Technique of Laparoscopic-Endoscopic Single-Site Surgery Radical Nephrectomy

EUROPEAN UROLOGY 56 (2009) 644 650 available at www.sciencedirect.com journal homepage: www.europeanurology.com Surgery in Motion Technique of Laparoscopic-Endoscopic Single-Site Surgery Radical Nephrectomy Jens-Uwe Stolzenburg a, Panagiotis Kallidonis b, Giles Hellawell c, Minh Do a, Tim Haefner a, Anja Dietel a, Evangelos N. Liatsikos a,b, * a Department of Urology, University of Leipzig, Leipzig, Germany b Department of Urology, University of Patras, Patras, Greece c Department of Urology, Northwick Park Hospital, London, United Kingdom Article info Article history: Accepted June 9, 2009 Published online ahead of print on June 23, 2009 Keywords: Single-site Laparoscopic surgery LESS Nephrectomy Abstract Background: Laparoscopic-endoscopic single-site surgery (LESS) represents the closest surgical technique to scar-free surgery. Objective: To assess the feasibility of LESS radical nephrectomy (LESS-RN). Design, setting, and participants: Ten patients with body mass index (BMI) 30 underwent LESS-RN for renal tumour by two experienced laparoscopists. Surgical procedure: TriPort (Olympus Winter & Ibe, Hamburg, Germany) was inserted through a transumbilical incision. A combination of standard laparoscopic instruments and flexible grasper and scissors was used. A 5-mm 308 camera was also used. The standard laparoscopic transperitoneal nephrectomy technique was performed. Measurements: Patient demographics, operative details, and final pathology were prospectively recorded. Postoperative evaluation of pain and use of analgesic medication were recorded. Results and limitations: Ten cases were successfully accomplished (two rightsided tumours and eight left-sided tumours; tumour diameter ranges: 4 8 cm). The mean patient age was 63.5 yr (22 77 yr), and median BMI was 23.56 (18.2 26.6). The mean operative time was 146.4 min (120 180 min), and the mean blood loss was 202 ml (50 900 ml). Pathological examination observed organ-confined T1 renal cell carcinoma in nine cases and pt3b tumour in one case. One bleeding complication occurred. Limitations regarding the intraoperative instrument ergonomics and the requirement for ambidexterity of the surgeon were noted. Conclusions: LESS-RN proved to be safe and feasible. Further clinical investigation in comparison to the established techniques should take place to evaluate the outcome of LESS-RN. # 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Department of Urology, University of Patras Medical School, Rion, 26 500, Patras, Greece. Tel. +30 2610 999386; Fax: +30 2610 993981. E-mail address: liatsikos@yahoo.com (E.N. Liatsikos). 0302-2838/$ see back matter # 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2009.06.022

EUROPEAN UROLOGY 56 (2009) 644 650 645 1. Introduction The European Association of Urology guidelines (2008) propose laparoscopic radical nephrectomy (LRN) as the first-line treatment approach for T1/T2-stage renal cell carcinoma (RCC) [1]. The minimally invasive nature of LRN has been proved by Fornara et al, who showed the limited acute systemic reaction associated with laparoscopic access in comparison to open nephrectomy [2,3]. Nevertheless, the laparoscopic ports used in LRN are (rarely) related to complications. Bleeding, hernia, and organ damage are related to trocar insertion. Moreover, the 1- to 2-cm incisions performed for trocar placement may result in multiple scar formation and compromised cosmetic outcome [4]. The performance of a transumbilical incision and insertion of all appropriate instruments through a specially designed single port allows the safe performance of several urologic procedures and minimises the number of ports. The latter technique is called laparoscopic-endoscopic singlesite surgery (LESS), while consensus on terminology remains to be clarified [5]. The umbilical approach has been successfully used for several procedures [6 10]. In the current report, we present our technique for LESS radical nephrectomy (LESS-RN) and present our preliminary experience with 10 cases. 2. Methods LESS-RN was performed in 10 patients with renal tumours. Two experienced laparoscopic surgeons performed all procedures (JUS, ENL). The indications for the nephrectomy were cases of T2 tumour stage or lower without evidence of lymphadenopathy or renal vein involvement. Additional selection criteria were body mass index (BMI) 30 and absence of health conditions precluding a laparoscopic procedure. Patients included in the study were not candidates for partial nephrectomy (ie, localisation in hilum, significant involvement of pelvicalyceal, nonfunctioning kidneys, tumour size) or the patient decided to undergo a radical procedure despite the selective indications for partial nephrectomy. In the latter cases, the patient decided between a laparoscopic partial or radical nephrectomy after a comprehensive discussion. If the patient decided to undergo the radical procedure, the possibility of a LESS-RN was proposed. All cases were evaluated with computed tomography preoperatively. Magnetic resonance imaging took place if deemed necessary. None of the patients had undergone previous abdominal surgery. Tumour size and localisation as well as operative time, blood loss, pathology result, incision length, and perioperative complications were recorded. Postoperative pain and need for analgesia were assessed by documentation via questionnaire of the patient s perceived pain on an analogical pain scale ranging from 1 10. Minimal pain was described as 1 while the worst possible pain was described as 10. Pain evaluation data were obtained three times daily starting on the first postoperative day and continuing for 3 d (until the third postoperative day). Administration of analgesic medication was recorded for the first two postoperative days. 2.1. Laparoscopic-endoscopic single-site surgery radical nephrectomy technique The technique of LRN is well standardised. The sequence of steps of LESS- RN is comparable to LRN. Our main goal is to describe the LESS-RN technique step by step, aiming to make this standardised technique reproducible. The following steps are presented: 1. Operative setup and patient positioning 2. Instruments 3. Port placement 4. Exposure of kidney (bowel reflection) 5. Ureter mobilisation 6. Hilar dissection and control of the renal pedicle 7. Final renal mobilisation 8. Specimen removal 2.1.1. Operative setup and patient positioning The patient is positioned in a modified lateral decubitus position (classical flank position, Fig. 1A and B) for trocar placement. Pressure points are minimised and the upper arm is brought cranially and secured on a cradle with posterior supports. The operative table is slightly flexed Fig. 1 (A) Patient in modified lateral decubitus position; (B) the visual aspect of the surgical team.

646 EUROPEAN UROLOGY 56 (2009) 644 650 Fig. 2 (A) Graphical representation of a TriPort; (B) graphical representation of roticulating instrument. in the middle. The level of the umbilicus of the patient is positioned over the break of the operative table. 2.1.2. Instruments A single-incision port that provides access for several instruments was used. The TriPort (Olympus Winter & Ibe, Hamburg, Germany) has three channels (one 12-mm and two 5-mm channels) and an insufflation channel (Fig. 2). The elastomeric composition of the TriPort valve component allows simultaneous insertion of laparoscopic instruments and laparoscope. A308lens high-definition laparoscopic camera (EndoEye, Olympus Medical, Tokyo, Japan) with 5-mm diameter was used in all cases. The laparoscope is inserted through one of the 5-mm channels and frees the 12-mm channel for insertion of instruments with diameter >5 mm such as Hem-o-lok clips (Teleflex Medical, Research Triangle Park, North Carolina, USA) and/or the vascular Endo GIA linear stapler. The use of a flexible forceps (RealHand, Novare Surgical Systems Inc, Cupertino, CA, USA) is essential for a single-port nephrectomy since triangulation of the conventional laparoscopic instruments is not possible in LESS. The flexible handpiece is articulated, and up to 908 of movement at the handpiece is mirrored at the forceps end (Fig. 2). A combination of flexible forceps and a conventional laparoscopic (straight) instrument (eg, scissors, ultrasound scissors, bipolar forceps) was used to perform the procedures. The instruments were inserted through one of the 5-mm channels and the 12-mm channel of the TriPort. Additional direct 3-mm instrument (without trocar) or 5-mm trocar placement (instrument exchange possible) and forceps insertion can be performed in cases of right-side nephrectomy for safe liver retraction. The instrument is inserted in the anterior axillary line below the 12th rib according to the preference of the surgeon. 2.1.3. Port placement The operative table is moved back into dorsal supine position and a minilaparotomy is performed for the insertion of the TriPort. The TriPort consists of a retractor and a valve (Fig. 3C). The retractor includes one internal ring and two external rings and a doubled-over cylindrical plastic sleeve. The valve is composed of elastomeric material for smooth instrument insertion. To deploy the TriPort, the inner ring is preloaded onto a trocar and the ring is pushed into the abdominal cavity with an introducer (Fig. 3A andb). The latter is retracted and the sleeve is tightened to draw the inner ring toward the abdominal wall and the outer ring. The latter manoeuvre provides tension that retracts the abdominal wall edges prior to securing with the external locking ring. The securely approximated rings represent an effective seal, preventing gas leakage. Fig. 3 (A) Graphical representation of the method which stabilises the inserted TriPort on the abdominal wall; (B) tightening of the TriPort sleeve; (c) a TriPort, including all necessary parts for placement.

EUROPEAN UROLOGY 56 (2009) 644 650 647 Fig. 4 (A) Dissection along the line of Toldt (notice the manoeuvre of the flexible grasper); (B) early mobilisation and ligation of the ureter. 2.1.4. Exposure of kidney (bowel reflection) During the performance of left nephrectomy, the white line of Toldt is incised from the level of the iliac vessels to above the spleen. Incision of the splenocolic ligament follows in order to mobilise the spleen along with the colon and pancreas. Careful dissection should be performed for the prevention of injury of the spleen or diaphragm. The roticulating forceps, held in the left hand, are used to expose the tissue (Fig. 4A). The straight instrument in the right hand is used to dissect the tissue and to cut along the line of Toldt. Right nephrectomy starts with peritoneal incision carried cephalad above the hepatic flexure, including the right triangular and right anterior coronary vessels. The dissection of the line of Toldt is performed. Colon retraction and division of all lateral ligaments follows. Gerota s fascia and the psoas muscle are identified. Colorenal attachments are also divided. Additional retraction of the liver may be required on the right side using 3- mm grasping forceps inserted directly through the skin. 2.1.5. Ureter mobilisation The middle portion of the ureter is located in the retroperitoneal fat medially to the psoas muscle. The flexible instrument is used to grasp the ureter, and the straight instrument is used for dissection. Dexterity in both of the surgeon s hands is essential during all steps of the procedure due to lack of triangulation and crossing of instruments as they pass through the TriPort. The gonadal vein is identified as the proximal mobilisation of the ureter takes place. The vessel should be swept medially. If small vessels are present, ligation should be performed in order to facilitate ureter mobilisation. The ureter is located just posterior to the gonadal vein. The ureter is elevated. Early dissection of the ureter provides an essential point for traction in single-port surgery. Metal clips are applied to ligate the ureter (Fig. 4B), and the dissection with scissors follows. Proximal mobilisation of the ureter up to level of the ureteropelvic junction is performed. 2.1.6. Hilar dissection and control of the renal pedicle The preparation of the vessels is performed using bipolar forceps or Maryland forceps and flexible grasper (Fig. 5A and B). Lumbar vessels should be clipped and divided. Retraction of these vessels may be useful for the preparation of the main vessels. The lower pole is lifted laterally and the hilum is under gentle tension in order to prepare the vessels. The renal vein is the first vessel to be identified. Nevertheless, the renal artery is usually prepared and ligated first. Clip insertion and individual dissection of the renal artery and vein take place. Two metal clips are applied in the aortal side and one on the kidney side for ligation of the renal artery (Fig. 6A). Hem-o-loks could also be used for additional security. The early division of the renal artery branches permits optimal exposure of the renal vein by grasping the dissected arteries with the help of the roticulating instruments. The renal vein is dissected with vascular Endo GIA staplers (Fig. 6B) or with the help of Hem-o-loks clips, similarly to LRN. 2.1.7. Final renal mobilisation In radical nephrectomy, the kidney is removed along with Gerota s fascia (including the perirenal fat). After control of the renal vessels, the lower pole is dissected using the monopolar scissors. All inferior and posterior attachments are divided. When the adrenal is excised along with the specimen, ligation of the adrenal vein is necessary; mobilisation of the upper pole takes place using the same technique as with the lower pole, and the kidney is released. Fig. 5 (A) Preparation of the renal artery; (B) ligation of the renal artery.

648 EUROPEAN UROLOGY 56 (2009) 644 650 Fig. 6 (A) Preparation of the renal vein; (B) ligation and dissection of the renal vein by vascular Endo GIA stapler. Fig. 7 Postoperative images of the umbilical incision (notice the limited length). 2.1.8. Specimen removal Since a standard 15-mm Endo-catch bag cannot be inserted through the TriPort, the bag has to be released from its introducer and metal ring. It is directly inserted into the abdominal cavity through the 12-mm channel of the TriPort. The latter method for retrieval bag insertion and specimen extraction is cumbersome and requires time because of the reduced manoeuvrability of the instruments. The design of a new 12-mm retrieval bag system that could be introduced through the samediameter channel of the TriPort would be useful. For specimen removal, the rectus fascia incision must be extended in a cranial and caudal direction to permit safe extraction of the intact specimen through the umbilicus. At the end of the procedure, a 16F Robinson drainage catheter can be placed through the umbilicus. Fascia and skin are carefully sutured to avoid possible umbilical hernia (Fig. 7). 3. Results All procedures were successfully accomplished without conversion to standard laparoscopy or an open procedure. The dissection was performed using various combinations of flexible and conventional instruments inserted through a 5-mm and a 12-mm channel of the TriPort. An additional laparoscopic 3-mm grasper was inserted in two patients for safe liver retraction in right-sided tumour (in the anterior axillary line below the 12th rib). Patient characteristics and perioperative data are shown in Table 1. The procedure was performed in two right-sided and eight left-sided tumours with sizes ranging between 4 8 cm. Pathological examination observed nine T1-stage tumours and one case of T3b tumour. Six tumours were located centrally, two were located on the upper pole, and two were located on the lower pole of the kidney. Histology revealed organ-confined renal cell carcinoma in all cases. A tumour with an adjacent simple renal cyst was excised in one patient. One intraoperative bleeding complication occurred and managed endoscopically. The patient was transfused with 2 units of concentrated blood cells. The evaluation of postoperative pain and the use of analgesic medication are presented in Table 2. 4. Discussion Laparoscopic surgery has allowed the performance of several major urologic operations through small incisions. In an attempt to avoid incisions, the performance of procedures through solitary abdominal incisions for traditional laparoscopic surgery is under extensive evaluation [11]. LESS for nephrectomy, pyeloplasty, and even donor nephrectomy have recently been performed [4,6 9]. Although laparoscopic procedures have several advantages over their open surgical counterparts, the advantages of single-site surgery over conventional laparoscopic

EUROPEAN UROLOGY 56 (2009) 644 650 649 Table 1 Patient characteristics and perioperative details Age BMI Pathology RCC tumour size/location/stage Incision length Time, min Blood loss, ml Right-side tumours 22 21.7 4 cm/central plus atrophic kidney/pt1a 3 cm 180 50 48 24 6 cm/upper/pt1b 4 cm 165 150 Left-side tumours 76 23.2 4 cm/central adjacent cyst/pt1a 4 cm 149 150 62 18.2 4 cm/lower/pt1a 4 cm 130 100 68 26.6 6 cm/upper/pt1a 4 cm 120 100 72 22.3 8 cm/central/pt2 6 cm 120 100 64 26.1 5 cm/central/pt1b 5 cm 125 100 74 21.5 4 cm/central (hilar)/pt1a 3 cm 140 80 77 26.2 6 cm/central/pt3b (vein involvement) 3.5 cm 150 180 72 25.8 5 cm/lower/pt1b 3 cm 155 900 (Intraoperative bleeding, transfusion with two units) Mean values 63.5 23.56 146.4 202 BMI = body mass index; RCC = renal cell carcinoma. Table 2 Average values of postoperative pain perception and analgesia requirement Average value of the pain score (range of values) On the day of operation 3.7 (2 6) First postoperative day 2.9 (2 4) Second postoperative day 2.2 (1 4) Third postoperative day 1.8 (1 3) Average consumption of piritramide (mg) after the operation (range of dose administration)* On the day of operation 7.1 (0 15) First postoperative day 2.6 (0 10) Second postoperative day 1.3 (0 8) *Administered intravenously. techniques are still to be proven [9]. Limited port-related morbidity and better cosmetic outcome have been proposed without adequate documentation as advantages of LESS [4]. The introduction of advanced equipment (roticulating forceps) and technical modifications (internal retraction using sutures) eliminated the need for the multiple triangulated ports of traditional laparoscopic surgery and made LESS feasible [6,11]. The lack of triangulation of conventional instruments due to the parallel insertion of these devices is one of the most important problems of LESS. The current series of LESS-RNs revealed that the combination of flexible and conventional instrumentation is efficient in minimising the impact of the latter problem in intraoperative ergonomics. Nevertheless, the performance of LESS requires ambidexterity in the surgeon since the instruments are often crossed at the point of entry in the multiport so that the external right-hand instrument becomes the left instrument internally and vice versa [11]. In addition, force applied to the flexible instrument tip dissipates along the flexible segment of the shaft, and, consequently, the manoeuvrability and the dissection and retraction capability of these instruments are compromised [11]. The crossing of instruments, the lack of triangulation, and the crowding of instruments outside the port and in the operative field render LESS a technique with a steep learning curve. Moreover, the camera used in the current series is 5 mm and does not provide a high-definition image. Thus, the quality of the image is lower in comparison to standard 12-mm cameras but remains acceptable. The rigid shaft of the above camera was responsible for interference with the other instruments. The introduction of prebent instruments which have an angled and rigid shaft may act to provide triangulation and minimise the instrument crossing encountered with flexible and conventional laparoscopic instruments. These instruments have longer curved shafts that improve manoeuvrability and decrease instrument clashing outside the port. In addition, newer flexible-tip or curved-grip cameras are already available. Robotic-assisted LESS, along with development of appropriate instruments, may also enhance LESS capabilities by avoiding port-site crowding and improving dissection control. The current study aimed to describe in detail the technique of LESS-RN and to evaluate the feasibility in centres without prior experience in LESS. All cases were performed according to current guidelines on RCC [1]. Patients with BMI 30 were not included since the umbilicus represents a challenging site in obese patients, as other investigators have reported [12,13]. The thick abdominal wall interferes with the instruments and makes their movement more difficult, while TriPort placement is also more demanding. Tumours of different localisation ranging between 4 8 cm were successfully managed. Combined use of conventional laparoscopic and flexible instruments inserted through a TriPort was performed, and LESS-RN proved to be feasible with the latter combination. LESS-RN required longer operative time in comparison to LRN, but the blood loss remained low. In fact, intraoperative blood loss ranged between 50 180 ml in 9 out of 10 cases. One complicated case had significant blood loss of 900 ml postoperatively. The patient was managed endoscopically. Postoperative pain was evaluated in an attempt to elucidate early postoperative quality-of-life aspects of the procedure. A comparative laparoscopic group would add additional integrity to the results of pain evaluation, and its lack represents a limitation of the current study. Although the current study assessed the safety and

650 EUROPEAN UROLOGY 56 (2009) 644 650 feasibility of LESS-RN, the population remains low for drawing any solid conclusions. In general, further clinical evaluation is deemed necessary in order for LESS-RN to establish itself as an alternative to LRN. Moreover, the evolution of conventional laparoscopic surgery to LESS may not have the same impact that laparoscopy had over open surgery. The proposed advantages of LESS-RN are the reduced port-related morbidity and the improved cosmetic results. Nevertheless, both advantages remain inadequately documented [7,9,11]. In addition, the operative time remains higher than LRN, probably due to the instrument-related challenges. Accumulation of experience with the flexible instruments will improve operative times. The current cases were performed by laparoscopic surgeons with experience performing hundreds of laparoscopic procedures. Although it is feasible for LESS-RN to be performed by less-experienced laparoscopists, the learning curve is expected to be steep. The introduction of prebent instruments would provide new options for LESS instrumentation. We performed an experimental study in dry and wet lab, and we observed that these instruments are easier to use and perform more quickly than flexible instruments. Moreover, clashing of instruments outside of the port was avoided (unpublished data). 5. Conclusions Our preliminary experience with LESS radical nephrectomies demonstrated the safety and feasibility of the procedure. The idea of performing complex surgery through one single entry is fascinating and holds enormous potential. We are just at the beginning of this exciting development. Further clinical investigation in comparison to the established open and laparoscopic radical nephrectomies should take place in order to evaluate the outcome of LESS tumour nephrectomy. Author contributions: Evangelos N. Liatsikos 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: Stolzenburg, Liatsikos, Hellawell. Acquisition of data: Hellawell, Haefner, Dietel, Do. Analysis and interpretation of data: Kallidonis. Drafting of the manuscript: Kallidonis. Critical revision of the manuscript for important intellectual content: Liatsikos, Kallidonis. Statistical analysis: None. Obtaining funding: Stolzenburg. Administrative, technical, or material support: Liatsikos. Supervision: Stolzenburg, Liatsikos. 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. Acknowledgement statement: The authors gratefully acknowledge the assistance of Jens Mondry (director, Moonsoft, Notzingen, Germany) in preparing Figs. 1 and 2. Appendix A. Supplementary data The Surgery in Motion video accompanying this article can be found in the online version at doi:10.1016/ j.eururo.2009.06.022 and via www.europeanurology.com. Subscribers to the printed journal will find the Surgery in Motion DVD enclosed. References [1] Ljungberg B, Hanbury DC, Kuczyk MA, et al. Renal cell carcinoma guideline. 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