Robotic technology may enable LESS to become more widely adopted.

I agree with you, but I think that the currently available robots need some modifications to overcome the limitations and difficulties of LESS

I agree with Dr. Abdel-Karim,

Currently, there is a single market-leader, which is actually monopolist regarding sales of commercially available robotic platforms. And robotic surgery is still industry-driven rather than surgeons-driven. As a result there is minimal (if any) progress in surgical robotics as there is not real competition on the market. I hope the ice will be broken next year as some interesting platforms are ready to reach the market like SPORT platform:

http://www.titanmedicalinc.com/

Dr. Julianov,

Did you try this SPORT platform? I have seen the videos through the link that you added; it looks great. Does it work in the same way in patients?.

Unfortunately I have not yet this chance. The platform is planned to be commercially available in 2015 in Europe. However I like the concept which is first applied to fexible GI-endoscopy prototypes as Endo-Samurai. I actually think that two working instruments are enough and that adding more robotic arms just for exposition/retraction makes machines unnecessarily expensive and just takes more space in the OR.

Dear all,

from my experience with robotic single site surgery in gynecology I am convinced that it can be performed successfully at least for routine surgery, However there are still two aspects which for my opinion will hinder a rapid increase in LEES/robotic single site: first:, the advantage of geometrically distant access points may be crucial or at least facilitating complex surgery predominantly in malignant disease. Thus, honestly spoken, it make no sense to reduce surgical quality in favour of reducing number of incisions. Second, at least in women, it seems that sometimes a larger incision in the region of the umbililicus may be less tolerated as a smaller one combined with other small incisions - this may be due to the special perception of the periumbilical region. This may also be due for NOTES, since not everybody likes to have injury of the stomach or the vagina just to avoid a small skin incision.

Rainer Kimmig

Dear Dr. Kimming,

I agree with you that its not accepted to reduce the surgical quality in favor of reducing the number of incisions by any means. However, although as we agree it is technically difficult, however LESS is not less effective than conventional laparoscopy as an option for treatment of malignant diseases and in urology many reports demonstrated that. Also, all what we have finally is the incision that we need for extraction of the specimen. I also assure you if the umbilical incision is closed meticulously, the incision site for LESS will be completely invisible.

Dear Aly,

if in fact the surgical quality is identical and the scar invisible there is no doubt that LESS will be the future: However, my personal experience teaches me - at least valid for myself - there are complex procedures I can do better by multiarm robotics compared to classical laparoscopy and particularly single site surgery. A lot of procedures in fact can be done by all of the thechniques in same quality. However there are also surgeons who do it best open - either due to their training or capability.

So, we agree that the quality of surgery is most important and not how to come there. So, there is no best access generally, but only individually: each surgeon has to decide how to access (with minimized injury) to guarantuee best surgical qualitiy and minimized morbiditiy of access, but with clear priority. Although surgical qualitiy is extremely difficult to measure we shold not confuse it with feasability.

Happy and Healthy New Year Aly

Yours Rainer

Dear Rainer,

I fully agree with what you said and still I do not argue that LESS is that easy as it needs a lot of modifications to survive.

Happy New Year and Many Returns.

Aly

One-port, single-incision laparoscopy is part of the natural development of minimally invasive surgery. Refinement and modification of laparoscopic instrumentation has resulted in a substantial increase in the use of laparoendoscopic single-site surgery (LESS) in urology over the past 2 years. Since the initial report of single-port nephrectomy in 2007, urologists have successfully performed various procedures with LESS, including partial nephrectomy, pyeloplasty, orchiectomy, orchiopexy, ureterolithotomy, sacrocolpopexy, renal biopsy, renal cryotherapy, and adrenalectomy. Further advancements in technology, such as magnetic anchoring and guidance systems, and robotic instrumentation, may allow broader application of this emerging surgical technique. Future research is required to determine the intraoperative and postoperative benefits of LESS in comparison with standard laparoscopy.

Dear Dr. Kiming

Re 12-30-2013.  For the females that chosen TV  Hybrid NOTES  ( Culdolaparoscopy)  there are good  options and results.

Re: vaginal extraction of the intact specimen following laparoscopic radical nephrectomy.

Tsin DA.

Letter to the Editor

J Urol. 2002 Sep;168(3):1110. No abstract available.

PMID: 12187243

Dear Daniel, dear Aly,

certainly some wonen and also men will ask for as few scars as possible. However, it has not been shown that morbidity in multiport surgery is higher compared to LESS and NOTES, although LESS and NOTES is feasible. But it is evident, that the LESS/NOTES approach is at least in part "to make simple surgery difficult" instead of making "difficult surgery easier" which is clearly the case for multiport surgery and especially modern robotic surgery. So, I think, LESS will only advance in fields where it may important to have only single incision, e.g. in intrauterine fetal surgery, and there rather as single port surgery. or in cases of simple surgery which can be done easily.  At least as gynecologist I would not invest my energy in LESS/NOTES in 2017 if I would to have to manage advanced surgery especially in gynecologic oncology.

By the way, although scares in the vagina (NOTES) are not visible, they may cause dyspareunia and thus reduce life quality at a very sensible point. This has also be taken into account.

Best wishes

Rainer

 Dear Aly  and Rainer.

Focusing in Urology:

Culdoscopy for general surgeons and gynecologists

Daniel A. Tsin

 Endoscopic Rev, Vol. 12, No. 27, May 2007.pages 11-14

Here is a quote of this paper:

“Hopefully, this paper will convince you of the advantages of extraction via the vaginal port. Also remember that culdolaparoscopy goes beyond that: think of the vaginal port both as an entrance and an exit port “

This team understood and improved the concept in urology.

Laparoscopic Transplantation Following Transvaginal Insertion of the Kidney: Description of Technique and Outcome

P. Modi, B. Pal, S. Kumar, J. Modi, Y. Saifee, R. Nagraj, J. Qadri, A. Sharmah, R. Agrawal, M. Modi, V. Shah, V. Kute, H. Trivedi. American Journal of Transplantation.  Volume 15, Issue 7 , July 2015 , Pages 1915–1922

Sincerely

Daniel