a sealing cap and they also have additional integration valves to prevent the loss of gas when not using a working tool. Richard Wolf has designed a wide range of new specific instruments for LESS that have curved and inserted sheath tubes that allow for a wide degree of freedom, both outside and inside the abdominal cavity, thus avoiding the external crush and the internal crossing of the instruments (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). Additionally, the inserted instruments have a DuoRotate system that makes it possible to get a translational movement of the sheaths and complete it with individualized rotation, and it requires their tip. The introduction of the device is very quick and easy thanks to the thread of the trocar sheath. The change and management of the tools are quick and easy, allowing for the use of instruments of up to 15mm. The tightness of the system is optimal thanks to the valves and the thread of the trocar sheath. Moreover, the extraction of the surgical specimen is performed quickly and safely, opening and closing the sealing unit.Main procedures performedAn impressive number and variety of urological procedures has been carried out successfully through the different single umbilical port platforms. There is accumulated experience in multicenter studies on the morbidity and complications of this type of surgery.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> We know that these complications are higher in cases of major cancer surgery, although they are more due to the technique itself than to the laparoendoscopic approach itself.The procedures on the kidney are the most reported. As for the kidney cancer procedures, cryoablation,<a class="elsevierStyleCrossRef" href="#bib0125">25</a> partial nephrectomy,<a class="elsevierStyleCrossRef" href="#bib0130">26</a> and radical nephrectomy<a class="elsevierStyleCrossRefs" href="#bib0135">27–29</a> have been described. Most authors use a fine accessory port for liver retraction, without compromising the esthetic result of LESS. A number of partial nephrectomies have also been safely described without vascular clamping.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> Renal reconstructive procedures such as pyeloplasty,<a class="elsevierStyleCrossRef" href="#bib0155">31</a> ureteral replacement with ileum, and ureteroneocystostomy with psoic bladder<a class="elsevierStyleCrossRef" href="#bib0160">32</a> have also been conducted. Pyeloplasty with LESS shows results similar to laparoscopic pyeloplasty, but with shorter hospital stay and fewer analgesic requirements.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> Pielolitectomy on horseshoe kidney has also been reported, with excellent results,<a class="elsevierStyleCrossRef" href="#bib0170">34</a> and ureterolithectomy<a class="elsevierStyleCrossRef" href="#bib0175">35</a> and colposacropexy.<a class="elsevierStyleCrossRef" href="#bib0180">36</a>Experiences are less frequent in the adrenal gland, probably due to the difficulty to reach the renal upper pole and the need to properly expose the gland, especially on the right side. When comparing the laparoscopic approach and LESS, both techniques are similar in the conversion rate, surgical time, bleeding, hospital stay, and complications, but the umbilical LESS group had fewer analgesic requirements.<a class="elsevierStyleCrossRefs" href="#bib0040">8,37</a> The transplantation field has been very prolific in the area of LESS. Transumbilical live donor nephrectomy implies an excellent cosmetic result for the donor, a shorter recovery period, and less need for analgesia.<a class="elsevierStyleCrossRef" href="#bib0190">38</a>Complex procedures have also been described, such as major oncologic pelvic surgery. Our center has initiated a radical cystectomy program with LESS with orthotopic neobladder<a class="elsevierStyleCrossRef" href="#bib0195">39</a> and is also conducting the largest series of LESS radical prostatectomy in the literature,<a class="elsevierStyleCrossRef" href="#bib0045">9</a> with very encouraging initial results, both oncological and functional, excellent pain control, and cosmetic outcome (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>), and with very low economic cost due to its reusability.<a class="elsevierStyleCrossRef" href="#bib0045">9</a><elsevierMultimedia ident="fig0030"></elsevierMultimedia>However, it is clear that transumbilical surgery has several disadvantages that the surgeon has to weigh. The first is the impossibility of a correct triangulation, so it is necessary to use specific instruments to solve this problem, being indispensable to carry out a specific training, even in surgeons with extensive prior experience in laparoscopic surgery.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> Moreover, the need for specific instruments involves an initial outlay to start a program with this technique, although the emergence of recent reusable devices makes it much more economically affordable. To date, there has been no cost-effectiveness analysis on the implementation of LESS in urology.Conflict of interestThe authors declare that they have no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres192068" "titulo" => array:5 [ 0 => "Abstract" 1 => "Context" 2 => "Acquisition of evidence" 3 => "Synthesis of evidence" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec179300" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres192067" "titulo" => array:5 [ 0 => "Resumen" 1 => "Contexto" 2 => "Adquisición de evidencia" 3 => "Síntesis de evidencia" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec179299" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "The evolution of minimally invasive surgery" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Single-site urological transumbilical surgery" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Trading houses and available devices" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Karl Storz" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Covidien" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Olympus" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Applied Medical" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "DaLim Surginet" ] 5 => array:2 [ "identificador" => "sec0045" "titulo" => "Richard Wolf" ] ] ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Main procedures performed" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of interest" ] 9 => array:2 [ "identificador" => "xack48762" "titulo" => "Acknowledgements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-07-12" "fechaAceptado" => "2012-07-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec179300" "palabras" => array:5 [ 0 => "Laparoendoscopic single-site surgery" 1 => "Natural orifice transluminal endoscopic surgery" 2 => "Urology" 3 => "Single-port" 4 => "Transumbilical approach" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec179299" "palabras" => array:5 [ 0 => "Cirugía laparoendoscópica a través de puerto único" 1 => "Cirugía laparoendoscópica a través de orificios naturales" 2 => "Urología" 3 => "Puerto único" 4 => "Abordaje transumbilical" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "ContextLaparoscopic 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 evidenceA 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 evidenceLESS 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. ConclusionsAlthough 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." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "ContextoLa cirugía laparoscópica en urología ha supuesto un avance importante, aunque no está exenta de cierta morbilidad asociada al empleo de múltiples trocares y de forma particular a la extracción del espécimen. Con intención de disminuir esta morbilidad y de mejorar la estética se están desarrollado otras técnicas, como la cirugía laparoendoscópica a través de orificios naturales (NOTES) y la cirugía laparoendoscópica a través de puerto único (LESS). Se pretende revisar el estado actual de la cirugía laparoendoscópica por puerto único en urología. Adquisición de evidenciaSe ha llevado a cabo una revisión no sistemática, a través de una búsqueda bibliográfica empleando los términos LESS y urología desde 2007 hasta 2012. Se describen la experiencia actual LESS en urología, sus principales indicaciones y los diferentes dispositivos de puerto único e instrumental disponibles en el mercado. Síntesis de evidenciaLa cirugía LESS nace como un paso más en la evolución constante de la cirugía mínimamente invasiva en un intento por mejorar la estética, reducir el traumatismo quirúrgico y disminuir el dolor y las complicaciones postoperatorias asociadas a la laparoscopia convencional con múltiples trocares. Desde la primera descripción en 2007, la experiencia se ha incrementado exponencialmente y la técnica LESS, asistida o no por robot, se está consolidando para un gran espectro de indicaciones urológicas (tanto en cirugía oncológica como reconstructiva), a mucha mayor escala que la técnica NOTES. A pesar de que la mayoría de los datos existentes son no aleatorizados y en escasas ocasiones son comparativos, con el sesgo de selección que ello representa, parece evidente que el beneficio estético y de control analgésico asociado a la cirugía LESS es real y reproducible. Las complicaciones asociadas a la misma son mayores en casos de cirugía oncológica mayor y se deben más a la propia técnica que al abordaje. ConclusionesAunque el beneficio real de la cirugía LESS en urología aún no puede cuantificarse oportunamente, la mejora cosmética, el menor dolor y una mayor satisfacción del paciente con su herida resultan evidentes. El entrenamiento apropiado en este tipo de procedimientos en centros de gran volumen y las constantes mejoras técnicas en el desarrollo instrumental por parte de la industria biomédica permiten que la técnica LESS transumbilical en urología haya nacido para quedarse." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: García-Medeiro JM, et al. Estado actual de la cirugía ransumbilical por puerto único en urología: retos y aplicaciones. Actas Urol Esp. 2013;37:106–13." ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1048 "Ancho" => 1386 "Tamanyo" => 100778 ] ] "descripcion" => array:1 [ "en" => "Main differences between conventional laparoscopy (Lap) and laparoendoscopic single-site surgery (LESS) and main problems that may be associated to LESS." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1040 "Ancho" => 2918 "Tamanyo" => 345840 ] ] "descripcion" => array:1 [ "en" => "Umbilical skin and fascial incision to conduct radical cystectomy (A). The Alexis retraction system (B) is placed, to which the GelPoint disposable port (Applied Medical) (C) is coupled, which allows for the introduction of various instruments and conventional laparoscopic lens (D)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 989 "Ancho" => 1335 "Tamanyo" => 192387 ] ] "descripcion" => array:1 [ "en" => "Reusable KeyPort® port (Richard Wolf) with 3 channels and ergonomic shape for transumbilical placement. It may be employed alone or with a 3.5-mm accessory trocar, through which minilaparoscopy instruments are inserted." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1578 "Ancho" => 1336 "Tamanyo" => 182685 ] ] "descripcion" => array:1 [ "en" => "Major manufacturers and single-port systems available on the market." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 902 "Ancho" => 1336 "Tamanyo" => 116445 ] ] "descripcion" => array:1 [ "en" => "Some instruments to carry out single-port laparoendoscopy." ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 533 "Ancho" => 801 "Tamanyo" => 70295 ] ] "descripcion" => array:1 [ "en" => "Excellent cosmetic results in a patient with umbilical-access KeyPort® radical prostatectomy without any residual scarring." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:39 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Current status and future perspectives in laparoendoscopic single-site and natural orifice transluminal endoscopio urological surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. 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Current state of single-port transumbilical surgery in urology: Challenges and applications

Estado actual de la cirugía transumbilical por puerto único en urología: retos y aplicaciones

J.M. García-Mediero, P.M. Cabrera, F. Cáceres, E. Mateo, A. García-Tello, J.C. Angulo

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jangulo.hugf@salud.madrid.org

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Hospital Universitario de Getafe, Fundación para la Investigación Biomédica, Servicio Madrileño de Salud, Universidad Europea de Madrid, Madrid, Spain

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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Umbilical skin and fascial incision to conduct radical cystectomy &#40;A&#41;&#46; The Alexis retraction system &#40;B&#41; is placed&#44; to which the GelPoint disposable port &#40;Applied Medical&#41; &#40;C&#41; is coupled&#44; which allows for the introduction of various instruments and conventional laparoscopic lens &#40;D&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The evolution of minimally invasive surgery</span><p id="par0005" class="elsevierStylePara elsevierViewall">For many urological procedures&#44; the laparoscopic access has proven effective in reducing postoperative morbidity&#44; mean length of stay&#44; and time of incorporation into working life&#44; and in improving the esthetics of the scar&#44; all without compromising the oncological and functional results of conventional open surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However&#44; various complications associated to the use and disposal of trocars during laparoscopic surgery have been described&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In order to reduce these complications and&#44; therefore&#44; decrease the morbidity of laparoscopic surgery and improve the esthetics&#44; other techniques are being developed&#44; such as laparoendoscopic surgery through natural orifices &#40;Natural orifice transluminal endoscopic surgery &#91;NOTES&#93;&#41; and laparoendoscopic single site surgery &#91;LESS&#93;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> NOTES&#44; in its strictest sense&#44; means not using any abdominal port&#46; Thus&#44; we avoid an external scar and its associated morbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The evident disadvantages of this type of surgery involve the complete loss of triangulation&#44; partial loss of visibility&#44; insufficient traction&#44; and important conflict of space&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The application of a 3&#46;5-mm accessory port was not considered incompatible with the term NOTES&#44; but a step further in the development of this technique and it has been called hybrid NOTES&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The first series of NOTES was reported in 2004 by Kalloo et al&#46; performing transgastric liver biopsies&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Several urological groups initially used a variety of terms&#44; such as E-NOTES&#44; SILS&#44; OPUS&#44; SPA&#44; SPL&#44; and SIL&#44; to describe the technique now better known as LESS or laparoendoscopic single-site surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">LESS presents all the advantages of NOTES&#44; such as improved esthetics and decreased abdominal trauma&#44; without the added difficulties of passing through a natural orifice &#40;stomach&#44; rectum&#44; vagina&#44; bladder&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Even so&#44; access in LESS still requires skin incision&#46; From a cosmetic point of view&#44; the ideal approach in LESS is carried out transumbilically&#44; either through a single-port access with several instrumentation channels&#44; a single skin incision in which several separate ports are inserted&#44; a single skin incision in which various ports are placed through various fascial incisions or even several small transumbilical incisions&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The navel&#44; due to its topographical situation&#44; is one of the most suitable places for the practice of LESS&#44; as it allows for access to both renal and retroperitoneal surgery&#44; as well as to processes of the bony pelvis&#46; Moreover&#44; strictly speaking&#44; it is an embryonic NOTES &#40;E-NOTES&#41;&#44; since the navel is a natural embryonic opening and the scar of an umbilical surgery can be completely hidden in the natural scar itself&#44; which means surgery &#8216;without incision&#8217;&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> or rather without apparent incision or with no incision visible&#46; The aim of this paper is to assess the current and foreseeable future of urologic surgery &#8216;without incision&#8217;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Urologic surgery has always been in the first line of minimally invasive surgery in the last decades of the history of medicine&#46; Transurethral resection&#44; extracorporeal shock wave lithotripsy&#44; retrograde intrarenal surgery&#44; ureterorenoscopy&#44; and percutaneous nephrolithotomy are some excellent examples of this evolution&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The kidney tumors previously requiring high morbidity incisions&#44; such as lumbotomy&#44; are treated routinely in most centers by means of laparoscopy&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> It is not surprising&#44; then&#44; that the specialty that was better prepared to give impetus to these new minimally invasive techniques has been urology&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Single-site urological transumbilical surgery</span><p id="par0035" class="elsevierStylePara elsevierViewall">Currently&#44; the term LESS encompasses the concept of minimally invasive surgery performed laparoscopically through a single port placed by a single incision&#44; using both conventional laparoscopic instruments and new instruments with a degree of deflection &#40;curved&#41; or flexible&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The first description of a real LESS procedure was performed in the gynecological field around 1972 and it consisted of a tubal ligation&#46; Through a 1-cm infraumbilical incision&#44; a laparoscopy optic was inserted to identify and cauterize each fallopian tube&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> The cosmetic benefit of this technique led to the gynecologists to explore more complex procedures&#44; including total hysterectomy with double adnexectomy in 1991&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> General surgeons also began to explore the benefits of this technique by performing appendectomies and cholecystectomies&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> In 1999&#44; they developed a new variant to conduct cholecystectomies by a single skin incision and 2 fascial ones&#44; enabling them to accommodate two 5-mm trocars through the same incision&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The first case of LESS urological surgery described in humans was performed through a flank incision&#44; through which&#44; and through an R-Port<span class="elsevierStyleSup">&#174;</span> single port &#40;Advance Surgical Concepts&#44; Wicklow&#44; Ireland&#41; nephrectomy of an atrophic kidney was completed&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The first transumbilical urological procedure with LESS was described by Ramal et al&#46; in 2007&#44; performing a nephrectomy through a single incision but with multiple trocars&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> The experience has increased exponentially and the LESS technique with the new single-port devices&#44; either disposable or reusable&#44; is emerging as an excellent choice for a wide range of urological indications&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">One option is to practice radical nephrectomy through a 7-cm pararectal incision by means of a single GelPort<span class="elsevierStyleSup">&#174;</span> port &#40;Applied Medical&#44; Rancho Santa Margarita&#44; USA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The Pfannenstiel incision has also been explored for radical nephrectomies and nephroureterectomies by means of a GelPort<span class="elsevierStyleSup">&#174;</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> These accesses have shown viable options to umbilical incision&#59; however&#44; most of the single-port urological experience was made through the navel because this wound is much less invasive&#44; it means a lower impact of the umbilical aponeurotic midline incision&#44; and prevents muscle injury&#44; which significantly reduces the incision pain and the morbidity associated with it&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">However&#44; as with many new surgical platforms&#44; LESS has faced significant ergonomic challenges&#44; some of which are still present&#46; Most problems are avoided with a specific training program and they are lessened with practice and with the proper knowledge of the instruments&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In conventional laparoscopy&#44; the arrangement of several trocars allows for correct triangulation to exert traction&#8211;countertraction tissues&#44; avoiding the intracorporeal clushing of the instruments&#46; The clushing&#44; both intra-and extracorporeal&#44; is the main problem with this technique &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The technical and equipment challenges have been very effectively described by Sawyer and Ponsky&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> who emphasize rapid innovation and at the same time highlight the difficulties inherent to the technique&#44; among which are the limitation of a reduced visual field in which all the instruments are in parallel&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In fact&#44; at the beginning of this technique&#44; the surgeons performed the procedure with conventional laparoscopic instruments through a single skin incision accompanied by several fascial incisions&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; Articulated clamps&#44; endobag&#44; and standard endoclips were used&#44; along with a 5-mm and 45&#176; rigid optic&#46; A significant clushing of intra and extracorporeal instruments and a significant learning curve were described&#46; Adrenalectomy was also carried out through a 2-cm skin incision and various fascial ones&#44; which came together to remove the piece&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The authors had in this case limited maneuverability&#44; with tearing of the fascia&#44; lack of vision&#44; and difficulty for vascular control&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">With the aim to overcome these difficulties&#44; we have developed new platforms that rely on a single skin and fascial incision&#44; with the potential to accommodate up to 3 or 4 instruments simultaneously &#40;Triport<span class="elsevierStyleSup">&#174;</span>&#44; QuadPort<span class="elsevierStyleSup">&#174;</span>&#44; Advance Surgical Concepts&#41;&#46; Another solution under the same philosophy is to carry out a single skin and fascial incision to allow for the introduction of several instruments using the Alexis system associated to GelPoint Advance Access Platform &#40;Applied Medical&#44; Rancho Santa Margarita&#44; CA&#44; USA&#41;&#44; which allows for the use of conventional laparoscopic instruments by conveniently distancing the instruments from the surgical field&#44; thus facilitating triangulation &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; However&#44; this device has the disadvantage of its disposable character due to the economic implications that this entails&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">A newly developed device is KeyPort<span class="elsevierStyleSup">&#174;</span> &#40;Richard Wolf GmBH&#44; Knittlingen&#44; Germany&#41;&#46; It is a reusable device with 3 channels and with a suitable ergonomic shape for its optimal transumbilical placement&#44; with perfect attachment to the aponeurosis&#44; without the need for anchorage points or to use other self-retention systems&#46; Moreover&#44; it has 3 channels that permit the introduction of both rigid instruments and with different degrees of rotation and deflection<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The reusable nature of this device involves a great advantage in economic terms&#46; In addition&#44; the working instruments designed for this system are Duo-Rotate&#59; that is&#44; they incorporate an intelligent double rotation system which allows for high precision and versatility of movement&#44; as well as the correct traction of the tissues&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The use of minilaparoscopy accessory ports &#40;3&#8211;3&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#41; is the ideal complement to LESS&#44; facilitating angulation and performing the sutures with minimum cosmetic impact&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> This assistance has been postulated as a bridge to save the step of conventional laparoscopy to LESS&#46; In certain procedures&#44; it may be necessary to place minilaparoscopy instruments without a trocar for liver retraction or puppet sutures for bladder or colon retraction&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Such assistance does not usually leave a scar&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Trading houses and available devices</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Karl Storz</span><p id="par0090" class="elsevierStylePara elsevierViewall">This house has 2 devices marketed for single port surgery&#44; X-Cone&#44; and EndoCone &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The first consists of 2 half metallic frames and a silicone sealing unit with 4 inlets&#46; Storz recommends using an instrument with curved distal end and a straight instrument in combination with a 5&#46;5-mm extra-long optic&#44; with an angle of 30&#176; and a length of 50<span class="elsevierStyleHsp" style=""></span>cm&#46; The insertion procedure is more complicated than other devices&#46; In case of performing too large an incision&#44; there is a loss of gas and if&#44; conversely&#44; it is smaller&#44; a muscle tear can occur by bringing the half frames together&#46; The instrumental change is quick and easy&#44; but the maximum diameter is 13<span class="elsevierStyleHsp" style=""></span>mm&#46; In order to remove the piece&#44; it is necessary to withdraw the complete sealing unit&#46; The second model is comprised by only 2 pieces&#58; an EndoCone trocar sheath without obturator and a cap provided with various holes6 for the passage of instruments and 2 for optic&#46; It is often used in combination with non-rotatable curved instruments &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; It is easily introduced&#44; although it has no blunt obturator to ensure safe introduction&#46; The management and exchange of the instruments are quick and easy&#44; and it also makes it possible to work with up to 15<span class="elsevierStyleHsp" style=""></span>mm&#46; It is a stable platform without pneumoperitoneum leakages&#46; Due to its robustness&#44; the durability is great&#44; although it may prove heavy and unbalanced&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Covidien</span><p id="par0095" class="elsevierStylePara elsevierViewall">This company pioneered the single port with the SILS-Port<span class="elsevierStyleSup">&#174;</span> system &#40;Single Incision Laparoscopic Surgery Port&#41;&#46; It is an expendable device composed of a cellular plastic base with 3 channels for the introduction of rigid trocars&#44; although it also offers special disposable rotatable and adjustable instruments &#40;Roticulator&#41; that are managed intuitively but with the drawback that the jaws always remain in the same position &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The introduction of the device is quite simple if we are helped with a curved forceps&#46; The exchange of the instruments is quick and easy&#44; being able to work with instruments of up to 15<span class="elsevierStyleHsp" style=""></span>mm&#46; The platform is stable&#44; although pneumoperitoneum leaks can occur&#44; especially when applied with robot-assisted surgery&#46; For the extraction of the piece&#44; we have to completely remove the port&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Olympus</span><p id="par0100" class="elsevierStylePara elsevierViewall">Olympus has 2 single-use systems marketed&#44; TriPort<span class="elsevierStyleSup">&#174;</span> and QuadPort<span class="elsevierStyleSup">&#174;</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The first one has 3 valves for 5-mm instruments and a 10-mm valve&#44; together with a connector for CO<span class="elsevierStyleInf">2</span> insufflation and another one for fume extraction&#46; The system is introduced through a special applicator and is fixed around the navel with the aid of a sleeve system&#46; This sleeve serves as a working channel and to protect the wound&#46; TriPort<span class="elsevierStyleSup">&#174;</span> has two 5-mm accesses and a 15-mm one&#46; QuadPort<span class="elsevierStyleSup">&#174;</span> has 4 channels &#40;5&#44; 10&#44; 12&#44; and 15<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; The greatest accesses can be adapted for 5-mm instruments through the corresponding sealing caps&#46; This company also has curved specific instruments for single-use LESS &#40;HiQLS&#41;&#44; which are introduced with the help of a special trocar&#46; The management and change of tools are quick and easy as it is a stable system&#44; without gas leak&#46; Removing the cap&#44; any surgical piece can be safely and easily extracted&#44; without removing the entire device&#46; Its disposable nature implies a high cost&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Applied Medical</span><p id="par0105" class="elsevierStylePara elsevierViewall">The most flexible solution in single-port surgery is probably the single-use GelPoint system&#44; with sleeve-separator system &#40;Alexis&#41; similar to the Olympus one and a gel cap &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 4</a>&#41;&#46; This gel cap makes it possible to place several trocars of any size at any point of the gel pad&#44; so that the instruments can be introduced to achieve the most favorable angle for triangulation&#46; All the Applied Medical instruments are fungible&#44; some of which are pre-curved &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; The introduction of the device is carried out in 2 steps&#58; first the sleeve is inserted with the help of a flexible insertion ring&#44; and then the GelPoint cap is placed&#46; The management and exchange of the instruments is very simple and quick&#44; and the free selection of diameters and positions of the trocars allows for great freedom of movement&#46; It is a very stable system&#44; with no loss of gas&#46; Removing the gel cap&#44; we can extract any surgical specimen safely and easily&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">DaLim Surginet</span><p id="par0110" class="elsevierStylePara elsevierViewall">This South Korean company has presented one of the latest disposable systems in the field of single-port systems&#44; OctoPort<span class="elsevierStyleSup">&#174;</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; It is a fungible platform consisting of a flexible silicone funnel system that holds the system firmly to the abdominal cover&#46; Then&#44; adapters are applied as needed&#46; Large sealing caps &#40;10&#8211;15<span class="elsevierStyleHsp" style=""></span>mm&#41; are set to the desired diameter of the instrument by means of smaller caps or changing their position&#46; This manufacturer does not offer special instruments for LESS&#46; The insertion of the device is done in several steps&#44; first&#44; we insert the base of the silicone ring&#44; then the silicone ring&#44; and finally the cover is fixed&#46; The management of the instruments is quick and easy thanks to the adapter-reducer and the flexible sealing caps&#46; The system is stable&#44; without loss of pneumoperitoneum&#46; Removing the cap&#44; we extract the surgical piece&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Richard Wolf</span><p id="par0115" class="elsevierStylePara elsevierViewall">The latest system to be marketed is the KeyPort<span class="elsevierStyleSup">&#174;</span> by Richard Wolf&#44; a reusable system which consists of 3 parts&#58; trocar sheath&#44; trocar&#44; and silicone sealing unit with 3 inlets with valves &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46; The sheath has 2 thread pitches that facilitate umbilical insertion and that&#44; in turn&#44; give stability to the system preventing a gas leak&#46; The tip of the distal end of the trocar is blunt and atraumatic&#46; The obturation unit has a valved inlet for 5-mm instruments&#44; another one for 5&#8211;15-mm instruments&#44; and a third one for the passage of the optic&#46; It also presents a connector for CO<span class="elsevierStyleInf">2</span> insufflation&#46; The 3 main inlets are equipped with a sealing cap and they also have additional integration valves to prevent the loss of gas when not using a working tool&#46; Richard Wolf has designed a wide range of new specific instruments for LESS that have curved and inserted sheath tubes that allow for a wide degree of freedom&#44; both outside and inside the abdominal cavity&#44; thus avoiding the external crush and the internal crossing of the instruments &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; Additionally&#44; the inserted instruments have a DuoRotate system that makes it possible to get a translational movement of the sheaths and complete it with individualized rotation&#44; and it requires their tip&#46; The introduction of the device is very quick and easy thanks to the thread of the trocar sheath&#46; The change and management of the tools are quick and easy&#44; allowing for the use of instruments of up to 15<span class="elsevierStyleHsp" style=""></span>mm&#46; The tightness of the system is optimal thanks to the valves and the thread of the trocar sheath&#46; Moreover&#44; the extraction of the surgical specimen is performed quickly and safely&#44; opening and closing the sealing unit&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Main procedures performed</span><p id="par0120" class="elsevierStylePara elsevierViewall">An impressive number and variety of urological procedures has been carried out successfully through the different single umbilical port platforms&#46; There is accumulated experience in multicenter studies on the morbidity and complications of this type of surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> We know that these complications are higher in cases of major cancer surgery&#44; although they are more due to the technique itself than to the laparoendoscopic approach itself&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The procedures on the kidney are the most reported&#46; As for the kidney cancer procedures&#44; cryoablation&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> partial nephrectomy&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> and radical nephrectomy<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#8211;29</span></a> have been described&#46; Most authors use a fine accessory port for liver retraction&#44; without compromising the esthetic result of LESS&#46; A number of partial nephrectomies have also been safely described without vascular clamping&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Renal reconstructive procedures such as pyeloplasty&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> ureteral replacement with ileum&#44; and ureteroneocystostomy with psoic bladder<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> have also been conducted&#46; Pyeloplasty with LESS shows results similar to laparoscopic pyeloplasty&#44; but with shorter hospital stay and fewer analgesic requirements&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Pielolitectomy on horseshoe kidney has also been reported&#44; with excellent results&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> and ureterolithectomy<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> and colposacropexy&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Experiences are less frequent in the adrenal gland&#44; probably due to the difficulty to reach the renal upper pole and the need to properly expose the gland&#44; especially on the right side&#46; When comparing the laparoscopic approach and LESS&#44; both techniques are similar in the conversion rate&#44; surgical time&#44; bleeding&#44; hospital stay&#44; and complications&#44; but the umbilical LESS group had fewer analgesic requirements&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;37</span></a> The transplantation field has been very prolific in the area of LESS&#46; Transumbilical live donor nephrectomy implies an excellent cosmetic result for the donor&#44; a shorter recovery period&#44; and less need for analgesia&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Complex procedures have also been described&#44; such as major oncologic pelvic surgery&#46; Our center has initiated a radical cystectomy program with LESS with orthotopic neobladder<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> and is also conducting the largest series of LESS radical prostatectomy in the literature&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> with very encouraging initial results&#44; both oncological and functional&#44; excellent pain control&#44; and cosmetic outcome &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#44; and with very low economic cost due to its reusability&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">However&#44; it is clear that transumbilical surgery has several disadvantages that the surgeon has to weigh&#46; The first is the impossibility of a correct triangulation&#44; so it is necessary to use specific instruments to solve this problem&#44; being indispensable to carry out a specific training&#44; even in surgeons with extensive prior experience in laparoscopic surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Moreover&#44; the need for specific instruments involves an initial outlay to start a program with this technique&#44; although the emergence of recent reusable devices makes it much more economically affordable&#46; To date&#44; there has been no cost-effectiveness analysis on the implementation of LESS in urology&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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          "titulo" => "The evolution of minimally invasive surgery"
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          "identificador" => "sec0010"
          "titulo" => "Single-site urological transumbilical surgery"
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          "titulo" => "Trading houses and available devices"
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              "titulo" => "Covidien"
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              "titulo" => "Richard Wolf"
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            0 => "Laparoendoscopic single-site surgery"
            1 => "Natural orifice transluminal endoscopic surgery"
            2 => "Urology"
            3 => "Single-port"
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            0 => "Cirug&#237;a laparoendosc&#243;pica a trav&#233;s de puerto &#250;nico"
            1 => "Cirug&#237;a laparoendosc&#243;pica a trav&#233;s de orificios naturales"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Context</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Laparoscopic surgery in urology is considered to be an important advance&#44; although it is not exempt from some morbidity associated to the use of multiple trocars and specifically to the extraction of the specimen&#46; In order to decrease this morbidity and improve esthetics&#44; other techniques are being developed&#44; such as natural orifice transluminal endoscopic surgery &#40;NOTES&#41; and laparoendoscopic single-site surgery &#40;LESS&#41;&#46; It is aimed to review the current status of laparoendoscopic single site surgery in urology&#46;</p> <span class="elsevierStyleSectionTitle">Acquisition of evidence</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A nonsystematic review has been carried out by means of the bibliographic search using the terms LESS and Urology from 2007 to 2012&#46; The current LESS experience in urology is described&#44; and its principal indications and the different single site devices and instruments available on the market are described&#46;</p> <span class="elsevierStyleSectionTitle">Synthesis of evidence</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">LESS surgery arose as one more step in the constant evolution of minimally invasive surgery in an attempt to improve esthetics&#44; reduce surgical trauma and decrease pain and the post-operative complications associated to the conventional laparoscopy with multiple trocars&#46; Since it was first described in 2007&#44; the experience has been increasing exponentially and the LESS technique&#44; whether assisted or not by robot&#44; is becoming consolidated for a large spectrum of urological indications &#40;both in oncological and reconstructive surgery&#41; on a much greater scale than the NOTES technique&#46; Even though most of the existing data are not randomized and very rarely comparative&#44; with the selection bias that this represents&#44; it seems clear that the esthetic benefit and analgesic control associated to the LESS surgery is real and reproducible&#46; 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&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Although the real benefit of the LESS surgery in urology cannot be appropriately quantified&#44; the cosmetic improvement&#44; less pain and greater patient satisfaction with their wound are clear&#46; 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&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Contexto</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La cirug&#237;a laparosc&#243;pica en urolog&#237;a ha supuesto un avance importante&#44; aunque no est&#225; exenta de cierta morbilidad asociada al empleo de m&#250;ltiples trocares y de forma particular a la extracci&#243;n del esp&#233;cimen&#46; Con intenci&#243;n de disminuir esta morbilidad y de mejorar la est&#233;tica se est&#225;n desarrollado otras t&#233;cnicas&#44; como la cirug&#237;a laparoendosc&#243;pica a trav&#233;s de orificios naturales &#40;NOTES&#41; y la cirug&#237;a laparoendosc&#243;pica a trav&#233;s de puerto &#250;nico &#40;LESS&#41;&#46; Se pretende revisar el estado actual de la cirug&#237;a laparoendosc&#243;pica por puerto &#250;nico en urolog&#237;a&#46;</p> <span class="elsevierStyleSectionTitle">Adquisici&#243;n de evidencia</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se ha llevado a cabo una revisi&#243;n no sistem&#225;tica&#44; a trav&#233;s de una b&#250;squeda bibliogr&#225;fica empleando los t&#233;rminos LESS y urolog&#237;a desde 2007 hasta 2012&#46; Se describen la experiencia actual LESS en urolog&#237;a&#44; sus principales indicaciones y los diferentes dispositivos de puerto &#250;nico e instrumental disponibles en el mercado&#46;</p> <span class="elsevierStyleSectionTitle">S&#237;ntesis de evidencia</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La cirug&#237;a LESS nace como un paso m&#225;s en la evoluci&#243;n constante de la cirug&#237;a m&#237;nimamente invasiva en un intento por mejorar la est&#233;tica&#44; reducir el traumatismo quir&#250;rgico y disminuir el dolor y las complicaciones postoperatorias asociadas a la laparoscopia convencional con m&#250;ltiples trocares&#46; Desde la primera descripci&#243;n en 2007&#44; la experiencia se ha incrementado exponencialmente y la t&#233;cnica LESS&#44; asistida o no por robot&#44; se est&#225; consolidando para un gran espectro de indicaciones urol&#243;gicas &#40;tanto en cirug&#237;a oncol&#243;gica como reconstructiva&#41;&#44; a mucha mayor escala que la t&#233;cnica NOTES&#46; A pesar de que la mayor&#237;a de los datos existentes son no aleatorizados y en escasas ocasiones son comparativos&#44; con el sesgo de selecci&#243;n que ello representa&#44; parece evidente que el beneficio est&#233;tico y de control analg&#233;sico asociado a la cirug&#237;a LESS es real y reproducible&#46; Las complicaciones asociadas a la misma son mayores en casos de cirug&#237;a oncol&#243;gica mayor y se deben m&#225;s a la propia t&#233;cnica que al abordaje&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Aunque el beneficio real de la cirug&#237;a LESS en urolog&#237;a a&#250;n no puede cuantificarse oportunamente&#44; la mejora cosm&#233;tica&#44; el menor dolor y una mayor satisfacci&#243;n del paciente con su herida resultan evidentes&#46; El entrenamiento apropiado en este tipo de procedimientos en centros de gran volumen y las constantes mejoras t&#233;cnicas en el desarrollo instrumental por parte de la industria biom&#233;dica permiten que la t&#233;cnica LESS transumbilical en urolog&#237;a haya nacido para quedarse&#46;</p>"
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        "texto" => "<p id="par0150" class="elsevierStylePara elsevierViewall">To Mr&#46; Mario Arenillas &#40;Veterinary&#44; Research Unit&#44; Biomedical Research Foundation of the <span class="elsevierStyleItalic">Hospital Universitario de Getafe</span>&#41;&#44; Mr&#46; Jes&#250;s Arconada &#40;<span class="elsevierStyleItalic">Grupo Taper</span>&#44; Madrid&#41;&#44; Mr&#46; Stefan Guill&#233;&#44; Mr&#46; Benjamin Seidenspinner&#44; Mr&#46; Juergen Steinbeck &#40;Richard Wolf GmbH&#44; Knittlingen&#44; Germany&#41;&#44; Mr&#46; Guillermo S&#225;nchez &#40;Applied Medical&#44; Madrid&#41; and Mr&#46; Jos&#233; Dom&#237;nguez &#40;photographer&#44; Hospital Universitario de Getafe&#41;&#44; for their help and cooperation&#46;</p>"
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Article information

ISSN: 21735786
Original language: English

DOI:10.1016/j.acuroe.2012.07.013

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2017 October	45	1	46
2017 September	43	9	52
2017 August	33	2	35
2017 July	48	3	51
2017 June	71	9	80
2017 May	75	8	83
2017 April	48	15	63
2017 March	57	36	93
2017 February	152	11	163
2017 January	67	1	68
2016 December	41	6	47
2016 November	59	3	62
2016 October	111	9	120
2016 September	67	6	73
2016 August	63	1	64
2016 July	53	1	54
2016 June	61	4	65
2016 May	63	8	71
2016 April	51	5	56
2016 March	83	10	93
2016 February	65	14	79
2016 January	45	12	57
2015 December	35	7	42
2015 November	32	4	36
2015 October	47	7	54
2015 September	47	3	50
2015 August	46	4	50
2015 July	98	3	101
2015 June	38	2	40
2015 May	30	1	31
2015 April	67	6	73
2015 March	48	5	53
2015 February	15	1	16
2014 July	1	0	1
2014 June	1	0	1
2014 May	3	1	4
2014 January	7	0	7
2013 December	10	1	11
2013 November	19	2	21
2013 October	15	4	19
2013 September	6	4	10
2013 July	0	1	1

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