Laparoendoscopic single-site surgery for the treatment of benign adnexal diseases: a pilot study

Comparison of single-incision and conventional laparoscopic surgery for benign adnexal masses

BACKGROUND

Our aim was to compare single incision and conventional laparoscopic surgeries performed for benign adnexal masses with regard to their intraoperative characteristics and postoperative pain levels.

MATERIAL AND METHODS

The main outcome measures were laparoscopic entry time, total operation time, amount of bleeding, intraoperative complications, post-operative pain scores, additional analgesic requirements, and length of hospital stay.

RESULTS

A total of 71 women, 39 in the conventional laparoscopy group and 32 in the SILS group, participated in the study. Demographic findings did not differ between the two groups. Similarly, rates of intraoperative complications, rates of conversion to laparotomy, pre- and postoperative hematocrit levels were not significantly different between the groups. Laparoscopic entry time was shorter in the SILS group (10.4 ± 5.9 min. vs. 5.28 ± 1.7 min.). However, total operation time was similar in the two groups. The groups did not show significant differences regarding additional analgesic requirements, or postoperative pain scores after 24 h. However, pain scores in the recovery room and after six and 12 h were lower in the SILS group.

CONCLUSION

SILS seems to be effective and safe for the treatment of benign adnexal masses. SILS appears to be advantageous regarding postoperative pain especially in the early period.

Laparoscopically assisted suprapubic surgery for adnexal tumors under epidural anesthesia

OBJECTIVE

To evaluate the feasibility and safety of laparoscopically assisted surgery for benign ovarian tumors via a single suprapubic incision under epidural anesthesia.

METHODS

Forty-three patients underwent laparoscopically assisted surgery via a single suprapubic incision under epidural anesthesia. Types of surgery were classified as follows: type I - suprapubic incision surgery without laparoscopic support, type II - suprapubic incision surgery with laparoscopic support but without CO₂ inflation; and type III - suprapubic incision surgery with laparoscopic support and CO₂ inflation.

RESULTS

Type I, II, and III procedures were performed on 16, 21, and six patients, respectively. Most patients (n = 35) were discharged on postoperative day 1 or 2. No surgical complication was encountered. Types of surgery exhibited different surgical characteristics. Type I was adopted for larger diameter tumors than types II or III (p = .016), whereas type III had a longer operative time (p = .024) than types I and II. Other characteristics, such as age, body mass index, and length of hospital stay, did not differ significantly among surgical types.

CONCLUSION

Laparoscopically assisted surgery for adnexal tumors via a single suprapubic incision under epidural anesthesia is feasible and safe, and should be viewed as an alternative approach to conventional minimally invasive surgery.

Ovarian Suspension With Adjustable Sutures: An Easy and Helpful Technique for Facilitating Laparoendoscopic Single-Site Gynecologic Surgery

STUDY OBJECTIVE

To describe a method of ovarian suspension with adjustable sutures (OSAS) for facilitating laparoendoscopic single-site gynecologic surgery (LESS) and to investigate the effect of OSAS on LESS.

DESIGN

Prospective cohort study (Canadian Task Force classification: II-2).

SETTING

University teaching hospital.

PATIENTS

One hundred seventy-eight patients with benign 5- to 15-cm cystic ovarian tumors who underwent LESS with OSAS (suspension group, n = 90) and without OSAS (control group, n = 88).

INTERVENTIONS

For patients who underwent OSAS (suspension group), 1 end of double-head straight needles with a polypropylene suture was inserted into the pelvic cavity through the abdominal skin to penetrate the cyst or ovarian parenchyma and puncture outside the abdominal skin. After cutting off the needles, both sides of the remaining suture were held together by a clamp, without knotting, so that the manipulator could "lift," "loosen," or "fix" the stitches to adjust the tension.

MEASUREMENTS AND MAIN RESULTS

The average time to create OSAS was 2.9 min. For the suspension and control groups, the average blood loss was 81.4 and 131.8 mL (p < .001), and the operative time was 42.0 and 61.3 min (p < .001), respectively. There were no significant differences in the incidence of complications (5.6% vs 9.1%; p = .365), but there were significant differences in conversions to standard non-single-site laparoscopy (5.6% vs 15.9%; p = .025) and laparotomy (1.1% vs 6.8%; p = .040). Logistic regression analysis revealed that the ratios of conversion to standard non-single-site laparoscopy (odds ratio [OR], 0.126; 95% confidence interval [CI], 0.311-0.508) and laparotomy (OR, 0.032; 95% CI, 0.002-0.479) were much lower in the suspension group; the risk of complications was comparable (OR, 0.346; 95% CI, 0.085-1.403).

CONCLUSION

OSAS is an easy, safe, and feasible method that offers advantages during LESS. Although routine use of OSAS is not necessary, OSAS can be considered during LESS to facilitate the surgery.

Learning Curve Analysis and Surgical Outcomes of Single-port Laparoscopic Myomectomy

STUDY OBJECTIVE

To identify learning curves for single-port laparoscopic myomectomy (SPLM) and evaluate surgical outcomes according to the sequence of operation.

DESIGN

A retrospective study.

SETTING

A university-based hospital (Canadian Task Force classification II-2).

PATIENTS

The medical records from 205 patients who had undergone SPLM from October 2009 to May 2013 were reviewed. Because the myomectomy time was significantly affected by the size and number of myomas removed by SPLM, cases in which 2 or more of the myomas removed were >7 cm in diameter were excluded. Furthermore, cases involving additional operations performed simultaneously (e.g., ovarian or hysteroscopic surgery) were also excluded. A total of 161 cases of SPLM were included.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We assessed the SPLM learning curve via a graph based on operation time versus sequence of cases. Patients were chronologically arranged according to their surgery dates and were then placed into 1 of 4 groups according to their operation sequence. SPLM was completed successfully in 160 of 161 cases (99.4%). One case was converted to multiport surgery. Basal characteristics of the patients between the 4 groups did not differ. The median operation times for the 4 groups were 112.0, 92.8, 83.7, and 90.0 minutes, respectively. Operation time decreased significantly in the second, third, and fourth groups compared with that in the first group (p < .001). Proficiency, which is the point at which the slope of the learning curve became less steep, was evident after about 45 operations.

CONCLUSION

Results from the current study suggested that proficiency for SPLM was achieved after about 45 operations. Additionally, operation time decreased with experience without an increase in complication rate.

Laparoendoscopic single-site surgery in gynecology: a review of the literature, tools, and techniques

Recent decades have witnessed a tremendous shift from laparotomy to laparoscopy as the surgical approach of choice in gynecology. Completion of increasingly complicated procedures has been facilitated by technical advances in instrumentation. Lately, increasing attention has been paid to reducing both the number and size of laparoscopic incisions, with the ultimate goal being the absence of any visible scar. Laparoendoscopic single-site surgery (LESS), or single-incision laparoscopy, describes the use of 1 small skin incision to complete laparoscopic surgical procedures where traditionally multiple incisions were created. In addition to examining the developing literature related to LESS in gynecology, the aims of this review were to describe the technical challenges encountered during performance of LESS and to provide practical solutions for instrumentation and surgical techniques that allow them to be overcome.

TARGET AUDIENCE

Obstetricians and gynecologists, family physicians

LEARNING OBJECTIVES

After completing this CME activity, physicians should be better able to identify potential benefits of LESS, and implement practical solutions for instrumentation and surgical techniques to overcome technical challenges faced during LESS.

Single-incision laparoscopic adnexectomy in an obese patient with previous laparotomies

Single-incision laparoscopic surgery appears to be feasible in obese patients who have undergone previous midline laparotomies.

Introduction:

No case of single-incision laparoscopic surgery in obese patients who had previously undergone multiple midline vertical laparotomies has been described in the literature to date. Hence we report the first case of single-port laparoscopic salpingo-oophorectomy in an obese patient who was affected by a left adnexal mass and who had previously undergone 3 midline vertical laparotomies.

Case Description:

A postmenopausal 57-year-old woman with a body mass index of 31.2 kg/m² and a history of 3 midline vertical cesarean deliveries and a right salpingo-oophorectomy was diagnosed with a left adnexal mass and underwent a single-incision laparoscopic salpingo-oophorectomy.

Discussion:

The patient was treated successfully. The operative blood loss was minimal. The postoperative hospital stay lasted 18 hours, and postoperative pain was short-lasting. No early or long-term postoperative complications were registered. On histopathologic examination, a diagnosis of ovarian serous cystadenoma was made. Even though this unique case is the first to be reported in the literature, its encouraging results suggest the use of this new surgical technique in similar clinical situations to verify whether the feasibility and safety reported in this article are confirmed.

Laparoendoscopic single-site surgery (LESS) for treatment of benign adnexal disease: single-center experience over 3-years

STUDY OBJECTIVE

To describe the effects of laparoendoscopic single-site (LESS) surgery performed over 3 consecutive years to treat adnexal disease and to report patient perioperative outcomes.

DESIGN

Retrospective clinical study (Canadian Task Force classification III).

SETTING

Tertiary care academic medical center.

PATIENTS

Women undergoing LESS because of a benign gynecologic indication, from January 2009 through December 2011.

INTERVENTIONS

Women with benign adnexal disease ≤10 cm underwent LESS surgery through a single 1.5- to 2.0-cm umbilical incision. Intraoperative and postoperative outcomes were carefully recorded, including the need for postoperative rescue analgesia.

MEASUREMENTS AND MAIN RESULTS

One hundred twenty-five patients were enrolled. Median patient age was 49 years, and median body mass index was 23. Surgical procedures included unilateral or bilateral salpingo-oophorectomy and unilateral or bilateral cyst enucleation. Median operative time was 48 minutes. Pain control was optimal, with an average visual analog score of 4/10. Both patients and surgeons were highly satisfied with the cosmetic result, and the cosmetic visual analog score was 9/10 at discharge and at 30 days after surgery. The number of women who underwent unilateral or bilateral salpingo-oophorectomy increased progressively and significantly yearly over the study period (16 vs 23 vs 40; p = .001). Median operative time for unilateral or bilateral salpingo-oophorectomy increased significantly from 2009 to 2010 and 2011 (34 vs 45 and 44 minutes; p = .001), together with median BMI (23 vs 23 vs 25; p = .04).

CONCLUSION

LESS is a desirable surgical approach in patients with simple adnexal disease.

Laparoscopic, minilaparoscopic and single-port hysterectomy: perioperative outcomes

OBJECTIVE

This study was designed to compare perioperative outcomes and postoperative pain of standard laparoscopic (S-LPS), minilaparoscopic (M-LPS), and laparoendoscopic single-site (LESS) hysterectomy.

METHODS

A single-institutional, matched, retrospective, cohort study was performed. Between May 2010 and March 2011, 85 consecutive women were submitted to a total laparoscopic hysterectomy by S-LPS, M-LPS, and single-port LESS. Perioperative outcomes of these three techniques were analyzed and compared.

RESULTS

Demographics and baseline characteristics of each group were absolutely comparable. The median operative time was longer [105 (range, 75-125) min] in the LESS group compared with the M-LPS group [90 (range, 60-120) min; p < 0.011] and S-LPS [80 (range, 50-110) min; p < 0.001]. No statistically significant differences have been reported for estimated blood loss or intra- and early postoperative complications. Postoperative pain control was better for LESS and M-LPS than S-LPS.

CONCLUSIONS

M-LPS and LESS hysterectomy can be performed safely, and both seem to be associated with a halving of early postoperative pain with a lower request of analgesics.

Laparoendoscopic single-site surgery (LESS) versus conventional laparoscopic surgery for adnexal preservation: a randomized controlled study

Objective

To compare the operative outcomes, postoperative pain, and subsequent convalescence after laparoendoscopic single-site surgery (LESS) or conventional laparoscopic surgery for adnexal preservation.

Study design

From December 2009 to September 2010, 63 patients underwent LESS (n = 33) or a conventional laparoscopic surgery (n = 30) for cyst enucleation. The overall operative outcomes including postoperative pain measurement using the visual analog scale (VAS) were evaluated (time points 6, 24, and 24 hours). The convalescence data included data obtained from questionnaires on the need for analgesics and on patient-reported time to recovery end points.

Results

The preoperative characteristics did not significantly differ between the two groups. The postoperative hemoglobin drop was higher in the LESS group than in the conventional laparoscopic surgery group (P = 0.048). Postoperative pain at each VAS time point, oral analgesic requirement, intramuscular analgesic requirement, and the number of days until return to work were similar in both groups.

Conclusion

In adnexa-preserving surgery performed in reproductive-age women, the operative outcomes, including satisfaction of the patients and convalescence after surgery, are comparable for LESS and conventional laparoscopy. LESS may be a feasible and a promising alternative method for scarless abdominal surgery in the treatment of young women with adnexal cysts

Is Single-Port Access Laparoscopy Less Painful Than Conventional Laparoscopy for Adnexal Surgery? A Comparison of Postoperative Pain and Surgical Outcomes

Objective. This study aimed to compare postoperative pain and surgical outcomes after transumbilical single-port access (SPA) and conventional multiport laparoscopic surgery for adnexal lesions. Methods. A retrospective case–control study was conducted matched by age, body mass index, and frequency of previous abdominal surgery. A total of 110 SPA laparoscopy patients (cases) were matched with a cohort of 107 patients who underwent conventional laparoscopy (controls) for benign adnexal lesions. SPA system consisted of a wound retractor, surgical glove, two 5-mm trocars, and one 11-mm trocar. Postoperative pain scores were measured immediately after surgery and at 6, 24, and 48 hours postsurgery using the numerical rating scale. Results. Postoperative pain scores did not differ between the 2 groups ( P = .552). However, higher number of painkiller administrations was observed in the SPA laparoscopy group (median 3 vs 1, P < .001). The type of surgery and intraoperative blood loss were the significant factors influencing the number of painkiller administrations after controlling for other parameters by linear regression ( P < .0001). The SPA laparoscopy group had less intraoperative blood loss (45.3 vs 87.5 mL, P < .001) and shorter hospital stay (2.1 ± 0.8 vs 2.7 ± 1.0 days, P < .001) compared with the conventional laparoscopy group. Operative time and perioperative complications did not differ between groups. Conclusions. There was no difference in pain intensity between the SPA and conventional laparoscopic group in this study. Future trials are warranted to better define the benefits of SPA surgery in terms of postoperative pain.

Teaching and training in laparoscopic surgery: experience of Catholic Laparoscopy Advanced Surgery School in the basic gynecological surgery

PURPOSE

To evaluate the effectiveness of our training method for basic "hands-on" laparoscopic courses.

METHODS

A prospective observational study between September 2008 and December 2010 at Catholic Laparoscopy Advanced Surgery School of the Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Sacred Heart-Rome, was conducted. Each course lasted for 3 days, divided into theoretical and practical parts, ending with a live surgery. Gynecologists who attended our 'hands-on' laparoscopic courses had no or minimum experience with laparoscopic technique. The teachers were expert laparoscopists of our Division, and every single group of participants had the same tutor for the entire course. Trainees completed self-assessment anonymous questionnaire of laparoscopic knowledge, before and immediately after the course.

RESULTS

During the study period, we performed 20 basic courses, enrolling 120 consecutive gynecologists. Among them, 114 (95%) decided to participate. Average age was 41 years (range 35-60 years) and 108 (94.7%) trainees were Italian. The subjective assessment showed an immediate improvement of motor skills.

CONCLUSIONS

Laparoscopic training course can improve both theoretical knowledge and motor skills. Such courses result in a short-term subjective improvement.