Single-port-access, hand-assisted laparoscopic surgery for benign large adnexal tumors versus single-port pure laparoscopic surgery for adnexal tumors

A preoperative scoring system to predict the probability of laparoendoscopic single-site extracorporeal cystectomy in patients with benign ovarian cysts

Objective

To develop a preoperative scoring system (PSS) to predict whether laparoendoscopic single-site extracorporeal (LESS-E) cystectomy can be performed in patients with benign ovarian cysts.

Method

We reviewed data on patients who underwent LESS cystectomy between August 2016 and October 2019 at the first Affiliated Hospital, Army Medical University. The independent predictors of LESS-E cystectomy in patients with benign ovarian cysts were identified using multivariate logistic regression analyses. A nomogram for predicting LESS-E cystectomy in patients with benign ovarian cysts was developed, and to simplify the score, we establish a preoperative scoring system to guide the choice of surgical approach in patients with highly probable benign ovarian cysts.

Results

Our analysis showed that age, BMI, height and the diameter of ovarian cysts were independent predictors of LESS-E cystectomy. A nomogram was developed based on these four factors, which had a concordance index of 0.838 and R2 = 0.415. To simplify the score, the predicted indicators in the regression model were scored by dividing the beta coefficient by the absolute value of the minimum beta coefficient, and the sum of each predictor score established a PSS. In the total set, the selected cutoff value according to the maximum point of the Youden index was 8, and a preoperative score ≥ 8 identified patients undergoing LESS-E cystectomy with a positive predictive value of 67.4% and a negative predictive value of 88.6%.

Conclusion

A PSS to predict the chances of LESS-E cystectomy was established. This system could be helpful for selecting the appropriate surgical strategy for patients with benign ovarian cysts.

Fast Leak-Proof, Intraumbilical, Single-Incision Laparoscopic Ovarian Cystectomy for Huge Ovarian Masses: "Hybrid Cystectomy and Reimplantation" Method

Background and Objectives: To introduce a new technique for fast leakage-proof, intraumbilical, single-incision laparoscopic ovarian cystectomy for huge ovarian masses (>10 cm) Materials and Methods: Seven consecutive, reproductive-aged women, including three adolescents, with huge ovarian masses (mature cystic teratoma, n = 4; endometrioma, n = 2; and mucinous cystadenoma, n = 1) who underwent transumbilical single-incision ovarian cystectomy with the new “hybrid cystectomy and reimplantation” method were included. The procedure was: (1) trans-umbilical single-incision laparoscopy; (2) inspection of the pelvic cavity and placing the mass in a laparoscopic endo-bag for cystic content leakage prevention; (3) in-bag resection using cold scissors and minimal cauterization of the cystectomy site; (4) in-bag tissue extraction; (5) rapid extracorporeal cystectomy with traction without electrocautery; (6) re-insertion of the retrieved ovarian cortex intracorporeally through the single port, and (7) intracorporeal suture of the retrieved tissue to the in situ ovary. Results: The mean patient age was 24.71 ± 6.56 (range 17–37) years and the mean maximal diameter of the masses was 17.71 ± 2.86 (range 13–22) cm. There was no case of unintended intracorporeal cyst rupture and no need for copious irrigation for washing and suctioning the leaked mass content. The mean total operating time was 76.42 ± 6.39 (range 65–85) min, the total volume of saline used for irrigation was 814.28 ± 331.35 (range 500–1500) mL, and the estimated blood loss was 107.14 ± 47.72 (range 50–200) mL. There were no perioperative complications. All patients except the two endometriosis patients had regular, normal menstruation. Conclusions: Our preliminary findings were encouraging in terms of the safety and efficiency of the new method. Future trials need to elucidate the benefits of this method in terms of fertility preservation.

Comparison of perioperative outcomes of single-port laparoscopy, three-port laparoscopy and conventional laparotomy in removing giant ovarian cysts larger than 15 cm

Background

Although conventional laparoscopy has gradually accepted as a surgical treatment for ovarian cancer, reducing the port numbers of laparoscopy still has great challenge for larger ovarian tumors. Thus, this study aims to explore the surgical outcomes of single-port laparoscopy for removing giant ovarian cysts (≥ 15 cm) and compare with laparotomy and three-port laparoscopy.

Methods

This study enrolled 95 patients with giant ovarian cysts (> 15 cm) who underwent single-port laparoscopy, three-port laparoscopy or laparotomy. Their medical records, perioperative surgical outcomes, and postoperative pain score and complications were analyzed and compared retrospectively.

Results

Single-port laparoscopy showed better perioperative outcomes and less postoperative pain than three-port laparoscopy and laparotomy. The time between post-surgery and getting out of bed in single-port laparoscopy was significant shorter than that in the laparotomy and three-port laparoscopy (17.53 ± 7.26 vs 29.40 ± 9.57 vs 24.56 ± 7.76, P < 0.01). The length of hospital stay in single-port laparoscopy was significantly shorter than that in other two groups (4.06 ± 0.5 vs 5.46 ± 1.63 vs 4.81 ± 0.83, P < 0.001). In addition, single-port laparoscopy had the lowest postoperative pain scores than in the laparotomy and three-port laparoscopy. There were no significant differences of total hospital cost, postoperative complications and time until gas passing among the three surgical groups. Importantly, in the removal of giant ovarian cysts, the proportion of cyst rupture in single-port laparoscopy was far lower than that in three-port laparoscopy (3.0 vs 22.2%).

Conclusions

For giant ovarian cysts, single-port laparoscopy is still a safe and efficient technique with the advantages of short operation time, less estimated blood loss, short hospital stay, lower spillage rate, and less postoperative pain.

Surgical technique for single-port laparoscopy in huge ovarian tumors: SW Kim's technique and comparison to laparotomy

OBJECTIVE

This study aimed to introduce a method to remove huge ovarian tumors (≥15 cm) intact with single-port laparoscopic surgery (SPLS) using SW Kim's technique and to compare the surgical outcomes with those of laparotomy.

METHODS

Medical records were retrospectively reviewed for patients who underwent either SPLS (n=21) with SW Kim's technique using a specially designed 30×30-cm2-sized 3XL LapBag or laparotomy (n=22) for a huge ovarian tumor from December 2008 to May 2016. Perioperative surgical outcomes were compared.

RESULTS

In 19/21 (90.5%) patients, SPLS was successfully performed without any tumor spillage or conversion to multi-port laparoscopy or laparotomy. There was no significant difference in patient characteristics, including tumor diameter and total operation time, between both groups. The postoperative hospital stay was significantly shorter for the SPLS group than for the laparotomy group (median, 2 [1 to 5] vs. 4 [3 to 17] days; P<0.001). The number of postoperative general diet build-up days was also significantly shorter for the SPLS group (median, 1 [1 to 4] vs. 3 [2 to 16] days; P<0.001). Immediate post-operative pain score was lower in the SPLS group (median, 2.0 [0 to 8] vs. 4.0 [0 to 8]; P=0.045). Patient-controlled anesthesia was used less in the SPLS group (61.9% vs. 100%).

CONCLUSION

SPLS was successful in removing most large ovarian tumors without rupture and showed quicker recovery and less immediate post-operative pain in comparison to laparotomy. SPLS using SW Kim's technique could be a feasible solution to removing huge ovarian tumors.

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.

Laparoendoscopic single-site versus conventional laparoscopic surgery for ovarian mature cystic teratoma

Objective

To compare the intraoperative and postoperative outcomes of laparoendoscopic single-site surgery (LESS) versus conventional laparoscopic surgery in women with ovarian mature cystic teratoma.

Methods

A retrospective review of 303 women who underwent LESS (n=139) or conventional laparoscopic surgery (n=164) due to ovarian mature cystic teratoma was performed. Intra- and postoperative outcomes were compared between the two groups.

Results

There was no intergroup difference in age, body weight, height, body mass index, comorbidities, tumor size, bilaterality of tumor, or the type of surgery. However, more patients in the LESS group had a history of previous abdominal surgery (19.4% vs. 6.7%, P=0.001). Surgical outcomes including operating time (89 vs. 87.8 minutes, P=0.734), estimated blood loss (69.4 vs. 68.4 mL, P=0.842), transfusion requirement (2.2% vs. 0.6%, P=0.336), perioperative hemoglobin level change (1.3 vs. 1.2 g/dL, P=0.593), postoperative hospital stay (2.0 vs. 2.1 days, P=0.119), and complication rate (1.4% vs. 1.8%, P=0.999) did not differ between LESS and conventional groups. Postoperative pain scores measured using a visual analogue scale were significantly lower in the LESS group at 8 hours (P=0.021), 16 hours (P=0.034), and 32 hours (P=0.004) after surgery, and 32 of 139 patients (23%) in the LESS group and 78 of 164 patients (47.6%) in the conventional group required at least one additional analgesic (P<0.001).

Conclusion

LESS was feasible and showed comparable surgical outcomes with conventional laparoscopic surgery for women with ovarian mature cystic teratoma. LESS was associated with less postoperative pain and required less analgesia.

A minimally invasive surgery robotic assistant for HALS-SILS techniques

This paper is focused in the design and implementation of a robotic surgical motion controller. The proposed control scheme addresses the issues related to the application of a robot assistant in novel surgical scenario, which combines hand assisted laparoscopic surgery (HALS) with the single incision laparoscopic surgery (SILS) techniques. It is designed for collaborating with the surgeon in a natural way, by performing autonomous movements, in order to assist the surgeon during a surgical maneuver. In this way, it is implemented a hierarchical architecture which includes an upper auto-guide velocity planner connected to a low-level force feedback controller. The first one, based on a behavior approach, computes a collision free trajectory of the surgical instrument tip, held by the robot, for reaching a goal location inside of the abdominal cavity. On the other hand, the force feedback controller uses this trajectory for performing the instrument displacement by taking into account the holonomic movement constraints introduced by the fulcrum point. The aim of this controller is positioning the surgical instrument by minimizing the forces exerted over the abdominal wall due to the fulcrum location uncertainty. The overall system has been integrated in the control architecture of the surgical assistant CISOBOT, designed and developed at the University of Malaga. The whole architecture performance has been tested by means of in vitro trials.