Laparoendoscopic Single Site (or LESS) Surgery is a novel surgical approach allowing for removal of diseased organs through a small, single skin incision.
This is in sharp contrast to more invasive surgical treatments such as traditional open surgery or multi-incision laparoscopic surgery (Figure 1). Often this single incision can be hidden within the belly button, thus making this a surgical approach that is not only less invasive, but also leaves the patient with a far less disfiguring scar that is often barely noticeable (Figure 3).
At the University of Florida, LESS procedures are routinely performed for select patients diagnosed with a kidney tumor or a nonfunctioning kidney where removal of the entire kidney is required as well as for ablation of large renal cysts (Figure 4).
Figure 1. Examples of CT scans demonstrating large 6 cm left kidney tumor (red arrows), large bilateral symptomatic kidney cysts (yellow arrows) and poorly functioning obstructed left kidney (green arrows) all treated by LESS surgery.
Li-Ming Su, MD, FRCS(Glasg)
David A. Cofrin Professor of Urologic Oncology
Chairman, Department of Urology
Click here for Video Biography
Laparoscopic single-site surgery requires that patients undergo a general anesthesia. While operative time varies from one individual to another, the average operating time is approximately 2-4 hours.
During LESS surgery, the entire operation is performed through a single incision made in the abdomen and typically at the belly button (Figure 5). Through this incision, the surgeon inserts a telescope (called laparoscope) and a series of hand-held laparoscopic surgical instruments through a specially designed gel diaphragm device placed into the abdomen to accomplish surgery or even removal on the affected kidney.
Figure 5. Single skin incision in the belly button, trocar configuration and final skin closure and postoperative cosmetic result following LESS surgery. Note that the final incision is barely visible. The laparoscocpe lens allows for 10X magnification of the operative field, allowing the surgeon to accomplish the surgical procedure with improved visualization and without placing his hands into the abdominal cavity. The surgeon uses a combination of straight and specially designed curved laparoscopic instruments to accomplish complex surgical tasks in the abdomen through the same single skin incision. The abdomen is filled with carbon dioxide gas to create a larger working space for the surgeon to accomplish the operation. This gas is later evacuated from the abdomen at the conclusion of the operation. In cases of a simple or radical nephrectomy, the entire affected kidney is dissected and removed from the single skin incision. Finally, the skin incision is closed using plastic surgery techniques to minimize scarring and optimize the cosmetic result.
The following is a slide show of the Laparoendoscopic Single Site (LESS) Nephrectomy.
Potential Risks and Complications
As with any major surgery, complications, although rare, may occur with LESS surgery. Potential risks and complications with these operations include, but are not limited to, the following:
- Bleeding: Blood loss during this procedure is typically less than 100 cc, with the rare need for a blood transfusion (<2% of patients). If you are interested in autologous blood transfusion (donating your own blood) prior to your surgery, you must make your surgeon aware. This can be arranged locally in Gainesville, FL at the Civitan Regional Blood center or at your local Red Cross.
- Infection: Although patients are given broad spectrum intravenous antibiotics immediately prior to surgery, infections of the urinary tract and skin incisions may still occur, but are rare. If you develop any signs or symptoms of infection after the surgery (fever, drainage from or redness around your incisions, urinary frequency/discomfort, and/or pain) please contact us immediately.
- Adjacent Tissue/Organ Injury: Although uncommon, adjacent organs and tissues may be injured as a result of your surgery. This includes the colon, bowel, vascular structures, nerves, muscles, spleen, liver, pancreas and/or gallbladder. If injury to your lung cavity occurs, a small chest tube may be required to evacuate air, blood, and fluid from around your lung, thus allowing your lung to expand and work properly. On rare occasions, further surgery may be required to address unexpected injuries to adjacent organs.
- Incisional Hernia: Although the single skin incision is routinely closed surgically, hernias at this site can occur rarely and may require further intervention.
- Conversion to Traditional Laparoscopic or Open Surgery: In the rare event of complications or due to difficulty in dissecting by means of a LESS approach to surgery, conversion to standard laparoscopy or even open surgery is sometimes required. This could result in larger incisions and possibly a longer recuperation period.
What to Expect After Surgery
After a period of recovery in the Recovery Room, you will be transported to your hospital room once you are aware and your vital signs are stable.
- Postoperative Pain: Although most patients in the first few days after surgery experience mild pain at their incision sites, this is generally well controlled by use of intravenous pain medication, a patient-controlled anesthesia pump, or oral pain medication provided by your nurse. You may experience some minor transient shoulder pain (1-2 days) related to the carbon dioxide gas used to inflate your abdomen during LESS surgery.
- Nausea: Nausea can occur following any surgery, especially those procedures that require general anesthesia. This is usually transient and controlled by medication which can be administered on an as-needed basis by your nurse.
- Urinary Catheter: A urinary catheter (also called foley catheter) is placed to drain your bladder at the time of surgery while you are asleep. This is in efforts to monitor your urine output over the first day or so following surgery. This is generally removed by your nurse once you are walking comfortably on the first postoperative day. It is not uncommon to have blood-tinged urine for a few days after your surgery while your catheter is in place.
- Diet: Your diet will be advanced slowly following surgery from liquids to solids as tolerated. It is often the case that your appetite will be poor for up to a week following surgery. In addition, your intestinal function is often sluggish due to the effects of surgery and general anesthesia. It is for these two reasons that we recommend taking only small amounts of liquids by mouth at any one time until you begin to pass flatus and your appetite returns. In the meantime, your intravenous catheter will provide the necessary hydration to your body as your oral intake improves.
- Fatigue: Fatigue is quite common following surgery and should subside in a few weeks following surgery.
- Incentive Spirometry: You will be expected to do some very simple breathing exercises to help prevent respiratory infections through use of an incentive spirometry device (these exercises will be explained to you by the nursing staff during your hospital stay). Coughing and deep breathing is an important part of your recuperation and helps prevent pneumonia and other pulmonary complications.
- Ambulation: On the evening of surgery it is very important to get out of bed and begin walking with the supervision of your nurse or family member to help prevent blood clots from forming in your legs. You can also expect to have SCD’s (sequential compression devices) wrapped around your lower legs and calf area to prevent blood clots called deep vein thrombosis from forming in your legs. In the days that follow surgery, patients are advised to walk at least 6 separate times a day in the hallways. This serves to further reduce the change of deep vein thrombosis and speed the return of bowel function.
- Constipation/Gas Cramps: You may experience sluggish bowels for several days following surgery as a result of the anesthesia. Suppositories and stool softeners are usually given to help with this problem. Taking a teaspoon of mineral oil daily at home will also help to prevent constipation. Narcotic pain medication can also cause constipation and therefore patients are encouraged to discontinue any narcotic pain medication as soon after surgery as tolerated.
- Hospital Stay: The length of hospital stay following LESS surgery is generally one day.
What to Expect After Discharge from the Hospital
- Pain Control: For the majority of patients, one to two days of oral narcotic pain medication may be necessary after which Extra Strength Tylenol is usually sufficient to manage their pain. Again, narcotics should be minimized to avoid constipation and oversedation.
- Showering: Patients can shower immediately upon discharge from the hospital allowing their incisions to get wet. Once out of the shower, pad your incision sites dry and avoid any heavy creams or lotions. Tub baths or hot tubs in the first 2 weeks are discouraged as this will allow for prolonged soaking of your incisions and increase the risk of infection. The sutures underneath the skin will dissolve in 4-6 weeks.
- Activity: Walking 6 times a day for the first two weeks after surgery on a level surface is strongly encouraged as prolong sitting or lying can increase your risk of pneumonia and deep vein thrombosis. It is permissible to climb stairs. No heavy lifting or exertion for up to 4 weeks following surgery. Patients may begin driving once they are off of narcotic pain medication and have full range of motion at their waist. Most patients can return to full activity including work on an average of 3-4 weeks after surgery.
- Diet: Patients may resume a regular diet once they begin to pass flatus and their appetite improves.
- Follow-up Appointment: Patients should make a follow-up appointment with their surgeon by contacting the UF & Shands Medical Plaza Urology Clinic at 352.265.8240. Your surgeon will let you know the timing and schedule of clinic visits following surgery.
- Pathology Results: The pathology results from your surgery are usually available in one week following surgery. Your results will be discussed with you either by phone or directly in the office during a follow-up clinic appointment.
Frequently Asked Questions (FAQs)
What is the advantage of laparoendoscopic single site (LESS) surgery over conventional multi-incision laparoscopic surgery?
- LESS surgery has been associated in research studies with similar outcomes to conventional laparoscopic surgery but with some studies suggesting less pain, scarring and improved cosmetic result.
Are there potential disadvantages of LESS surgery?
- LESS surgery has its limitations as there can be more limited maneuverability of surgical instruments when operating from a single skin incision as compared to multi-incision laparoscopy. However, with specially designed instrumentation and with experience, this limitation can be easily overcome.
What patients are not good candidates for LESS surgery?
- LESS may not be a good option for all cases or patients. Patients with very large kidney tumors may be best served by a conventional laparoscopic or open approach. Patients with extensive prior abdominal surgery or obesity are often more challenging by a LESS approach. Patients with medical conditions such as severe lung and heart disease may not be able to tolerate a laparoscopic approach due to the need to undergo a general anesthetic.
What happens if complications arise and conversion to an alternative surgical approach is required?
- Although extremely rare, conversion to standard laparoscopic surgery may be required with the addition of one or two skin incisions. However, conversion to open surgery is generally not required as our LESS surgeons are all fellowship trained in advanced laparoscopic techniques.