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Laparoendoscopic
Single-Site
Surgery LESS Is More |
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Laparoendoscopic Single-Site
Surgery LESS Is More
By Caroline Helwick
ECCC (November 10, 2010) For
many gynecological procedures,
single-site laparoscopy offers
the potential for better
cosmesis the result of virtually
scarless surgery and less
port-site postoperative pain,
according to John Yacoub, MD,
Director of Minimally Invasive
Surgery at St. Agnes Hospital in
Baltimore, Maryland.
In a booth presentation
sponsored by Ethicon
Endo-Surgery, Inc, Dr Yacoub
said he encourages
laparoendoscopic single-site
surgery (LESS) primarily because
it achieves the same result as
traditional laparoscopy but with
the advantage of less pain,
along with faster recovery and
return to normal. Better
cosmesis, he added, is a strong
benefit but should not be the
sole reason for using a
single-port approach.
Dr Yacoub acknowledged that LESS
has a steep learning curve and
requires a longer operating
time, at least initially. The
clinician averages six to eight
cases before becoming
proficient, but the results
after the learning curve are
equal to regular laparoscopy. Data supporting LESS in
gynecology is starting to
emerge, as several institutions
have recently reported results
on their large series (Fader AN
et al. Am J Obstetr Gynecol.
2010; 203:501.e1-6; Song T et
al. J Min Invasive Gynecol.
2010; 17: 456-460.)
The Trend Toward Less
LESS has gradually
evolved from the initial
three-trocar technique to much
simpler instrumentation, Dr
Yacoub observed, commenting that
LESS is what is being used
today.
One device that has afforded Dr
Yacoub many successful LESS
outcomes is the Ethicon
Endo-Surgery (EES) Single Site
Laparoscopy Access System. It is
simple to insert, allows
rotation without removal of
instruments, has the CO2 inlet
on the side, and is compatible
with the X-TRACT Morcellator, he
noted. In addition, he likes the
fact that instrument torque
begins immediately with this
device, that there is less
dependence on articulation, and
that there is easy access to the
peritoneal cavity.At any time,
you can open the device and
examine the tissue, then put the
device back into the abdomen and
proceed.
Dr Yacoub advised attendees
interested in doing LESS to
start with the simpler
procedures, such as
oophorectomies and tubal
ligations, and get a feel for
the change in the approach
before applying LESS to more
complex procedures. But he
pointed out that not all
conditions are amenable to LESS.
Poor candidates are patients
with extensive, multifocal
adhesions, which typically
require multiple angles of
approach, and women with large
uteri, which make access to
uterine arteries difficult. High
body mass index and severe
endometriosis are other possible
contraindications. LESS is
somewhat better suited for
laparoscopically-assisted
vaginal hysterectomy than for
total laparoscopic hysterectomy.
And clearly, surgeon expertise
is very important, he added, as
is access to and understanding
of the right technology and
instrumentation.
What to Take Into
Account
Several factors will
influence the success of LESS:
incisions, port choice,
visualization, instrumentation,
energy modality, morcellation,
and suturing, according to Dr
Yacoub.
Dr Yacoub prefers intraumbilical
incisions because cosmesis is
better, although periumbilical
incisions provide more space, he
said. For port insertion he
creates a pneumoperitoneum,
especially in patients with a
history of adhesions. He makes a
1.5-mm incision on the skin and
extends the incision in the
fascia to about 2 cm. He uses
either a bariatric length
30-degree scope or an
articulating scope (Olympus
EndoEYE and Storz
ENDOCAMELEON®).
Because bleeding can be more
problematic with LESS than with
traditional laparoscopy, it is
important to choose the best
energy modality that is, one
that provides the most
consistent hemostasis. The
Harmonic ACE is associated with
minimal lateral thermal spread,
is multifunctional (seals, cuts,
and transects), and seals 5-mm
vessels. Dr Yacoub recommends
this product for total vaginal
hysterectomies but prefers the
EnSeal for supracervical
hysterectomies.
Key Principles and
Applications
Several principles are
the key to successful LESS,
according to Dr Yacoub, who
cited proper positioning of
instrumentation and operators,
optimal use of triangles and
uterine manipulators, and
appropriate instrument length.
Certainly, correct positioning
is the key to successful lysis
of adhesions, Dr Yacoub
emphasized. While this may be
challenging at first, when you
position correctly you can do a
successful lysis with a single
port, at least when the
adhesions are in a single area,
he said. When they are in
multiple areas, you need
different angles to access
safely. LESS may not be the best
approach for this.
When using LESS for
supracervical hysterectomy, the
clinician should not deviate
from the principles of
traditional surgery, according
to Dr Yacoub.
For safe morcellation, Dr Yacoub
noted that visualization of the
blade is very important, and
this is facilitated with the
X-TRACT device. In addition,
X-TRACT is compatible with the
LESS access system, is
lightweight, is low-profile, and
has a longer shaft. These are
important features in
single-site laparoscopy, he
said.
For total laparoscopic
hysterectomy via single-site
surgery, Dr Yacoub advised
listeners to remember the
triangles and the position of
the instruments, complete each
side separately down to the
cardinal ligament, and, most
importantly, ensure hemostasis.
In anterior and posterior
colpotomies, he stressed that
ureters must be identified and
advocated the use of sponge on a
stick to facilitate
visualization, especially when
bleeding occurs. With sponge on
a stick, we can identify the
area to treat with the energy
device, visualize the sacral
ligaments, and put in sutures
the way we want, he said.
Cuff suturing can be somewhat
challenging with a single port,
but there are options, Dr Yacoub
added. Basically, you should use
whatever method and instrument
you need to get support, and you
should not stray from the
principles of traditional
surgery, he said. You want to
assure long-term support of the
vaginal cuff.
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