*3.2.3 LESS common bile duct exploration*

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, and this may have influenced the results [72].

#### **3.3 LESS pancreatic surgery**

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 laparoscopy for advanced pancreatic cancer [76, 77].

#### *3.3.1 Technical considerations*

The approach in LESS distal pancreatectomy is mostly transumbilical. Occasionally, an additional 5 mm trocar is inserted in the left upper quadrant to be used by the surgeon's right hand and subsequently for drainage [78]. Various modifications of gastric suspension technique have been developed to facilitate better exposure of the pancreas [79–81]. The Lasso technique, in which a ribbon tape is looped around the pancreas body or tail, can be used to provide additional traction, particularly in cases of LESS distal pancreatectomy without splenic preservation [81, 82]. The pancreatic mobilization and dissection follow the principles of standard laparoscopic pancreatic resection, and the resected specimen is extracted through the umbilical site.

#### *3.3.2 Outcomes*

In a recent review, Chatzizacharias et al. analysed the data on LESS distal pancreatectomy from eight case studies. Conversion to open rate was 0–19%, and postoperative complications, mainly pancreatic fistula, were reported in 22% (0–50%) of patients. The length of hospital stay ranged between 1 and 15 days [39].

More importantly, Han et al. compared the outcomes between patients undergoing LESS and conventional laparoscopic distal pancreatectomy. With the exception of significantly longer operative time and duration of hospital stay reported with the LESS approach, perioperative outcomes did not differ between the two groups [83]. Likewise, two comparative analyses, including a case-control study, yielded no significant differences between conventional laparoscopic and LESS distal pancreatectomy in the operative time, intraoperative bleeding, conversion rate, resection status, hospital stay, and complications [75, 84]. The spleen was preserved more in the conventional group than in the LESS group, but this difference was not significant [83, 84]. A recent comparison between LESS and the more widely accepted robotic distal pancreatectomy has evidenced a significantly longer operative time and hospital stay, larger intraoperative blood loss, less spleen preservation, and higher grade II/IIIa postoperative complications in the LESS group. There were no significant differences in pain scores, tumour size, conversion rate, and overall complications between the two groups [85]. Overall, although it has been shown to be safe and feasible, these findings highlight the question of any real value of LESS approach in the context of pancreatic surgery.

#### **3.4 LESS splenic surgery**

Despite the scarcity of high-level evidence, there has been a dramatic increase in the number of laparoscopic splenectomies performed over the last 2 decades. The procedure is currently considered the gold standard for management of surgical diseases in normal or slightly enlarged spleens [86]. More recently, and as a bridging procedure towards pure natural orifice transluminal endoscopic surgery, Barbaros and Dinççağ were the first to describe LESS splenectomy in two female patients with idiopathic thrombocytopenic purpura [87]. Other common indications for this approach are splenic cystic disease, hereditary spherocytosis, myeloproliferative disorder, and splenic aneurysms and neoplasms [88].

#### *3.4.1 Technical considerations*

For LESS splenectomy, either a transumbilical or a lateral rectus incision can be utilized depending on the size of spleen. The technique used for splenic

**63**

*LaparoEndoscopic Single-Site Upper Gastrointestinal Surgery*

advantages over multiport laparoscopic splenectomy [92].

The current evidence shows that LESS upper GI surgery is feasible, and its adoption is expanding worldwide. A successful LESS procedure requires proper instrumentation, adequate laparoscopic experience, and careful patient selection. The demonstration of a significant and consistent increase in the adverse events associated with certain LESS applications in upper GI surgery should represent a word of caution in performing these procedures. While cosmetic improvement is a natural corollary to LESS, real advantages of the approach in upper GI surgery are still controversial. Prospective randomized studies are largely awaited to further explore the benefits of this technique for patients as well as to elucidate the costeffectiveness of the approach. The advent of new instruments and platforms may significantly counteract technical issues associated with LESS surgery and facili-

dissection is similar to multiport laparoscopic splenectomy. Not uncommonly, a 3 mm instrument is inserted through the left flank to facilitate spleen retraction and dissection of retroperitoneal adhesions [89]. Others used a cloth tape to encircle and tug the splenic hilum, therefore providing better exposure and easy introduction of the stapler into the splenic hilum [90]. Once the spleen is completely free, an endobag is deployed, and the spleen is retrieved intact or

A systematic review published by Fan et al. summarized the evidence on LESS splenectomy from 29 articles, with a total of 105 patients. The median length of hospital stay varied from 1 to 11 days. The postoperative complication rate was 0–33.3%, and the rates of conversion to open and multiport laparoscopic surgery were 1.9 and 2.9%, respectively. Bleeding from the splenic or short gastric vessels were the main reasons for conversion. No perioperative death was observed [88]. In a comparison between reduced-port, multiport, and LESS splenectomy, Monclova et al. reported significantly longer operative time in the LESS group, and this was partly related to the higher spleen weight. Importantly, there was a significant advantage in the LESS and reduced-port groups in the body image index with respect to the multiport group, pointing to better cosmetic outcome. Other perioperative outcomes were comparable among the two groups [91]. Wu et al. conducted a comprehensive meta-analysis comparing the outcomes of LESS and conventional laparoscopic splenectomies. They pooled and meta-analysed the data of 332 patients from nine comparative and one prospective case-control study. While postoperative pain scores favoured the LESS approach, the conversion rate and operative time slightly favoured conventional laparoscopic surgery, though without statistical significance. Ultimately, no differences were observed with regard to morbidity, mortality, analgesics requirements, and postoperative hospitalization. The authors pointed out that LESS splenectomy is safe and feasible with no obvious

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

morcellated.

*3.4.2 Outcomes*

**4. Conclusions**

tates the current steep learning curve.

The authors declare no conflict of interest.

**Conflict of interest**

dissection is similar to multiport laparoscopic splenectomy. Not uncommonly, a 3 mm instrument is inserted through the left flank to facilitate spleen retraction and dissection of retroperitoneal adhesions [89]. Others used a cloth tape to encircle and tug the splenic hilum, therefore providing better exposure and easy introduction of the stapler into the splenic hilum [90]. Once the spleen is completely free, an endobag is deployed, and the spleen is retrieved intact or morcellated.
