NEW ORLEANS (EGMN) – Laparoendoscopic single-site surgery has been gaining credibility in urology and general surgery but has been less accepted in gynecologic surgery, even though it offers many advantages to patients and is not much different from traditional laparoscopic surgery, said Dr. Kevin Stepp.

Dr. Stepp, director of gynecologic surgery education at MetroHealth/Cleveland Clinic, presented a video on basic laparoendoscopic single-site (LESS) techniques for a total hysterectomy and related his experience using the procedure to the Society of Gynecologic Surgeons at its annual meeting.

With LESS, there is only one incision through the umbilicus. Specific instrumentation and a single port that allows multiple devices to access the abdomen are used. Dr. Stepp said he has employed the TriPort laparoscopic access device, made by Advanced Surgical Concepts. Other techniques and ports are available, and each has its own advantages, he said.

The surgical entry is through the traditional laparoscopic technique, with instruments advanced through the TriPort. The port’s plastic sleeve is pulled up as the port and instruments are advanced, until the port is firmly in place against the abdomen, said Dr. Stepp. The port is clamped in place.

Dr. Stepp recommended suturing the peritoneum to the fascia in obese patients to prevent the port’s inner ring from slipping into the preperitoneal space.

With laparoscopy, there is always the potential for what Dr. Stepp called “sword fighting” or the clashing of instruments. With a single port, instrument handles are close together. But LESS-specific instrumentation – designed with flexible tips – helps minimize the potential for sword fights, he said. There is a camera that can flex greater than 90 degrees in any direction, for instance.

Several companies make instruments with reticulated hands that allow the operator to triangulate and increase the distance from each operating hand.

The LESS total hysterectomy is performed in a manner similar to the laparoscopic technique. “For total hysterectomies, we find it easier to begin with the primary surgeon standing near the patient’s left shoulder,” said Dr. Stepp.

Once the uterus is ready for removal, it can be delivered vaginally, he said. The vaginal cut can be closed laparoscopically, but the learning curve is greater, he said.

Suturing can be facilitated with a suturing device, but with a multichannel port, the suture sometimes can get wrapped around other devices. “We suggest removing them if possible” during suturing, he said.

Initial experience has shown that LESS is not much different from conventional three-port laparoscopy, said Dr. Stepp. It is important to keep the instruments lubricated and maintain the seal around the port. The camera can be kept in a vertical position, which is good for posterior views and helps it stay out of the way of operative instruments outside the body. Or the camera can be kept in a more horizontal position, flat against the patient’s abdomen and chest; that also keeps it out of the way of the operative instruments. And by using the right and left flexion on the camera, the distance can be increased even further, providing more work space, he said.

“If you use three ports for your laparoscopy, you can do this,” Dr. Stepp told attendees.

It also is possible to do it without losing money, if device purchases are made judiciously. TriPort and its competitors seem to cost (U.S.) $300-$350. Some tools already on the shelf can be used, but the newer LESS-specific devices may run (U.S.) $100-$400 each.

Dr. Stepp reported on 22 patients who underwent LESS at MetroHealth, 19 of them for hysterectomies. The initial operative time was just under 3 hours, but so far in 2009, the surgeons have shaved 30 minutes off the procedure, and they’re doing larger uteri, he said. Surgery time was directly related to body mass index and uterine weight. The mean uterine weight was 324 g, but the procedure has been done on uteri weighing up to 1,600 g.

To Dr. Stepp, the most exciting development was the reduction in narcotics use. Patients were taking narcotics an average of 2.5 days, and then using ibuprofen for 5 days.

Patients desiring to go back to work were on the job in 3.5 days.

The presence of adhesions did not change operative time. There were no interoperative complications and no conversions. Vaginal bleeding on day 6 in one patient was repaired with sutures.

Dr. Stepp and his colleagues have performed LESS on all patients they would have addressed with three surgical incisions, including emergent cases.

“It is truly an amazing time, an exciting time for minimally invasive surgery,” Dr. James Carter, director of gynecologic minimally invasive surgery at the Medical University of South Carolina, Charleston, said in discussing Dr. Stepp’s work. He said that it should encourage gynecologic surgeons to push the envelope, as urology and general surgery colleagues have.

The tips from Dr. Stepp “should perhaps shorten the learning curve,” he added.

Dr. Stepp disclosed that he is a consultant for Covidien, a health care device and supplies company.

Copyright (c) 2009 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

新奥尔良 (EGMN)——Kevin Stepp博士称，腹腔镜内镜单一切口（LESS）手术应用于泌尿外科和普通外科的可靠性已得到认可，但关于其应用于妇科手术的接受度还不高，尽管该术式确实可以给患者带来许多益处，与传统腹腔镜手术的差别也不是非常大。

Stepp博士是MetroHealth与克利夫兰临床医学中心妇科手术教育处的主任。他在2009年妇外科医师学会科学年会上播放了其应用基础LESS技术进行子宫全切术的视频，并介绍了他应用该技术的经验。

LESS手术时，患者腹壁上只有一个经脐切口，术中需借助特殊器械和一个孔眼以方便多个装置进入腹腔进行操作。Stepp博士使用的是爱尔兰Advanced Surgical Concepts（ASC）公司的TriPort腹腔镜产品，但他认为其他品牌的产品也是可行的，每一种产品都有其自身的独特优势。

Stepp博士介绍说：“通过传统的腹腔镜技术建立外科通道，器械通过TriPort进入。当导入套管装置和器械置入时，导入套管装置的塑料外套向上拉起，直到导入套管装置紧紧固定在腹壁上。”

Stepp博士建议，对于肥胖的患者可将腹膜缝在筋膜上以防导入套管装置的内环滑到腹腔内。

在腹腔镜操作过程中，一直可能会有Stepp博士称为“刀剑相击”或器械碰撞的情况发生。因为只有一个单一孔道，所以器械之间非常接近。但是他说，LESS手术特殊器械即可弯曲的头部设计可以减少器械碰撞的可能性，以一个例子来说明，目镜可以在任何方向上弯曲90º以上。

几家公司将器械制成网状把手，这样可以使术者成三角形从而增加术者手与手之间的距离。

通过LESS技术行子宫全切术的方法与普通的腹腔镜技术相似。Stepp博士说：“行子宫全切术时，我们发现开始时术者站在患者的左肩附近操作会容易一些。”

他说，当准备移除子宫时，可通过经阴道途径。阴道切口可以在腹腔镜下缝合，但该技术的学习曲线要相对长一些。

可通过缝合装置进行缝合，但使用一个多通道的导入套管装置，缝合有时会被其他的器械干扰，他说：“我们建议在缝合时尽量取出其他器械。”

他说，最初的经验显示，LESS手术与传统的三孔腹腔镜手术差别并不是很大。保持器械的润滑和导入套管装置周围的密封是很重要的。目镜可以保持在一个垂直的位置，这样对于后面的视野有利并且不会妨碍操作器械在体外部分的操作。或者，目镜可以保持在一个更加水平的位置，与患者的腹壁或胸壁齐平，这样也不会妨碍操作器械的活动。此外，通过目镜的左右弯曲，这个距离可以更远，这样就可以提供更多的操作空间。

Stepp博士告诉与会者：“如果你可以做三个孔的腹腔镜手术，你就可以用这个技术。”

并且如果购买设备时审慎一些用这种技术可能并不会花费很多。购买TriPort或其竞争产品需花费300～350美元。一些已经在使用的器械可以继续使用，但新型LESS特殊装置每一个都需花费100～400美元。

Stepp博士报告，MetroHealth医学中心应用LESS技术治疗了22例患者，其中19例为子宫切除术。他说在该技术应用之初，手术全程耗时约3小时，但到了2009年，手术时间已缩短了30分钟，而且可以切除体积相对较大的子宫。手术时间与患者体重指数（BMI）和子宫重量直接相关。平均子宫重量为324克，但迄今为止应用该技术成功切除的子宫最重已达1,600克。

对于Stepp博士而言，最振奋人心的一点在于麻醉药使用的减少。患者平均使用麻醉药的时间为2.5天，然后使用布洛芬5天。

有工作意向的患者3.5天后就能返回工作岗位。

粘连的存在与否，并没有影响手术时间。既没有发生术中并发症，也没有因操作失败而更换术式。1例患者在术后第6天发生阴道出血，予缝合修补。

Stepp博士及其同事对所有拟行三孔腹腔镜手术的患者实施了LESS手术，包括急诊病例。

“这真的是一个神奇时刻，一个关于微创手术的惊喜时刻”，在讨论Stepp博士的工作时，美国南卡罗来纳州医科大学妇科微创手术部主任James Carter博士如是说。

他说应鼓励妇外科医师挑战技术极限，就像泌尿外科和普通外科的同事们那样。

他还补充说，Stepp博士的经验之谈应有助于缩短听众的学习曲线。

Stepp博士透露他是Covidien医疗设备公司的顾问。 

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