Blaudeau, a gynecologist, performs about three LESS procedures a week. “We’ve been doing this for about 18 months,” he says. “We were among the first in the country to adapt this technique.
“There’s no downside. From a healing standpoint, the abdominal wall recovers faster, and there’s less pain because of the umbilical location having less enervation and no trauma to the abdominal muscle.”
The single small incision from a LESS hysterectomy, often hidden in the umbilicus, also means practically no visible scarring. “I’ve had patients call me the next day, laughing at me, saying, ‘You’re kidding me. This is all this was?’” Blaudeau says.
Recovery is days faster. Patients are driving in three days and back to work in five to seven days. Robotic laparoscopy takes a few days more to recover, “and patients have more discomfort from having multiple upper abdominal incisions,” Blaudeau says.
LESS’s access also avoids any retraction-related pain. “That’s the brilliance of this procedure,” Blaudeau says. “The wrap-around view of the camera doesn’t put a strain on the abdomen wall, unlike a robotic arm that picks up the abdomen wall.
“I was skeptical at first as to whether this approach made much difference,” Blaudeau says. “But the lesson I learned is that we can make surgery even less invasive and hurt less than with the traditional laparoscopic approach or robotics. Better is better, when it comes to pain.”
The first indication of LESS’s positive impact on patients began as soon as Blaudeau started using the procedure. “The recovery room nurses would ask us what we were doing different. Our patients were waking up needing less narcotic pain medication,” he says. “The only difference was that single port in the belly button.”
That one port turns a single incision into a portal for up to four instruments, a camera, and arms for CO2 gas insufflation and smoke evacuation. “When you look at how simple the design is, it’s ridiculous,” Blaudeau says.
Olympus’ TriPort+, the port used by Blaudeau, has two rings that connect at the skin surface. The internal ring slides into the belly cavity before springing open, then connects to the outer ring. “The interplay of the two rings is what gives it such flexibility,” he says.
Blaudeau also likes directly dissecting into the abdominal cavity with an “open” visual approach. “There are no blind trocar placements. That decreases the risk of vascular injury,” he says.
The LESS procedure holds few restrictions for patient eligibility. “I had a patient who was 400 pounds,” Blaudeau says, and adds that diabetics benefit from fewer incisions.
“Maybe if I had a patient with a significant amount of contraindications to laparoscopy in general, like prior abdominal surgery with a lot of abdominal adhesions, then I would not use a LESS approach,” Blaudeau says.
With no downsides, “the cost aspect will drive it to be popular,” Blaudeau says. The additional cost of a LESS procedure runs about $350 for the port versus the additional cost of robotic laparoscopy averaging around $2,500. “When you look at the cost of a little piece of plastic then look at the $2 million cost of a robot, it’s not even appropriate to use the David and Goliath comparison,” he says.
With the single port, the instruments must now do all the flexing. Enter Olympus’ Endo-Eye laparoscope. At only five mm, the surgeon can see an 80° field of view. “It’s a much better picture. It’s HD, and your view’s not altered by angles or fog, because the camera lens itself is at the end of the laparoscope,” Blaudeau says. “The flexible-tip allows surgeons to curving around blood vessels and see perspectives they’ve not ever seen before.”
This means quite a change for straight-stick laparoscopy surgeons. “It’s like a pilot who’s always flown level and now he’s doing barrel rolls and having to orient himself,” Blaudeau says.
But having trained 200 surgeons from all over country on the procedure, Blaudeau says, “the initial learning curve is pretty quick for a straight-stick surgeon.”
Blaudeau has used the LESS procedure to perform total laparoscopic hysterectomies, supra-cervical hysterectomies, and bilateral oophorectomies. But other specialties are quickly jumping on the bandwagon, including general surgery, urology and thoracics. Gallbladder procedures and appendectomies top the popularity list so far.
“We’re at the infancy of this technology,” Blaudeau says. “It’s not as big a step as moving from open surgery to laparoscopy. This is more of a refinement.