More or LESS

Authors: R Bergamaschi

Publish Date: 2011/10/21

Volume: 15, Issue: 4, Pages: 369-370

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Abstract

LESS Laparoendoscopic singlesite surgery is an acronym coined by the Laparoendoscopic SingleSite Surgery Consortium for Assessment and Research LESSCAR 1 to describe surgery performed through a single port This concept differs from laparoscopic surgery performed through multiple ports Yet readers might be surprised to know that there has not been a precise definition of a port Port size may vary from 2 mm to 12 cm not withstanding the fact that laparotomy is the oldest single site The objective of this editorial is to present a critical insight into the role of LESS performed percutaneously with pneumoperitoneum in diseases of the colon and rectum However any aspects of LESS with transluminal access and/or without specimen will not be addressed hereinThere are at least three categories for discussion Although there are currently no universal regulations governing the implementation of new surgical procedures innovation in surgery should not occur through “gutsy” papers 2 The American College of Surgeons Committee on Emerging Surgical Technologies and Education Statement may be inadequate due to its voluntary nature 3 This holds true in light of the evidence that surgeons largely do not seek prior institutional review board IRB approval and there is concern that patients may serve as unwitting research subjects 4 As much as there is a need for innovation in surgery such innovation must be implemented in accordance with the rules of evidence 5 Knowing such rules means understanding that the random operation design is biased in favor of the surgeon’s pretrial routine surgical access and technically simple procedures 6 LESS is neither Therefore the question is what study designs are available to minimize the inclusion of the learning curve into a randomized controlled trial RCT The process of care study is a design that prospectively measures what is done to the patient in addition to what happens to the patient ie outcomes 7 Process of care studies should be carried out prior to any RCT in order to minimize the inclusion of the learning curve The study by Geisler and Garrett 8 is a prospective nonrandomized series of patients undergoing LESS for diseases of the colon and rectum The authors should be commended for obtaining IRB approval and candidly reporting on 83 elective resectional cases performed in less than 2 years Unfortunately Geisler and Garrett’s 8 study did not quite adhere to the process of care study design as no details of methodology may be modified once a study is underway Candidates for intervention should be selected on the basis of predetermined criteria External validity must be proven by more than one surgeon reproducing outcomes by means of the same methodology The question remains regarding to the true motive behind implementation of LESS surgery Partnership with industry marketing in a competitive nongovernmentrun health care system or selfpromotion to boost an academic career in a governmentrun health care system are all unacceptable examples of potential forces If the goal truly is patient benefit then efforts should be underway to identify colorectal diseases where LESS can offer overt clinical advantages with minimal risk Inflammatory bowel disease IBD patients with preexisting ileostomy and/or anticipated need for proximal diversion are potential candidates for LESS with extraumbilical access at the abdominal wall defect intended for specimen extraction and diversion In fact in IBD patients there is a high likelihood for reoperation in a lifetime In accordance with the LESSCAR consensus statement 1 the bar for considering LESS in colorectal cancer patients must be much higher More or less at this point in time it is not possible to predict what LESS will become 9

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