the less approach has been utilized for various indications in adults , including donor nephrectomy , simple nephrectomy , and reconstructions such ureteral reimplantation and pyeloplasty .
the safety and efficacy of the standard laparoscopic approach has also been described in pediatric populations , in which studies have compared outcomes between the laparoscopic and open approaches . however , there is a paucity of literature regarding application of the less approach in children .
concerns regarding the application of less in children are the smaller working space and the need for specialized instrumentation . in this article , we review our experience with less in children .
we detail the intraoperative outcomes and the measures taken to reduce the level of difficulty .
this was a retrospective analysis of all patients younger than 5 years who underwent less between july 2010 and june 2012 .
the parameters analyzed included operating room time , blood loss , hospital stay , and complications .
all procedures were performed with the patient in a position similar to that used for standard laparoscopy .
the patient was placed at the edge of the table with the arms padded and secured .
it was made certain that no tubes ( suction , irrigation ) were placed on the torso .
the patients were secured with the help of tape ; however , the use of a bean bag would also be suitable .
the surgeon stood while the assistant ( camera driver ) sat to make space in the operating area .
all procedures were done by use of the r - port multi - instrument access port ( advanced surgical concepts , bray , ireland ) , except for one in which a gelpoint port ( applied medical , rancho santa margarita , ca , usa ) was used .
the ports are single - use and have one 10-mm port channel and two 5-mm channels for instrument access .
the port features a plastic sleeve that connects two rings , one abdominal and one peritoneal .
the ports were inserted by using the open technique . an umbilical skin crease incision was made and the fascia incised .
. the opening should not be too large , because the port tends to slip out ; neither should it be too small , because this may cause difficulty in introduction of both the port and the instruments .
once the port was inserted , the plastic sleeve was pulled down so that the plastic rings ( abdominal and peritoneal ) approximated and the port fit snugly on the abdominal wall . in three of our cases , an accessory port was used .
the common reasons for introduction of accessory ports included difficulty in upper pole dissection , inadequate exposure of the renal hilum , and difficulty in suturing in reconstructive procedures .
the gelpoint mini port accommodates various abdominal wall and incision sizes , provides continuous access , and ensures improved articulation of both 5-mm and 10-mm instruments .
the choice of instruments is a matter of surgeon preference ; the surgeon should choose instruments he is familiar with .
the nephrectomy followed the typical steps of dissection of the ureterogonadal packets followed by dissection of the hilum ( fig .
the hilum was secured by using hem - o - lok clips ( teleflex medical , research triangle park , nc , usa ) with two clips placed on the patient side . in one case , an endo gia stapler ( covidien surgical , norwalk , ct , usa ) was placed through a 10-mm port inserted through the gelpoint port .
the less approach affords the advantage of retrieval of the specimen from the port itself without the need to extend the incision ( figs . 1 , 2 ) .
before a pyeloplasty in pediatric patients , we preferred to place an ultrasound - guided antegrade ureteral catheter . before placing the patient in the laparoscopy position ,
an ultrasound - guided percutaneous access was gained , and two guide wires were placed in the pelvicaliceal system . over one guide wire
a nephrostomy was inserted , whereas over another the ureteral catheter was coiled in the renal pelvis .
the advantages of this arrangement are that the ureteral catheter apart from being used as a splint can also be used as a conduit for passage of the stent . in addition , as a protocol , we removed the ureteral catheter first , followed by the nephrostomy .
the antegrade ureteral catheter and nephrostomy help to avoid the urethral route for stent removal .
the salle stent works on a similar principle except that it is inserted intraoperatively and has a flower at its end that is self - retaining .
intraoperatively during dissection , the nephrostomy was clamped , which distends the pelvis and facilitated dissection .
all pyeloplasties were done with a modified anderson technique , and the pelvis in all cases was extrarenal and required reduction .
the pelvis was hitched up by using a suture placed strategically through the abdominal wall .
this helped in dissection of the pelviureteral junction and avoided the need to place an extra port .
a triport access port was used during the procedure . an ultrasound - guided antegrade ureteral splint along with a percutaneous nephrostomy
the stitch was placed by using a taper - cut needle on a 3/8th circle needle ( fig .
the antegrade ureteral catheter that acted as a splint was removed on the third postoperative day , and the nephrostomy was clamped for 24 hours and removed .
all procedures were performed with the patient in a position similar to that used for standard laparoscopy .
the patient was placed at the edge of the table with the arms padded and secured .
it was made certain that no tubes ( suction , irrigation ) were placed on the torso .
the patients were secured with the help of tape ; however , the use of a bean bag would also be suitable .
the surgeon stood while the assistant ( camera driver ) sat to make space in the operating area .
all procedures were done by use of the r - port multi - instrument access port ( advanced surgical concepts , bray , ireland ) , except for one in which a gelpoint port ( applied medical , rancho santa margarita , ca , usa ) was used .
the ports are single - use and have one 10-mm port channel and two 5-mm channels for instrument access .
the port features a plastic sleeve that connects two rings , one abdominal and one peritoneal .
the ports were inserted by using the open technique . an umbilical skin crease incision was made and the fascia incised .
. the opening should not be too large , because the port tends to slip out ; neither should it be too small , because this may cause difficulty in introduction of both the port and the instruments .
once the port was inserted , the plastic sleeve was pulled down so that the plastic rings ( abdominal and peritoneal ) approximated and the port fit snugly on the abdominal wall . in three of our cases , an accessory port was used .
the common reasons for introduction of accessory ports included difficulty in upper pole dissection , inadequate exposure of the renal hilum , and difficulty in suturing in reconstructive procedures .
the gelpoint mini port accommodates various abdominal wall and incision sizes , provides continuous access , and ensures improved articulation of both 5-mm and 10-mm instruments .
the choice of instruments is a matter of surgeon preference ; the surgeon should choose instruments he is familiar with .
the nephrectomy followed the typical steps of dissection of the ureterogonadal packets followed by dissection of the hilum ( fig .
the hilum was secured by using hem - o - lok clips ( teleflex medical , research triangle park , nc , usa ) with two clips placed on the patient side . in one case , an endo gia stapler ( covidien surgical , norwalk , ct , usa ) was placed through a 10-mm port inserted through the gelpoint port . the less approach affords the advantage of retrieval of the specimen from the port itself without the need to extend the incision ( figs . 1 , 2 ) .
before a pyeloplasty in pediatric patients , we preferred to place an ultrasound - guided antegrade ureteral catheter . before placing the patient in the laparoscopy position ,
an ultrasound - guided percutaneous access was gained , and two guide wires were placed in the pelvicaliceal system . over one guide wire
a nephrostomy was inserted , whereas over another the ureteral catheter was coiled in the renal pelvis .
the advantages of this arrangement are that the ureteral catheter apart from being used as a splint can also be used as a conduit for passage of the stent . in addition , as a protocol , we removed the ureteral catheter first , followed by the nephrostomy .
the antegrade ureteral catheter and nephrostomy help to avoid the urethral route for stent removal .
the salle stent works on a similar principle except that it is inserted intraoperatively and has a flower at its end that is self - retaining .
intraoperatively during dissection , the nephrostomy was clamped , which distends the pelvis and facilitated dissection .
all pyeloplasties were done with a modified anderson technique , and the pelvis in all cases was extrarenal and required reduction .
the pelvis was hitched up by using a suture placed strategically through the abdominal wall .
this helped in dissection of the pelviureteral junction and avoided the need to place an extra port .
a triport access port was used during the procedure . an ultrasound - guided antegrade ureteral splint along with a percutaneous nephrostomy
the stitch was placed by using a taper - cut needle on a 3/8th circle needle ( fig .
the antegrade ureteral catheter that acted as a splint was removed on the third postoperative day , and the nephrostomy was clamped for 24 hours and removed .
a total of 11 less procedures were performed on 10 patients ( 1 was bilateral ) .
an accessory port ( 3 mm ) was inserted in 3 patients . in children undergoing nephrectomy ( n=7 ) ,
the mean age was 3.141.7 years , and the mean operating room time was 97.512.54 minutes .
no perioperative complications were encountered . in the pyeloplasty group , the mean operating room time was 19247.16 minutes and the mean patient age was 2.432.3 years .
a follow - up renogram at 6 months was available for two patients and showed good drainage . in all our patients who underwent ablative procedures ,
mean length of stay was 3.6 days ( range , 3 to 6 days ) .
since the first description of less surgery in 2007 , various surgical procedures have been performed with this approach in urology and allied surgical fields .
the literature is scant regarding the application of this approach in small patients , however . as with any surgical procedure ,
the advantages of less in the pediatric age group are well - defined tissue planes , absence of fat , and thin abdominal walls .
the challenges in development of less revolve around technique and anesthesia - related issues . from a technical standpoint ,
although a few workers have used articulating and bent instruments , we used standard instruments in our series .
the technical challenges one encounters are in - line camera and instrument angles and a need for coordination with an experienced camera driver .
the various maneuvers that we have used to reduce instrument clashing are as follows : 1 ) camera driver position : the camera driver sits behind the surgeon , which allows the operating surgeon increased space for movement and decreases crowding in the surgical field .
2 ) use of long and short instruments in either hand : the instrument can be an articulating or a nonarticulating instrument .
3 ) hand and instrument crossover : this is useful during dissection of the upper pole , because this is one of the most challenging steps in the procedure .
4 ) use of a hitch stitch in reconstructive procedures : among the various maneuvers one can use to avoid an extra port is the use of a transabdominal hitch stitch .
this stitch is passed through the abdominal wall and is useful in reconstructive procedures such as pyeloplasty . a similar
5 ) use of a long suction and a harmonic scalpel : we do not use articulating or prebent instruments ; however , an extra - long suction is useful during dissection of the upper pole .
6 ) use of a camera with coaxial light cable : a camera with a coaxial light cable helps in decreasing instrument clashing ; alternatively , a flexible tip camera helps in providing the surgeon a vantage of the operating field without causing clashing .
7 ) use of an accessory port : it is debatable whether adding an extra port defeats the purpose of performing the procedure through a single incision .
the steps particularly relevant to facilitating suturing are , first , the use of one straight instrument and one bent instrument ( to improve triangulation ) ; second , the use of a hitch stich for retraction of the redundant pelvis and orienting the anatomy during the anastomosis ; and third , the use of an extra 3-mm port to facilitate suturing .
there are reports describing pediatric less in children using the silstm ( covidien , norwalk , ct , usa ) port . from an anesthesia perspective
it is the responsibility of the anesthetist and the surgeon to ensure that the child is positioned properly on the table .
it should be ensured that the access port fits snugly , thus preventing subcutaneous emphysema .
in addition , the pneumoperitoneum pressures should be kept at 8 - 10 , and all efforts made to prevent hypothermia .
it has been argued that less with a scar hidden in the umbilicus is cosmetically superior than a scar in the adjacent abdominal wall . in the pediatric age group
evidence suggests that visible scarring in children reduces their self - esteem , resulting in impaired socialization skills .
thus , lesser scarring through the umbilical incision offered with less will have a lower psychosocial impact on the growing child .
it is known that infants have a greater risk of port site hernias ; however , we did not notice any defects in the scars on follow - up in any of our cases . in the series by koh et al .  
two patients developed unilateral hydroceles in the first postoperative week . in the pediatric population ,
the relatively less fat and thin musculature make dissection easy and facilitate easy port insertion .
the characteristics of the abdominal wall also make retrieval of specimens easy without the need to extend the incision .
advances in instrumentation that may be beneficial for pediatric patients include the spider surgical system ( transenterix , durham , nc , usa ) .
this is a single - access device that has two flexible channels that are inserted in the abdomen .
the use of magnets for retraction has been described in adults ; however , their utility in children has yet to be proven .
the shortcomings and difficulties in development of less in the pediatric age group include the lack of adequately powered randomized studies comparing less with conventional laparoscopy in various procedures .
patient safety is the prime consideration , because in children there is no room for error .
there is a need to develop simulators in the future for less training in the pediatric age group
u. s. food and drug administration data show that the development of pediatric medical devices lags by 2 years compared with adult equipment .
although a head - on comparison between standard laparoscopy and less in a pediatric population was beyond the scope of this study , we have eluded to our anecdotal experience with standard laparoscopic pyeloplasty in children .
the real advantages of less in children in terms of cosmesis and the perceived " smaller " length of incision need to be proven in larger randomized controlled trials .
the results from our series show that less is technically feasible in small patients as young as 4 months of age .
the development of smaller instruments will allow further growth of this technique in this patient subgroup .
 purposewe report our experience with laparoendoscopic single - site ( less ) urological procedures in children less than 5 years of age.materials and methodsten patients ( 11 procedures ) underwent less through the umbilicus . 
 seven patients underwent nephrectomy and three patients underwent pyeloplasty ( one simultaneous bilateral ) . 
 r - port port ( advanced surgical concepts , ireland ) was used in nine cases , in one case , the gelpoint access port ( applied medical , rancho santa margarita , ca , usa ) was used . the olympus endoeye camera with coaxial light cable 
 was used . 
 the hilum was secured in all cases with hem - o - lok clips ( teleflex medical , research triangle park , nc , usa ) except in one case in which an endo gia stapler ( covidien surgical , norwalk , ct , usa ) was used.resultsall procedures were technically successful . 
 accessory port ( 3 mm ) was used in 3 patients . mean age in nephrectomized patients was 3.141.7 years , the mean operative room time ( ort ) was 97.512.54 minutes . in the pyeloplasty group , 
 mean ort was 19247.16 minutes and mean age was 2.432.3 years . 
 bilateral pyeloplasty was done in a 4-month - old infant . 
 the ort in this case was 180 minutes . 
 a follow - up renogram done in the pyeloplasty patients ( n=2 ) showed good drainage . 
 mean length of stay was 3.6 days ( range , 3 to 6 days).the analgesic requirement was 23.86 mg ( range , 12.5 to 50 mg ) of diclofenac sodium.conclusionsless is technically feasible in patients as young as 4 months of age . 
 it has the potential to offer better cosmesis . 
 this needs to be proved in further comparative studies . 
 development of miniature instruments will further the growth of less in this age group . 
INTRODUCTION
MATERIALS AND METHODS
1. Positioning
2. Access port
3. Instruments
4. Ureteral stenting
RESULTS
DISCUSSION
CONCLUSIONS