Year : 2012 | Volume
: 28 | Issue : 1 | Page : 1--2
Is LESS is actually more?
Nitin S Kekre
Department of Urology, Christian Medical College, Vellore, Tamil Nadu, India
Nitin S Kekre
Department of Urology, Christian Medical College, Vellore, Tamil Nadu
|How to cite this article:|
Kekre NS. Is LESS is actually more?.Indian J Urol 2012;28:1-2
|How to cite this URL:|
Kekre NS. Is LESS is actually more?. Indian J Urol [serial online] 2012 [cited 2019 Aug 26 ];28:1-2
Available from: http://www.indianjurol.com/text.asp?2012/28/1/1/94937
Surgeons since long have long attempted to make surgery less invasive. While the advantages of less morbidity and improved cosmesis are obvious, it has made the procedure more technically challenging with a steeper learning curve. The advent of laparoendoscopic single-site surgery (LESS), technically, perhaps an extension of conventional laparoscopic surgery, is a case in point.
The idea itself is not new. In the early 1970s, Wheeless, a gynacologist described more than 4000 cases of single-port laparoscopic tubal ligation.  This technique was to become the standard of care for tubal ligation in later years. Two decades later Inoue reported a technique of single-port laparoscopic appendectomy. 
With more centers attempting this procedure and the lack of a standard nomenclature became obvious. A veritable "battle of acronyms" started with SILS (single-incision laparoscopic surgery), MISPORT (minimally invasive single-port surgery), SPES (single-port endoscopic surgery), OPUS (one-port umbilical surgery), SPL (single-port laparoscopy), UNOTES (umbilical natural orifice transluminal endoscopic surgery), and STLS (single-trocar laparoscopic surgery) describing the same procedure. 
The lack of standardization prompted the NOTES Working Group of the Endourological Society and the Laparoendoscopic Single-Site Surgery Consortium for Assessment and Research to standardize the terminology to LESS in 2008. LESS was defined as "any minimally invasive surgical procedure that is performed through a single incision/location, using conventional laparoscopic or newly emerging instrumentation," adding that "it does not distinguish between a single laparoscopic port, multiple laparoscopic ports, or a single multi-port platform." Finally, it does not exclude "any procedure that requires enlargement of the access site for specimen extraction or removal."  The adoption of this new nomenclature in surgery has been variable with urologists being more inclined to comply.
With the initial reporting of the first LESS nephrectomy by Rane in 2007 and the limitations of instrumentation somewhat overcome by the availability of bent and articulating instruments many urologist have performed this procedure.  Widespread adoption however has been limited even in high-volume tertiary care centres. This is partly due to the steeper learning curve, poor ergonomics, and the general view that it holds little advantage over conventional laparoscopic surgery. Attempts have been made to improve ergonomics and to further lessen the learning curve by the insertion of additional 2 mm needle scopic ports. These instruments however have poor holding strength, small jaws, and no rotation. Magnetic anchoring and guidance systems have been described, but their use still remains experimental.  With the widespread availability of robotic platforms (Robotic-LESS) it is expected that the ergonomic barriers of LESS will be considerably lessened.
More concerning is the fact that available evidence has failed to show any real benefit to LESS compared to conventional laparoscopy.  Data however are retrospective and prospective trials are necessary. The exact position of LESS and its mainstream adoption will to large extent depend on these results.
In this issue of the Indian Journal of Urology we have a short symposium on LESS describing the state of the art and perhaps forecasting its role in the future.
Only the time would decide the role of LESS in the armamentarium of endourologist. I would like to express my gratitude to Dr. M.R Desai and Dr. P.B Rao for their help in guest editing this symposium.
This issue also has three videos which have won the prize at the USI annual meeting. But the response of the members to this section has been less than enthusiastic and I would request you all to send your videos, which may have educational value.
With best wishes,
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