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    Laparoscopic single-site surgery represents future of laparoscopy, expert says

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    Nadiad, India—Does laparoendoscopic single-site surgery (LESS) represent another modification or a major surgical advance?

    That's the question Arvind P. Ganpule, MD, chief of the division of laparoscopy, Muljibhai Patel Urological Hospital, Nadiad, India, posed at the AUA annual meeting in Chicago while presenting results of a study on the procedure.

    "I feel that single-port surgery is the future as far as laparoscopy is concerned," said Dr. Ganpule, a co-author of the study. "I think it has rejuvenated interest in laparoscopic surgery. Surgeons are excited about the utilization of single port, and it is going to give robotic procedures tough competition."

    Dr. Ganpule noted that learning the procedure can be a long, multi-step process.

    "The learning curve is steep," Dr. Ganpule told Urology Times. "If you look at this series, you will see that it shows a stepladder pattern. You start by attending instructional courses. This is followed by procedures on animal models, simple nephrectomies, and donor nephrectomies."

    The concept of conducting an entire surgical procedure through a single port is relatively new. The Laparo-Endoscopic Single-Site Surgery Consortium for Assessment and Research (LESSCAR) held its inaugural meeting last year in Cleveland. Once the learning curve is surmounted, applications for the procedure seem to expand rapidly.

    The cases that Dr. Ganpule reported included 19 donor nephrectomies, six simple nephrectomies, five pyeloplasties, five BPH-related prostatectomies, one nephroureterectomy, one ureteroneocystostomy, and one adrenalectomy for pheochromocytomas.

    The mean age of the patients was 36.6 years (range, 5 to 62 years), and the mean operative time was 153.3349.87 minutes. Average blood loss was 151.8185.87 mL (50 to 300 mL), and the average hospital stay was 4 days. In addition, the mean visual analogue scale (VAS) pain score was <2.8 on discharge and fell to <1 at 15 days after surgery.

    A more detailed look at six representative simple nephrectomies found the mean estimated blood loss to be 108 mL and the mean operating time to be 135 minutes. The average length of hospital stay for these patients was 2.75 days. Incision lengths ranged from 3 cm to 6 cm, with 4.42 cm being the mean. VAS scores ranged from 2 to 4 at discharge and dropped to 0 at 2 weeks post-discharge in all but one patient, who showed a VAS score of 1.

    Some caveats exist

    Dr. Ganpule said LESS is advantageous in that it can be applied in a variety of urologic presentations as a safe alternative to conventional laparoscopic surgery. LESS procedures are usually accompanied by reduced pain and shorter convalescence and are associated with good cosmesis.

    Disadvantages include the aforementioned steep learning curve and the need to be proficient in both single-handed dissection and single-handed suturing. Another disadvantage is that because a majority of the procedures are conducted through the umbilicus, surgeons need to get used to a new top-down viewing angle in many procedures.

    Dr. Ganpule also noted that realization of the full promise of the procedures might require new procedure-specific technology. Although standard laparoscopic instruments may be used, they tend to be of inadequate length in some clinical situations. They also lack needed flexibility and can clash in the crowded environment of a single port.

    Another expanding technology may benefit single-port surgery.

    "I think the combination of the robot and single-port surgery may have a future. This may reduce the bending and clashing of instruments we sometimes have now and may provide longer instruments for circumstances such as dissecting the upper pole," Dr. Ganpule said.

    He concluded with a reminder that surgeons contemplating LESS procedures should climb the learning curve one step at a time.

    "The take-home message is that one should learn single-port surgery gradually, in a stepwise pattern," Dr. Ganpule said. "If done this way, any surgeon now doing laparoscopy should be able to learn single-port procedures. However, they should not embark on single-port surgery with inadequate laparoscopic experience or supporting infrastructure."

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