Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1550_Библиотеки_им_академика_М_И_Перельмана
.pdf
321
25 Single-Port Laparoscopy: Issues and Complications
increased abdominal pressure can slow bleeding, thereby improving the operative
visibility and identi fi cation of the offending site. Hemostatic agents [such as
Surgicel
®
(Ethicon, Somerville, NJ)] can be used for temporary compression while
allowing prompt decision making regarding continuation with SPL, conventional
laparoscopy, hand-assisted laparoscopy (HAL), or open surgery.
Bowel injury is a particular concern for SPL for a few reasons. First, the angle
from the umbilicus to the target organ is typically more horizontal than usual,
thereby placing bowel structures in line with instruments entering the abdominal
cavity. Second, the inherent increased clashing associated with SPL may obscure
obvious intraabdominal resistance that can occur when instruments contact visceral
structures. Therefore, careful introduction of instruments angled toward the anterior
abdominal wall can potentially prevent iatrogenic injury to small or large intestine.
Furthermore, meticulous dissection is necessary during bowel mobilization to limit
the potential for thermal injury. The surgeon should thoroughly evaluate the opera-
tive fi eld at the conclusion of SPL cases with particular attention to bowel structures
adjacent to the portal of entry. Postoperative management should follow standard
care although heightened attention to occult signs of bowel injury including focal
trocar site pain and leukopenia should alert the clinician [
19 ] .
Wound-related complications present a potentially unique complication
related to SPL. Ergonomically, one may assume that the local tissue trauma may
be analogous to traction during open surgical procedures. This is in part related
to attempting to maximize the operative fulcrum at the anterior abdominal wall
by stretching the incision as much as possible. Such concerns may particularly
occur with use of the GelPOINT
®
or GelPort
®
devices (Applied Medical Systems,
Rancho Santa Margarita, CA) whereby the Alexis wound retractor can be rotated
until the tissues are maximally extended. To date, however, no series have docu-
mented permanent tissue damage or trauma during SPL cases. Several groups
have noted postoperative incisional hernias, which underscore the need for care-
ful closure at the conclusion of SPL cases. In summary, attention to the incision
and wound is crucial to avoid iatrogenic wound complications during SPL
procedures.
Conclusions
Careful consideration of pertinent issues associated with SPL is critical to ensure
safe and successful completions of cases. Nonetheless, in the setting of complica-
tions, surgeons must be prepared to adapt to scenarios with consideration of the
unique challenges related to SPL. Learning from the experiences of others often
provides a basic framework, which can be tailored to individual practices and surgi-
cal experience.
Con fl ict of Interest The author has no con fl icts of interest or disclosures regarding the subject
matter of this chapter.
322
J.D. Raman
References
1. Gill IS, Advincula AP, Aron M, et al. Consensus statement of the consortium for laparoendo-
scopic single-site surgery. Surg Endosc. 2010;24:762–8.
2. Raman JD, Bagrodia A, Cadeddu JA. Single-incision, umbilical laparoscopic versus conven-
tional laparoscopic nephrectomy: a comparison of perioperative outcomes and short-term
measures of convalescence. Eur Urol. 2009;55:1198–204.
3. Tugcu V, Ilbey YO, Mutlu B, et al. Laparoendoscopic single-site surgery versus standard lap-
aroscopic simple nephrectomy: a prospective randomized study. J Endourol.
2010;241315–20.
4. Mir SA, Best SL, Donnally III CJ, et al. Minimally invasive nephrectomy: the in fl uence of
laparoendoscopic single-site surgery on patient selection, outcomes and morbidity. Urology.
2011;77:631–4.
5. Desai MM, Berger AK, Brandina R, et al. Laparoendoscopic single-site surgery: initial hun-
dred patients. Urology. 2009;74:805–11.
6. White WM, Haber GP, Goel RK, et al. Single-port urologic surgery: single-center experience
with the fi rst 100 cases. Urology. 2009;74:801–4.
7. Ylinas E, Ploussard G, Durand X, et al. Evaluation of combined oncological and functional
outcomes after radical prostatectomy: trifecta rate of achieving continence, potency and cancer
control – a literature review. Urology. 2010;76:1194–8.
8. White WM, Haber GP, Autorino R, et al. Robotic laparoendoscopic single-site radical pros-
tatectomy: technique and early outcomes. Eur Urol. 2010;58:544–50.
9. Skinner EC, Stein JP, Skinner DG. Surgical benchmarks for the treatment of invasive bladder
cancer. Urol Oncol. 2007;25:66–71.
10. Huang WC, Levey AS, Serio AM, et al. Chronic kidney disease after nephrectomy in patients
with renal cortical tumours: a retrospective cohort study. Lancet Oncol. 2006;7:735–40.
11. Han WK, Kim DS, Jeon HG, et al. Robot-assisted laparoendoscopic single-site surgery: partial
nephrectomy for renal malignancy. Urology. 2011;77:612–6.
12. Cindolo L, Berardinelli F, Gidaro S, et al. Laparoendoscopic single-site partial nephrectomy
without ischemia. J Endourol. 2010;24:1997–2002.
13. Raman JD, Bensalah K, Bagrodia A, et al. Laboratory and clinical development of single key-
hole umbilical nephrectomy. Urology. 2007;70:1039–42.
14. Haber GP, White MA, Autorino R, et al. Novel robotic da Vinci instruments for laparoendo-
scopic single-site surgery. Urology. 2010;76:1279–82.
15. Choi KH, Ham WS, Rha KH, et al. Laparoendoscopic single-site surgeries: a single-enter
experience of 171 consecutive cases. Korean J Urol. 2011;52:31–8.
16. Permpongkosol S, Ungbhakorn P, Leenanupunth C. Laparo-endoscopic single site (LESS)
management of benign kidney diseases: evaluation of complications. J Med Assoc Thai.
2011;94:43–9.
17. Best SL, Donnally C, Mir SA, et al. Complications during the initial experience with laparoen-
doscopic single-site pyeloplasty. BJU Int. 2011;108(8):1326–9.
18. Irwin BH, Cadeddu JA, Tracy CR, et al. Complications and conversions of upper tract urologi-
cal laparoendoscopic single-site surgery (LESS): multicentre experience: results from the
NOTES Working Group. BJU Int. 2011;107(8):1284–9.
19. Bishoff JT, Allaf ME, Kirkels W, et al. Laparoscopic bowel injury: incidence and clinical pre-
sentation. J Urol. 1999;161:887–90.
Part IV
Future Perspectives
325
A. Rane et al. (eds.), Scar-Less Surgery,
DOI 10.1007/978-1-84800-360-6_26, © Springer-Verlag London 2013
Keywords Laparoendoscopic single site • Single port • Robotic • Natural ori fi ce
NOTES • LESS • Laparoscopic • VeSPA
Introduction
Laparoscopy has largely been embraced in urology as it can offer better cosmesis,
less bleeding, diminished pain, and faster recovery. Nevertheless, for some time
investigators have been exploring techniques to decrease the size and number of
incisions even further. In this vain and with the aim to limit pain and decrease com-
plications further, techniques such as NOTES (natural ori fi ce translumenal endo-
scopic surgery) and LESS (laparoendoscopic single-site) surgery have been
developed [ 1, 2 ] .
R. V. Khanna , M.D.
Department of Urology , SUNY Upstate Medical University ,
750 East Adams Street , Syracuse , NY 13210 , USA
e-mail: khannara@upstate.edu
M. M. Desai , M.D.
Department of Urology , Keck Medical Center,
University of Southern California Institute of Urology , 1441 Eastlake Avenue,
Suite 7416 , Los Angeles , CA 90033 , USA
e-mail: adityadesai2003@gmail.com
R. J. Stein , M.D. (
*)
Center for Robotic and Image-Guided Surgery,
Glickman Urological and Kidney Institute, Cleveland Clinic ,
Q10, 9500 Euclid Avenue , Cleveland , OH 44195 , USA
e-mail: steinr@ccf.org
Chapter 26
Robotic LESS Urological Surgery:
Experience and Future Perspectives
Rakesh Vijay Khanna, Mihir M. Desai , and Robert J. Stein
326
R.V. Khanna et al.
“Scarless surgery,” with little to no postoperative pain due to the absence of
abdominal wall trauma, has been the driving force behind the development of
NOTES. Nevertheless, complexity, risk, and the lack of appropriate technology
have limited the ability to perform these procedures thus far [
3 ] .
LESS appears to provide many bene fi ts of NOTES, including enhanced cosmesis
and decreased abdominal wall trauma, without the added risks of traversing a true
natural ori fi ce [
4 ] . Postoperative pain may be lessened with the transumbilical
approach due to the absence of muscle transection and due to the restriction of pain-
ful stimuli to a solitary locus.
Attempts to perform urologic surgery through a single incision began in 2005
with a report by Hirano et al., who used a specialized resectoscope tube and
standard laparoscopic instruments to perform a retroperitoneoscopic adrenalec-
tomy [ 5 ] .
Rane et al . were the fi rst to report laparoscopic urological surgery through a
single multi-channel port in the clinical setting [ 6 ] . The authors were able to com-
plete a single-port nephrectomy for a nonfunctioning kidney and a transperitoneal
ureterolithotomy with a mean operating time of 90 min and no intraoperative com-
plications. In early 2007, Raman et al. reported their initial experience with “key-
hole” nephrectomy in pigs and humans using a single incision to introduce three
adjacent trocars (one 10-mm and two 5-mm). Using a combination of bent and
articulating instruments, they were able to complete the three human nephrectomies
with a mean operative time of 133 min through a mean incision of 3 cm with no
complications [ 7 ] .
Since these pioneering reports, groups from different institutions have published
several clinical series with LESS so that almost the entire spectrum of urological
extirpative and reconstructive laparoscopic procedures has been demonstrated to be
feasible [ 8, 9 ] .
Based on these early experiences, it has been largely recognized that LESS is
accompanied by several technical challenges that need to be addressed before
this approach might be widely adopted. Dif fi culties encountered with LESS
include (1) a lack of triangulation, (2) counterintuitive instrument movement, (3)
clashing of instruments, and (4) challenging visualization secondary to an in-
line view.
To reduce some of these limitations, new equipment has been designed, devel-
oped, and applied in these early series, including access devices, articulating/ fl exible
instruments, and de fl ectable scopes [ 10 ] . Nevertheless, besides the signi fi cant cost
considerations of disposable equipment, these devices are usually dif fi cult to mas-
ter, requiring advanced laparoscopic skills. The surgeon and assistant also need to
stand in close proximity, and the technique requires a skilled camera driver and
constant coordination.
With the advent and acceptance of surgical robotics has come the natural fusion
of this technology with LESS. Bene fi ts of the da Vinci
®
Surgical System (Intuitive
Surgical, Sunnyvale, CA) for LESS include easier articulation using EndoWrist
®
(Intuitive Surgical, Sunnyvale, CA) instruments, three-dimensional vision, and
motion scaling. These features improve ergonomics and range of motion during
LESS, especially for fi ne dissection and suturing.
327
26 Robotic LESS Urological Surgery: Experience and Future Perspectives
Robotic LESS: Preclinical Investigation
Box et al. were the fi rst to accomplish a robot-assisted hybrid NOTES nephrectomy
in a porcine animal model [
11 ] . They placed the robotic scope through one 12-mm
abdominal trocar site, while the right and left arms of the robot were placed trans-
vaginally and transcolonically via 12-mm trocars, respectively. The assistant oper-
ated the camera through the midline port. The kidney was dissected and removed
intact through the vagina. The total operative time was 150 min, and no complica-
tions were reported. Repeated arm collision was noted due to limited port separa-
tion. Formerly, the authors were unable to remove the kidney with the standard da
Vinci robotic system. However, the da Vinci S system provided an increased range
of motion and increased instrument length compared to the previous generation
robot. The authors also noted that the EndoWrist technology helped to achieve
instrument triangulation while the robotic arms provided strong traction, which
were signi fi cant advantages over pure NOTES.
Haber et al. reported a large experience with robotic NOTES in the laboratory
setting [ 12 ] . Using 10 pigs, 30 robotic NOTES procedures were performed, includ-
ing 10 pyeloplasties, 10 partial nephrectomies, and 10 complete nephrectomies.
The fi rst robotic arm and camera were placed through a 2-cm umbilical incision,
whereas the second robotic arm was placed though the vagina. The mean opera-
tive time was 154 min, with a mean warm ischemia time during partial nephrec-
tomy of 25.4 min. No intraoperative complication occurred. The time to robot
preparation was found to be inversely correlated to increasing case number. Due
to space limitations around the umbilicus, a considerable restriction in movement
was encountered. Furthermore, friction between the robotic arm and camera
resulted in unexpected intracorporeal movement of the instruments. While the
robotic arm placed through the vagina had a full range of motion, in a third of the
radical nephrectomy cases, the instrument was unable to reach the upper pole of
the kidney.
Desai et al. reported the technical feasibility of performing transvesical robotic
radical prostatectomy in two fresh male cadavers (prostate volume 46 and 30 ml)
[ 13 ] . In the fi rst procedure, four laparoscopic transvesical trocars and in the second
a single-port device were used and placed percutaneously into the bladder. A pneu-
movesicum was established in both cases and the da Vinci S robotic system was
used. All steps of the procedure were performed transvesically and robotically. Both
procedures were technically successful, with no need for additional ports or conver-
sion to standard laparoscopy. The operative duration was 3 h for the multiport pro-
cedure and 4.2 h for the single-port procedure. Clashing of the da Vinci arms
represented the major technical dif fi culty with the single-port procedure but did not
occur in the multiport procedure.
In these preliminary studies, clashing of the robotic instruments remained a
signi fi cant obstacle. Joseph et al. proposed a novel robotic docking technique to min-
imize collision of the robotic arms [ 14 ] . They described a “chopstick” arrangement
in which the instruments are crossed such that the right instrument is on the left side
and the left instrument is on the right. The robotic console is then directed to control
328
R.V. Khanna et al.
the left instrument with the right hand, and vice versa. The authors subsequently
compared the “chopstick” arrangement to standard single-port placement in a laparo-
scopic box trainer. They noted that the “chopstick” arrangement improved times and
reduced instrument collision, camera manipulations, clutching, and errors across all
tasks. It is the author’s experience that while this arrangement can be useful in certain
situations, it is usually not effective for use during a complete procedure.
Robotic LESS: Clinical Experience
As experience with standard “laparoscopic” single-site surgery has grown, so too
has the complexity of the procedures performed. The same holds true for robotic
single-site surgery (Table 26.1 ). Kaouk et al. reported the initial clinical experi-
ence with robotic single-port surgery, using the da Vinci S system and a multichan-
nel single port, the R-Port
®
(Advanced Surgical Concepts, Dublin, Ireland), to
perform a radical prostatectomy, pyeloplasty, and radical nephrectomy [ 15 ] . The
robotic camera and a 5-mm robotic port were placed through the R-Port, while a
second 5- or 8-mm robotic trocar was placed alongside the multichannel port
though the same incision. Using this robotic setup, surgeons completed all proce-
dures successfully without the need for the placement of additional ports, and no
intraoperative complications occurred. Operative times, estimated blood losses,
and hospital lengths of stay were within the ranges of those reported with conven-
tional laparoscopy.
From the same group of investigators at the Cleveland Clinic, Stein et al. reported
robotic LESS using the GelPort
®
(Applied Medical, Rancho Santa Margarita, CA)
[ 16 ] . Two pyeloplasties (mean operative time 235 min), one radical nephrectomy
(operative time 200 min), and one partial nephrectomy (operative time 180 min) for
an 11-cm angiomyolipoma were performed. No complications were reported. A
12-mm camera port, two 8-mm robotic ports, and a 12-mm assistant port were
placed through the GelPort. While use of the robot required a longer incision than
for standard LESS procedures, the GelPort allowed for a larger-pro fi le working
platform, fl exibility for port placement, and easier access for the assistant.
Together with their experience in a cadaveric model, Barret et al. also presented
their initial case of a robot-assisted LESS radical prostatectomy [ 17 ] . One 12-mm
trocar and two 8-mm robotic ports were placed through a 4-cm umbilical incision.
Fascial dissection permitted 3–3.5-cm separation between robotic trocars. An addi-
tional 5-mm port was placed in the lower abdomen to assist with suctioning and to
serve as the drain site. Disadvantages of this con fi guration included some external
clashing of the robotic arms and dif fi culty with instrument exchange. The operative
time was 150 min (5 min to control the dorsal venous complex and 30 min to per-
form the urethrovesical anastomosis), and fi nal pathologic examination revealed
negative surgical margins. The authors pointed out that before embarking on single-
site surgery in the clinical setting, it was important to gain experience with the
limited working environment using pelvic trainers and cadaver models.
329
26 Robotic LESS Urological Surgery: Experience and Future Perspectives
Table 26.1 Robotic LESS: early clinical experience
References No. of ports Procedure Port used Operative time Outcome Complications Comment
Kaouk et al. [
15 ] 3 1 radical
prostatectomy
R-Port
®
(Advanced
Surgical
Concepts,
Dublin,
Ireland)
5 h (45 min for
anastomo-
sis)
Margins
negative
None
1 pyeloplasty 4. 5 h None
1 radical
nephrectomy
2.5 h None
Stein et al. [
16 ] 4 2 pyeloplasties GelPort
®
(Applied
Medical,
Rancho Santa
Margarita,
CA)
235 min None Longer incision required. Allows
more fl exibility of port
placement and easier access for
the assistant
1 radical
nephrectomy
200 min None
1 partial
nephrectomy
180 min 1 transfusion
Barret et al. [
17 ] 1 1 radical
prostatectomy
4-cm umbilical
incision
150 min
(30 min for
anastomo-
sis)
Negative
margins
None An additional 5-mm port placed at
drain site
Barret et al. [
18 ] 1 1 radical
prostatectomy
Umbilical
incision with
ports placed
in a rhomboid
fashion
210 min
(35 min for
anastomo-
sis)
Negative
margins
None
White et al. [
19 ] 20 20 radical
prostatecto-
mies
SILS™ port
(Covidien,
Cupertino,
CA)
189.5 min 4 positive
margins
1 ileus, 1
transfu-
sion, 1
pulmo-
nary
embolus,
1
urosepsis
Retraction dif fi cult and advise
liberal use of marionette sutures
30° upward-looking lens, stagger-
ing of robotic cannulae helps to
reduce instrument clashing
Using a combination of 8- and
5-mm instruments maximizes
bene fi ts of both
(continued)
330
R.V. Khanna et al.
Table 26.1 (continued)
References No. of ports Procedure Port used Operative time Outcome Complications Comment
Kaouk et al. [
20 ] 2 2 partial
nephrectomy
TriPort™
(Olympus,
Tokyo, Japan)
170 min None Pediatric robotic instruments were
utilized, resulting in increased
range of motion
White et al. [
21 ] 10 10 radical
nephrectomy
SILS 167.5 min Negative
magins
1 wound
infection
GelPort/
GelPOINT
Choi et al. [
22 ] 73 56 partial
nephrecto-
mies
Homemade
single-port
device
198 min Mean T
1/2
26 min
2
conver-
sions
Single-port device cost-effective,
provided adequate range of
motion and more cost-effective
than other available devices
2 positive
margins
1 renal vein
injury
1 ureter
injury
1 postopera-
tive
bleeding
12
nephroure-
terectomies
227 min 1 acute renal
failure, 1
retroperi-
toneal
abcess
2 radical
nephrecto-
mies
248 min 1 conversion
1 simple
nephrectomy
128 min 1 bowel
injury
2
adrenalecto-
mies
167 min Nil
331
26 Robotic LESS Urological Surgery: Experience and Future Perspectives
The same group reported a second case of robotic LESS radical prostatectomy
[ 18 ] . Again, the operation was performed with the da Vinci interface and standard
trocars. Ports were placed in a rhomboid fashion with the endoscope in the upper
corner (12-mm), a 5-mm trocar in the lower corner for suction and retraction pur-
poses, and 8-mm working ports on either side. Clashing between instruments was
noted externally, and this impaired the assistant’s performance. The total operative
time was 210 min. Dorsal venous control was accomplished in 3 min, whereas the
urethrovesical anastomosis was performed in 35 min. No perioperative complica-
tions were observed.
Extensive experience with robotic LESS radical prostatectomy has recently been
described by White et al. [
19 ] . They reported 20 cases performed via a 3–4.5-cm
periumbilical incision. Optimal port positioning was achieved by placing an 8-mm
robotic port on the right side, under fi nger guidance, at the most caudal portion of
the incision directed as far laterally as possible. This same positioning was then
repeated on the opposite side with a 5- or 8-mm robotic port. The multichannel
SILS™ port (Covidien, Cupertino, CA) was then deployed through the fascial inci-
sion into the abdominal cavity. The robotic camera and a 5-mm assistant port were
then inserted through the single-port device and a prostatectomy performed with the
aid of “marionette” sutures. The mean operative time was 187.6 min, and the EBL
was 128.8 ml. Pathology revealed four positive margins, with two occurring during
the fi rst three cases. The authors reported that tissue retraction can be dif fi cult sec-
ondary to the lack of the fourth robotic arm and advised liberal use of the “mario-
nette” sutures. Furthermore, crowding of instruments and leaking of carbon dioxide
through the single-port access device on occasion limited the assistant’s ability to
suction or retract tissues.
Laparoscopic partial nephrectomy represents a technically demanding procedure
under the best of circumstances. Kaouk and Goel reported on their experience with
seven LESS partial nephrectomies, two of which were performed with the robot: a
2.8-cm left lower pole tumor and a 1.1-cm right lower pole tumor [ 20 ] . Both were
excised without hilar clamping using a harmonic scalpel. The multichannel TriPort™
(Olympus, Japan) and 5-mm robotic instruments were utilized for the procedure.
The authors noted that the smaller (5-mm) instruments de fl ect rather than articulate,
resulting in an increased range of motion. One 5-mm robotic trocar was placed
though the TriPort, whereas the second robotic trocar was placed through the same
skin incision alongside the TriPort. This arrangement diminished clashing and
improved the second robotic arm’s range of motion. The operative time was 170 min.
Based on the authors’ experience, small, exophytic, anterior, interpolar to lower
pole renal masses are best suited to LESS and robotic LESS approaches.
White et al. [ 21 ] recently described their technique of robotic LESS radical
nephrectomy using either the SILS port or the GelPoint
®
(Applied Medical,
Rancho Santa Margarita, CA). The patient is positioned in a modi fi ed fl ank posi-
tion and an incision is made extending 1 cm below to 2 cm above the umbilicus.
The abdomen is then entered. With the SILS port, the robotic trocars are placed
through separate laterally directed fascial stab sites, whereas with the GelPOINT,
the trocars are placed through the port itself. The robot is then positioned over the
Соседние файлы в папке Библиотека им академика М.И. Перельмана