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

Transumbilical laparoendoscopic single-site surgery vs. multiport laparoscopic surgery for benign ovarian cysts: a retrospective cohort study

BACKGROUND

Transumbilical laparoendoscopic single-site surgery (TU-LESS) has gained increasing attention due to the potential to maximize the benefits of laparoscopic surgery. This study aimed to compare outcomes of TU-LESS and multiport laparoscopic surgery (MLS) for the treatment of benign ovarian cysts.

METHODS

This retrospective cohort study included patients with benign ovarian cysts that were admitted to the Second Hospital of Hebei Medical University between September 2010 and September 2022. Inverse probability of treatment weighting (IPTW) approach weighting were used to compare outcomes of TU-LESS and MLS for benign ovarian cysts. The primary outcome was the rate of cystic content spillage.

RESULTS

A total of 528 patients with benign ovarian cysts were included and 236 (44.6%) patients underwent TU-LESS. The risk of cystic content spillage [relative risk (RR) = 4.37, 95% confidence interval (CI): 2.59-7.38), P < 0.001] and operation time (β = 4.94, 95% CI: 1.40-8.48, P = 0.017) during TU-LESS was significantly higher than that during MLS. While hospital stay (β=-0.10, 95% CI: -0.198 - -0.004, P = 0.043) during TU-LESS was significantly shorter. IPTW analyses yielded similar patterns of results. For ovarian cysts < 10 cm, the risk of cystic content spillage, operation time and EBL during TU-LESS was significantly higher than that during MLS (all P < 0.05). On the contrast, for ovarian cysts ≥ 10 cm, the risk of cystic content spillage, operation time and EBL during TU-LESS was significantly lower than that during MLS (all P < 0.05).

CONCLUSIONS

TU-LESS had a significantly higher risk of cystic content spillage, longer operation time than MLS. While for ovarian cysts ≥ 10 cm, TU-LESS had a lower risk of cystic content spillage, shorter operation time, and less EBL than MLS. More experienced surgeons are needed to perform TU-LESS in benign ovarian cysts.

Laparoscopic surgery of large adnexal masses (>12 cm): Single port or conventional?

INTRODUCTION

We aimed to compare single-port laparoscopic surgery (SPLS) and conventional multiport laparoscopic surgery (CMLS) for large adnexal mass (AM).

METHODS

Patients undergoing laparoscopy (LS) due to huge AMs (≥12 cm) between 2016 and 2021 were evaluated retrospectively. The SPLS procedure was applied in 25 cases, and CMLS was performed in 32 cases. The premier result was the grade of the postoperative improvement according to the Quality of Recovery (QoR)-40 questionnaire score (24 h after the surgical procedure; postoperative day 1). Observer Scar Assessment Scale (OSAS) and Patient Observer Scar Assessment Scale (PSAS) were also evaluated.

RESULTS

A total of 57 cases undergoing SPLS (n = 25) or CMLS (n = 32) due to a large AM (≥12 cm) were analyzed. No meaningful distinctions in age, menopausal status, body mass index, or mass size were observed between the two cohorts. The operation time was shorter in the SPLS than CPLS cohort (42.2 ± 3.3 vs. 47.6 ± 6.2; p < 0.001). Unilateral salpingo-oophorectomy was performed in 84.0% of cases in the SPLS cohort and 90.6% of patients in the CMLS cohort (p = 0.360). The QoR-40 points were significantly higher in the SPLS than the CMLS group (154.9 ± 12.0 vs. 146.2 ± 17.1; p = 0.035). The OSAS and PSAS scores were lower in the SPLS than the CMLS group.

CONCLUSION

LS can be used for large cysts that are not considered to be at risk of malignancy. The postoperative recovery time was shorter in patients undergoing SPLS compared to CMLS.

Comparison of single-port laparoscopy and laparotomy in early ovarian cancer surgical staging

OBJECTIVE

s The aims of this study were to assess the feasibility of single-port laparoscopic surgical staging (SPLS) in early ovarian cancer and to compare the surgical outcomes of SPLS with those of staging laparotomy.

METHODS

Between January 2014 and December 2018, 40 patients underwent SPLS and 41 patients underwent staging laparotomy at Yonsei Cancer Center. The patients were diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage I ovarian cancer. Variables such as patient age, body mass index (BMI), tumor size, FIGO stage, and perioperative surgical outcomes and survival outcomes of SPLS and laparotomy were compared.

RESULTS

The total operation time was similar between the 2 groups (SPLS: 201.4 vs. laparotomy: 203.0 minutes, P=0.806). The median tumor diameters in the SPLS and laparotomy groups were 11.0 (2.5-28 cm) and 15.4 (6-40 cm), respectively (P=0.001). The SPLS group had lower tumor spillage rate (5.0% vs. 19.5%, P=0.047), less intraoperative blood loss (102.0 vs. 371.5 mL, P<0.001), less postoperative pain, and shorter postoperative hospital stay (5 vs. 9.5 days, P<0.001). The intraoperative major complication rate was similar between groups (2.5% vs. 4.9%, P=0.571). There was no significant difference in progression-free survival between the 2 groups (P=0.945). There were no deaths in either group.

CONCLUSION

SPLS is feasible in early ovarian cancer and has better perioperative surgical outcomes, in some aspects, than staging laparotomy without compromising survival outcomes. SPLS could be performed in patients suspected to have early ovarian cancer.

Guideline No. 404: Initial Investigation and Management of Benign Ovarian Masses

OBJECTIVE

To provide recommendations for a systematic approach to the initial investigation and management of a benign ovarian mass and facilitate patient referral to a gynaecologic oncologist for management.

INTENDED USERS

Obstetricians, gynaecologists, family physicians, internists, nurse practitioners, radiologists, general surgeons, medical students, medical residents, fellows, and other health care providers.

TARGET POPULATION

Women ≥18 years of age presenting for evaluation of an ovarian mass (including simple and unilocular cystic masses, endometriomas, dermoids, fibromas, and hemorrhagic cysts) who are not acutely symptomatic and without known genetic predisposition to ovarian cancer.

OUTCOMES

This guideline aims to encourage conservative management and help reduce unnecessary surgery and long-term health complications, maintain fertility, and decrease operative costs and improve overall patient care and outcomes by providing criteria for referral of patients with ultrasound imaging findings suggestive of a malignant mass to a gynaecologic oncologist.

EVIDENCE

Databases searched: Medline, Cochrane, and PubMed. Medical terms used: benign asymptomatic and symptomatic ovarian cysts, adnexal masses, oophorectomy, ultrasound diagnosis of cysts, simple ultrasound rules, surgical and medical therapies for cysts, screening for ovarian cancer, ovarian torsion, and menopause. Initial search was completed by 2017 and updated in 2018. Exclusion criteria were malignant ovarian cystic masses, endometriosis therapies, and other adnexal pathologies unrelated to the ovary.

VALIDATION METHODS

The content and recommendations were drafted and agreed upon by the authors. The Society of Obstetricians and Gynaecologists of Canada's Board of Directors approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework.

BENEFITS, HARMS, COSTS

Implementation of the recommendations could reduce costs due to unnecessary surgeries and hospitalizations and reduce lost work days and the risk of loss of fertility, early menopause, and surgical complications.

SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES)

RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Two-step sentinel lymph node mapping strategy in endometrial cancer staging using fluorescent imaging: A novel sentinel lymph node tracer injection procedure

OBJECTIVE

The current sentinel lymph node (SLN) tracer injection procedure for endometrial cancer commonly uses cervical injection, which can detect SLNs of the uterine cervix but not the uterine body. This study describes an SLN tracer injection procedure, titled two-step SLN mapping, which can identify SLNs of the uterine body and cervix using fluorescent imaging with indocyanine green (ICG) and results of SLN biopsy.

METHODS

In 50 consecutive patients with endometrial cancer, two-step SLN mapping was performed during laparoscopic surgical staging with the PINPOINT® real-time fluorescence imaging system. The first step was to identify SLNs of the uterine body. In total, 4-6 mL of ICG was injected into the bilateral uterine cornual areas, and lymphatic channels were traced, followed by identification and removal of paraaortic SLNs. The second step was to identify SLNs of the uterine cervix by injecting 4 mL of ICG into the cervix. After harvesting the mapped pelvic SLNs, complete pelvic and paraaortic lymphadenectomy was performed to validate the two-step SLN mapping strategy.

RESULTS

Our two-step SLN mapping strategy produced excellent SLN detection rates: 100% (50/50) overall for SLNs; 98.0% (49/50) for pelvic SLNs; 94.0% (47/50) for bilateral SLNs; and 86.0% (43/50) for paraaortic SLNs. We detected microscopic metastasis in harvested SLNs of 4 patients (8.0%). The sensitivity, specificity, and negative predictive value of SLN detection were all 100%. There was no false negative case.

CONCLUSION

The two-step SLN mapping strategy to identify lymph nodes from the uterine fundus and cervix was feasible. This strategy could be more accurate in identifying paraaortic lymph node metastasis than the cervical injection method.