Isobaric (gasless) laparoscopic uterine myomectomy

Clinical effectiveness of gasless laparoscopic myomectomy with the subcutaneous steel wire-lifting method for fibroids

BACKGROUND/OBJECTIVE

Laparoscopic myomectomy (LM) is primarily conducted using the pneumoperitoneum method, with only few LMs performed using the gasless method (GLM). We aimed to assess the feasibility of GLM.

METHODS

This retrospective chart review was performed in a university-affiliated hospital. We included 1301 patients who underwent GLM with the subcutaneous steel wire-lifting method (GLMS) between 2008 and 2021.

RESULTS

A total of 6287 fibroids were removed (nodes per patient: 4.83 ± 4.51). Systematic reviews showed that compared with conventional LM, GLMS had longer operation time, greater number and larger size of fibroids removed, and lower intraoperative blood loss. The rates of severe perioperative complications, homologous blood transfusion, and open conversion were acceptable at 0.8 %, 0.5 %, and 0.3 %, respectively. Operation time, weight of surgical specimen, body mass index (BMI), and the maximum diameter of fibroids removed were important predictors of higher risk, including massive surgical bleeding. The prediction model of massive surgical bleeding showed a relatively good out-of-bag estimate of error rate of 8.6 %, with a high negative predictive value, albeit a low positive predictive value, making it unsuitable for real-world clinical applications.

CONCLUSIONS

GLMS is an excellent procedure that combines safety, proficiency, and economic efficiency for fibroid removal, except in patients with severe obesity. Beyond the cost-benefit perspective, GLMS appears well-suited to countries with low average BMI, such as Japan, East-Asian countries, and LMICs in Africa.

Antenatal myomectomy of huge pedunculated fibroid

A female patient in her 20s presented at 10 weeks of pregnancy with abdominal pain. She was known to have a 17-cm fibroid a year ago, which, on repeat imaging, was found to have increased in size to 29 cm. A 12-cm increase in size over a year therefore led to concerns that it would increase in pregnancy, causing risk of thrombosis, decrease in venous return, miscarriage, fibroid torsion, fibroid necrosis, preterm labour and uterine rupture. Following a multidisciplinary team review with obstetricians, neonatologists, gynaecologists and radiologists, the patient opted to proceed with an open myomectomy at 14 weeks gestation, which was performed successfully. The pregnancy continued uneventfully until term when she delivered a healthy girl infant at 38+2 weeks via an elective caesarean section.

Gasless Total Laparoscopic Hysterectomy with New Abdominal-Wall Retraction System

Background and Objectives

Gasless laparoscopy is an alternative method to reduce the number of carbon dioxide (CO₂)-insufflated, pneumoperitoneum-related problems including shoulder pain, postoperative nausea/vomiting, and decreased cardiopulmonary function. In this study, we investigated the feasibility of gasless total laparoscopic hysterectomy (TLH) with a newly developed abdominal-wall retraction system.

Methods

Abdominal-wall retraction for gasless laparoscopy was performed using the newly developed J-shape retractor and the Thompson surgical retractor. Surgical outcomes between gasless TLH and conventional CO₂-based TLH were compared for each of 40 patients for the period from January 2017 to October 2019.

Results

Between gasless TLH and conventional CO₂-based TLH, no significant differences were observed for age, body mass index, parity, or surgical indications. The mean retraction setup time from skin incision was 7.4 min (range: 4-12 min) with gasless TLH. The mean total operation times were 87.9 min (range: 65-170) with gasless TLH and 90 min (range: 45-180) with conventional TLH, which showed no significant difference. Estimated blood loss and uterus weight also showed no significant intergroup difference. No major complications related to the ureter, bladder, or bowel were encountered.

Conclusion

Our new abdominal-wall retraction system for gasless TLH allowed for easy setup and a proper operation field in the performance of laparoscopic hysterectomy.

Gasless single-port access laparoscopy using a J-shaped retractor in patients undergoing adnexal surgery

OBJECTIVE

The aim of this study was to compare gasless single-port access (SPA) laparoscopy using a J-shaped retractor and conventional SPA laparoscopy in patients undergoing adnexal surgery. Study design The medical records of 80 patients who underwent laparoscopic adnexal surgery between May 2017 and April 2019 were reviewed. Of the 80 patients, 40 patients underwent gasless SPA laparoscopy using a J-shaped retractor and 40 underwent conventional SPA laparoscopy. All surgeries were performed by one laparoscopic surgeon. Surgical outcomes were compared between the two groups.

RESULTS

There are no significant differences in age, body mass index, parity, previous abdominal surgery, tumor marker, and tumor diameter between the gasless and conventional groups. The median retraction setup time from skin incision was 7 min (range 5-12 min) in gasless SPA laparoscopic adnexal surgery. The median total operation times were 55.5 min (range 30-155 min) in the gasless group and 55 min (range 30-165 min) in the conventional group without a significant difference. Additionally, there were no differences in operation type, conversion rate of laparotomy, use of an additional trocar, and pathological outcomes between the two groups. No major complications, such as urologic, bowel, and vessel injuries, were found in both groups.

CONCLUSIONS

Gasless SPA laparoscopy using a J-shaped retractor appears to offer a better alternative to conventional SPA laparoscopy that avoids the potential negative effects of carbon dioxide gas in selected cases.

The effects and costs of laparoscopic versus abdominal myomectomy in patients with uterine fibroids: a systematic review and meta-analysis

BACKGROUND

Abdominal myomectomy (AM) and laparoscopic myomectomy (LM) are commonly see surgery for the uterine fibroids, several randomized controlled trials (RCTs) have compared the role of AM and LM, the results remained inconsistent. Therefore, we attempted this meta-analysis to analyze the role of LM versus AM in patients with uterine fibroids.

METHODS

We searched PubMed et al. databases from inception date to July 31, 2019 for RCTs that compared LM versus AM in patients with uterine fibroids. Two authors independently screened the studies and extracted data from the published articles. Summary odd ratios(OR) or mean differences(MD) with 95% confidence intervals(CI) were calculated for each outcome by means of fixed- or random-effects model.

RESULTS

Twelve RCTs with a total of 1783 patients were identified, with 887 patients for and 897 patients for AM. Compared with AM, LM could significantly decrease the blood loss (OR = - 29.78, 95% CI -57.62- - 0.95), shorten the duration of postoperative ileus (OR = - 10.91, 95% CI -18.72- - 3.11), reduce the length of hospital stay (OR = - 1.57, 95% CI -2.05- - 1.08), but LM was associated with longer duration of operation (OR = 16.10, 95% CI 6.52-25.67) and higher medical cost (OR = 17.61, 95% CI 7.34-27.88).

CONCLUSIONS

LM seems to be a better choice for patients with uterine fibroids, more related studies are needed to identify the role of LM and AM for the treatment of uterine fibroids.

Gasless single-incision laparoscopic inguinal hernia repair: initial experience

PURPOSE

Laparoscopic hernioplasty has been gaining its popularity in the past decade for its rapid recovery. Single-incision surgery, as its possible advancement, has also received more attention. Traditional laparoscopic surgery with carbon dioxide insufflation precluded patients with underlying cardiovascular or pulmonary disease from minimal invasive surgery. We report our early experience with gasless single-incision laparoscopic inguinal hernia repair via totally extraperitoneal (TEP) approach.

METHODS

Between 2010 and 2012, 15 consecutive patients underwent gasless laparoscopic inguinal hernia repair by the same surgeon, using abdominal wall lifting technique with a self-tailored device. Patient demographics, hernia characteristics, operative findings and postoperative outcomes were analyzed prospectively.

RESULTS

Of the 15 patients, all had unilateral hernia. Two presented with acute incarceration, in which one required bowel resection. There was no conversion to open surgery or insertion of additional ports. The median operating time was 80 min (range 51-130) for elective repair and 178 min (range 135-220) for emergency repair. The median hospital stay was 1 day (range 1-6) with minimal requirement of analgesics. Median time taken to resume normal activity was 2 days (range 1-6). No major medical complications or mesh infection was encountered. One patient developed hematoma and was successfully managed by salvage laparoscopic reoperation. During a median follow-up of 54 months (range 38-60), none experienced recurrence.

CONCLUSION

Gasless single-incision TEP is feasible with favorable results, even in high-risk patients with compromised cardiorespiratory status. This technique can also be applied to emergency setting in patients with incarcerated inguinal hernia requiring bowel resection. Future large scale randomized study is needed to verify the effectiveness of this technique.

A systematic review on efficacy and safety of gasless laparoscopy in the management of uterine leiomyoma

Uterine leiomyoma causes considerable morbidity in women. This study systematically reviewed the efficacy and safety of gasless laparoscopic myomectomy (GLM) in the management of uterine leiomyoma by comparing GLM with other minimally invasive procedures. Cochrane Library, Pub- Med, EMBASE, Web of Science, WANFANG database and China National Knowledge Infrastructure (CNKI) were searched for studies published in English or Chinese between January 1995 and May 2015, and related references were traced. Study outcomes from randomized controlled trials and retrospective cohort studies were presented as mean difference (MD) or odds ratio (OR) with a 95% confidence interval (CI). Seventeen studies (including 1862 patients) meeting the inclusion criteria, including 934 treated with GLM and 928 treated with other minimally invasive procedures were reviewed. The results of meta-analysis revealed that GLM resulted in significantly shorter operating time [MD=-10.34, 95% CI (-18.12,-2.56), P<0.00001], shorter hospital stay [MD=-0.47, 95% CI (-0.88,-0.06)], less time to flatus [MD=-2.04, 95% CI (-2.59,-1.48)], less postoperative complications [OR=0.20, 95% CI (0.06, 0.62)] and less blood loss [MD =-30.74, 95% CI (-47.50,-13.98)]. On the other hand, there were no significant differences in duration of post-operative fever [MD=-0.52, 95% CI (-1.46, 0.42)] between the two groups. Additionally, GLM was associated with lower febrile morbidity, lower postoperative abdominal pain, and higher postoperative hemoglobin than other minimally invasive procedures for the treatment of uterine leiomyoma. In conclusion, GLM and other minimally invasive procedures are feasible, safe, and reliable for uterine leiomyoma treatment. However, available studies show that GLM is more effective and safer than other minimally invasive approaches.

Early postoperative pain after keyless abdominal rope-lifting surgery

BACKGROUND AND OBJECTIVES

Keyless abdominal rope-lifting surgery is a novel, gasless, single-incision laparoscopic surgical technique. In this study we aimed to compare the postoperative pain from keyless abdominal rope-lifting surgery with carbon dioxide laparoscopy performed for benign ovarian cysts.

METHODS

During a 20-month period, 77 women underwent surgery for a benign ovarian cyst. Keyless abdominal rope-lifting surgery and conventional carbon dioxide laparoscopy techniques were used for the operations in 32 women and 45 women, respectively. The 2 operative techniques were compared with regard to demographic characteristics; preoperative, intraoperative, and postoperative data including early postoperative pain scores; and frequency of shoulder pain and analgesic requirements.

RESULTS

Data regarding demographic characteristics, preoperative findings, cyst diameters and rupture rates, intra-abdominal adhesions, intraoperative blood loss, and postoperative hospital stay did not differ between groups (P > .05). However, the mean operative and abdominal access times were significantly longer in the keyless abdominal rope-lifting surgery group (P < .05). Visual analog scale pain scores at initially and at the second, fourth, and 24th hours of the postoperative period were significantly lower in the keyless abdominal rope-lifting surgery group (P < .05). Similarly, keyless abdominal rope-lifting surgery caused significantly less shoulder pain and additional analgesic use (P < .05).

CONCLUSION

Keyless abdominal rope-lifting surgery seems to cause less pain in the management of benign ovarian cysts in comparison with conventional carbon dioxide laparoscopy.

Comparison of tubal sterilization procedures performed by keyless abdominal rope-lifting surgery and conventional CO2 laparoscopy: a case controlled clinical study

Objective. To evaluate the safety and efficacy of Keyless Abdominal Rope-Lifting Surgery (KARS), for tubal sterilization procedures in comparison with the conventional CO₂ laparoscopy. Material and Methods. During a one-year period, 71 women underwent tubal ligation surgery. Conventional laparoscopy (N = 38) and KARS (N = 33) were used for tubal sterilization. In KARS, an abdominal access pathway through a single intra-abdominal incision was used to place transabdominal sutures that elevated the abdominal wall, and the operations were performed through the intraumbilical entry without the use of trocars. In CO₂ laparoscopy, following the creation of the CO₂ pneumoperitoneum a 10 mm trocar and two 5 mm trocars were introduced into the abdominal cavity. Tubal sterilizations were performed following the creation of the abdominal access pathways in both groups. The groups were compared with each other. Results. All operations could be performed by KARS without conversion to CO₂ laparoscopy or laparotomy. The mean operative time of the two groups was not significantly different (P > 0.05). Intra- and postoperative findings including complications, bleeding, and hospital stay time did not differ between groups (P > 0.05). Conclusion. KARS for tubal sterilization seems safe and effective in terms of cosmesis, postoperative pain, and early hospital discharge.

Management of benign ovarian cysts by a novel, gasless, single-incision laparoscopic technique: keyless abdominal rope-lifting surgery (KARS)

BACKGROUND

To find the most efficacious method to minimize the side effects and maximize the advantages of laparoscopic surgery, this study aimed to define and document a gasless, single-incision abdominal access technique for the management of benign ovarian cysts.

METHODS

During a 1½ year period, 55 women underwent surgery for a benign ovarian cyst. Conventional carbon dioxide (CO(2)) laparoscopy was used for 33 of the women, and 22 of the women underwent a novel, gasless, single-incision laparoscopic surgery. An abdominal access pathway through a single intraabdominal incision was used to place transabdominal sutures that elevated the abdominal wall, and the operations were performed through the intra-umbilical entry without the use of trocars. Thus, the new technique was called keyless abdominal rope-lifting surgery (KARS). Two operative groups were compared to assess the feasibility of the new technique.

RESULTS

All the operations could be performed by KARS without conversion to CO(2) laparoscopy or laparotomy. However, for two patients in the conventional laparoscopy group, minilaparotomy had to be performed for tissue retrieval. Although the two techniques had many similar results, the total operative times and the abdominal access times in the KARS group were significantly longer than in the conventional laparoscopy group (p < 0.05). Simple oral analgesics were adequate for postoperative pain relief in both groups.

CONCLUSIONS

The KARS technique is a gasless, single-incision laparoscopic procedure that can be performed safely and effectively in terms of cosmesis, postoperative pain, and fertility preservation for the management of benign adnexal pathologies.

Early experience with isobaric laparoendoscopic single-site surgery using a wound retractor for the management of ectopic pregnancy

OBJECTIVE

To report our initial experience with isobaric (gasless) transumbilical laparoendoscopic single-site (LESS) surgery using a wound retractor for the management of ectopic pregnancy.

STUDY DESIGN

Twelve consecutive cases of ectopic pregnancy were managed by isobaric LESS surgery with the subcutaneous abdominal wall-lift method. In each case, a wound retractor was used as a transumbilical working port with insertion into the peritoneal cavity through a 2.5-cm vertical umbilical incision. Subsequent surgical procedures were performed with multiple conventional laparoscopic instruments through single umbilical port.

RESULTS

All cases of ectopic pregnancy were successfully managed by isobaric LESS surgery. Procedures included salpingectomy in eight cases of ampullary pregnancy and two cases of isthmic pregnancy, salpingectomy and local methotrexate injection in one case of isthmic pregnancy, and salpingo-oophorectomy for one case of ovarian pregnancy. Neither extraumbilical incisions nor conversion to laparotomy was required. In a case of ruptured ampullary pregnancy with massive hemoperitoneum, intraoperative autologous blood salvage and donation avoided the need for the transfusion of bank blood. Although postsurgical umbilical seroma was noted in one case and systemic methotrexate administration was required for persistent ectopic pregnancy in one case of isthmic pregnancy respectively, there were no major surgical complications in this series. The technique yielded excellent cosmetic results with minimum postoperative scar concealed within umbilicus. Retrospective comparison of surgical parameters including surgical duration, estimated blood loss, frequency of postoperative analgesic use, time of bowel recanalization, postoperative inflammatory response and postoperative hospital stay did not show any significant differences between isobaric LESS surgery group and conventional isobaric multiport laparoscopic surgery group.

CONCLUSIONS

Based on the satisfactory outcome achieved in these initial 12 cases of ectopic pregnancy treated by isobaric LESS surgery, the wound retraction system combined with the subcutaneous abdominal wall-lift method appears to contribute favorably to LESS surgery for the management of ectopic pregnancy because the device permits free circumferential access and retraction during procedures without the closed condition required during pneumoperitoneum.

Gasless laparoendoscopic single-site surgery with abdominal wall lift in general surgery: initial experience

BACKGROUND

Laparoendoscopic single-site surgery (LESS) was motivated by the desire to make minimally invasive surgery even more "minimal." We performed gasless laparoendoscopic single-site surgery (GLESS) with abdominal wall lift (AWL) for cholecystectomy and fenestration of liver cyst. This study aims to assess the safety and feasibility of the techniques.

METHODS

From June to December 2009, 18 cases of gasless laparoendoscopic single-site cholecystectomy (GLESC) and 4 cases of fenestration of liver cyst (GLESF) were performed in Qilu Hospital of Shandong University, Shandong, China. Subcutaneous abdominal wall lifting system, LAP protector, flexible laparoscopes, and bent and articulating instruments were used during the procedures. Clinical data regarding patient demographics, operating time, blood loss, complications, and postoperative hospital stay were collected and analyzed retrospectively in the study.

RESULTS

17 cases of GLESC and 4 cases of GLESF were performed successfully, and 1 case of GLESC was converted to laparoendoscopic single-site cholecystectomy using AWL combined with low-pressure pneumoperitoneum. Mean body mass index was 23.7 ± 3.1 kg/m(2) for GLESC and 22.9 ± 1.5 kg/m(2) for GLESF. Mean operating time was 64 ± 17 min for GLESC and 101 ± 10 min for GLESF. Mean blood loss was 8 ± 3 ml for GLESC and 24 ± 11 ml for GLESF. Despite minor wound complication, no postoperative complications were observed during mean follow-up of 118 and 95 days for GLESC and GLESF, respectively.

CONCLUSION

GLESS with AWL is safe and feasible for cholecystectomy and fenestration of liver cyst. The techniques provide satisfactory operative field exposure and an easier access method for LESS. Instrument collisions are greatly ameliorated both extra- and intracorporeally through use of flexible laparoscopes and bent and articulating instruments. This may prove to be a better approach for LESS techniques.

Laparoscopic resection of endometriosis in a patient with a ventriculoperitoneal shunt using the LapDisc

The surgical approach in a patient with a ventriculoperitoneal shunt in need of abdominal surgery remains controversial. The risk of increased intracranial pressure with pneumoperitoneum in laparoscopy is still unresolved. We used the LapDisc (Ethicon, Inc., Somerville, New Jersey) to access the shunt and temporarily seal it, which enabled us to perform laparoscopic resection of endometriosis without subjecting the shunt to high intraabdominal pressure. The benefits of this approach are the ability to perform laparoscopy, less skin-to-shunt contact minimizing infection, and elimination of possible increased intracranial pressure secondary to pneumoperitoneum. With the progress made in the management of hydrocephalus, patients with ventriculoperitoneal (VP) shunts enjoy a longer lifespan. Therefore, the gynecologic laparoscopic surgeon can expect to treat a patient with a VP shunt in place.

Gasless laparoscopy for benign gynecological diseases using an abdominal wall-lifting system

OBJECTIVES

The use of gasless laparoscopy with an abdominal wall-lifting device for benign gynecological diseases was compared to conventional laparoscopy with CO(2) pneumoperitoneum.

METHODS

From February 2007 to July 2007, 76 women with uterine and/or adnexal benign diseases and candidates for laparoscopic surgery were recruited in this study. Thirty-two women underwent gasless laparoscopic surgery and 44 women underwent pneumoperitoneum laparoscopic surgery.

RESULTS

Diverse pathologies, including adnexal cyst, uterine myoma and ectopic pregnancy, were treated successfully with gasless laparoscopic surgery. Compared with the patients in the pneumoperitoneum group, the similar hospital stay (P=0.353) and intraoperative blood loss (P=0.157) were observed. However, the mean operative time in the gasless group was significantly longer than that in the pneumoperitoneum group (P=0.003). No severe intraoperative or postoperative complications were found in either group, except for one case of laparotomic conversion in the pneumoperitoneum group due to dense pelvic adhesions. The total hospital charges were significantly less in the gasless group than in the pneumoperitoneum group (P=0.001). In 38 cases of ovarian cyst resection, the mean operative time in the gasless group remained longer than that in the pneumoperitoneum group (P=0.017). The total hospital charges were also significantly less in the gasless group than in the pneumoperitoneum group (P<0.001).

CONCLUSION

Our preliminary results demonstrated that the laparoscopic procedure using the gasless technique was a safe, effective method to treat benign gynecological diseases. Moreover, it was easy to master. As a minimally invasive treatment, gasless laparoscopic surgery provides a good choice to patients in the undeveloped regions in China without increasing the patients' and the government's burden significantly.

New tool (Laparotenser) for gasless laparoscopic myomectomy: a multicenter-controlled study

OBJECTIVE

To assess feasibility and safety of a new surgical instrument-Laparotenser-in the procedure of gasless laparoscopic myomectomy.

DESIGN

Multicenter controlled study.

SETTING

Academic departments of obstetrics and gynecology, Italy.

PATIENT(S)

Thirty patients scheduled for gasless laparoscopic myomectomy (experimental group) and another group of 30 patients from our historical records that have undergone traditional laparoscopic myomectomy, matched with the cases for number of fibroids and for size of the main fibroid (control group).

INTERVENTION(S)

Gasless laparoscopic myomectomy using Laparotenser.

MAIN OUTCOME MEASURE(S)

Surgical data.

RESULT(S)

No significant differences in total operative time, postoperative ileus, hospitalization, time to return to full activity/work, and complication rates were observed between groups. Intraoperative blood loss, hemoglobin level, and surgical difficulty were significantly higher in the experimental than in the control group. Postoperative pain and number of analgesic vials used were significantly lower in the experimental group than in the control group.

CONCLUSION(S)

Although performed during the learning curve period, the use of the Laparotenser instrument in gasless laparoscopic myomectomy is a safe procedure.

The uterus and fertility

OBJECTIVE

To review the current understanding of the role the uterus plays in embryo implantation and to outline congenital anomalies and acquired diseases that impact normal uterine function.

DESIGN

The publications related to the embryo implantation, Mullerian anomalies, uterine polyps, uterine synechiae, and myomas were identified through Medline and reviewed.

CONCLUSION(S)

Congenital anomalies and acquired diseases of the uterus may negatively impact on the complex processes of embryo implantation. Hysteroscopic surgery to correct uterine septa, intrauterine synechiae, and myomas that distort the uterine cavity may benefit women with infertility or recurrent pregnancy loss. The effect of endometrial polyps on fertility is uncertain, but their removal, once identified, is justifiable. Complex congenital anomalies such as unicornuate uterus and uterus didelphys may negatively affect fertility and pregnancy outcome, and surgical treatment may benefit select patients.

Isobaric gasless laparoscopy versus minilaparotomy in uterine myomectomy: a randomized trial

BACKGROUND

Isobaric gasless laparoscopy and minilaparotomy have been used as more recent minimally invasive approaches to myomectomy. This randomized trial aimed to compare the surgical and immediate postoperative outcomes for myomectomy performed by isobaric gasless laparoscopy with those for minilaparotomy.

METHODS

A total of 100 patients with symptomatic uterine myomas requiring myomectomy were randomly allocated to the gasless laparoscopy group or the minilaparotomy group. The randomization procedure was based on a computer-generated list. The primary outcome was a comparison of the discharge times between the two procedures. A power calculation verified that more than 26 patients for each group was necessary to detect a difference of more than 24 h in discharge time with an alpha error level of 5% and a beta error of 80%. Continuous outcome variables were analyzed using the Student's t-test. Discrete variables were analyzed with the chi-square test or Fisher's exact test. A p value less than 0.05 was considered statistically significant.

RESULTS

The mean discharge time was longer for minilaparotomy than for gasless laparoscopy (98.4 +/- 1.4 vs 52.8 +/- 1.6 h; p < 0.001). Gasless laparoscopy resulted in shorter times for canalization (21.6 +/- 1.1 vs 32 +/- 1.3 h; p < 0.05) and surgery (79.5 +/- 25.1 vs 103.5 +/- 24.9 min; p < 0.001). The intraoperative blood loss was less with gasless laparoscopy (154.2 +/- 1.2 vs 188.6 +/- 1.3 ml; p < 0.001). No intraoperative complications occurred, and no case was returned to the theater in either group. No conversion to standard laparotomy was necessary.

CONCLUSIONS

Isobaric gasless laparoscopy and minilaparotomy can be suitable options for uterine myomectomy. Several surgical and immediate postoperative outcomes were significantly better in the gasless laparoscopy group than in the minilaparotomy group. However, further controlled prospective studies are required to confirm the results.