Transumbilical Single-Port Surgery: Evolution and Current Status

Transcription

1 european urology 54 (2008) available at journal homepage: Review Laparoscopy Transumbilical Single-Port Surgery: Evolution and Current Status David Canes *, Mihir M. Desai, Monish Aron, Georges-Pascal Haber, Raj K. Goel, Robert J. Stein, Jihad H. Kaouk, Inderbir S. Gill Center for Laparoscopic and Robotic Surgery, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA Article info Article history: Accepted July 3, 2008 Published online ahead of print on July 14, 2008 Keywords: Laparoscopy Single port NOTES Transumbilical Abstract Context: Single-port transumbilical laparoscopy, also known as embryonic natural orifice transumbilical endoscopic surgery (E-NOTES), has emerged as an attempt to further enhance cosmetic benefits and reduce morbidity of minimally invasive surgery. Within a short span, several clinical reports have emerged in the urologic literature. As this field is poised to move forward, a complete understanding of its evolution and current status is timely. Objective: To summarize and review the history of E-NOTES across surgical disciplines. This review emphasizes nomenclature, surgical technique, instrumentation, and perioperative outcomes. Specific urological and nonurological applications of single-port surgery to date are summarized. Evidence acquisition: Using the National Library of Medicine database, the English-language literature was reviewed for the past 40 yr. Keyword searches included: scarless, scar free, single port/trocar/incision, intraumbilical, and transumbilical. Within the bibliography of selected references, additional sources were retrieved. Evidence synthesis: The gynecologic and general surgical literature includes approximately 19 papers fulfilling the search criteria, encompassing extirpative procedures only. The urologic literature contains eight published reports of single-trocar transumbilical procedures. These reports are summarized in a chronological manner and grouped by subject. No prospective studies comparing outcomes to standard laparoscopy have been reported. Technical feasibility has been demonstrated for a broad range of extirpative and reconstructive procedures on the upper and lower urinary tracts, including simple and radical nephrectomy, donor nephrectomy, renal cryotherapy, pyeloplasty, ileal ureteral replacement, sacrocolpopexy, and varicocelectomy. Conclusions: E-NOTES has made its initial forays into laparoscopic surgery. Ongoing refinement in technique and instrumentation is likely to expand its future role. # 2008 Published by Elsevier B.V. on behalf of European Association of Urology. * Corresponding author. Department of Urology, Glickman Urological and Kidney Institute, 9500 Euclid Avenue, A-100, Cleveland, OH 44195, United States. Tel ; Fax: address: canesd@ccf.org (D. Canes) /$ see back matter # 2008 Published by Elsevier B.V. on behalf of European Association of Urology. doi: /j.eururo

2 european urology 54 (2008) Introduction Laparoscopic surgery is a well-established alternative to open surgery across disciplines. Although the magnitude of impact varies by procedure, in general, the benefits of laparoscopy on postoperative pain, cosmesis, hospital stay, and convalescence are widely recognized. Current efforts are aimed at further reducing the morbidity associated with minimally invasive surgery. To this end, two recent innovations are being developed, either pure or hybrid: (1) natural orifice translumenal endoscopic surgery (NOTES), whereby intraperitoneal access is gained through the mouth, anus, vagina, or urethra and the viscus-of-entry is perforated to reach the surgical target; and (2) embryonic natural orifice transumbilical endoscopic surgery (E-NOTES), wherein the surgical scar is virtually concealed within the umbilicus, an embryonic natural orifice. This review seeks to place E-NOTES in its historical context; describe its gynecologic, general surgical, and urologic applications to date; and describe current instrumentation and limitations. 2. Methods Efforts aimed at further reductions in morbidity while maintaining the same high standard of surgical cure are valuable. Indirect evidence for potential benefits of E-NOTES and NOTES already exists. For instance, a reduction in port size decreases operative morbidity [1]. Mostafa et al compared patients undergoing needlescopic versus conventional laparoscopic appendectomy [2]. The needlescopic group had shorter hospital stay (1.3 d vs 3.2 d), reduced narcotic requirements, and faster return to work (8 d vs 17 d) than the conventional group. Similarly, in a randomized prospective comparison of conventional laparoscopic cholecystectomy versus the same procedure using downsized trocars (3.5 mm), Bisgaard et al detected important decrements in morbidity [3]. The group Table 1 Nonurologic E-NOTES procedures Procedure Year First report Approx no. of cases Transumb, single trocar Comments Tubal ligation 1969 Wheeless [4] >4000 U Has been performed as outpatient procedure under local anesthesia with sedation Total hysterectomy, BSO 1991 Pelosi et al [8] 1 U First case of complex extirpative pelvic surgery using a solitary intraumbilical incision Supracervical hysterectomy, BSO 1992 Pelosi et al [9] 4 U Concomitant intrauterine cannula for manipulation; offset eyepiece on laparoscope with 5-mm working channel; standard lap instruments used Appendectomy 1992 Pelosi et al [10] 180 U Cholecystectomy 1997 Navarra et al. [13] 1 Ovarian cystectomy 2001 Kosumi et al [15] 1 U Performed in an infant aged 2 mo where, after grasping the cyst through a trocar, cyst was aspirated and delivered through the umbilical incision Salpingectomy for ectopic pregnancy 2005 Ghezzi et al [16] 10 U Single umbilical trocar and percutaneous sling suture to retract the affected tube Peritoneal dialysis catheter 2005 Blessing et al [18] 25 Lap-assisted ventriculoperitoneal shunt 2006 Goitein et al [19] 7 5-mm periumbilical trocar with laparoscope allowed safe intraperitoneal placement of catheter tip Lap-assisted gastrostomy 2006 Kawahara et al [31] 22 Incision and 10-mm trocar placed at PEG site; stomach grasped and exteriorized with 3-mm instrument Meckel s diverticulectomy 2007 Cobellis et al [17] 9 U Abbreviations: E-NOTES, embryonic natural orifice transumbilical endoscopic surgery; BSO, bilateral salpingo-oophorectomy; PEG, Percutaneous endoscopic gastrostomy.

3 1022 european urology 54 (2008) with downsized trocars reported less incisional pain in the first postoperative week. Although limiting the size and/or number of trocars is clearly not the sole means of decreasing overall morbidity, the effect of restricting access to the umbilicus only (E-NOTES) or of removing transabdominal incisions completely (NOTES) warrants further evaluation. With each procedure, the possibility of inserting additional ports as necessary always exists, such that surgical safety and outcomes remain uncompromised Nonurologic E-NOTES procedures A review of nonurologic E-NOTES procedures is summarized in Table 1 and detailed in the following sections Tubal ligation Clifford Wheeless first published his technique of laparoscopic tubal ligation in 1969 [4]. He reported 2 yr later on 85 patients who had been sterilized using his single-incision outpatient technique [5]. Through a 1-cm, curved infraumbilical incision, he established CO 2 insufflation and inserted a laparoscope with an offset eyepiece. The uterus itself was manipulated externally with a tenaculum inserted through the vagina, bringing the fallopian tubes into view. A biopsy forceps was used to grasp and cauterize each fallopian tube. Wheeless later updated his series, reporting on 3600 cases, 2600 of which had one-incision tubal ligation [6]. The cosmetic benefits of this technique were recognized by Singh, who had performed >1000 single-trocar tubal sterilization procedures by 1977 [7]. He remarked, Wound healing is so satisfactory that no scar is grossly visible postoperatively Hysterectomy, bilateral salpingo-oophorectomy In 1991, Pelosi et al performed total hysterectomy with bilateral salpingo-oophorectomy (BSO), the first complex extirpative procedure using the single-puncture technique [8]. The following year, supracervical hysterectomy was performed for benign uterine disease in four patients, with application of the term minilaparocopy [9]. Similar to the technique for tubal sterilization, a laparoscope was used with an offset eyepiece and a 5-mm working channel through which standard laparoscopic instruments were inserted. The uterus was manipulated with a tranvaginal cannula. In their discussion, the authors highlighted presumed advantages of their technique: simplicity, lower cost, decreased trocar-site-related complications, improved cosmesis, and ability to convert to standard laparoscopy or open surgery when required Appendectomy Pelosi also reported the first series (n = 25) of single-trocar appendectomies in 1992 [10]. A larger series by D Alessio et al followed in 2001, with 116 patients undergoing one-trocar transumbilical laparoscopic-assisted appendectomy (TULAA) [11]. In 28 additional cases (19%), the majority of which had inflamed retrocecal appendix, additional trocars were inserted. Open surgery was required for six patients (4%). This group used an 11-mm Hasson trocar and an 11-mm laparoscope with a 5-mm working channel. The appendix was grasped and delivered through the umbilical incision, and the appendectomy was performed extracorporeally. Mean operative time was 35 min. The single-trocar group returned to normal activity at 7 d compared to 10 d for the multiple trocar group and 14 d for the open surgical cases. The authors commented that from an aesthetic point of view the transumbilical incision is practically invisible. In 2007, Ates et al reported 35 patients undergoing single-port appendectomy [12]. They used a specialized trocar with dual 5-mm working channels (Applied Medical, Rancho Santa Margarita, CA, USA). A laparoscope with an offset eyepiece and 6-mm working channel (Karl Storz, Tuttlingen, Germany) was employed. A percutaneous sling suture through the mesoappendix provided countertraction on the appendix, taking over the role usually reserved for a second instrument through an additional trocar Cholecystectomy The first transumbilical cholecystectomy was reported in 1997 by Navarra [13], followed shortly thereafter by Piskun in 1999 [14]. In the latter report, two separate 5-mm trocars were placed through a single intraumbilical incision. Two intraabdominal stay sutures facilitated surgical manipulation. The 5-mm fasciotomies were joined for specimen extraction. No extraumbilical incisions were required. The procedure was successfully completed without intraoperative complication in 10 patients Ovarian cystectomy Single-port ovarian cystectomy in an infant aged 2 mo was reported in 2001 [15]. The 6-cm cyst was accessible through a single 10-mm umbilical trocar grasped through the working channel of a Wolf cerebral endoscope (Panoview telescope, Richard Wolf, Knittlingen, Germany) and delivered to the umbilical incision where the cyst was aspirated, decorticated, and delivered back into the peritoneal cavity Salpingectomy for tubal ectopic pregnancy Normally a three-trocar procedure, laparoscopic salpingectomy through a single umbilical trocar was reported in 2005 [16]. Similar to the cases of appendectomy, these 10 cases of salpingectomy were aided by placing a midline percutaneous sling suture through the affected tube, suspending the fallopian tube and obviating the need for a second trocar Meckel s diverticulectomy In 2007, the single-trocar transumbilical approach to Meckel s diverticulectomy was used in nine patients [17]. In each case, the intestinal segment was brought out through the umbilical incision and bowel work was performed extracorporeally. A wide fasciotomy beneath the 10-mm skin incision was necessary to facilitate exteriorization and reintroduction of the ileum without inducing vascular congestion Miscellaneous Application of a single trocar to direct placement of intraperitoneal drains has been described, although morbidity data are lacking. Blessing et al elucidated their single-trocar technique for placement of a peritoneal dialysis catheter in 2005 [18]. Goitein et al described laparoscopically assisted ventroculoperitoneal shunt placement in 2006 [19], avoiding the typical

4 european urology 54 (2008) Table 2 E-NOTES urologic procedures Procedure First author Year No. of cases Comments Simple nephrectomy, ureterolithotomy Rane et al [22] R-port via extraumbilical flank incision for nephrectomy Simple nephrectomy, radical nephrectomy Raman et al [23] Multiple ports, single umbilical incision, additional 3-mm liver retraction port Simple nephrectomy Desai et al [24] Single transumbilical port exclusively Renal cryotherapy; sacrocolpopexy Kaouk et al [25] Single transumbilical port exclusively 4 Pyeloplasty, ileal ureter, psoas hitch ureteroneocystostomy Live-donor nephrectomy; partial nephrectomy Desai et al [29] Single transumbilical port; 2-mm needlescopic grasper Gill et al [27] Single transumbilical port; 2-mm 3 needlescopic grasper Pediatric varicocelectomy Kaouk et al [28] 2008 First experience in pediatrics Radical prostatectomy; Radical cystectomy Kaouk et al [30] Single transumbilical port exclusively; 3 ileal conduit urinary diversion Abbreviations: E-NOTES, embryonic natural orifice transumbilical endoscopic surgery. small midline laparotomy incision. A periumbilical 5-mm trocar with laparoscope was placed, allowing inspection of the peritoneal cavity to choose an ideal site for catheter insertion. The introducer/dilator was passed under laparoscopic vision, and the tip was guided toward the pelvis Urologic E-NOTES procedures Gettman et al recently recognized in a NOTES consensus paper that whereas NOTES is still evolving predominantly in the lab, single-access procedures such as E-NOTES are already being clinically implemented [20]. A review of urologic E-NOTES procedures is summarized in Table 2 and is detailed in the following sections Ports Recently, two trocar options for transumbilical laparoscopy have been reported in the urologic arena. These proprietary, multilumen, single-trocar systems include the R-port Fig. 2 Mock intraoperative view of the Uni-X multichannel port, where a combination of flexible and bent instruments allows tip separation and triangulation distally. Inset shows the port fixed in its intraumbilical position with fascial sutures. Of the three channels, the longer camera channel with insufflation inlet is seen. Fig. 1 Intraoperative photograph of the multichannel R- port in a transumbilical incision with a camera occupying one 5-mm inlet and the insufflation channel attached. (Advanced Surgical Concepts, Wicklow, Ireland), and the Uni-X single laparoscopic port system (Pnavel Systems, Morganville, NJ, USA). Multilumen access through a single intraumbilical incision can also be performed using standard laparoscopic trocars placed through adjacent fascial punctures. The R-Port consists of two components: (1) a fascial retractor containing an inner and an outer ring with an intervening plastic sleeve, and (2) a multichannel valve (one at 12 mm, two at 5 mm). Each component is covered with a thermoplastic elastomer that maintains a tight seal on pneumoperitoneum while allowing the smooth introduction of instruments and accessories. After making a vertical intraumbilical incision and releasing dermis from the fascia, a 2-cm fasciotomy is made in an open or Hasson fashion. The inner ring is loaded within a nonbladed introducer that

5 1024 european urology 54 (2008) Table 3 Multichannel ports for single-port procedures Port Manufacturer Lumens Fixation mech Valve mech R-port Uni-X Advanced Surgical Concepts, Wicklow, Ireland Pnavel Systems, Morganville, NJ, USA One at 12 mm, two at 5 mm Inner/outer ring, intervening taut plastic sleeve Gel elastomer Three at 5 mm Fascial sutures Rubber inlet Table 4 Specialized instruments Instrument Manufacturer Size Comment Flexible grasper, needle holder, scissors Flexible laparoscopic grasper, needle holder, scissors Flexible endoscope Rigid 308 endoscope Bent laparoscopic grasper RealHand; Novare Surgical Systems, Cupertino, CA, USA Autonomy Lapro-Angle; Cambridge Endo, Framingham, MA, USA Olympus Surgical, Orangeburg, NY, USA Pnavel Systems Inc, Morganville, NJ, USA 5mm 5 mm Bulky handle can be obstacle with external instrument crowding 5 mm Bulk of standard laparoscopic cameras exacerbate crowding. These streamlined digital cameras minimize clashing 5 mm Position of curved shaft can be altered by rotational knob deploys the inner ring intraperitoneally. Slack is removed, whereby the taut plastic sleeve effectively tents open the fasciotomy and tightly approximates the rings to create an effective seal. Once deployed, the retractor is reminiscent of a miniature hand port to which the multivalve cap with insufflation inlet is attached (Fig. 1). The Uni-X system consists of an inverted-cone-shaped, plastic outer unit converging on three separate 5-mm inlets. The device is also inserted using a Hasson technique. Four fascial sutures affixed to the device effectively create a tight seal for pneumoperitoneum (Fig. 2). Features of the R-Port and Uni-X systems are compared in Table Instrumentation In addition to standard laparoscopic instruments, either bent or flexible instrumentation has been used to facilitate dissection and/or intracorporeal suturing. A list of instruments can be seen in Table Animal studies In the porcine model, Zeltser et al reported single-trocar nephrectomy using novel magnetically anchored instruments, each deployed through the 15-mm umbilical portal of entry [21]. The relatively thin porcine abdominal wall allowed fixation of both a camera and a robotic cautery arm using magnetic couplers. Each of these was hardwired to external guidance systems, and light was provided by fiberoptic cables surrounding the umbilical trocar itself. Standard laparoscopic graspers and the vascular stapler were manipulated through the umbilical trocar, and tissue dissection was accomplished with the robotic arm. The specimen was extracted through the solitary umbilical incision. As of this writing, the use of magnetically anchored instruments to facilitate urologic E-NOTES procedures has not been reported in humans. 3. Results 3.1. Clinical applications Nephrectomy, ureterolithotomy, pyeloplasty The first two cases of single-port surgery in urology were reported by Rane et al, in abstract form, at the 2007 World Congress of Endourology in Cancun, Mexico [22]. The first report of single-port, nontransumbilical, simple nephrectomy described an R- port situated in a flank incision for retroperitoneoscopy. The patient was a 36-yr-old man with a small, nonfunctioning right kidney. The second case described laparoscopic transperitoneal ureterolithotomy for an impacted 2.5-cm proximal ureteral stone, performed exclusively with an intraumbilical R-port. Subsequently, the first multitrocar single-incision transumbilical nephrectomy was reported by Raman et al [23]. Following an initial porcine feasibility demonstration, three human nephrectomies were performed: two for benign nonfunction and one for a 4.5-cm clear-cell carcinoma. Mean operative time was 133 min. Through a single umbilical incision, three adjacent conventional trocars (one at 12 mm, two at 5 mm) were placed. The hilum was transected using an endovascular stapler through the 12-mm port. On the right side (nephrectomy for carcinoma), static liver retraction required an extraumbilical skin incision for a 3-mm instrument. Dissection was facilitated by flexible laparoscopic instruments (RealHand, Novare Surgical Systems, Cupertino, CA, USA) and either an

6 european urology 54 (2008) angled, rigid 5-mm endoscope or a flexible-tip video endoscope (Olympus Surgical, Orangeburg, NY, USA). The first single-port transumbilical nephrectomy was reported by Desai et al in 2007 [24]. Specialized instrumentation and accessories included the R-port; a 5-mm, 308 endoscope (EndoEye; Olympus Medical, Tokyo, Japan); and curved laparoscopic grasping instruments (Advanced Surgical Concepts). The transperitoneal left nephrectomy, performed for benign nonfunctioning kidney after failed pyeloplasty, was performed in 3.6 h without any extraumbilical skin incisions. The endoscope occupied one inlet at all times, and a combination of a bent grasper and straight scissors or harmonic scalpel allowed tissue presentation under tension sufficient for precise dissection. Hemolock clips (Teleflex Medical, Research Triangle Park, NC, USA) were used for renal artery and vein control. This same report described single-port transumbilical pyeloplasty for primary right ureteropelvic junction (UPJ) obstruction [24]. A 2-mm needlescopic grasper was used through a Veres Minisite port (USSC, Norwalk, CT, USA) that had been used to establish pneumoperitoneum in the left hypochondrium. A 5-mm atraumatic grasper placed transumbilically through one of the three proprietary inlets was used for liver retraction as needed. The solitary umbilical incision was used to exteriorize a penrose drain at the conclusion of the case. No functional outcomes were reported Cryotherapy, kidney biopsy, sacrocolpopexy Kaouk et al reported seven patients undergoing single-port transumbilical urologic laparoscopic procedures [25]: renal cryotherapy (n = 2), wedge kidney biopsy (n = 1), and sacrocolpopexy (n = 4). In these cases, the Uni-X single port was used. These seven patients underwent transperitoneal procedures through the umbilicus without extraumbilical incisions. For this series, standard laparoscopic instruments, a flexible 5-mm endoscope (Olympus Surgical), and bent laparoscopic instruments (Pnavel Systems) were used. Three additional patients underwent extraumbilical skin incisions: retroperitoneoscopic cryotherapy (n = 2) with incision at the tip of the 12th rib, and radical nephrectomy (n =1) with a 12-mm trocar placed through a standard Gibson incision for various intraoperative manipulations and ultimate specimen extraction. The first series of single port cryotherapy was reported by Goel and Kaouk [26]. E-NOTES cryotherapy was performed in two patients undergoing a transperitoneal approach for anterior tumors, and four patients had retroperitoneoscopic single-port cryotherapy with the multilumen port positioned at the tip of the 12th rib for posterior tumors. Mean tumor size was 2.6 cm. Although instrument clashing was frequent, cryotherapy was feasible without intraoperative complication, and mean hospital stay was 2.3 d. In these cases, an endoscope with a flexible tip allowed the assistant to change the surgical view while leaving the external segment still, thereby maximizing space for the primary surgeon s movements Live-donor nephrectomy Gill et al reported the initial four patients who underwent E-NOTES live-donor nephrectomy for transplantation [27]. Through an intraumbilical incision, the novel R-Port was inserted into the abdomen. A 2-mm Veres needle port, inserted via skin needlepuncture to create pneumoperitoneum, was used to selectively insert a needlescopic grasper for tissue retraction. The vessels were controlled in identical fashion to standard donor nephrectomy: the artery was controlled with hemolock clips (Teleflex Medical, Research Triangle Park, NC), and the vein was controlled with an articulating vascular Endo-GIA stapler (US Surgical, Norwalk, CT). Excellent donor vascular and tissue dissection could be performed, and a quality donor kidney was retrieved transumbilically after preentrapment; median umbilical incision length was 4 cm (Figs. 3 and 4). E-NOTES donor nephrectomy was successful in all four patients without any extraumbilical skin incision or conversion to standard laparoscopy. Median operating time was 3.3 h, blood loss was 50 cc, warm ischemia time was 6.2 min, and hospital stay was 3 d. One patient had two left renal arteries; each was controlled individually. Median length of harvested renal artery was 3.3 cm, renal vein was 4 cm, and ureter was 15 cm. No intraoperative complications occurred. Fig. 3 Donor allograft on the back bench demonstrates vessel length commensurate with standard laparoscopy.

7 1026 european urology 54 (2008) bilateral single-session pyeloplasty, and psoas hitch ureteroneocystostomy [29]. In addition, complex extirpative procedures requiring reconstruction have been accomplished, including E-NOTES partial nephrectomy, radical prostatectomy, and radical cystectomy with extended pelvic lymphadenectomy [30]. 4. Discussion 4.1. Technical challenges Fig. 4 Postoperative photograph at 2 wk following embryonic natural orifice transumbilical endoscopic surgery (E-NOTES) donor nephrectomy. Median donor visual analog scale (VAS) upon discharge was 2/10. Convalescence was completed by 2 wk, as reflected by VAS scores of 0/10 at 2 wk with no patient taking any pain medications. All allografts functioned immediately upon transplantation, with early nadir serum creatinine mg/dl. Since starting our E-NOTES program, we have performed nine consecutive E-NOTES donor nephrectomies and are in the process of comparing outcomes of E-NOTES and standard laparoscopy. E-NOTES donor nephrectomy appears to have relevance and promise, especially for this typically younger, altruistic population. Although this initial experience is encouraging, more data and experience at additional centers are necessary Pediatric E-NOTES The first series of single port urologic laparoscopy in children was reported by Kaouk and Palmer, who successfully performed E-NOTES varicocelectomy in three adolescents aged yr [28]. Each patient had grade 3 varicoceles, and the testicular artery and vein were transected between clips. At 2-mo followup, no varicocele recurrence or complication had occurred, including hydrocele, infection, or incisional sequelae Unpublished data To date at the Cleveland Clinic, complex reconstructive E-NOTES urologic procedures have been performed, including ileal ureteral interposition, Triangulation Wide spacing of trocars is considered a tenet of multitrocar standard laparoscopy. Instrument triangulation allows proper tissue retraction, which is essential for proper dissection along anatomical tissue planes. Placing several parallel instruments makes triangulation more difficult. Using at least one flexible or curved instrument offsets the shafts sufficiently to accomplish some degree of triangulation. Often this requires counterintuitive movements on the outside, where the surgeon s instruments may cross each other. Although generally frowned upon during standard laparoscopy, crossing instruments may often be necessary in single-port access surgery Retraction The use of fixation or sling sutures can achieve retraction that is normally accomplished by an additional assistant trocar. These can either be static intra-abdominal sutures affixed to the parietal peritoneum or percutaneous sutures grasped and manipulated extracorporeally to maintain variable traction as dissection proceeds. The general literature shows that these techniques have proved useful for salpingectomy [16], appendectomy [12], and cholecystectomy [14]. In the case of pyeloplasty, suturing the lateral cut edge of Gerota s fascia to the lateral abdominal wall is another example of securing wide exposure of the operative field without adding ports Instrument crowding External crowding and clashing of instruments is the most salient and frustrating aspect of the learning curve for these procedures. One must choose instruments that will set the stage for success. For one, the instrument profile should be as slim as possible. A primary advantage of the EndoEye camera system (Olympus Medical) is its streamlined profile, whereas the standard laparoscopic light cable enters the lens at 908 and its interaction with adjacent instruments is severely limiting, even prohibitive.

8 european urology 54 (2008) Using instruments of differential overall lengths is also helpful. If one camera and two instruments occupy the multichannel port, varying lengths prevent the bulkiest portion of each instrument (the external handle) from overlapping extracorporeally. We have found, for instance, that using a standard laparoscopic grasper and a bariatric suction cannula, which is longer than the standard length lap instruments, minimizes external clashing to some degree. In addition, a vigilant camera controller anticipates clashing and chooses an alternate camera angle that, like a pair of scissors opening, moves the camera away from the active surgical instruments Inline vision During standard laparoscopy, depth perception is lost when the camera lines up with the shaft of a working instrument. This can become an issue during single-port surgery. The surgeon must become accustomed viewing angles that would otherwise seem suboptimal during standard laparoscopy. The flexible-tip endoscope ameliorates this problem to some degree Patient-related limitations Using the umbilicus as the portal of entry limits the appropriate candidates for this approach. For uppertract surgery in obese patients during standard laparoscopy, trocars are typically shifted laterally and are based off of bony landmarks. The umbilicus itself ceases to become a useful landmark because its distance to the target organ increases; for this reason, obese patients are not suitable for E-NOTES. Similarly, the umbilicus in tall patients may be too far from the upper pole of the kidney. Such considerations would play a role in patient selection. An umbilical hernia is not a contraindication because direct umbilical access affords the opportunity for simultaneous hernia repair. These challenges underscore the need for technical facility and broad experience with standard multiport laparoscopy as a prerequisite to attempting E-NOTES procedures Future instrumentation Early experience demonstrates that specific areas exist for task-specific instrument development. Currently, large external movements are required for internal maneuvering, causing instrument clashing. Robotic or motorized instruments could address this problem, since fine movements would be generated at the instrument tip itself. Instrumentation with low-profile, streamlined handpieces would also address issues of extracorporeal crowding. Flexible instrumentation must be refined; currently, force applied to the instrument tip dissipates along the flexible portion of the shaft, limiting some maneuvers during blunt dissection Impact on standard laparoscopy Single-port laparoscopy has had a positive effect on standard laparoscopy. Undoubtedly, single-port laparoscopy, even with flexible instrumentation, is technically more challenging than straight laparoscopy; however, we are still in the initial learning curve. This new technique of single-port surgery has brought to light various superfluous aspects of standard laparoscopy and seems to have facilitated these cases as well. Instead of routinely placing ancillary assistant ports for upper-tract surgery, for example, one may substitute a static or dynamic retraction suture or discover that lateral retraction in a given case is unnecessary. 5. Conclusions As with many surgical leaps forward, one needs simply to look back in history to find wheels being reinvented as themes repeat. The same is true for E- NOTES, where we now walk on a previously trodden path. Our gynecology colleagues paved the way almost 40 yr ago, having performed thousands of virtually scar-free tubal ligations. These were indeed the first E-NOTES procedures, complete with concomitant manipulation of the uterus using the vaginal natural orifice and all of this before standard multiple-trocar laparoscopy was even in our collective consciousness. Without mainstream standard laparoscopy to bolster its existence, however, it would take many years for single-port surgery to reappear in published series. After the pioneering efforts in single-port gynecologic surgery, such procedures took little foothold. Instrumentation to perform complex maneuvers intracorporeally did not exist. This accounts for several reports of single-port surgery that can best be regarded as hybrid reports, in which the pathologic target organ was exteriorized through the umbilicus and extracorporeal open surgery was performed [11,15,17]. Several decades would pass before flexible instrumentation caught up with the surgical concept. Currently, although the cosmetic benefit is apparent, the true impact of E-NOTES on perioperative pain and morbidity are not known. Patient attitudes about scar-free surgery have also not been quantified. Cost differences between single- and multiple-port laparoscopy are being studied but are not yet known.

9 1028 european urology 54 (2008) The incremental benefit in morbidity is not likely to match that seen with the jump from open to conventional laparoscopic surgery. This, however, is no justification for accepting the status quo. A prospective multi-institutional clinical trial comparing E-NOTES to standard laparoscopy is essential to discern whether incremental benefits exist. Flexible multichannel robotic systems and standalone deployable miniature robots are not far off. When these technologies become widely available, both E-NOTES and NOTES procedures will advance even further. Currently, careful case selection is paramount so that these procedures can be explored safely, with a low threshold to convert to standard laparoscopy as indicated for safety and quality of care. Author contributions: David Canes had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Gill, Desai, Kaouk, Canes. Acquisition of data: Canes, Goel, Aron, Stein. Analysis and interpretation of data: Canes, Haber. Drafting of the manuscript: Canes, Gill, Desai. Critical revision of the manuscript for important intellectual content: Canes, Gill. Statistical analysis: None. Obtaining funding: None. Administrative, technical, or material support: None. Supervision: None. Other (specify): None. Financial disclosures: I certify that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None. Funding/Support and role of the sponsor: None. References [1] Soble JJ, Gill IS. Needlescopic urology: incorporating 2-mm instruments in laparoscopic surgery. Urology 1998;52: [2] Mostafa G, Matthews BD, Sing RF, Kercher KW, Heniford BT. Mini-laparoscopic versus laparoscopic approach to appendectomy. BMC Surg 2001;1:4. [3] Bisgaard T, Klarskov B, Trap R, Kehlet H, Rosenberg J. Microlaparoscopic vs conventional laparoscopic cholecystectomy: a prospective randomized double-blind trial. Surg Endosc 2002;16: [4] Wheeless CR. A rapid, inexpensive and effective method of surgical sterilization by laparoscopy. J Reprod Med 1969;3(5):65 9. [5] Wheeless CR. Outpatient laparoscope sterilization under local anesthesia. Obstet Gynecol 1972;39: [6] Wheeless Jr CR, Thompson BH. Laparoscopic sterilization. Review of 3600 cases. Obstet Gynecol 1973;42: [7] Singh KB. Tubal sterilization by lararoscopy. Simplified technique. N Y State J Med 1977;77: [8] Pelosi MA, Pelosi 3rd MA. Laparoscopic hysterectomy with bilateral salpingo-oophorectomy using a single umbilical puncture. N J Med 1991;88: [9] Pelosi MA, Pelosi 3rd MA. Laparoscopic supracervical hysterectomy using a single-umbilical puncture (minilaparoscopy). J Reprod Med 1992;37: [10] Pelosi MA, Pelosi 3rd MA. Laparoscopic appendectomy using a single umbilical puncture (minilaparoscopy). J Reprod Med 1992;37: [11] D Alessio A, Piro E, Tadini B, Beretta F. One-trocar transumbilical laparoscopic-assisted appendectomy in children: our experience. Eur J Pediatr Surg 2002;12:24 7. [12] Ateş O, Hakgüder G, Olguner M, Akgür FM. Single-port laparoscopic appendectomy conducted intracorporeally with the aid of a transabdominal sling suture. J Pediatr Surg 2007;42: [13] Navarra G, Pozza E, Occhionorelli S, Carcoforo P, Donini I. One-wound laparoscopic cholecystectomy. Br J Surg 1997;84:695. [14] Piskun G, Rajpal S. Transumbilical laparoscopic cholecystectomy utilizes no incisions outside the umbilicus. J Laparoendosc Adv Surg Tech A 1999;9: [15] Kosumi T, Kubota A, Usui N, Yamauchi K, Yamasaki M, Oyanagi H. Laparoscopic ovarian cystectomy using a single umbilical puncture method. Surg Laparosc Endosc Percutan Tech 2001;11:63 5. [16] Ghezzi F, Cromi A, Fasola M, Bolis P. One-trocar salpingectomy for the treatment of tubal pregnancy: a marionette-like technique. BJOG 2005;112: [17] Cobellis G, Cruccetti A, Mastroianni L, Amici G, Martino A. One-trocar transumbilical laparoscopic-assisted management of Meckel s diverticulum in children. J Laparoendosc Adv Surg Tech A 2007;17: [18] Blessing Jr WD, Ross JM, Kennedy CI, Richardson WS. Laparoscopic-assisted peritoneal dialysis catheter placement, an improvement on the single trocar technique. Am Surg 2005;71: [19] Goitein D, Papasavas P, Gagné D, Ferraro D, Wilder B, Caushaj P. Single trocar laparoscopically assisted placement of central nervous system-peritoneal shunts. J Laparoendosc Adv Surg Tech A 2006;16:1 4. [20] Gettman MT, Box G, Averch T, et al. 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10 european urology 54 (2008) [23] Raman JD, Bensalah K, Bagrodia A, Stern JM, Cadeddu JA. Laboratory and clinical development of single keyhole umbilical nephrectomy. Urology 2007;70: [24] Desai MM, Rao PP, Aron M, et al. Scarless single port transumbilical nephrectomy and pyeloplasty: first clinical report. BJU Int 2008;101:83 8. [25] Kaouk JH, Haber GP, Goel RK, et al. Single-port laparoscopic surgery in urology: initial experience. Urology 2008;71:3 6. [26] Goel RK, Kaouk JH. Single port access renal cryoablation (SPARC): a new approach. Eur Urol 2008;53: [27] Gill IS, Canes D, Aron M, et al. Single port transumbilical (E-NOTES) donor nephrectomy. J Urol 2008;180: [28] Kaouk JH, Palmer JS. Single-port laparoscopic surgery: initial experience in children for varicocelectomy. BJU Int 2008;102:97 9. [29] Desai MM, Stein RJ, Rao P, et al. E-NOTES (embryonic natural orifice surgery) for advanced reconstruction: initial experience. Urology. In press. [30] Kaouk JH, Goel RK. Single port laparoscopic pelvic surgery: a scar-less approach. Abstract presented at: Annual Meeting of the Society of Gastrointestinal and Endoscopic Surgeons; April 9 12, 2008; Philadelphia, PA, USA. Abstract 201. [31] Kawahara H, Kubota A, Okuyama H, et al. One-trocar laparoscopy-aided gastrostomy in handicapped children. J Pediatr Surg 2006;41: Editorial Comment on: Transumbilical Single- Port Surgery: Evolution and Current Status Richard Zigeuner Department of Urology, Medical University Graz, Graz, Austria Richard.zigeuner@meduni-graz.at In this review article [1], the authors report on further progress in the rapidly evolving field of laparoscopy. Transumbilical single-port surgery, also referred to as embryonic natural orifice transumbilical endoscopic surgery (E-NOTES), has been performed only in a limited number of patients so far; the authors institution is the most experienced. Despite this fact, the authors critically reflect on the question of true clinical advantages of E-NOTES without exaggerated enthusiasm. The procedures are more technically challenging, even in the hands of very experienced laparoscopists, which may limit the widespread use of the method. The very timely issue of cost-effectiveness compared to standard laparoscopy cannot currently be clarified because data are lacking; however, higher costs may be expected due to the requirement of more sophisticated instruments. Most importantly, because this novel method is in its infancy, we have no information about whether technical progress will translate into patient benefit. Using E-NOTES, separate incisions for additional trocars can be spared, but the incision must still be enlarged for kidney retrieval after nephrectomy. There is no doubt that laparoscopy has brought relevant benefit for patients, as proven in prospective trials in renal surgery [2,3]. With regard to prostatectomy, the other widely used laparoscopic procedure in urology, the real clinical advantage of laparoscopy over open surgery has not been proven [4,5]. Despite the absence of any prospective randomised data proving superiority of laparoscopy over the open approach, laparoscopic and robotic prostatectomies are increasingly performed worldwide, even against the background of published disadvantages regarding higher incontinence and readmission rates [5]. Consequently, the scientific urologic community has to maintain critical assessment of any novel methods, even against pressure from industry and marketing. As the authors correctly state, prospective trials comparing E-NOTES to conventional laparoscopy are essential to prove clinical advantages. References [1] Canes D, Desai MM, Aron M, et al. Transumbilical singleport surgery: evolution and current status. Eur Urol 2008;54: [2] Rassweiler J, Gumpinger R, Miller K, Hölzermann F, Eisenberger F. Multimodal treatment (extracorporeal shock wave lithotripsy and endourology) of complicated renal stone disease. Eur Urol 1986;12: [3] Fornara P, Doehn C, Seyfarth M, Jocham D. Why is urological laparoscopy minimally invasive? Eur Urol 2000;37: [4] Jurczok A, Zacharias M, Wagner S, Hamza A, Fornara P. Prospective non-randomized evaluation of four mediators of the systemic response after extraperitoneal laparoscopic and open retropubic radical prostatectomy. BJU Int 2007;99: [5] Touijer K, Eastham JA, Secin FP, et al. Comprehensive prospective comparative analysis of outcomes between open and laparoscopic radical prostatectomy conducted in 2003 to J Urol 2008;179: DOI: /j.eururo DOI of original article: /j.eururo

11 1030 european urology 54 (2008) Editorial Comment on: Transumbilical Single- Port Surgery: Evolution and Current Status Jens Rassweiler Department of Urology, SLK Kliniken Heilbronn, D Heilbronn, Germany Canes and colleagues focus our attention on a further modification of laparoscopic surgery: the transumbilical single-port surgery [1]. Their historical overview demonstrates clearly that this is an old technique pioneered by gynecologists in the 1960s using an operative laparoscope with an offset eyepiece comparable to the rigid nephroscopes used during percutaneous renal surgery [2,3]. However, in the year 2008, it seems that things have to be more fancy. Whereas laparoscopists initially used the umbilicus as an easy-to-hide entrance for the trocar, in the era of natural orifice transluminal endoscopic surgery (NOTES), the umbilicus has gained more importance, being recognized as an embryonic natural orifice. This has resulted in the new term E-NOTES. But the reader should be aware of the distinct differences between NOTES and the transumbilical laparoscopic single port technique. NOTES has been pioneered by gastroenterologists and surgeons who used the technology of a flexible gastroscope with different working channels to perforate the stomach and then to reach the peritoneal cavity. In the peritoneal cavity, complex procedures such as appendectomy and cholecystectomy have been carried out using specialized flexible endoscopes and devices (ie, intraluminal clip appliers). After transoral removal of the organ, the gastric wall was closed with intraluminal suturing techniques [4]. Single-port surgery is completely different and goes back to the operative resectoscope developed by Buess in the 1980s for transanal endoscopic microsurgery [5]. This device consists of a rectoscope 40 mm in diameter with up to five ports for insertion of the telescope and curved instruments. The principle of this device has been modified for transumbilical laparoscopy with three ports for insertion of a rigid or flexible telescope and flexible or bent instruments. Although the necessity and importance of an operative nephroscope, a complex gastro- or coloscope, and an operative resectoscope has been proven over decades for intraluminal surgery, the role of such devices for transluminal and laparoscopic surgery remains uncertain. It is impressive to see what type of laparoscopic procedures have been carried out, but in my view, there is still no argument for not using the standard trocar technique, which provides efficient solutions to the main problems of E-NOTES, such as triangulation, retraction, instrument crowding, and in-line vision. However, endoscopic surgey will definitely benefit from the technological input (ie, flexible instruments, staplers) of these new old techniques. References [1] Canes D, Desai MM, Aron M, et al. Transumbilical singleport surgery: evolution and current status. Eur Urol 2008;54: [2] Rassweiler J, Gumpinger R, Miller K, Hölzermann F, Eisenberger F. Multimodal treatment (extracorporeal shock wave lithotripsy and endourology) of complicated renal stone disease. Eur Urol 1986;12: [3] Wheeless CR. A rapid, inexpensive and effective method of surgical sterilization by laparoscopy. J Reprod Med 1969;5: [4] Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavitiy. Gastointest Endosc 2004;60: [5] Buess G, Kipfmüller K, Hack D, Grüssner R, Heintz A, Junginger T. Technique of transanal endoscopic microsurgery. Surg Endosc 1988;2:71 5. DOI: /j.eururo DOI of original article: /j.eururo