Laparoendoscopic single-site surgery is safe, feasible in pediatric patients, according to study

Washington-Laparoendoscopic single-site surgery (LESS), often described as the next evolutionary step in minimally invasive surgery, appears to be bringing its benefits into pediatric wards.

A study from the Robert Wood Johnson Medical School and Bristol-Myers Squibb Children's Hospital, New Brunswick, NJ, compared LESS to standard multiple-port surgery in a series of children undergoing nephrectomy or varicocelectomy. The study's authors enumerate the benefits of LESS as improved cosmesis, reduction in iatrogenic bowel injury, reduced risk of visceral and vascular injuries associated with port placement, lower risk of wound infections and incisional hernias, and possible cost reductions derived from the use of a single port.

'Steep' learning curve

"The learning curve is definitely steep," Dr. Johnson told Urology Times. "There are many technical challenges that differ significantly from those seen with classic laparoscopy.

"In classic laparoscopy, the surgeon can triangulate the instruments to acquire tension and traction. Triangulation is not possible in LESS. The single port also creates instrument crowding. The camera is inserted through the single port, giving a perspective or orientation that is different from what many have become used to in laparoscopy."

To arrive at this estimation of benefits and challenges in LESS pediatric procedures, Dr. Johnson and colleagues conducted a study of seven patients aged 12 to 19 years. Six of the youths underwent left varicocelectomy and one underwent a left nephrectomy. The operating times in the children undergoing the varicocelectomies ranged from 48 to 91 minutes (average, 70.7 minutes). Blood loss in all procedures was minimal, and patients were released the day of the operation with no complications.

The nephrectomy was performed in a 12-year-old patient. The procedure took 163 minutes and was accompanied by a 20-cc blood loss. The patient was hospitalized for one day and released without complications.

All procedures were conducted through a single port placed via a 2- to 3-cm incision in the umbilicus, making the resultant scar nearly if not completely invisible, Dr. Johnson said.

Time needed to gauge benefits

"There are a lot of potential benefits [of LESS] such as faster recovery times, but it will take some time to see if they pan out," she said. "All of the kids in this series made a quick recovery, but it will take more than 10 cases to determine the procedure's effect on recovery times." (An additional three cases were conducted since the abstract was submitted.)

"We are assuming that having one incision compared to three reduces post-op pain. And every port that is inserted carries the risk of complications such as hernias at the incision site, bleeding at the site, and the risk of damage to vasculature and the bowel," said Dr. Johnson.

"It should be noted that these procedures are being conducted for benign presentations. Patient selection is very important because these are challenging procedures, especially nephrectomies, where acquiring control of the hilum can be difficult,"she explained.

Dr. Johnson said instruments and technologies designed specifically for LESS procedures are becoming available and added that improvements in instrument design are needed if the slope of the learning curve is to be reduced enough to allow more surgeons and institutions to adopt LESS procedures.

Improved cosmesis, seen as a significant benefit in LESS procedures, may prove to be an even greater benefit in pediatric patients. Adult scars are reasonably stable but scars in young patients can hypertrophy as the children grow, Dr. Johnson noted.

"At this point, it is clear that this technique is safe and feasible in a pediatric population, and has a role in pediatric urology," she concluded.