Purpose. The emergence of robotic-assisted surgical techniques has gained significant indications in terms of reduced trauma, shortened recovery, and higher patients' satisfaction. However, limitations by present surgical robotic systems used in natural orifice transluminal endoscopic surgery (NOTES) gynecology still exists, such as arm collisions, countertraction, instrument dexterity, and, in particular, space confinement due to the narrow pelvic anatomy. The current study evaluated the use of a miniaturized single-site surgical robotic system and its feasibility in performing robotic NOTES gynecological procedures using a live porcine animal model. Methods. Using a transrectal approach, the fully internalized robotic arms were deployed in a reverse configuration to access the lower pelvic cavity of the animals to perform NOTES gynecological procedures. Results. Robotic-assisted transrectal gynecological procedures were successfully performed using the new robotic system. A hemi-hysterectomy with unilateral salpingo-oophorectomy was completed in the first animal and a total hysterectomy with bilateral salpingo-oophorectomy in the second animal with an average docking time of 22.5 minutes and console time of 63 minutes and 58 minutes, respectively. The overall blood loss for each procedure was estimated to be <20 mL per animal with no intraoperative complications. Conclusions. The reverse configuration of the miniaturized surgical robotic system has demonstrated its capability to provide a potential solution to maintain clear visualization of the surgical field, optimal triangulation, and dexterity robotic NOTES gynecological procedures within the deep confined space of the pelvic cavity.

The aim of this study was to provide an evidence-based systematic review of the use of laparoscopic and robotic adrenalectomy in the treatment of adrenal disease as part of the International Consultation on Urological Diseases and European Association of Urology consultation on Minimally Invasive Surgery in Urology. A systematic literature search (January 2004 to January 2014) was conducted to identify comparative studies assessing the safety and efficacy of minimally invasive adrenal surgery. Subtopics including the role of minimally invasive surgery for pheochromocytoma, adrenocortical carcinoma (ACC) and large adrenal tumours were examined. Additionally, the role of transperitoneal and retroperitoneal approaches, as well as laparoendoscopic single-site (LESS) and robotic adrenalectomy were reviewed. The major findings are presented in an evidence-based fashion. Large retrospective and prospective data were analysed and a set of recommendations provided by the committee was produced. Laparoscopic surgery should be considered the first-line therapy for benign adrenal masses requiring surgical resection and for patients with pheochromocytoma. While a laparoscopic approach may be feasible for selected cases of ACC without adjacent organ involvement, an open surgical approach remains the 'gold standard'. Large adrenal tumours without preoperative or intra-operative suspicion of ACC may be safely resected via a laparoscopic approach. Both transperitoneal and retroperitoneal approaches to laparoscopic adrenalectomy are safe. The approach should be chosen based on surgeon training and experience. LESS and robotic adrenalectomy should be considered as alternatives to laparoscopic adrenalectomy but require further study.

To describe a method of ovarian suspension with adjustable sutures (OSAS) for facilitating laparoendoscopic single-site gynecologic surgery (LESS) and to investigate the effect of OSAS on LESS.

Prospective cohort study (Canadian Task Force classification: II-2).

University teaching hospital.

One hundred seventy-eight patients with benign 5- to 15-cm cystic ovarian tumors who underwent LESS with OSAS (suspension group, n = 90) and without OSAS (control group, n = 88).

For patients who underwent OSAS (suspension group), 1 end of double-head straight needles with a polypropylene suture was inserted into the pelvic cavity through the abdominal skin to penetrate the cyst or ovarian parenchyma and puncture outside the abdominal skin. After cutting off the needles, both sides of the remaining suture were held together by a clamp, without knotting, so that the manipulator could "lift," "loosen," or "fix" the stitches to adjust the tension.

The average time to create OSAS was 2.9 min. For the suspension and control groups, the average blood loss was 81.4 and 131.8 mL (p < .001), and the operative time was 42.0 and 61.3 min (p < .001), respectively. There were no significant differences in the incidence of complications (5.6% vs 9.1%; p = .365), but there were significant differences in conversions to standard non-single-site laparoscopy (5.6% vs 15.9%; p = .025) and laparotomy (1.1% vs 6.8%; p = .040). Logistic regression analysis revealed that the ratios of conversion to standard non-single-site laparoscopy (odds ratio [OR], 0.126; 95% confidence interval [CI], 0.311-0.508) and laparotomy (OR, 0.032; 95% CI, 0.002-0.479) were much lower in the suspension group; the risk of complications was comparable (OR, 0.346; 95% CI, 0.085-1.403).

OSAS is an easy, safe, and feasible method that offers advantages during LESS. Although routine use of OSAS is not necessary, OSAS can be considered during LESS to facilitate the surgery.

Natural orifice translumenal endoscopic surgery (NOTES) and single-port surgery (SPS) have maximized the enhanced aesthetic profile of laparoscopic surgery. Nevertheless, these modalities also accentuate the inherent limitations of subvisibility and decreased instrument dexterity of motion. The goal of this study was to evaluate the utility of a miniature laparoscopic camera to alleviate these obstacles.

A miniature laparoscopic camera was inserted via an endoscopic working channel or embedded into laparoscopic tools. Following laparoscopic trainer studies, operations were conducted on pigs using standard laparoscopic, SPS, and NOTES approaches. Additionally, the camera was used to perform colonoscopies on mice, rats, and pigs.

The camera enabled visualizing the dissection area behind the renal vessels during laparoscopic nephrectomy and in the Triangle of Calot in laparoscopic cholecystectomy while providing accurate and detailed visualization of the operative field. The camera was successfully passed through the working channel of a standard gastroscope and used during NOTES procedures. It was used during colonoscopy to evaluate the distal colon in pigs and allowed the diagnosis of small colonic polyps with good image quality. Additionally, it could be easily passed beyond colonic strictures created in a porcine model. Finally, its miniature size enabled performance of colonoscopies on rats serving as animal models for colonic polyps.

The miniature laparoscopic camera provides adequate images with enhanced visibility in conventional laparoscopic, SPS, and NOTES procedures. We believe that this device or similar miniature cameras may greatly aid the future development of NOTES and SPS by enhancing the safety and ease of performing these procedures. Further development is being conducted in order to integrate this camera into standard instruments and to allow an even better image quality.

Conventional laparoscopic dismembered pyeloplasty (LP) is an established alternative to open pyeloplasty given equivalent intermediate-term outcomes and decreased morbidity. Laparoendoscopic single-site (LESS) pyeloplasty has the potential to further decrease the morbidity of LP, while yielding superior cosmesis. It is, however, technically very challenging even with the use of an accessory port, largely because of the difficulty of intracorporeal suturing through a single umbilical incision. Application of the da Vinci robotic surgical platform to LESS pyeloplasty (R-LESS) has the potential to overcome these limitations. We describe our technique for R-LESS pyeloplasty using the da Vinci Si robot. We have found that use of the robotic system in conjunction with certain technique modifications helps to reduce the technical difficulty of LESS pyeloplasty and to shorten the physical learning curve associated with the procedure.