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Muacevic A, Adler JR, Pajai S, Mohammad S. Laparoendoscopic Single-Site Surgery (LESS): A Shift in Gynecological Minimally Invasive Surgery. Cureus 2022; 14:e32205. [PMID: 36620796 PMCID: PMC9813544 DOI: 10.7759/cureus.32205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022] Open
Abstract
Laparotomy was once the preferred modality of treatment for various gynecological conditions. However, over the years, with the advancements worldwide, a new technique for surgery, laparoscopy, came into play. Since then, laparoscopy is preferred over laparotomy for diagnostic and therapeutic purposes since it was less invasive than laparotomy. Further advancements include laparoendoscopic single-site surgery (LESS), which is a procedure that, as the name implies, only uses one port. It includes using a single incision near the umbilicus in contrast to laparoscopy, which traditionally includes one main port incision and various other side ports. Through the port, multiple devices can be inserted into the cavity. The use of a single port can reduce post-operative complications and help reduce the duration of hospital stays. A single incision near the umbilicus would not leave a very significant scar, and the wound healing time would be comparatively less, reducing the hospital stay time. This novel technique is, therefore, an amalgamation of traditional surgery and recently surfacing minimally invasive surgery. Other modalities which are being used widely include vaginal natural orifice transluminal endoscopic surgery (vNOTES). Since the ports formed are frequently inconspicuous, these procedures leave patients with "scarless" results.
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Application of robotic single-site surgery with optional additional port for endometriosis: a single institution's experience. J Robot Surg 2021; 16:127-135. [PMID: 33651315 DOI: 10.1007/s11701-021-01217-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 02/20/2021] [Indexed: 10/22/2022]
Abstract
To evaluate the safety and feasibility of treating stage I-IV endometriosis patients with robotic single-site surgery (RSSS). A retrospective chart review was conducted on 334 patients with endometriosis treated by a single surgeon at a university hospital from January 2015 to November 2019. Surgeries were performed in a single institution between 2015 and 2019. All patients presented with pelvic pain and underwent surgical resection of the lesion. American Society of Reproductive Medicine (ASRM) standards were used to classify endometriosis. The primary goal of this study is to investigate the feasibility and safety of RSSS for surgical resection of stage I-IV endometriosis patients. We will compare patient characteristics and surgical parameters, such as blood loss, operating time, and postoperative complications, across different endometriosis stages to evaluate the effectiveness of this novel technique. RSSS was used for all cases, with no conversions to laparotomy or traditional laparoscopy. One to two additional ports were placed in 41 patients with deeply infiltrating endometriosis (DIE) involving the colorectal and urinary tract and/or extensive pelvic adhesions. Across patient groups, there were no significant differences in age, BMI, fertility history, abdominal surgery history, and hysterectomy ratio (P > 0.05). The median operation time was 140.25 min (range: 85.50-260.00 min, P < 0.05) and median blood loss was 31.25 mL (range: 15-100 mL, P < 0.05). Histopathology supported the diagnosis in 259/334 patients. The undiagnosed patients were associated with lower ASRM scores. For 83.3% of patients (295/334), the length of hospital stay was < 24 h. The postoperative complication rate was 6.0% (20/334), although only two cases were severe. Our results indicate that RSSS is an alternative, safe, and acceptable platform for the surgical treatment of all stages of endometriosis.
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Ma J, Yang J, Cheng S, Jin Y, Zhang N, Wang C, Wang Y. The Learning Curve of Laparoendoscopic Single-Site Surgery in Benign Gynecological Diseases. J INVEST SURG 2021; 35:363-370. [PMID: 33395538 DOI: 10.1080/08941939.2020.1867673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To analyze and draw the learning curve of laparoendoscopic single-site surgery (LESS) in various benign gynecological diseases, so as to provide a reference for applying this cutting-edge technique. METHODS A retrospective analysis of LESS was conducted. Factors influencing the LESS learning process were assessed using Cox's proportional hazards regression. The cumulative sum (CUSUM) value and the learning curve were calculated and visualized based on operation time (OT), blood loss (BL), conventional laparoscopic surgery (CLS), conversion rate (CV), and complications (CP). The CUSUM value was defined as the sum of CUSUMOT, CUSUMBL, CUSUMCV, and CUSUMCP. RESULTS A total of 445 cases, including adnexectomies (n = 147), ovarian cystectomies (n = 175), and myomectomies (n = 123) were analyzed. Multivariate regression analysis indicated that adhesion grade (HR, 1.462; 95% CI, 1.016-1.994; p = .045), surgical type (HR, 1.283; 95% CI, 1.042-1.429; p = .024), and surgeon CLS experience (HR, 1.372; 95% CI, 1.097-2.246; p = .012) were independent factors predicting surgeons' mastery of the LESS technique. Among gynecologists with CLS experience, the cutoff points were 17, 20, and 27 cases for adnexectomy, ovarian cystectomy, and myomectomy, respectively. For those without CLS experience, the corresponding cutoff values were 19, 27, and 35 cases. CONCLUSION The learning curve of LESS for benign gynecological diseases indicates a stepwise process, during which the surgeon's CLS experience is the key, especially in ovarian cystectomy and myomectomy. For the training of young gynecologists, CLS should be emphasized in the early stage, and LESS should be introduced gradually.
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Affiliation(s)
- Jun Ma
- Department of Obstetrics and Gynecology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jiani Yang
- Department of Obstetrics and Gynecology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Shanshan Cheng
- Department of Obstetrics and Gynecology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yue Jin
- Department of Obstetrics and Gynecology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Nan Zhang
- Department of Obstetrics and Gynecology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Chao Wang
- Department of Obstetrics and Gynecology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yu Wang
- Department of Obstetrics and Gynecology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Laparoscopic Vessel Endometriosis Resection Surgery: A Case Report and Review of Literature. Case Rep Obstet Gynecol 2019; 2019:1375208. [PMID: 31915556 PMCID: PMC6930385 DOI: 10.1155/2019/1375208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/13/2019] [Accepted: 08/27/2019] [Indexed: 11/17/2022] Open
Abstract
Background Endometriosis usually occurs in the pelvis and often involves the ovaries, the uterosacral and broad ligaments, and the pelvic peritoneum. In rare instances, it can occur in the vasculature of the pelvis. Patients with endometriosis present with abnormal pain, menstrual cycle disruption and infertility. Management of endometriosis is usually surgical with excision of the tissue via laparoscopic means. Case A 42-year-old Gravida 5, Para 2-0-3-2 patient with a 22 year history of endometriosis, who had had multiple laparoscopic endometriosis resections, total abdominal hysterectomy, and an exploratory laparotomy with bilateral salpingo-oophorectomy, presented with left pelvic pain when standing, dyspareunia, and a 3.7 cm cyst on ultrasound. The patient underwent laparoscopic vessel endometriosis resection and excision of endometriotic nodules from external iliac vessels. Final pathology report showed evidence of old endometriosis in all locations. On interval follow-up, the patient reported sustained relief from pain. Conclusion Complete resection of endometriosis from large vessels can be successfully achieved laparoscopically by a well-experienced surgeon with delicate, proper techniques.
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Moon HS, Shim JE, Lee SR, Jeong K. The Comparison of Robotic Single-Site Surgery to Single-Port Laparoendoscopic Surgery for the Treatment of Advanced-Stage Endometriosis. J Laparoendosc Adv Surg Tech A 2018; 28:1483-1488. [DOI: 10.1089/lap.2018.0118] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Hye-Sung Moon
- Department of Obstetrics and Gynecology, Robot Surgery Center, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Ji Eun Shim
- Department of Obstetrics and Gynecology, Robot Surgery Center, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Sa Ra Lee
- Department of Obstetrics and Gynecology, Robot Surgery Center, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Kyungah Jeong
- Department of Obstetrics and Gynecology, Robot Surgery Center, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
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Rezai S, Giovane RA, Minton H, Bardawil E, Zhang Y, Patil NM, Henderson CE, Guan X. Laparoendoscopic Single-Site Surgery for Management of Heterotopic Pregnancy: A Case Report and Review of Literature. Case Rep Obstet Gynecol 2018; 2018:7232637. [PMID: 30069420 PMCID: PMC6057289 DOI: 10.1155/2018/7232637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 04/15/2018] [Accepted: 04/26/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Heterotopic pregnancy occurs when two pregnancies occur simultaneously in the uterus and an ectopic location. Treatment includes removal of the ectopic pregnancy with preservation of the intrauterine pregnancy. Treatment is done laparoscopically with either a Laparoendoscopic Single-Site Surgery (LESS) or a multiport laparoscopic surgery. CASE We present a case of a first trimester heterotopic pregnancy in a 42-year-old gravida 5, para 0-1-3-1 female with previous history of left salpingectomy, who underwent laparoscopic right salpingectomy and lysis of adhesions (LOA) via Single-Incision Laparoscopic Surgery (SILS). CONCLUSION Although LESS for benign OB/GYN cases is feasible, safe, and equally effective compared to the conventional laparoscopic techniques, studies have suggested no clinically relevant advantages in the frequency of perioperative complications between LESS and conventional methods. No data on the cost effectiveness of LESS versus conventional methods are available. LESS utilizes only one surgical incision which may lead to decreased pain and better cosmetic outcome when compared to multiport procedure. One significant undesirable aspect of LESS is the crowding of the surgical area as only one incision is made. Therefore, all instruments go through one port, which can lead to obstruction of the surgeon's vision and in some cases higher rate of procedure failure resulting in conversion to multiport procedure.
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Affiliation(s)
- Shadi Rezai
- Department of Obstetrics and Gynecology, Southern California Kaiser Permanente, Kern County, 1200 Discovery Drive, Bakersfield, CA 93309, USA
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, 10 Floor, Houston, TX 77030, USA
| | - Richard A. Giovane
- University of Alabama, Department of Family Medicine, 801 Campus Drive, Tuscaloosa, AL 35487, USA
| | - Heather Minton
- University of Birmingham, School of Medicine, 1720 2 Avenue, Birmingham, AL 35294, USA
| | - Elise Bardawil
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, 10 Floor, Houston, TX 77030, USA
| | - Yiming Zhang
- Division of Reproductive Medicine, Jinan Central Hospital Group, 105 Jiefang Road, Jinan City, Shandong Province 250013, China
| | - Ninad M. Patil
- Department of Pathology & Immunology, Baylor College of Medicine, 6651 Main Street, 4 Floor, Houston, TX 77030, USA
| | - Cassandra E. Henderson
- Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Lincoln Medical and Mental Health Center, 234 East 149 Street, Bronx, NY 10451, USA
| | - Xiaoming Guan
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, 10 Floor, Houston, TX 77030, USA
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[Surgical management of endometrioma: Different alternatives in term of pain, fertility and recurrence. CNGOF-HAS Endometriosis Guidelines]. ACTA ACUST UNITED AC 2018; 46:278-289. [PMID: 29510964 DOI: 10.1016/j.gofs.2018.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Indexed: 11/22/2022]
Abstract
Surgical management of ovarian endometrioma is most often part of a global approach of endometriosis pathology. Isolated endometrioma are rare. Laparoscopic cystectomy is the gold standard for surgical management of endometrioma. Nevertheless, this technique impacts the ovarian function. The hemostasis of the ovarian cyst bed should be performed to conserve the ovarian stroma. Ultrasonography-guided cyst aspiration, laparoscopic drainage and simple bipolar coagulation are not recommended as first line of treatment. Based on the actual literature, we cannot state the place of laser-vaporization and plasma-energy ablation in surgical management. Ethanol sclerotherapy could be an alternative to treat recurrent endometrioma. Uncompleted surgical removal of endometriosis lesions increases the recurrence rate. Endometriosis management should take into account the research and treatment of all the pelvic lesion, especially before surgical management of endometrioma. In this context, the evaluation of ovarian reserve could be useful before surgery.
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Moulton LJ, Jernigan AM, Michener CM. Postoperative Outcomes after Single-port Laparoscopic Removal of Adnexal Masses in Patients Referred to Gynecologic Oncology at a Large Academic Center. J Minim Invasive Gynecol 2017; 24:1136-1144. [PMID: 28673874 DOI: 10.1016/j.jmig.2017.06.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 06/27/2017] [Accepted: 06/27/2017] [Indexed: 01/13/2023]
Abstract
STUDY OBJECTIVE To report surgical and pathologic outcomes after single-port laparoscopy (SPL) for adnexal masses in patients referred to a gynecologic oncology practice at a single academic institution. DESIGN A retrospective analysis (Canadian Task Force Classification II.2). SETTING A single academic institution with multiple hospital centers. PATIENTS Women who underwent at least 1 single-port laparoscopic surgery for the treatment of an adnexal mass from 2009 to 2015 after referral to a gynecologic oncology practice. INTERVENTION Data were collected on the surgical procedure, patient demographic variables, 30-day surgical outcomes, and hernia development. MEASUREMENTS AND MAIN RESULTS Three hundred twenty-five surgeries were performed in 322 patients with a median follow-up of 42.7 months. The median age was 54.5 years, and the median body mass index was 28.1 kg/m2. All patients underwent unilateral or bilateral salpingectomy or oophorectomy with or without hysterectomy (26.5%). The median operative time was 90.0 minutes. The median mass dimension was 6.4 cm with 17.9% (n = 60) greater than 10 cm. Masses were categorized as simple (11.4%) and complex (69.5%). Although the majority (87.4%) of masses were benign, 7.4% were malignant, and 5.2% were borderline. Benign masses were physiologic (16.6%), serous cystadenomas (19.1%), mucinous cystadenomas (6.8%), endometriomas (12.3%), myomas (12.3%), and mature teratomas (9.2%). In malignant cases (7.4%), serous carcinoma was the most frequent histology (58.3%). The rate of adverse outcomes within 30 days, including reoperation (0.0%), intraoperative injury (1.5%), venous thromboembolism (0.3%), and transfusion (0.6%), was low. The development of incisional cellulitis was 4.6%. The rate of incisional hernia was 4.0%, with a median occurrence of 18.3 months. Diabetes mellitus (p = .03) and obesity (p = .04) were significant predictors for a hernia, but mass complexity (p = .28), American Society of Anesthesiologists class (p = .83), and smoking (p = .82) were not. CONCLUSION In patients undergoing SPL for the removal of adnexal masses in a gynecologic oncology practice, the rate of benign disease is high. SPL removal of adnexal masses is feasible and safe with favorable surgical outcomes, rare short-term adverse outcomes, and a low incisional hernia rate.
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Affiliation(s)
- Laura J Moulton
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Amelia M Jernigan
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Louisiana State University Healthcare Network, New Orleans, Louisiana
| | - Chad M Michener
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio
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Guan X, Nguyen MTA, Walsh TM, Kelly B. Robotic Single-Site Endometriosis Resection Using Firefly Technology. J Minim Invasive Gynecol 2016; 23:10-1. [DOI: 10.1016/j.jmig.2015.08.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 08/01/2015] [Indexed: 10/23/2022]
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Gargiulo AR, Feltmate C, Srouji SS. Robotic single-site excision of ovarian endometrioma. FERTILITY RESEARCH AND PRACTICE 2015; 1:19. [PMID: 28620524 PMCID: PMC5424348 DOI: 10.1186/s40738-015-0011-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 12/11/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Conventional single-incision laparoscopic surgery has been successfully employed for treatment of ovarian endometriomas. However, this technique presents surgeons with formidable ergonomic challenges, that make its widespread adoption unlikely. Robotic assistance in single-incision laparoscopic surgery provides adequate instrument triangulation through a single fulcrum, while eliminating ergonomic challenges to the surgeon. The objective of this video is to describe a novel technique of laparoscopic excision and ablation of ovarian endometriomas with single-site robotic assistance. Footage from a single surgical case is shown in our video. The da Vinci Si surgical system with da Vinci Single-Site platform was utilized. A flexible CO2 laser fiber was employed as the main energy tool. To describe a technique of single-incision laparoscopic excision and ablation of endometriomas with robotic assistance. Footage from a single surgical case is shown in this video. The da Vinci Si surgical system with da Vinci Single-Site platform was utilized. A flexible CO2 laser fiber was employed as the main energy tool. RESULTS Our technique achieved excellent surgical, clinical and cosmetic results, with complete excision and ablation of the endometriomas and no complications. The procedure was completed in day-surgery setting. CONCLUSION Our step-by-step video tutorial shows how the dedicated single incision laparoscopy technology for the da Vinci Si surgical system can be safely and effectively applied to the excision and ablation of ovarian endometriomas.
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Affiliation(s)
- Antonio R Gargiulo
- Division of Reproductive Endocrinology and Infertility, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA USA.,Center for Robotic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA USA
| | - Colleen Feltmate
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA USA.,Center for Robotic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA USA
| | - Serene S Srouji
- Division of Reproductive Endocrinology and Infertility, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA USA.,Center for Robotic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA USA
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Zhao M, Zhao J, Hua K, Zhu Z, Hu C. Single-incision multiport laparoscopy versus multichannel-tipped single port laparoscopy in gynecologic surgery: outcomes and benefits. Int J Clin Exp Med 2015; 8:14992-14998. [PMID: 26628982 PMCID: PMC4658871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 09/07/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To estimate the feasibility and safety of single-incision multiport laparoscopy (SIMPL) used in patients who underwent laparoendoscopic single-site surgery (LESS) for gynecologic disease, and the cosmetic outcome and economic benefit compared with multichannel-tipped single port laparoscopy (MSPL). INTERVENTION We underwent LESS via a single 2.5- to 3.0-cm umbilical incision with the Single-Incision Multiport Laparoscopic Surgery Trocar available on the market, briefly named MSPL. Since January 2014, we improved the procedure and named SIMPL. In SIMPL group, two traditional laparoscopic trocar (diameter=5 mm) and one mini-laparoscopic trocar (diameter =3 mm) were inserted into the peritoneum separately through a single 1.5- to 1.8-cm umbilical transcutaneous incision. Subject demographics and clinical variables were collected and perioperative outcomes analyzed. In addition, the size of umbilicus was measured in all patients prior to the operation and the levels of cosmetic satisfaction were evaluated at 4 weeks after surgery. MEASUREMENTS AND MAIN RESULTS From January 2014 to December 2014, there were 32 patients who underwent SIMPL for ovarian cystectomy. Hospital cost was significantly lower in SIMPL group compared with MSPL group (RMB 10207.0 vs 17973.7 yuan), P<0.001. Compared with MSPL group, the SIMPL group reported significantly higher cosmetic satisfaction at 4 weeks afer surgery (P<0.1). Besides, the SIMPL procedures performed in benign gynecologic surgery were myomectomy (n=8), salpingpoophorectomy (n=2), salpingectomy (n=5), adhesiolysis and fimbrioplasty (n=32), ovarian drilling (n=3), salpingotomy for ectopic pregnancy (n=3). All surgeries were completed successfully without conversion to the traditional laparoscopic approach. Two postoperative complications occurred were delay healing of umbilicus incision after myomectomy. The cosmetic satisfactory rate was 100%. CONCLUSION According to our experience, SIMPL is safe and efficient for simple gynecologic operation, with lower cost and better cosmetic results than MSPL. Beyond cosmetic and economic results, further randomized studies are needed to identify a possible benefit.
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Affiliation(s)
- Mingzhi Zhao
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University Shanghai 200090, China
| | - Jing Zhao
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University Shanghai 200090, China
| | - Keqin Hua
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University Shanghai 200090, China
| | - Zhiling Zhu
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University Shanghai 200090, China
| | - Changdong Hu
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University Shanghai 200090, China
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