laparoscopic surgery provides a higher degree of patient satisfaction than does open surgery from a cosmetic perspective , and it is also effective in reducing postoperative pain , operative wound complications , blood loss , and the length of hospital stay . accordingly , it has been remarkably developed in the field of urology over the past 20 years .
it has also been performed prevalently as a treatment regimen , which is comparable to open surgery .
usually , the laparoscopic technique requires three to six ports . with technical advancements and the increased demand for minimally invasive surgery ,
however , laparoendoscopic single - site surgery ( less ) performed via a single incision window has recently been introduced .
there is still only one type of less port that has become commercially available in korea up to the present .
various studies have been conducted with the r - port ( advanced surgical concepts , dublin , ireland ) , which has been frequently used worldwide , but this port can not be used in a korean clinical setting .
many surgeons in korea therefore perform less by using a homemade single - port device . in this study
, we report our initial experiences with less performed by a single surgeon using a homemade single - port device in the field of urology .
between april 2009 and april 2010 , a total of 30 patients underwent less performed by a single surgeon .
of these , there were seven cases of nephrectomy ( 5 radical nephrectomies ) , five cases of nephroureterectomy with bladder cuff excision , four cases of ureterolithotomy , eight cases of marsupialization , and six cases of varicocelectomy .
, a single incision was made at the umbilicus and the peritoneum was confirmed accordingly .
then , after an incision was made , an alexis wound retractor ( applied medical , rancho santa margarita , ca , usa ) was placed .
the exterior side was connected to a surgical glove and then fixed by using a silk ( fig .
this was followed by the placement of a homemade single - port device ( fig .
the homemade single - port device was prepared by fixing 3 to 4 general type laparoscopic ports in each finger .
a 10 mm rigid laparoscope or flexible laparoscope ( endoeye , olympus surgical , orangebur , sc , usa ) was inserted into the peritoneum through the 12 mm trocar and the flexible laparoscopic instruments ( laparoangle , cambrigeendo , framingham , ma , usa ; and roticulator , autosuture , norwalk , ct , usa ) were inserted through the remaining trocars ( fig .
in which a nephrectomy or nephroureterectomy was performed , a 4.0 cm incision was made .
resected specimens of renal cell carcinoma ( rcc ) or renal pelvis tumor were entrapped by use of a lap - bag ( sejong medical , paju , korea ) and extracted along the longitudinal axis , and there were no morcellated specimens in our cases . in cases with right - sided disease , the liver was retracted by use of a diamond flex angled circular retractor ( snowden pencer , cardinal health , dublin , oh , usa ) through a 5 mm port . in other cases ,
for the methods in which the instruments were crossed in both hands , a laparoscopic triangle was secured .
the surgical procedure was performed by using laparoscopic instruments that can be flexed ( fig .
after the surgical procedure was completed , the homemade single - port device and alexis wound retractor were removed .
the surgical procedure was completed after the application of dermabond ( ethicon , somerville , nj , usa ) .
mean visual analogue pain scales on the operative day and the first postoperative day were 6.3/10 and 3.1/10 , respectively .
cases that were converted to conventional surgery were found to correspond to patients who concurrently had xanthogranulomatosis and a ureteropelvic junction stone in the right kidney . in these patients , a simple nephrectomy was attempted . because of the severe adhesion to the adjacent tissues and the persistent presence of bleeding , however , no further surgical procedures were available . accordingly , surgical procedures progressed after the additional insertion of two ports .
the operative time was 405 minutes , and the estimated blood loss was 2,050 ml .
two cases that were converted to open surgery were cases of nephroureterectomy for a ureteral tumor .
one incision extension was performed because of complete renal hilar lymphadenectomy by the open technique , and one open conversion with gibson 's incision was performed because of severe adhesion around the distal ureter .
lymphadenectomy around the renal pedicles and external iliac vessels , which was similar to conventional laparoscopic surgery , was performed in most cases .
bladder cuff excision was performed by the extravesical approach and the bladder repair was performed by suture with a conventional laparoscopic needle holder using 3 - 0 vicryl with laparoty clips ( ethicon endosurgery , cincinnati , oh , usa ) in 4 cases .
cumulative perioperative outcomes for each operation are presented in table 2 . in all surgical cases ,
there were no accidents or complications in association with the use of a homemade single - port device during the surgery . for cases in which surgery
was performed for more than 2 hours , however , the surgical glove was stretched in three cases . in one case of ureterolithotomy ,
less via an umbilicus was first performed by piskun in 1999 for a cholecystectomy . since then
, it has been frequently performed in the field of urology as well as in the field of surgery .
kaouk et al reported that less was successfully performed in a total of 10 cases .
less was also reported to be successfully performed in the first 100 cases of a single center .
the conventional type of laparoscopic surgery requires 3 to 6 ports , and as a result many patients complain of transient pain at the incision site .
besides , in cases of pelvic surgery , damage to the inferior epigastric artery sometimes occurs after the insertion of a lateral port . in the case of less via an umbilicus , however , a single port only is used while maintaining the advantages of the conventional type of laparoscopic surgery .
in addition , it is also excellent from a cosmetic perspective compared with the open technique .
less leaves almost no operative scars . besides , because an incision is made via the umbilicus , damage to the organs on the peritoneal wall can be minimized .
furthermore , it may also be effective for bilateral cases . in the cases reported here ,
patients who had a bilateral lesion were also able to undergo bilateral less by using a single incision via a single umbilicus .
this implies that a single incision can be maximally used as compared with cases in which a laparoscopic port must be inserted , including those with a bilateral ureteral stone or bilateral renal tumor , which are often encountered in the field of urology . despite these advantages ,
however , the laparoscopic instruments are crossed in an x - shape as compared with the conventional types of laparoscopic surgery . accordingly , because it is difficult to manipulate the laparoscopic instruments , the surgical time is prolonged and refined surgery is difficult ; there are therefore some patients who are unwilling to undergo single - incision laparoscopic surgery . in our 30 patients ,
this patient was found to have xanthogranulomatosis pyelonephritis and was suspected of having an adhesion to the adjacent tissue .
actually , in the operation field , the adhesion was more severe than what was expected . within 3 hours
the learning curve for less can be overcome within a relatively short time . in all surgical cases ,
it was found to be decreased without a great difference from the surgical time of conventional laparoscopic procedures . in cases in which the surgical procedure was difficult due to adhesion or to difficulty in manipulating the laparoscopic instruments after a single incision was attempted ,
the scope of the surgical procedure could be widened because a conversion to conventional laparoscopy could be made at any time .
the laparoscopic ports that were used herein have been used overseas as well as in korea .
only one type of less port is approved for human use in korea , and this is commercially available only in korea . in association with this , park et al first reported nephrectomy in pediatric patients .
han et al reported their initial experiences with nephrectomy by using a homemade single - port device .
jeong et al compared the surgical outcomes of conventional laparoscopic adrenalectomy with those of less adrenalectomy .
park et al first reported their initial experiences with nephroureterectomy for a renal pelvis tumor .
in overseas countries , the r - port ( advanced surgical concepts , dublin , ireland ) is the representative less port .
the homemade single - port device that was used herein has advantages compared with the conventional types of r - port in that it is less expensive ( r - port vs. less port , 550,000 krw vs 350,000 krw ) , the instruments can be manipulated more freely , and a maximal number of five ports can be used .
based on these advantages , various types of laparoscopic ports can be designed according to the surgery or individual preferences . however , there are also disadvantages as follows
. the glove can become bulged following a long - term surgery and this may interfere with the surgical procedure .
the glove can also be pierced while a needle is inserted and then pulled out .
compared with the commercially available less port , there are additional processes where a port is made and then placed .
less is a relatively safe , effective treatment technique in benign disease . for malignant disease , however , prospective study of less with large samples is needed .
less was very difficult to perform in advanced disease in our cases as compared with conventional laparoscopic surgery .
various types of single - port devices have now become commercially available , but we consider the homemade single - port device to be a relatively cost - effective and convenient device .
if various types of surgical instruments for less and appropriate ports specified for less are developed , less should be an alternative to the conventional types of laparoscopic surgery .
 purposewe present our initial experience with laparoendoscopic single - site surgery ( less ) by a single surgeon in the urologic field.materials and methodsfrom may 2009 to april 2010 , 30 consecutive patients underwent less including seven cases of nephrectomy , five cases of nephroureterectomy with bladder cuff excision , four cases of ureterolithotomy , eight cases of marsupialization , and six cases of varicocelectomy . 
 we performed a retrospective analysis of the medical records of the above patients . 
 the single port was made with a surgical glove and an alexis wound retractor ( applied medical , rancho santa margarita , ca , usa ) . 
 the wound retractor was put into the peritoneal space through an umbilical incision , and a laparoscopic triangle was secured by crossing both instruments . 
 all operations were performed by the transperitoneal approach.resultsmean patient age was 54.8 years . 
 mean operative time was 171.2109.1 minutes . 
 mean estimated blood loss was 265.0395.5 ml . 
 mean incision length was 3.21.4 cm . 
 mean length of hospitalization was 5.22.9 days . 
 there was one laparoscopic conversion and two open conversions . 
 there were two cases of transient ileus that improved with conservative treatment . 
 mean visual analogue pain scales on the operative day and first postoperative day were 6.3/10 and 3.1/10 , respectively.conclusionsin our experience , less for urologic surgery is feasible , safe , and clinically applicable . 
 we consider the homemade single - port device to be a relatively cost - effective and convenient device . 
 if surgical instruments for less and appropriate ports specified for less are developed , less would be a surgical treatment technique that could be used as an alternative to the conventional types of laparoscopic surgery . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS