February 13, 2009

New laparoscopic technique uses only one incision

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Ted Anderson, M.D., Ph.D., left, and S. Duke Herrell, M.D., are employing a new laparoscopic technique that uses a single incision rather than multiple incisions. (photo by Susan Urmy)

New laparoscopic technique uses only one incision

The umbilical cord is the gateway for nourishment to babies in the womb. Now the remnants of that gateway can serve as a convenient exit ramp for unwanted tumors and organs.

S. Duke Herrell, M.D., associate professor of Urologic Surgery, has performed Vanderbilt Medical Center's first kidney removal through a single laparoscopic incision in a patient's navel.

The patient, who has renal failure and needs a kidney transplant, had a cancerous tumor in one kidney. The kidney had to be removed to make the patient eligible for a transplant.

“We were able to go in through a single 5 cm (approximately two inches) incision around the umbilicus and take her kidney out intact,” said Herrell, who is director of Minimally Invasive Urologic Surgery and Robotics. “Five centimeters sounds like a big incision but there is a lot of skin in the umbilicus, so you can hide the incision in those folds.”

This new form of belly button surgery is also known as LESS, or laparoendoscopic single-site surgery. What makes this approach unique is that the camera and all of the laparoscopic instruments go through a single small incision.

This feature is simultaneously responsible for the increased benefit to the patient and increased challenge for the surgeon. In addition to a single small scar, patients may also experience faster recovery times. Herrell's patient went home the next day.

“We have been working on the idea of trying to make the entry into the body less invasive for quicker healing and less scarring,” Herrell explained. “We have gone from big open incisions to smaller incisions, including laparoscopy and robotics, and now to this single port access through the navel. The progression of that is where it gets interesting.”

In normal laparoscopic surgery, three to five small incisions are made around the abdomen and tubes or trocars are placed in the incisions. Then the laparoscopic instruments, including a camera, are inserted through the tubes and the surgeon triangulates the instruments to cut and suture tissue. But putting the same instruments into a single small space around the navel is much trickier.

“You're bringing all of these instruments through access points that are close together so they tend to clash,” said Herrell. “As a surgeon, you need a lot of experience in laparoscopic surgery and you must be able to think three-dimensionally so you can manipulate things without clashing and still perform the procedure safely.”

Ted Anderson, M.D., Ph.D., director of the Division of Gynecology, just performed his first LESS procedure on a patient with a 9 cm endometrioma, a benign cystic mass of the ovary.

Anderson removed the patient's entire right ovary through a single 2.5 cm incision in the navel.

“Another surgeon proposed making a midline incision from her belly button down to her pubic bone,” said Anderson. “But she was facing a monthlong recovery.”
Instead, Anderson's patient opted for a single incision in the navel for a chance at a faster recovery.

“She needed pain pills for just one day and was back to her exercise program, including jogging, that weekend and returned to work the following Monday,” Anderson marveled.
He calls the LESS technology the new kid on the surgical block.

“We are still learning because this is a new endeavor,” Anderson said.

“It's more challenging than a normal laparoscopy because the range of movement is restricted but I think the advantages to the patient may turn out to be pretty substantial.”