Pregnancy-preserving Laparoendoscopic Single-site Surgery for Gynecologic Disease: A Case Series

Application of transumbilical single port laparoscopic surgery for adnexal masses in pregnancy

OBJECTIVE

To evaluate the safety and feasibility of single-port laparoscopy during pregnancy in short term and long term.

METHODS

A multicenter retrospective study was conducted to investigate the clinical data of 38 pregnant women with adnexal masses who underwent transumbilical single-port laparoscopic surgery from January 2017 to March 10, 2023.

RESULTS

The mean operation time was 72.7 ± 29.6 (30-160) min. The mean intraoperative blood loss was 30.5 ± 80.4 mL, the mean postoperative first defecation time was 2.5 ± 0.7 days, and the mean total hospital stay was 6.9 ± 1.4 days. None of the patients used analgesic drugs postoperatively. Two patients developed missed abortions within 1 month of surgery, one underwent induction of labor due to a dead fetus at 24 weeks and 5 days of gestation, and the other patients did not develop adverse events after surgery. Mean birth weight was 3322.3 ± 396.3 g. The fetal heart rate was 139 ± 6.4 bpm before operation and 149 ± 2.7 bpm after operation. The APGAR score at 1 and 10 min was 9.2 ± 0.6 points and 9.9 ± 0.2 points, respectively. The mean follow-up time was 23.9 ± 16.1 (4.7-56) months, 90% (27/30) of the children had moderate developmental quotient, and 10% (3/30) of the children had good developmental quotient, without borderline low developmental quotient or mental retardation.

CONCLUSION

It is safe, practical, and worthwhile to promote transumbilical single port laparoscopic surgery for pregnancies with adnexal masses in both short and long term.

Non-obstetric surgery during pregnancy and the effects on maternal and fetal outcomes: A systematic review

BACKGROUND AND OBJECTIVE

Non-obstetric surgery is fairly common in pregnant women. We performed a systematic review to update data on non-obstetric surgery in pregnant women. The aim of this review was to evaluate the effects of non-obstetric surgery during pregnancy on pregnancy, fetal and maternal outcomes.

METHODS

A systematic literature search of MEDLINE and Scopus was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search span was from January 2000 to November 2022. Thirty-six studies matched the inclusion criteria, and 24 publications were identified through reference mining; 60 studies were included in this review. Outcome measures were miscarriage, stillbirth, preterm birth, low birth weight, low Apgar score, and infant and maternal morbidity and mortality rates.

RESULTS

We obtained data for 80,205 women who underwent non-obstetric surgery and data for 16,655,486 women who did not undergo surgery during pregnancy. Prevalence of non-obstetric surgery was between 0.23% and 0.74% (median 0.37%). Appendectomy was the most common procedure with median prevalence of 0.10%. Near half (43%) of the procedures were performed during the second trimester, 32% during the first trimester, and 25% during the third trimester. Half of surgeries were scheduled, and half were emergent. Laparoscopic and open techniques were used equally for abdominal cavity. Women who underwent non-obstetric surgery during pregnancy had increased rate of stillbirth (odds ratio (OR) 2.0) and preterm birth (OR 2.1) compared to women without surgery. Surgery during pregnancy did not increase rate of miscarriage (OR 1.1), low 5 min Apgar scores (OR 1.1), the fetus being small for gestational age (OR 1.1) or congenital anomalies (OR 1.0).

CONCLUSIONS

The prevalence of non-obstetric surgery has decreased during last decades, but still two out of 1000 pregnant women have scheduled surgery during pregnancy. Surgery during pregnancy increases the risk of stillbirth, and preterm birth. For abdominal cavity surgery, both laparoscopic and open approaches are feasible.

Single-port laparoscopy versus conventional laparoscopy of benign adnexal masses during pregnancy: a retrospective case-control study

OBJECTIVE

To compare operative outcomes between single-port laparoscopy (SPL) and conventional laparoscopy (CL) to remove adnexal masses during pregnancy.

METHODS

This retrospective case-control study included all patients who had undergone laparoscopic removal of benign adnexal masses during pregnancy between October 2010 and January 2020. Multiple clinical characteristics and operative outcomes were retrospectively analysed and compared between patients who had undergone SPL versus CL, including cosmetic satisfaction with the scar, measured on a 10-point scale (10 indicating very satisfied).

RESULTS

A total of 64 patients were included (SPL, n = 22; and CL, n = 42). Overall scar satisfaction scores significantly favoured SPL versus CL (9.1 ± 1.7 versus 8.1 ± 1.3, respectively), however, surgery duration was significantly longer for SPL than CL (69.2 ± 21.0 min versus 54.7 ± 20.7 min). No incisional hernia was detected in the study. Operative blood loss, decrease in estimated haemoglobin level, length of hospital stay, and hospitalization expenses were comparable between the two groups. Pregnancy and fetal outcomes were not remarkably different.

CONCLUSION

For removal of benign adnexal masses during pregnancy, SPL may offer superior cosmetic satisfaction versus CL, and was not associated with additional perioperative danger, economic burden, or adverse pregnancy and neonatal outcomes.

Laparoendoscopic single-site surgery for adnexal disease during pregnancy: A single-center preliminary experience

Purpose

This study aimed to evaluate the safety and efficacy of laparoendoscopic single-site surgery (LESS) in treating adnexal disease during pregnancy.

Methods

Medical records of included patients were retrospectively reviewed and follow-ups of all the patients were performed until the delivery of the fetus. The clinical characteristics, surgical interventions, postoperative complications, and pregnancy outcomes were analyzed.

Results

Six cases were included, with the gestational age ranging from 19 to 31 weeks 1 day. Procedures included salpingo-oophorectomy (n = 3), ovarian or paratubal cystectomy with detorsion (n = 2), and adnexal detorsion (n = 1). The median duration of surgery was 35 min (range, 20–60 min), and the estimated blood loss ranged from 5 to 50 ml. No major intraoperative or postoperative complications were noted. The final pathologic results included high-grade serous ovarian carcinoma, ovarian borderline serous cystadenoma, ovarian simple cyst, endometrioma, and mesosalpinx cyst. Five patients had a spontaneous vaginal delivery at full-term, and one patient had a cesarean section preterm followed by comprehensive staging surgery of ovarian cancer.

Conclusion

Based on the data we included, LESS performed by experienced surgeons appeared to be a safe and feasible alternative to multiport laparoscopic surgery for the management of selected patients with adnexal disease during pregnancy. More studies with large sample sizes at multiple centers are warranted.

Paratubal Cystectomy in a Pregnant Woman Using the Single-Incision Laparoscopic Surgery (SILS) Technique

Introduction

The proliferation of prenatal ultrasound has enhanced the detection of adnexal masses during pregnancy. The presentation necessitates a clear approach to investigation and treatment that balances both maternal and fetal risk. Laparoscopy is a safe approach to surgical management in the pregnant patient, and SILS may contribute to minimising perioperative complications. Case Presentation. We present the case of a 21-year-old female in her second trimester of pregnancy presenting with a large 20 cm right adnexal cyst. We proceeded with laparoscopic cystectomy via the SILS technique. There were no intraoperative complications, and she recovered well postoperatively.

Conclusion

Laparoscopic resection of adnexal lesions is safe during pregnancy and should be favoured over the open approach. SILS minimises incision sites and has potential for reduction in perioperative morbidity.

Critical Steps to Performing a Successful Single Site Laparoscopic Myomectomy for Large Pedunculated Fibroid during Pregnancy

STUDY OBJECTIVE

To demonstrate tips and tricks for the successful use of single site laparoscopic surgery (SILS) for pedunculated myomectomy during pregnancy.

DESIGN

Stepwise demonstration with narrated video footage SETTING: An academic tertiary care hospital affiliated with Baylor College of Medicine. Our patient is a 39-year-old pregnant G1P0 with a symptomatic 12 centimeter degenerating pedunculated fibroid refractory to conservative pain management.

INTERVENTIONS

Recent literature has indicated that the majority of laparotomic myomectomies performed during pregnancy showed overall positive pregnancy outcomes and low complications. This indicates that myomectomy in pregnancy is safe and can be utilized in cases unresponsive to conservative management.¹ However, cases in literature discussing the single-site techniques for laparoscopic myomectomy during pregnancy has been sparse.² Four case series were reviewed; a total of 62 pregnant patients underwent laparoendoscopic single site surgery without any complications.^3-6 Utilizing laparoscopy in myomectomy compared to laparotomy during pregnancy, permits decreased postoperative pain, quicker recovery, and lowered risk of post-operative complications.^7-9 Single site laparoscopic surgery also aids in improved patient cosmesis and can be utilized for the fibroid removal. Literature has demonstrated that laparoscopic single site is safe and feasible during all stages of pregnancy.^3,4 Nevertheless, this approach may be challenging for inexperienced surgeons due to the lack of triangulation and crowding of instruments in single site laparoscopy.⁸ At 21 weeks 3 days pregnancy, our patient underwent single incision laparoscopic surgery myomectomy. A 2.5 cm skin incision was made at the umbilicus to the abdominal cavity and a GelPOINT Mini was inserted. Through the laparoscope we can observe that a 12 cm pedunculated fibroid was protruding from the right uterine fundus on a 4 cm stalk. A 0-Vicryl suture was tied around the base of the stalk. The stalk was then cauterized with bipolar energy and transected with the harmonic scalpel, completely detaching the fibroid. Subsequently, an Endo Catch bag was placed around the fibroid and brought up to the umbilical incision. Utilizing a scalpel, bag contained morcellation was completed within 22 minutes and the contents removed. As a result, the estimated blood loss was 50cc and the total operative time was 123 minutes. The extended operating time was due to slow movements to avoid disrupting the fetus. She had an unremarkable postoperative course, no medications were needed for pain management, and was discharged home on post-operative day 2. At 38 weeks, she successive delivered with elective cesarean delivery with no complications. Histopathology showed fragments of leiomyoma with diffuse necrosis. Tips and tricks: 1. Single site entry technique utilizes the open Hasson technique, which reduces the risk of injury to the pregnant uterus and dilated surrounding vessels. 2. Through 2.5 cm incision, the surgeon placed a suture in the fibroid stalk since the other hemostasis agents like vasopressin are contraindicated in pregnancy. 3. Due to difficulties related to single site surgery, the surgeon should possess extensive expertise in single site surgery 4. Minimizing manipulation of the uterus to reduce the disturbance of the pregnant uterus 5. V-loc suture allows for faster and simplified the uterine incision closure. 6. If the surgeon encounters excessive difficulty during the surgery, a 5 mm accessory port can be placed 7. During tissue extraction, gentle traction should be used to reduce the provoking the pregnant uterus. 8. When transecting the fibroid stalk, it is important to leave a stump of more than 1 cm to increase suturing ease and prevent accidental suturing of the uterus.

CONCLUSION

Single incision laparoscopic surgery myomectomy for pedunculated fibroids may be a practical technique in women refractive to conservative management. When performed by an experienced surgeon the patient may benefit from faster specimen removal and recovery.

Decidualized ovarian endometrioma mimicking malignancy in pregnancy: a case report and literature review

BACKGROUND

Ovarian endometrioma is a common gynecologic disease among reproductive-aged women. Pregnancy-related hormonal status may lead to changes of decidualization, which may resemble ovarian malignancies in sonographic appearance. Here we present a case of decidualized ovarian endometrioma clinically mimicking malignant transformation.

CASE PRESENTATION

A 37-year-old pregnant woman presented to our hospital at 25 + 5 weeks of gestation with a persistent left adnexal mass that was first detected on routine ultrasound in the first trimester. Transvaginal and transabdominal ultrasound showed a cystic mass of size 8.4 × 5.8 cm in the left ovary with abundant blood flow signals in the papillary medium echo of the capsule wall and inner wall, raising concern for malignant ovarian tumor. After a multidisciplinary discussion, the patient underwent laparoscopic left salpingo-oophorectomy. The results of the frozen section revealed decidualized endometrioma and the final histopathology confirmed endometrioma with extensive decidualization. The patient's postoperative recovery was uneventful and she was discharged on the 4th postoperative day.

CONCLUSIONS

Decidualized ovarian endometrioma is rare. Sonography and magnetic resonance imaging are helpful for differential diagnosis. Conservative management of expectant management and serial monitoring should be adopted if decidualized endometriosis is suspected.

Single-Port Laparoscopic Surgery for Adnexal Mass Removal During Pregnancy: The Initial Experience of a Single Institute

OBJECTIVE

Single-port laparoscopy has become a feasible and safe approach for the management of benign adnexal masses during pregnancy. To our knowledge, there are few reports on the feasibility and safety of single-port laparoscopy for adnexal mass removal during pregnancy. Our study reports the use of single-port laparoscopy in adnexal mass removal during pregnancy in our hospital.

METHODS

We included 10 cases of single-port laparoscopic surgery for adnexal mass removal during pregnancy in the West China Second University Hospital between January 2017 and March 2020. Median values were found using SPSS20. When the p-value was <0.05, the median and interquartile range were used. All patients provided informed consent.

RESULTS

The following median values were recorded: surgical time, 112.50 min; blood loss, 25 ml; postoperative hospital stay, 3 days; postoperative pain [visual analog scale (VAS)] at 6 h, 3; and postoperative pain (VAS) at 24 h, 2. Our study reported no postoperative spontaneous abortions. There was one preterm birth.

CONCLUSION

Single-port laparoscopy appears to be safe for both the mother and the fetus.

Laparoendoscopic single-site compared with conventional laparoscopic surgery for gynaecological acute abdomen in pregnant women

Objective

To estimate the safety and feasibility of laparoendoscopic single-site surgery (LESS) in pregnant patients with acute abdomen.

Methods

Baseline characteristics, surgical results, and obstetric and neonatal outcomes were retrospectively compared between single and multiport procedures in patients who underwent laparoscopic surgery during pregnancy between 2017 and 2021.

Results

Fifty-four pregnant patients were included: 26 who underwent LESS (salpingectomy, 11 cases/cystectomy, 15 cases) and 28 who underwent conventional laparoscopic surgeries (salpingectomy, 12 cases/cystectomy, 16 cases) during pregnancy. One patient in the single-port group required additional ports. No patients converted to laparotomy. In patients undergoing salpingectomy, the single-port group showed lower 8- and 24-h postoperative pain scores, shorter hospital stays, and lower Self-rating Anxiety Scale scores prior to discharge versus conventional laparoscopy. One patient experienced postoperative vaginal bleeding and a missed abortion during follow-up. In patients receiving cystectomy, 8- and 24-h pain scores, postoperative hospital stay, and anxiety scores were lower in the single-port versus multiport group. Other outcomes were comparable between the groups.

Conclusion

The feasibility and efficacy of laparoscopic surgery during pregnancy is similar between single- or multiport routes, however, the single-port route may be associated with less postoperative pain, shorter hospital stay, and lower anxiety.

Minimally invasive surgical management of a cornual ectopic pregnancy, with and without a concurrent intrauterine pregnancy

OBJECTIVE

To describe techniques for resection of a cornual heterotopic pregnancy.

DESIGN

This video demonstrates a surgical technique for excision of a cornual heterotopic pregnancy with narrative video footage using two case examples.

SETTING

The incidence of cornual heterotopic pregnancy is unknown; however, the incidence of heterotopic pregnancy itself has increased through the use of assisted reproductive technologies and the majority of cornual heterotopic pregnancies occur after assisted reproductive technologies use. These cases have been treated traditionally using exploratory laparotomy and cornual wedge resection with good outcomes. With advancements in minimally-invasive surgical techniques, laparoscopic resection of cornual heterotopic pregnancies has been demonstrated to be safe and feasible.

PATIENT(S)

A patient with an 8-week cornual heterotopic pregnancy and a patient with a 10-week cornual ectopic pregnancy.

INTERVENTIONS

Laparoscopic resection of the cornual ectopic pregnancy.

MAIN OUTCOME MEASURE(S)

Feasibility of a "purse-string" technique for the resection of a heterotopic cornual pregnancy.

RESULT(S)

Robotic-assisted laparoscopic resection of a cornual heterotopic pregnancy can be performed with minimal blood loss with the use of the "purse-string" technique in settings where vasopressin cannot be used for hemostasis. This technique includes the use of a 2-0 V-Loc suture in a circumferential fashion around the ectopic pregnancy, which allows for faster suturing and immediate tension at the myometrium. The same suture is then used to close the defect, which allows for a simpler and efficient closure with minimal entry into the myometrium.

CONCLUSION(S)

In this video, we demonstrate the successful resection of cornual heterotopic pregnancy using a "purse-string" surgical technique. This technique allows for minimal blood loss in cases where additional techniques for hemostasis cannot be used, such as injection of vasopressin and uterine artery ligation.

Laparoscopic Single-site "In-bag" Ovarian Dermoid Cystectomy in a 16-week- pregnant Patient

STUDY OBJECTIVE

To demonstrate a novel "in-bag" ovarian cystectomy technique for a large adnexal mass in pregnancy.

DESIGN

Stepwise demonstration with narrated video.

SETTING

An academic tertiary care hospital. The patient was a 26-year-old woman, gravida 1, para 0, at gestational age of 7 weeks and 3 days who presented to the emergency department with persistent left pelvic pain and was diagnosed with a 16 cm × 10 cm × 12 cm dermoid cyst. She re-presented at gestational age of 16 weeks and 3 days with worsening pelvic pain, and the decision was made to proceed with surgical intervention.

INTERVENTIONS

Laparoscopic transumbilical single-site surgery for the surgical management of adnexal masses in pregnancy has been demonstrated to be feasible and safe [1-3]. However, single-site laparoscopic ovarian cystectomy can be very challenging in pregnancy, especially when the need for suturing arises. Exteriorizing the ovary and cyst after intraperitoneal drainage may allow for extracorporeal suturing that is faster and easier; however, it may increase the probability of spillage of cystic contents if it is not performed in a bag, which can then cause peritonitis in cases of dermoid cysts. A combination of in-bag and extracorporeal ovarian cystectomy is a novel alternative minimally invasive approach that is cosmetic, safe, and effective. Several helpful techniques in this novel combination technique include the following: • Creating an umbilical incision of at least 2 cm or one that is large enough for better manipulation of both the surgical bag and adnexal mass. • Tightening the bag appropriately around the infundibulopelvic ligament so that it is not too tight leading to compromised blood supply and tissue necrosis, yet not too loose resulting in leakage of cystic contents. • Ensuring that the infundibulopelvic ligament is stabilized within the surgical bag. • Inserting small-sized wound retractor into the bag for better exposure during cystectomy. • Having a double-suction irrigation setup for large adnexal masses, as demonstrated in this patient, to reduce the spillage of cystic contents. The procedure was successfully performed in approximately 110 minutes, and the fetal heart rate postprocedure was 128 bpm through bedside transabdominal ultrasound. Estimated blood loss was 5 mL, and the patient was discharged the same day with an uneventful 4-week postoperative follow-up.

CONCLUSION

Laparoscopic single-site "in-bag" ovarian dermoid cystectomy is feasible, effective, and safe in pregnant patients with a large adnexal mass. This technique results in better stabilization of the ovarian cyst and reduction of cystic content spillage.