*3.2.1.2 Outcomes*

*Recent Advances in Laparoscopic Surgery*

laparoscopic wedge resection [33].

*3.1.2.1 Technical considerations*

single-site incision.

8–19 months [31–33].

*3.2.1 LESS hepatic surgery*

**3.2 LESS hepatobiliary surgery**

lesions, and hepatocellular carcinoma [38].

ment and morbid obesity [40–42].

*3.1.2.2 Outcomes*

endophytic tumours <5 cm, with unfavourable locations, such as the fundus, high lying in the posterior wall of the stomach, or close to the gastroesophageal junction or the pyloric ring [31–33]. Several advantages are offered by the LESS intragastric approach including direct visualization of tumours during resection, minimal dissemination of the tumour into the peritoneal cavity, easy delivery of the specimen through the single-site incision, and extracorporeal repair of the gastrotomy site [31]. In addition, it obviates the need for multiple incisions, thus resulting in better cosmesis, and reduces the possibility of deformity by significantly preserving the normal gastric tissue with more precise resection compared with conventional

LESS intragastric resection may be performed either as a "pure" LESS procedure or less commonly as a "hybrid" procedure with intraoperative gastroscopy [33, 34]. Both umbilical and left upper quadrant incision can be used to obtain access to the peritoneal cavity. A 2–3 cm incision is performed on the anterior wall or the lower body greater curvature of the stomach, and a single multichannel port or three standard ports are inserted through the abdominal incision and gastrotomy site [32, 33]. After creating a pneumostomach, the tumour is located, excised, and retrieved through the

Despite the small number of cases reported in the literature, the procedure appears to be safe and effective, with favourable outcomes. In previous series, no conversion to conventional laparoscopy or open surgery was necessary nor were additional trocars. Postoperative complications occurred in 0–25% and were mostly intragastric and surgical site bleeding [31, 32, 35, 36]. The operative time, number of used staplers, time to first oral intake, hospital stay, and complications were not significantly different from conventional laparoscopic wedge resection [33]. No local recurrence or distant metastasis was detected during a follow-up period of

The first report of LESS hepatectomy was published by Aldrighetti et al. in 2010.

The authors performed a left lateral sectionectomy via a supraumbilical incision for a solitary colorectal metastasis [37]. Nonetheless, because LESS liver resection requires advanced surgical skills and has a significant learning curve, only a limited number of reports are currently available in the literature. The procedure has been used for wide range of conditions: liver adenoma, focal nodular hyperplasia, haemangioma, hydatid and simple cyst, intrahepatic biliary stones, metastatic liver

Patients should be cautiously selected for LESS liver resection. Superficial hepatic lesions limited to the left lateral section are preferable, even though bigger or more technically challenging resections for less favourably located tumours have been described with increased experience in the technique [39]. Lesions less than 5 and 10 cm are the recommended cut-off points for malignant and benign tumours, respectively [39]. Other contraindications include vascular or extrahepatic involve-

**58**

Benzing et al. recently performed a comprehensive systematic review on LESS hepatectomy pooling the available data of 124 minor and 7 major resections of 133 patients from 15 studies [46]. The majority of minor resections were left lateral sectionectomies and wedge resections for both benign and malignant diseases; 6 of the 7 major resections were performed due to malignancy, including 4 for colorectal metastasis. Overall, the conversion to multiport laparoscopic/open rate ranged between 0 and 25% which, for the most part, was due to technical difficulties, intraoperative bleeding, and uncertainty of the oncologic margin of the resection. Free resection margins could be achieved in all but one patient with malignancy, demonstrating the efficacy of the technique. The median length of hospital stay was reported between 1 and 21 days, and the overall morbidity and mortality rates were 6.8% (0–33%) and 0.8%, respectively [46].

Few studies have compared the outcomes of LESS and conventional laparoscopic left lateral liver sectionectomy, and the results were inconclusive or conflicting. Including only patients with benign liver diseases, an RCT demonstrated a significantly shorter length of hospital stay in the LESS group [47]. This difference, however, disappeared in the other two non-randomized matched and unmatched comparisons, when patients with malignant tumours were also included [48, 49]. A further advantage observed only by Struecker et al. for the LESS technique was shorter operative time, which was attributed to the easy retrieval of the specimen through the umbilical incision [49]. The intraoperative blood loss, conversion, and postoperative morbidity and analgesics requirements were similar between the two groups in all studies. It was indicated that in wellselected patients with either benign or malignant hepatic lesions, LESS left lateral sectionectomy can provide a safe and effective alternative to multiport laparoscopic surgery [47–49].

Choi et al. described the surgical outcomes of LESS- and standard laparoscopyassisted donor right hepatectomy. The LESS group had significantly shorter operative time, less blood loss, earlier resumption of enteral feeding, and lower pain scores. There were no significant differences between the groups with respect to length of hospital stay, R0 resection, and postoperative morbidity and mortality [50]. These results were replicated by Han et al. who described the surgical outcomes of LESS and conventional laparoscopic method for major and minor hepatectomies. Nevertheless, in this retrospective study, patient background and the type of procedures differed between the two groups, meaning the analysis was constrained by selection bias [51].

#### *3.2.2 LESS cholecystectomy*

The LESS approach has been increasingly used in gallbladder surgery, and its indications are expanding by virtue of the advances in instrumentation and surgical experience. Over the last two decades, hundreds of studies have been published reporting outcomes of LESS cholecystectomy and describing different operative techniques for the procedure with variable success rates [52].

#### *3.2.2.1 Technical considerations*

The access to the peritoneal cavity in LESS cholecystectomy is obtained through paraumbilical or more commonly intraumbilical incision, which, although provides the best cosmetic outcome, is associated with higher rates of wound complications and incisional hernia [52]. A single 20–30 mm fasciotomy incision with a reusable or disposable single-access device can be used. "Swiss cheese" technique, a multiple facia puncture technique using multiple low-profile ports, is an acceptable alternative though carries risk of air leak and facial weakness [52, 53]. Various types of instruments have been used in LESS cholecystectomy including standard straight and curved instruments, with the latter offers the advantage of triangulation within the operative field [53]. During dissection, several technical variations are adopted to achieve adequate gallbladder anchorage and a clear critical view of safety while obviating the necessity of an extra port: suture suspension ("puppet technique"), internal retraction, transabdominal endoloop, and magnet grasper [54]. Gallbladder is thereafter delivered through a single-access device or connected facial openings with or without the use of a retrieval bag.

#### *3.2.2.2 Outcomes*

Several meta-analyses have compared the outcomes of LESS cholecystectomy with traditional multiport (three or four ports) laparoscopic cholecystectomy [55–66]. Although early reports showed no significant differences in terms of reported pain and quantity of on-demand analgesics delivered, the three most recent meta-analyses included more RCTs with different inclusion criteria and showed less postoperative pain following LESS cholecystectomy particularly in the first 24 h [64–66]. This discrepancy in results is possibly ascribable to the less tissue trauma in LESS cholecystectomy as surgeons progress along the learning curve and gain experience with the technique. The operative time was significantly longer in the LESS group in all meta-analyses, whereas open conversion rate and length of hospital stay were nearly identical between the two groups. Conversion to multiport and/or open cholecystectomy in the LESS group was mainly due to omental adhesions, obesity, Mirizzi syndrome, and obscure anatomy of Calot's triangle [59, 62]. Of note, the overall short-term postoperative morbidity rate, surgical site infection, and port-site hernia were consistently higher, though not statistically significant, in the LESS group than the conventional group [55–65]. This was further bolstered by a recent large pooled analysis indicating that mild and severe adverse events were significantly higher in LESS cholecystectomy than in conventional laparoscopic cholecystectomy. When the results were adjusted to the type of technique used (4-port or 3-port), statistically significant differences were still noted [66]. Possible explanation of this raised risk of complications is the impaired exposure of the operative field in LESS cholecystectomy and the technical difficulty encountered by surgeons early during their learning phase. Moreover, the natural progression of this new technique to broader indications such as acute cholecystitis entails higher rates of adverse events.

Compared to conventional cholecystectomy, the inherent benefits of the LESS technique, specifically postoperative satisfaction and cosmetic outcomes, were significantly in favour of LESS cholecystectomy at different time points during the first postoperative year, which was at the expense of higher surgery costs. These results were replicated in most RCTs and all pooled analyses regardless of the scoring

**61**

*LaparoEndoscopic Single-Site Upper Gastrointestinal Surgery*

for LESS cholecystectomy to become widely accepted.

*3.2.3 LESS common bile duct exploration*

and this may have influenced the results [72].

laparoscopy for advanced pancreatic cancer [76, 77].

**3.3 LESS pancreatic surgery**

system employed: visual analogue scale (VAS), body image and cosmesis (BIQ ), cosmesis, and wound satisfaction scores [56–66]. Meanwhile, apart from marginal advantage of LESS cholecystectomy early in the postoperative course, studies could not demonstrate any significant differences in the quality of life between LESS and conventional laparoscopic cholecystectomy in the first 12 months postoperatively [58, 63–66]. It is noteworthy to mention that despite the evidence for better patients' satisfaction and cosmetic results in LESS cholecystectomy, cosmetic outcome is not the main factor that drives patient preference. Rather the risk of complications seems to exercise a higher influence on patients in determining the choice of procedure [67]. This indicates that an improved postoperative morbidity rate is a prerequisite

While the past decade has seen a dramatic increase in the adoption of LESS technique in gallbladder surgery, technical limitations have restricted its use in bile duct surgery to only highly selected cases. LESS exploration of the common bile duct (CBD) allows for combined treatment of cholelithiasis and choledocholithiasis using cholecystectomy and CBD drainage, a one-stage minimally invasive procedure with cosmetic advantage. At present, only a few case series of LESS CBD exploration have been reported in the literature, using either a single multichannel port or multiple trocars through a single intraumbilical or paraumbilical incision. Both transcystic and choledochotomy approaches with or without the assistance of a needlescopic grasper have been employed in LESS CBD exploration with successful ductal clearance rates ranging between 75 and 100%; conversion to open and conventional laparoscopic surgery was reported in 0–7.7% and 0–8.3%, respectively, and postoperative complications occurred in 0–25% [68–72]. Furthermore, Chuang et al. described a novel LESS transfistulous bile duct exploration and stone removal without drainage for Mirizzi syndrome type II with 80% success rate [73]. Supporting previous results and adding more evidence to the safety of the technique, the same authors reported 101 consecutive cases of successful LESS CBD exploration and concluded that in experienced hands, the procedure is feasible and a safe option for treatment of complicated and noncomplicated choledocholithiasis under low threshold for conversion [74]. In a series comparing 17 LESS and 17 conventional laparoscopic cholecystectomy and CBD exploration, Kim and colleagues reported (the study evidenced) a longer operating time in the LESS cohort but with less analgesics requirement and a shorter hospital stay. The stone clearance rate (100%) and incidence of complications were similar between the two groups [71]. A subsequent similar analysis by Chuang et al. did not show any significant difference in the operative outcomes between LESS and conventional laparoscopic CBD exploration. The former group however had a significantly higher rate of acute cholecystitis than the latter group,

The application of LESS approach to pancreatic surgery still remains an open debate. This procedure is generally considered as technically demanding due to its complexity and the need to perform fine dissections in a narrow surgical space. Indications for LESS pancreatic surgery include splenic artery aneurysm, pancreatic fibrosis, cysts, and benign and malignant neoplasms [12, 75]. The most commonly performed procedure is LESS distal pancreatectomy with or without spleen preservation for localized lesions; others include pancreatic necrosectomy and staging

*DOI: http://dx.doi.org/10.5772/intechopen.82486*

#### *LaparoEndoscopic Single-Site Upper Gastrointestinal Surgery DOI: http://dx.doi.org/10.5772/intechopen.82486*

*Recent Advances in Laparoscopic Surgery*

*3.2.2.1 Technical considerations*

*3.2.2.2 Outcomes*

experience. Over the last two decades, hundreds of studies have been published reporting outcomes of LESS cholecystectomy and describing different operative

The access to the peritoneal cavity in LESS cholecystectomy is obtained through paraumbilical or more commonly intraumbilical incision, which, although provides the best cosmetic outcome, is associated with higher rates of wound complications and incisional hernia [52]. A single 20–30 mm fasciotomy incision with a reusable or disposable single-access device can be used. "Swiss cheese" technique, a multiple facia puncture technique using multiple low-profile ports, is an acceptable alternative though carries risk of air leak and facial weakness [52, 53]. Various types of instruments have been used in LESS cholecystectomy including standard straight and curved instruments, with the latter offers the advantage of triangulation within the operative field [53]. During dissection, several technical variations are adopted to achieve adequate gallbladder anchorage and a clear critical view of safety while obviating the necessity of an extra port: suture suspension ("puppet technique"), internal retraction, transabdominal endoloop, and magnet grasper [54]. Gallbladder is thereafter delivered through a single-access device or connected

Several meta-analyses have compared the outcomes of LESS cholecystectomy with

traditional multiport (three or four ports) laparoscopic cholecystectomy [55–66]. Although early reports showed no significant differences in terms of reported pain and quantity of on-demand analgesics delivered, the three most recent meta-analyses included more RCTs with different inclusion criteria and showed less postoperative pain following LESS cholecystectomy particularly in the first 24 h [64–66]. This discrepancy in results is possibly ascribable to the less tissue trauma in LESS cholecystectomy as surgeons progress along the learning curve and gain experience with the technique. The operative time was significantly longer in the LESS group in all meta-analyses, whereas open conversion rate and length of hospital stay were nearly identical between the two groups. Conversion to multiport and/or open cholecystectomy in the LESS group was mainly due to omental adhesions, obesity, Mirizzi syndrome, and obscure anatomy of Calot's triangle [59, 62]. Of note, the overall short-term postoperative morbidity rate, surgical site infection, and port-site hernia were consistently higher, though not statistically significant, in the LESS group than the conventional group [55–65]. This was further bolstered by a recent large pooled analysis indicating that mild and severe adverse events were significantly higher in LESS cholecystectomy than in conventional laparoscopic cholecystectomy. When the results were adjusted to the type of technique used (4-port or 3-port), statistically significant differences were still noted [66]. Possible explanation of this raised risk of complications is the impaired exposure of the operative field in LESS cholecystectomy and the technical difficulty encountered by surgeons early during their learning phase. Moreover, the natural progression of this new technique to broader indications

techniques for the procedure with variable success rates [52].

facial openings with or without the use of a retrieval bag.

such as acute cholecystitis entails higher rates of adverse events.

Compared to conventional cholecystectomy, the inherent benefits of the LESS technique, specifically postoperative satisfaction and cosmetic outcomes, were significantly in favour of LESS cholecystectomy at different time points during the first postoperative year, which was at the expense of higher surgery costs. These results were replicated in most RCTs and all pooled analyses regardless of the scoring

**60**

system employed: visual analogue scale (VAS), body image and cosmesis (BIQ ), cosmesis, and wound satisfaction scores [56–66]. Meanwhile, apart from marginal advantage of LESS cholecystectomy early in the postoperative course, studies could not demonstrate any significant differences in the quality of life between LESS and conventional laparoscopic cholecystectomy in the first 12 months postoperatively [58, 63–66]. It is noteworthy to mention that despite the evidence for better patients' satisfaction and cosmetic results in LESS cholecystectomy, cosmetic outcome is not the main factor that drives patient preference. Rather the risk of complications seems to exercise a higher influence on patients in determining the choice of procedure [67]. This indicates that an improved postoperative morbidity rate is a prerequisite for LESS cholecystectomy to become widely accepted.
