Comparison of Single-Port Robotic Donor Nephrectomy and Laparoscopic Donor Nephrectomy.

Purpose: To compare the intra- and postoperative outcomes of single-port robotic donor nephrectomies (SP RDNs) and laparoscopic donor nephrectomies (LDNs). Materials and Methods: We retrospectively reviewed our institutional database for patients who received LDN or SP RDN between September 2020 and December 2022. Donor baseline characteristics, intraoperative outcomes, postoperative outcomes, and recipient renal function were extracted and compared between LDN and SP RDN. SP RDN learning curve analysis based on operative time and graft extraction time was performed using cumulative sum analysis. Results: One hundred forty-four patients underwent LDN and 32 patients underwent SP RDN. LDN and SP RDN had similar operative times (LDN: 190.3 ± 28.0 minutes, SP RDN: 194.5 ± 35.1 minutes, p = 0.3253). SP RDN patients had significantly greater extraction times (LDN: 83.2 ± 40.3 seconds, SP RDN: 204.1 ± 52.2 seconds, p < 0.0001) and warm ischemia times (LDN: 145.1 ± 61.7 seconds, SP RDN: 275.4 ± 65.6 seconds, p < 0.0001). There were no differences in patient subjective pain scores, inpatient opioid usage, or Clavien-Dindo II+ complications. Short- and medium-term postoperative donor and recipient renal function were also similar between the groups. SP RDN graft extraction time and total operative time learning curves were achieved at case 27 and 13, respectively. Conclusion: SP RDN is a safe and feasible alternative to LDN that minimizes postoperative abdominal incisional scars and has a short learning curve. Future randomized prospective clinical trials are needed to confirm the findings of this study and to identify other potential benefits and drawbacks of SP RDNs.

Management of Staple Line Leaks after Laparoscopic Sleeve Gastrectomy.

Background and Objectives: Laparoscopic sleeve gastrectomy has become one of the most popular bariatric surgeries in the United States with a low rate of morbidity and effective weight loss. However, staple line leak remains a feared complication requiring a lengthy and difficult treatment course until resolution. This study outlines the various treatment methods used within a high-volume bariatric practice for successful leak resolution without necessitating a conversion procedure. Methods: A retrospective review was conducted on all patients with staple line leak after laparoscopic sleeve gastrectomy in a three-surgeon bariatric practice from January 1, 2010 to December 31, 2019. Results: A total of 10 staple line leaks were identified with a leak rate of 0.9%. Patients presented on average 29.3 days postoperatively and were all diagnosed on computed tomography. Three patients were initially managed operatively with washout and drainage procedure. Six patients were managed endoscopically initially with either stent or over-the-scope clip placement. Most patients required multiple interventions with an average of 2.4 interventions per patient. Average time to leak resolution was 48.2 days (15-95 days). Conclusion: Management of staple line leaks after laparoscopic sleeve gastrectomy requires a multimodal approach usually requiring multiple interventions before leak resolution. We demonstrate effective utilization of varying interventions that lead to effective leak resolution and avoid conversion operations.

Is obesity a contraindication for kidney donation?

INTRODUCTION: To enlarge the donor pool, kidney donors with obesity have been considered. We hypothesized that it is safe for patients with obesity to serve as living kidney donors. METHODS: In this single-center retrospective analysis, we examined the effect of obesity (body mass index (BMI) of 30-35 kg/m2) on glomerular filtration rate (GFR) and creatinine in patients undergoing laparoscopic donor nephrectomy. Other outcomes included intraoperative, 30-, and 90-day complications. We examined the trajectory between patients with obesity versus patients without obesity over time using mixed effects models for the outcomes of creatinine in mg/dL and GFR in mL/min/1.73 m2. RESULTS: Among donors with obesity versus donors without obesity, there were no significant differences in demographics or comorbidities. Baseline creatinine in donors with obesity was significantly greater than that of donors without obesity (p = 0.02). Operative time was significantly longer in donors with obesity versus without obesity (p = 0.03). There was no significant difference in 30-day morbidity between donors with obesity versus without obesity (6.52 vs. 3.57%, respectively; p = 0.38). The rate of graft complications was 8.7% in donors with obesity versus 7.1% in donors without obesity (p = 1.0). 90-day complications were infrequent, and not significant different between the groups. At 6, 12, and 24-month postoperative follow-up, the mean creatinine level in patients with obesity was not significantly different from that of patients without obesity (1.23 vs. 1.31, 1.23 vs. 1.26, and 1.17 vs. 1.19 at 6, 12, and 24 months, respectively). Mean GFR was also not significantly different at 6, 12, and, 24 months. CONCLUSION: Postoperative creatinine and GFR changes were not significantly different in patients with obesity versus without obesity after laparoscopic donor nephrectomy. These findings suggest that carefully screened living kidney donors with obesity do not experience decreased postoperative renal function.

Renal Safety of Intravenous Ketorolac Use After Donor Nephrectomy.

INTRODUCTION: The benefit and short-term safety of ketorolac have been established in previous studies however, the risk of bleeding and long-term renal impairment in patients undergoing donor nephrectomy remain unclear. We report our experience at a high-volume transplant center. METHOD: Between January 1996 and January 2014, 862 consecutive patients underwent laparoscopic donor nephrectomy. Exclusion criteria included nonsteroidal anti-inflammatory drug allergy, asthma, bleeding disorders, long-term opioid use, intraoperative blood loss >700 mL, peptic ulcer disease, bleeding diathesis, and baseline creatinine greater than 1.9 mg/dL. Intravenous ketorolac was administered within 30 minutes following the surgical procedure at a dose of 15 to 30 mg every 6 hours. Patients were categorized into 2 groups according to the administration of ketorolac after surgery. Differences between the groups were analyzed. Primary outcomes were changes in serum creatinine and hemoglobin levels. Poor outcome was defined as postsurgical complications. RESULTS: During this time, 469 (55.3%) received ketorolac. The mean donor age was 39 years, and 360 (42.5%) were male. Left kidneys were procured in 82%. Operative time averaged 210 minutes and warm ischemia time117 seconds. Baseline demographic and operative outcomes were comparable in both groups. No statistically significant differences were found between the ketorolac group and the nonketorolac group in preoperative and postoperative hemoglobin levels and serum creatinine at 1 week, 1 year, and 5 years (P = .6). Ketorolac use was not associated with increased perioperative morbidity (P = NS). CONCLUSION: The use of intravenous ketorolac in patients undergoing donor nephrectomy was not associated with an increased risk of bleeding or renal impairment.

Robotic-assisted vs. laparoscopic donor nephrectomy: a retrospective comparison of perioperative course and postoperative outcome after 1 year.

Safety is of utmost importance in live donor nephrectomies. In this study, we describe our initial experience with robot-assisted laparoscopic donor nephrectomy (RDN) in comparison with the standard laparoscopic donor nephrectomy (LDN). We retrospectively reviewed 95 patients who either underwent RDN or LDN performed by a single surgeon from 2011 to 2016 at a tertiary institution. Donor perioperative course and postoperative outcome along with recipient outcomes were compared. Of the 95 cases, 73 were classified as LDN and 22 were classified as RDN. There were no significant differences between the two groups in age, sex, BMI, race, and ASA status. Operative times (p < 0.001) were longer in the RDN group, but eventually approached LDN times. Warm ischemia (p = 0.002) and extraction times (p = 0.05) were also longer in the RDN cohort. The donor length of hospital stay, complication rates, and postoperative change in eGFR from baseline were similar in both cohorts up to 1 year. Recipient outcomes, including delayed graft function, graft failure, and renal function up to 1 year, were also comparable. In this study, we compared the longest postoperative course so far in both donors and recipients between RDN and LDN. Up to 1 year, RDN does not negatively impact outcomes. Proficiency with RDN also quickly improved to match LDN, making it a suitable procedure for newer surgeons.

Factor VIII elevation may contribute to portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy: a multicenter review of 40 patients.

BACKGROUND: Portomesenteric vein thrombosis (PMVT) has been increasingly reported after laparoscopic sleeve gastrectomy (LSG). Factor VIII (FVIII) is a plasma sialoglycoprotein that plays an essential role in hemostasis. There is increasing evidence that FVIII elevation constitutes a clinically important risk factor for venous thrombosis. OBJECTIVES: To report the prevalence of FVIII elevation as well as other clinical characteristics in a multicenter series of patients who developed PMVT after LSG. SETTING: University hospitals. METHODS: A retrospective review was conducted of all patients that developed PMVT after laparoscopic bariatric surgery from 2006 to 2016 at 6 high-volume bariatric surgery centers. RESULTS: Forty patients who developed PMVT postoperatively, all after LSG, were identified. During this timeframe, 25,569 laparoscopic bariatric surgery cases were performed, including 9749 LSG (PMVT incidence after LSG = .4%). Mean age and body mass index were 40 years (18-65) and 43.4 kg/m2 (35-59.7), respectively. Abdominal pain was the most common (98%) presenting symptom. Of patients, 92% had a hematologic abnormality identified, and of these, FVIII elevation was the most common (76%). The vast majority (90%) was successfully managed with therapeutic anticoagulation alone. A smaller number of patients required small bowel resection (n = 2) and surgical thrombectomy (n = 1). There were no mortalities. CONCLUSIONS: A high index of clinical suspicion and prompt diagnosis/treatment of PMVT usually leads to favorable outcomes. FVIII elevation was the most common (76%) hematologic abnormality identified in this patient cohort. Further studies are needed to determine the prevalence of FVIII elevation in patients seeking bariatric surgery.

Outcomes of robot-assisted versus laparoscopic repair of small-sized ventral hernias.

INTRODUCTION: The aim of the study is to investigate the outcomes of the da Vinci robot-assisted laparoscopic hernia repair of small-sized ventral hernias with circumferential suturing of the mesh compared to the traditional laparoscopic repair with trans-fascial suturing. METHODS: A retrospective review was conducted of all robot-assisted umbilical, epigastric and incisional hernia repairs performed at our institution between 2013 and 2015 compared to laparoscopic umbilical or epigastric hernia repairs. Patient characteristics, operative details and postoperative complications were collected and analyzed using univariate analysis. Three primary minimally invasive fellowship trained surgeons performed all of the procedures included in the analysis. RESULTS: 72 patients were identified during the study period. 39 patients underwent robot- assisted repair (21 umbilical, 14 epigastric, 4 incisional), and 33 patients laparoscopic repair (27 umbilical, 6 epigastric). Seven had recurrent hernias (robot: 4, laparoscopic: 3). There were no significant differences in preoperative characteristics between the two groups. Average operative time was 156 min for robot-assisted repair and 65 min for laparoscopic repair (p < 0.0001). The average defect size was significantly larger for the robot group [3.07 cm (1-9 cm)] than that for the laparoscopic group [2.02 cm (0.5-5 cm)] (p < 0.0001), although there was no significant difference in the average size of mesh used (13 vs. 13 cm). There was no difference in patients requiring postoperative admission or length of stay between the two groups. The mean duration of follow-up was 47 days. There was no difference in complication rate during this time, and no recurrences were reported. CONCLUSION: There are no significant differences in terms of safety and early efficacy when comparing small-sized ventral hernias repaired using the robot-assisted technique versus the standard laparoscopic repair.

Laparoscopic Sleeve Gastrectomy and Gastric Bypass for The Aging Population.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the two most common bariatric surgeries for treating morbid obesity. The purpose of this study is to determine differences in outcomes from RYGB or SG between patients ages ≥ 60 years and < 60 years. METHODS: A retrospective review of patients who underwent RYGB and SG at our institution from 01/2008 to 05/2012 was conducted. Forty patients from each group (≥60 years and < 60 years) were matched based on gender, body mass index (BMI), co-morbidities, and type of bariatric surgery performed, and their charts were reviewed up to 1 year post-operatively. Primary end points measured were mean length of stay, operative time, incidence of complications, and readmissions in the first post-operative year. A secondary end point measured was percent total weight loss (%TWL) and excess weight loss (%EWL). RESULTS: There were no significant differences between group < 60 and group ≥ 60 in operative time (210 vs. 229 min; p = 0.177), in-hospital post-operative complication rates (2.5 vs. 5 %; p = 1.0), long-term complication rates (2.5 vs. 10 %; p = 0.359), and 30-day readmission rates (2.5 vs. 12.5 %; p = 0.2). Patients in group < 60 had shorter lengths of stay (2.2 vs. 2.7 days; p = 0.031), but this difference is not clinically significant. Both groups achieved similar %TWL (21.4 vs. 20.5 %; p = 0.711) and %EWL (50.6 vs. 50.7 %; p = 0.986). CONCLUSIONS: Advanced age (≥60 years) is not a significant predictor of a worse outcome for SG and RYGB.

Laparoscopic-Assisted Transversus Abdominis Plane Block for Postoperative Pain Control in Laparoscopic Ventral Hernia Repair: A Randomized Controlled Trial.

BACKGROUND: Laparoscopic ventral hernia repair (LVHR) is associated with considerable postoperative pain. Transversus abdominis plane (TAP) blocks have proven effective in controlling postoperative pain in a variety of laparoscopic abdominal operations. To date, no studies have focused on TAP blocks in LVHR. Our goal was to assess whether TAP blocks reduce opioid requirements and pain scores after LVHR. STUDY DESIGN: Patients undergoing LVHR were randomly assigned to receive a TAP block or placebo injection. The primary end points were cumulative opioid use at 1, 3, 6, 12, 18, and 24 hours postoperatively and pain scores recorded at 1 and 24 hours postoperatively. RESULTS: Patients in the experimental TAP group (n = 52) and control group (n = 48) were comparable with respect to patient demographics and clinical characteristics. In the postanesthesia care unit, the TAP group had significantly lower pain scores than the control group (p < 0.05). Patients in the TAP group used less opioids than the control group at each time point assessed after 6 hours postoperatively (p < 0.05). There was no significant difference in pain scores at 24 hours postoperatively (p > 0.05). CONCLUSIONS: Transversus abdominis plane blocks given during LVHR significantly decrease both short-term postoperative opioid use and pain experienced by patients.

Robotic assisted laparoscopic prostatectomy in men with proctocolectomy and restorative ileal pouch-anal anastomosis.

We conducted a retrospective chart review of robotic prostatectomies done by a single surgeon between 2003 and 2012. During that time period, we identified two patients within the year 2012, with ileal pouch-anal anastomosis (IPPA) who also underwent robotic prostatectomies. The demographics and postoperative characteristics of the two patients were assessed. In both patients, prostatectomy, bilateral nerve sparing, and pelvic lymphadenectomy were successfully performed and the integrity of ileal pouch was maintained. There was a mean surgical time of 144.5 minutes, and an average estimated blood loss was 125 mL. Both patients were discharged on the second day postoperatively. In both patients there was a Gleason upgrade to 3 + 4, with negative margins, and preservation of fecal and urinary continence by their six-month followup. Owing to surgical modifications, these two surgeries represent the first successful robotic prostatectomies in patients with a J-pouch.

Safety of outpatient laparoscopic cholecystectomy in the elderly: analysis of 15,248 patients using the NSQIP database.

BACKGROUND: Studies have shown that laparoscopic cholecystectomy (LC) in an ambulatory setting is a safe alternative to the traditional overnight hospital stay. However, there are limited data on the morbidity and mortality of outpatient LC in elderly patients. We evaluated the safety of ambulatory LC in the elderly and identified risk factors that predict inpatient admission. STUDY DESIGN: A retrospective analysis was performed using the American College of Surgeon's NSQIP database between 2007 and 2010. The database was searched for patients older than 65 years of age who underwent elective LC at all participating hospitals in the United States. Data from 15,248 patients were collected and we compared patients who underwent ambulatory procedures with those patients who were admitted for an inpatient stay. RESULTS: Seven thousand four hundred and ninety-nine (48.9%) patients were ambulatory and 7,799 (51.1%) were nonambulatory. Postoperative complications included mortality (0.2% vs 1.5%; p < 0.001), stroke (0.1% vs 0.3%; p < 0.001), myocardial infarction (0.1% vs 0.6%; p < 0.001), pulmonary embolism (0.1% vs 0.3%; p = 0.005), and sepsis (0.2% vs 0.7%; p < 0.001) for ambulatory and nonambulatory cases, respectively. We identified significant independent predictors of inpatient admission and mortality, including congestive heart failure, American Society of Anesthesiologists class 4, bleeding disorder, and renal failure requiring dialysis. CONCLUSIONS: We believe ambulatory LCs are safe in elderly patients as demonstrated by low complication rates. We identified multiple risk factors that might warrant inpatient hospital admission.

What circumstances prompt a workplace discussion in medical evaluations for back pain?

PURPOSE: To determine how frequently workplace topics emerge in the interactions between patients and providers in an evaluation for low back pain (LBP) and to determine its association with patient and provider characteristics. METHODS: Adults with work-related LBP (N = 97; 64 % male; median age = 38) completed a demographic questionnaire and a survey of disability risk factors, then agreed to audio-taping of their visits with a participating occupational healthcare provider (n = 14). Utterance-level verbal exchanges were categorized by trained coders using the Roter interaction analysis system. In addition, coders flagged any instance of workplace discussion between patients and providers. RESULTS: Workplace discussions occurred in 51 % of visits, and the most frequent topic was physical job demands. Workplace discussions were more frequent among the oldest and youngest patients and when patients were seen by providers who were more patient-centered and made more efforts to establish patient rapport and engagement. However, patients reporting numerous disability risk factors and workplace concerns in the pre-visit questionnaire were no more likely to discuss workplace topics with their providers (p > 0.05). Only the patient-centered orientations of providers and patients remained statistically significant predictors in multivariate modeling (p < 0.05). CONCLUSIONS: Workplace discussions are facilitated by a patient-centered orientation and by efforts to establish patient engagement and rapport, but workplace discussions are no more frequent among patients with the most significant workplace concerns. Screening questionnaires and other assessment tools may be helpful to foster workplace discussions to overcome possible barriers for returning to work.

Robot-assisted laparoscopic prostatectomy and previous surgical history: a multidisciplinary approach.

Previous abdominal or prostate surgery can be a significant barrier to subsequent minimally invasive procedures, including radical prostatectomy (RP). This is relevant to a quarter of prostatectomy patients who have had previous surgery. The technological advances of robot-assisted laparoscopic RP (RALP) can mitigate some of these challenges. To that end, our objective was to elucidate the effect of previous surgery on RALP, and to describe a multidisciplinary approach to the previously entered abdomen. One-thousand four-hundred and fourteen RALP patients were identified from a single-surgeon database. Potentially difficult cases were discussed preoperatively and treated in a multidisciplinary fashion with a general surgeon. Operative, pathological, and functional outcomes were analyzed after stratification by previous surgical history. Four-hundred and twenty (30 %) patients underwent previous surgery at least once. Perioperative outcomes were similar among most groups. Previous major abdominal surgery was associated with increased operative time (147 vs. 119 min, p < 0.001), as was the presence of adhesions (120 vs. 154 min, p < 0.001). Incidence of complications was comparable, irrespective of surgical history. Major complications included two enterotomies diagnosed intraoperatively and one patient requiring reoperation. All cases were performed robotically, without conversion to open-RP. There was no difference in biochemical disease-free survival among surgical groups and continence and potency were equivalent between groups. In conclusion, previous abdominal surgery did not affect the safety or feasibility of RALP, with all patients experiencing comparable perioperative, functional, and oncologic outcomes.

Polyester composite versus PTFE in laparoscopic ventral hernia repair.

INTRODUCTION: Both polyester composite (POC) and polytetrafluoroethylene (PTFE) mesh are commonly used for laparoscopic ventral hernia repair. However, sparse information exists comparing perioperative and long-term outcome by mesh repair. METHODS: A prospective database was utilized to identify 116 consecutive patients who underwent laparoscopic ventral hernia repair at The Mount Sinai Hospital from 2004-2009. Patients were grouped by type of mesh used, PTFE versus POC, and retrospectively compared. Follow-up at a mean of 12 months was achieved by telephone interview and office visit. RESULTS: Of the 116 patients, 66 underwent ventral hernia repair with PTFE and 50 with POC mesh. Patients were well matched by patient demographics. No difference in mean body mass index (BMI) was demonstrated between the PTFE and POC group (31.8 vs. 32.5, respectively; P=NS). Operative time was significantly longer in the PTFE group (136 vs.106 minutes, P<.002). Two perioperative wound infections occurred in the PTFE group and none in the POC group (P NS). No other major complications occurred in the immediate postoperative period (30 days). At a mean follow-up of 12 months, no significant difference was demonstrated between the PTFE and POC groups in hernia recurrence (3% vs. 2%), wound complications (1% vs. 0%), mesh infection, requiring removal (3% vs. 0%), bowel obstruction (3% vs. 2%), or persistent pain or discomfort (28% vs. 32%), respectively (P=NS). CONCLUSION: Our study demonstrated no significant association between types of mesh used and postoperative complications. In the 12-month follow-up, no differences were noted in hernia recurrence.

Laparoendoscopic single site (LESS) splenectomy with a conventional laparoscope and instruments.

BACKGROUND AND OBJECTIVES: We present 2 cases of laparoendoscopic single site surgery (LESS) splenectomy performed with a conventional laparoscope and instruments, and the use of a novel internal retraction device. METHODS: One patient underwent LESS splenectomy for idiopathic thrombocytopenia purpura (ITP), and a pediatric patient with sickle cell disease underwent LESS splenectomy and cholecystectomy. In each case, a 2-cm vertical incision was made within the confines of the umbilical ring, and a SILS port (Covidien, Norwalk CT) inserted. A 5-mm, 30-degree laparoscope and standard 5-mm instruments were used. After isolation of the splenic hilum, one 5-mm trocar of the SILS port was upsized to 12mm, and a laparoscopic stapler was used to divide the splenic artery and vein. An internal retractor consisting of a laparoscopic bulldog clamp with a hook attachment was used to retract the gallbladder, and to secure the specimen retrieval bag during splenic extraction, which eliminated the need for a fourth trocar. RESULTS: Total operative time was 160 minutes for the LESS splenectomy, and 216 minutes for the LESS splenectomy and cholecystectomy. Both procedures were successfully completed with conventional instrumentation and a SILS port, without the need for additional incisions or trocars. No complications occurred, and both patients had an uneventful recovery. CONCLUSIONS: LESS splenectomy is a feasible procedure that can be performed safely. Although articulating instruments and laparoscopes may offer advantages, they are not necessary for performing LESS splenectomy.

Laparoscopic single site adrenalectomy using a conventional laparoscope and instrumentation.

BACKGROUND AND OBJECTIVES: We present a case of Laparoendoscopic Single Site Surgery (LESS) left adrenalectomy performed with a conventional laparoscope and instruments. METHODS: A 45-year-old male was diagnosed with hyperaldosteronism. Computed tomography detected a left adrenal nodule. Bilateral adrenal vein sampling was consistent with a left-sided source for hyperaldosteronism. RESULTS: Total operative time for LESS left adrenalectomy was 120 minutes. The surgery was performed with conventional instruments, a standard 5-mm laparoscope, and a SILS port, with no additional incisions or trocars needed. No complications occurred, and the patient reported an uneventful recovery. CONCLUSIONS: LESS adrenalectomy is a feasible procedure. Although articulating instruments and laparoscopes may offer advantages, LESS adrenalectomy can be done without these.

Laparoendoscopic single site surgery can be performed completely with standard equipment.

PURPOSE: To determine the feasibility of laparoendoscopic single site surgery (LESS) with nonarticulating instruments and conventional trocars. METHODS: After Institutional Review Board approval, a prospective database was used to identify 30 patients who underwent LESS. All procedures were begun using three 5 mm trocars, nonarticulating instruments, and a 5 mm, 30-degree laparoscope. RESULTS: Twenty-six patients underwent LESS cholecystectomy. Four patients underwent LESS appendectomy; 2 for acute appendicitis and 2 for interval appendectomy. The mean patient age was 37.1 ± 14 years for the cholecystectomy group and 29.3 ± 2.2 years for the appendectomy group. Mean body mass index was 28.4 ± 7 kg/m2 for the cholecystectomy group and 25 ± 5.6 kg/m2 for the appendectomy group. Eight patients (31%) undergoing LESS cholecystectomy required an additional 5 mm port; 6 (26%) required 1 additional port for gallbladder retraction, 1 case (4%) required 2 additional ports to control cystic artery bleeding, and 1 case (4%) was converted to a traditional 4 trocar cholecystectomy because of chronic inflammation and multiple adhesions. None of the patients in the appendectomy group required an additional port. The mean operative time was 94 ± 19 minutes for cholecystectomy and 65 ± 19 minutes for appendectomy. Ninety-two percent (N=24) of patients in the laparoscopic cholecystectomy group were discharged within 24 hours. One patient underwent postoperative endoscopic retrograde cholangiopancreatography with bile duct stone removal and was discharged after 48 hours. One patient remained until postoperative day 2 for pain control. All patients in the LESS appendectomy group were discharged within 24 hours. There were no postoperative complications. CONCLUSIONS: Although operative time for LESS is increased compared with laparoscopic cholecystectomy and appendectomy, LESS can be performed safely. In our institutional experience, LESS was successfully performed using standard laparoscopic instruments, laparoscope, and trocars. Although longer follow-up is necessary, early data supports the feasibility and safety of LESS. A low threshold should exist for the addition of extra trocars, especially during a surgeon's early experience with LESS.

Completely intracorporeal retraction of the gallbladder for laparoendoscopic single site (LESS) surgery.

Laparoendoscopic single site surgery (LESS) cholecystectomy requires a creative solution to retract the gallbladder. Transabdominal suture retraction is a commonly used technique to achieve adequate exposure of the critical structures within Calot's triangle. To avoid the multiple punctures of the gallbladder and abdominal wall required by such suture retraction, we developed a novel internal retractor specifically for use during LESS cholecystectomy. This retractor consists of a laparoscopic bulldog clamp fitted with a small metal hook, and was successfully used in a recent case of LESS cholecystectomy.