*3.1.2.1 Technical considerations*

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 single-site incision.

### *3.1.2.2 Outcomes*

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 8–19 months [31–33].

#### **3.2 LESS hepatobiliary surgery**

### *3.2.1 LESS hepatic surgery*

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 lesions, and hepatocellular carcinoma [38].

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 involvement and morbid obesity [40–42].

**59**

*LaparoEndoscopic Single-Site Upper Gastrointestinal Surgery*

a retrieval bag prior to removal through the port site.

6.8% (0–33%) and 0.8%, respectively [46].

scopic surgery [47–49].

*3.2.2 LESS cholecystectomy*

Transumbilical incision with a 3-trocar technique has been the preferred approach; right upper quadrant or supraumbilical incisions can be useful in the setting of portal hypertension with umbilical varices or lesions in distant segments [43, 44]. Several methods were adopted to avoid instrument collision including the use of single ports with a large outer cap or self-retaining sleeves [38]. During parenchymal dissection, simultaneous in-line radiofrequency precoagulation can be used to reduce the risk of bleeding [45]. Similar to other foregut procedure, the resection specimen is placed into

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

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 laparo-

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].

The LESS approach has been increasingly used in gallbladder surgery, and its indications are expanding by virtue of the advances in instrumentation and surgical

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

*3.2.1.1 Technical considerations*

*3.2.1.2 Outcomes*
