Rapid technological developments in the 1970’s contributed to the emergence of operative laparoscopy as a revolution in surgery. In recent years, there has been a surge of interest in laparoendoscopic single-site (LESS) and natural orifice translumenal endoscopic surgery (NOTES), novel techniques that have the potential to further minimize the invasiveness and morbidity of surgery. Innovations in instrument design and in novel surgical platforms including robotic technology have rapidly been developed in an effort to enhance the future clinical applicability of these techniques. In this chapter, we review the current status and future directions of LESS and NOTES technology, focusing on the current research in the field.

Laparoendoscopic single site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) are emerging platforms to further reduce the invasive profile of surgery. As feasibility of an increasing array of procedures in both platforms is being demonstrated, with out comes comparable to multiport laparoscopy, there has been a parallel proliferation of concepts, terminology and technology. In this article, we describe the rationale behind the evolving paradigm shift towards truly “scarless” surgery and address the terminology associated with these surgical approaches.

Ten years ago the Americangastroenterologist Anthony Kalloo described for thefirst time the concept of Natural Orifice TransluminalEndoscopic Surgery – NOTES. His revolutionary visiongenerated such an unprecedented worldwide momentumof creativity and renovation in the surgical communityto push the current limit of the research in the minimalinvasive surgery field toward the unimaginable goal ofnon visible scar surgery. At present time several NOTESapplications are continuously reported by many teams all around the world and the aim of the present paperwas to illustrate the clinical evidence registered up tonow as well as to inform about the ongoing researchefforts made to perform non visible scar surgery to treatmore complex surgical diseases

Minimally invasive surgery is advancing to new frontiers that attempt to limit patient morbidities while providing excellent surgical outcomes. At the forefront of these efforts is natural orifice surgery, where surgical incisions can theoretically be eliminated. The purpose of this report is to describe the evolution of the clinical development of the natural orifice translumenal endoscopic radical prostatectomy (NOTES RP). It details the early experimental cadaver and animal work and the many challenges encountered to bring this procedure to clinical fruition. While the procedure remains in its infancy the clinical application to human patients shows its potential merit to positively impact the surgical control of prostate cancer. Early clinical experience does not allow the ability to draw definitive conclusions about the procedure at this time but the potential benefits for a new minimally invasive inexpensive treatment for prostate cancer patients is promising.

LaparoEndoscopic Single-Site (LESS) nephroureterectomy is a recent iteration of laparoscopic renal surgery whereby the minimally-invasive approach of laparoscopy has been condensed to a single operative access site in efforts to minimize convalescence and improve cosmesis. To date, LESS nephroureterectomy has been reported successful for both adult and pediatric patient populations, most commonly for treatment of upper tract urothelial carcinoma in adults. For the treatment of upper tract urothelial carcinomas, comparative oncologic effectiveness of LESS compared to conventional laparoscopy or open surgery is pending further investigation. Overall, LESS nephroureterectomy has proven its role as a feasible and safe option of minimally-invasive surgery, minimizing the number and length of the surgical incisions used.

OBJECTIVES: Background. Nephron-sparing surgery (NSS) ensures excellent oncological and functional outcomes in treating small renal masses. Laparo-Endoscopic-Single-Site Surgery (LESS) is one of the major advances in the evolution of minimally invasive surgery.METHODS: A prospective evaluation of patients underwent LESS NSS at our institutions for a solitary, exophytic, enhancing, small (≤ 4.0 cm) renal masses and normal controlateral kidney was done. Peri-operative, pathological, hematological data together with a subjective evaluation of the pain (VAS) and the scars were collected. A comprehensive electronic literature search was conducted in May 2011 using the Medline database to identify all publications relating to LESS NSS. RESULTS: Fourteen patients were operated by a LESS (mean operative time: 125min and 137.4 min; mean blood loss: 207 ml and 113 ml). The mean warm ischemia time in the LESS clamped NSS was 11.1±2.4 min using an early unclamped technique. Neither conversion to open surgery nor transfusions occurred. Three patients required conversion to standard laparoscopy. Postoperatively, we recorded 1 Clavien II (acute gastritis), 1 Clavien IIIa (urinary fistula after NSS) and 1 Clavien IV (cerebral stroke) complications. Pathology revealed 13 T1a clear cell carcinoma, 4 complex renal cysts, 2 oncocytoma and 1 angiomyolipoma (surgical margin positive). With a minimal postoperative pain (VAP: 1.8 in POD1) the patients were discharged after 4.4days without variation in eGFR. No local or distant progression was detected. Current literature suggest that LESS NSS can safely and effectively be performed in a variety of urologic settings and represent one of the major interests among the LESS procedures . Although, the quality of evidence of all available studies remains low, mostly being small case series or case control studies from selected centers. CONCLUSIONS: LESS NSS in selected renal masses is feasible, provides postoperative outcomes overlapping the standard counterpart and ensures subjective satisfaction. A more extensive surgical experience and a prolonged follow-up are necessary to point out the role of this technique.unclamp NSS and 6 patients by a clamp LESS NSS

OBJECTIVES: To summarize the available tools available for performing LaparoEndoscopic Single-Site surgery in Urology.METHOD: A comprehensive electronic literature search was conducted in May 2011 using the Medline database to identify all publications relating to NOTES and LESS in urology and information on devices were also obtained by accessing company Websites.RESULTS: Multiple access ports are available and allow to insert several instruments through multiple channels inside a larger single port. Due to lack of triangulation intracorporally, companies developed various articulating and bent instruments, limiting clashing and allowing increased working space. The ideal endoscope for LESS should remove the light cord and camera head from the operative field. Articulating and low profile scopes are now available. Furthermore, surgeons can use extra-long scopes.CONCLUSION: Various tools currently are available for single-site surgery. Randomized studies are needed to determine the Platform selection.

Continued advancement in laparoscopyand a desire for less-invasive surgical approach has ledto the development of novel surgical approaches, inclu-ding laparoendoscopic single-site surgery (LESS). LESSin urology has not reached the pinnacle yet. Objectiveof this study is to provide an evidence-based analysis ofthe current status and future directions of minimal accessand minimally invasive urological surgery represented byLESS in comparison with classic multiport laparoscopicsurgery. Since the initial report of single-port nephrec-tomy in 2007, the majority of laparoscopic proceduresin urology have been described with a single-site appro-ach. Multi-center experience has validated Urological LESS procedures as technically feasible and safe for va-rious urologic diseases.Certainly, several issues must be overcome before LESScan practiced universally in urology. Development ofinstrumentation and platform, long term follow up andlarge-scale randomized controlled trials are needed toprovide an accurate comparative analysis with otherprocedures to confirm the significant benefits of LESS

Laparoendoscopic single-site surgery (LESS) should theoretically improve perioperative results and cosmesis minimizing skin incision. LESS surgery is technically demanding and the result of any procedure depends on the surgeon skill and experience, on the condition to be treated and finally on careful patient selection. As cosmesis is the main advantage over standard laparoscopy, LESS is particularly indicated in young patients with low BMI. While at the beginning LESS surgery was limited to demolitive procedures, increasing experience lead to widen indications to reconstructive and more challenging conditions. New technologies and robotics may increase LESS indications in the next future

Laparoendoscopic single-site surgery (LESS) represents the next step of laparoscopic surgery and a major advancement towards scarless surgery. LESS radical nephrectomy is an evolving technique based on technological advancement of laparoscopic instruments as well as the refinement of existing techniques. The current report describes LESS nephrectomy technique, presents the experience with the technique in a series of 42 patients and reviews current literature in the field of LESS nephrectomy

OBJECTIVES: To review and synthesize the evidence available in the literature on laparoendoscopic single-site (LESS) pyeloplasty and other reconstructive procedures. METHODS: A literature search was performed to capture original articles related to LESS urological reconstructive procedures. We outlined the differences in technique and clinical outcomes related to their safety and efficacy.RESULTS: We found 28 retrospective studies, with a total of 146 patients. Procedures included pyeloplasty (91), ureterolithotomy (44), sacrocolpopexy (4), bladder diverticulectomy (4), partial cystectomy (2), one of which associated to augmentation cystoplasty, ureteroneocystostomy (1), ileal ureter (1), and retrocaval ureter (1). Mean operative time was 215 minutes for LESS pyeloplasty and 186 minutes for LESS ureterolithotomy

Laparoscopic adrenal surgery is a standard procedure for the management of benign adrenal pathology and small malignant tumors. There has been an increasing interest over the last few years in the use of laparoendoscopic single-site surgery (LESS). From recent literatures, LESS adrenalectomy was demonstrated that this technique was safe and feasible despite the relatively difficult anatomical location of the adrenal gland. We reviewed the surgical techniques and outcomes of LESS adrenalectomy including robot-assisted approach and gave an overview of the current role of LESS in adrenalectomy

OBJECTIVES: Our purpose was to summarize the current status of Laparo-endocopic single site surgery (LESS) in the pelvis.METHODS: A comprehensive literature search was conducted in May 2011 using the medline database to identify publications relating to LESS surgery in the pelvis.RESULTS: LESS can be safely performed in the pelvis with comparable outcomes to standard minimally invasive approaches. Small series have demonstrated good outcomes in the hands of experienced surgeons in a number of urological settings in the pelvis. Challenges in LESS surgery are continual being overcome by advancing technologies such as with the robotic platform;however, significant improvements are necessary to reduce the difficulty with LESS surgery and dispersion amongst urological surgeons. CONCLUSION: LESS pelvic procedures are evolving. Wide ranges of procedures have been described using LESS approach, however, in small series and short follow-up. Further examination of LESS pelvic approach with well-designed studies will be crucial to determine the future role of such an approach.

OBJECTIVES: LaparoEndoscopic SingleSite (LESS) surgery presents many technical and ergonomic obstacles. The solution to these current limitations may lie within emerging technologies, primarily the daVinci robotic platform. The purpose of this review was to examine the available literature as it pertains to robotic laparoendoscopic single-site surgery (R-LESS) and detail our experience with this approach at our institution.METHODS: An electronic literature search was conducted using the Medline database to identify all publications relating to R-LESS and/or robotic single port surgery in urology. Additionally, a retrospective review of our single center experience was completed. RESULTS: Fifteen original articles and two abstracts were identified in the literature and included dry lab investigation, animal experiments, single case reports,cumulative series, and two retrospective comparative analyses. Most detailed technique, perioperative outcomes, and associated procedural nuances. CONCLUSIONS: R-LESS urologic surgery is feasible and can be performed using several approaches. R-LESS reduces difficulties encountered with conventional LESS urologic surgery. An ideal robotic system is needed and would be task specific, deployable through a single incision, possess articulating instruments, and have reduced external housings.

OBJECTIVES: To review the development of miniaturized laparoscopic instruments with particular attention to the urological field and focusing on nomenclature, history and outcomes. METHODS: A comprehensive literature search was conducted in order to find articles related to Minilaparoscopy, Needlescopy, Microlaparoscopy. The most relevant papers over the last 30 years were selected in base to the experience from the panel of experts, journal, authorship and /or content. RESULTS: 258 manuscripts were found, 14 of them review, 126 about general surgery, 86 gynecology, 55 urology, 31 thoracic surgery. Minilaparoscopy is the main topic in 169 papers, Needlescopy in 58 and Microlaparoscopy in 32. No clinical randomized trials prospective non-randomized match-case control.CONCLUSIONS: We are facing a Minilaparoscopy of second-generation with superior performance granted by new endoscopes and most effective instruments. Up to date, Minilaparoscopy has demonstrated in almost all urologic indication to be feasible, safe and able to improve cosmetic and postoperative pain control. Anyway, clinical randomized trials are still lacking and only studies from other discipline can corroborate this trend

Natural Orifice Transluminal Endoscopic Surgery (NOTES) has emerged recently in the experimental surgical field, innovating for the passage of luminal barrier, the absence of scars and reduction of post-operative pain. Among the various ports of access (transvaginal, transgastric, transvesical and transcolonic), this paper is an update on advances ＆ controversies of transvesical port for NOTES Urological applications.

This articles discusses the preclinical development of natural orifice surgery in urology. Rationale for this approach is provided. The description of transvaginal nephrectomy and NOTES prostatectomy is described.

With improved technologies and the development of new techniques, has emerged the concept of “scarless surgery” in an attempt to treat certain diseases obviating the need for incisions to access the peritoneal cavity, resulting in direct benefit to patients and assuming an improvement in quality of life and offering an advantage over conventional laparoscopy. Laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) are evolutions of laparoscopy, and they are complementary techniques that should be included in this new concept. NOTES is an emerging surgical modality that uses endoscopic instruments through hollow viscera to enter the peritoneal cavity and allow surgical procedures without incisions. The NOTES procedure may provide additional benefits when compared with current minimally invasive procedures. Potential advantages include no skin incisions, improved cosmetic result, reduced postoperative pain, diminished risk of postoperative hernias, and earlier recovery. NOTES surgery has still some inconvenient regarding instrumentals, viewing orientation, control of complications. Attempts to overcome the current limitations of the technique have given rise to the concept of hybrid NOTES, which is performed with the assistance of transabdominal ports for the use of conventional laparoscopy equipment. NOTES is a very promising technique although further investigation is necessary until implementing NOTES surgery in the common clinical practice.

LESS and NOTES are the further step forward the “scarless” surgery recently, which have challenged the main principles of conventional multiport laparoscopy. To develop the surgical skills for these novel techniques, the guideline for training program should be neccesary for its clinical practice to reduce the complications. In this paper, we will summary the challenges of these new technique and introduce our experience of training courses.