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Goh et al. Mini-invasive Surg 2021;5:30 https://dx.doi.org/10.20517/2574-1225.2021.42 Page 7 of 8

related bladder injury.

Retroperitoneal single-port laparoscopic hysterectomies (SP-rH) have been performed to identify the ureter
and internal iliac artery, followed by ligation of the uterine artery where it originates from the internal iliac
[12]
artery. SP-rH can result in less intraoperative bleeding and a decreased risk of ureteral damage . However,
in patients with renal transplantation, the retroperitoneal approach can be challenging due to anatomical
distortions. Furthermore, the major blood vessel supplying the kidney is derived from the external iliac
vessels, and inadvertent injury to these vessels using the retroperitoneal approach may affect the function of
the allograft kidney. At the same time, identifying the ureter of the allograft kidney may have limited benefit
as it is transplanted to the dome of the bladder which is away from the surgical site.

Another obstacle is the high BMI of our second patient in addition to possible adhesions from her previous
Caesarean section. Such a patient profile may make LESS more technically challenging and less attractive to
surgeons. Some potential issues during the procedure include visual limitations and difficulty in obtaining
good triangulation without collisions between instruments. However, in our experience, LESS can still be
effectively performed. To improve mobility during the procedure, our surgeon used bariatric laparoscopic
instruments and a 50-cm telescope. Additional surgical steps were also performed as the floppy bladder
obstructed the view of the vaginal wall. Our surgeon used prolene 2-0 to suspend the uterovesical fold to the
anterior abdominal wall in order to lift up the bladder. As a result, the vaginal wall can be easily visualised,
which helps facilitate closure of the vaginal wall.

In conclusion, performing a LESS THBSO in renal transplant recipients using conventional laparoscopic
instruments provides safe and effective outcomes which are comparable to conventional laparoscopy in the
case reports described. There can be clear advantages to performing LESS when appropriate cases are
selected, when it is performed by a surgeon experienced in minimally invasive surgery and when a multi-
disciplinary team is involved in optimising the care of the patient.

DECLARATIONS
Authors’ contributions
Performed data acquisition and writing of report: Goh WA, Tan EMX
Made contributions to conception of the study, editing and review of the report: Nadarajah R

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
A written informed consent for publication was obtained from all participants.