Surgeon Impressions and Technical Difficulty Associated with Laparo-endoscopic Single-site Surgery (less): A Sages Learning Center Study

Introduction: Interest in Laparo-Endoscopic Single-Site Surgery (LESS) is rapidly growing amongst surgeons. The purpose of this study was to characterize current surgeon impressions about LESS and to determine the relative difficulty of performing a simulated LESS task.
Methods: This study was conducted at the 2009 SAGES Learning Center. Participants (n=56) were asked to complete pre-test and post-test questionnaires regarding their level of training, their experience with LESS, their opinions about LESS, and their impressions concerning the usefulness of articulating instruments. Technical skill performance was evaluated using a standardized FLS Peg Transfer task scored according to time and error metrics. Participants first completed one repetition in a conventional laparoscopic environment (LAP), then two additional repetitions in a simulated LESS environment in which a multi-port access device was used and all instruments were inserted through a single incision. In a randomized order, participants completed the LESS FLS task with straight (1 repetition) and articulating (1 repetition) graspers. Comparisons were performed using paired t-tests and ANOVA; values are mean ± sd.
Results: Complete data were collected for 45 of 56 (80%) participants; incomplete data were excluded. 18 were private and 9 academic practicing surgeons (9.9 ± 7.7 years in practice). Other participants included 9 MIS fellows, 7 residents, and 2 allied health professionals. 13% performed <10 advanced laparoscopic cases per year, 33% between 11-50, 18% between 51-100, and 36% >100. 5 surgeons had performed at least one LESS case in the past 6 months (range 1-25). On a 5 point scale (1 very uncomfortable, 5 very comfortable performing LESS), 44% responded 1, 24% were 2, 20% were 3, 4% were 4, and 7% were 5. Compared to conventional laparoscopy, 25% of participants believe that LESS will decrease post-operative pain and 18% believe that a faster recovery will be achieved. Additionally, 97% believe that LESS is technically more demanding and 73% believe that LESS will be associated with an increased rate of complications. The FLS performance data supported these impressions regarding increased technical difficulty, as LAP scores were significantly better than both LESS Straight and LESS Articulating scores. Furthermore, 59% indicated that articulating instruments did not help in performing the Peg task and the LESS Straight scores were significantly better than LESS Articulating scores. Despite these obstacles, 82% believe that LESS will be adopted by surgeons in the next 5 years, 97% believe that LESS will provide better cosmesis, and 100% would offer LESS to their patients if appropriately trained.

Conventional Laparoscopic LESS
Straight Instruments
Articulating Instruments
N= 45 62.8 ± 62.1 34.6 ± 29.0* 18.9 ± 114.9*
*p< 0.001 comparing LAP vs. LESS Straight, LAP vs. LESS Articulating, and LESS Straight vs. LESS Articulating; high scores indicate superior performance

Conclusion: Despite the increased technical difficulty associated with a LESS approach, the majority of surgeons feel that LESS will be adopted. Further improvements in instrumentation and operative strategies are needed, in conjunction with robust training methods, including simulation, such that LESS procedures can be safely and efficiently performed.

Session: Podium Presentation

Program Number: S029

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