A comparison of three approaches for laparoscopic single-site (LESS) myomectomy: conventional, robotic, and hand assisted

Robotic-assisted laparoscopic versus abdominal and laparoscopic myomectomy: A systematic review and meta-analysis

BACKGROUND

Myomectomy is the preferred treatment for women with uterine fibroids and fertility requirements. There are three modalities are used in clinical practice for myomectomy: abdominal myomectomy (AM), laparoscopic myomectomy (LM), and robot-assisted laparoscopic myomectomy (RLM).

OBJECTIVES

To compare the perioperative and postoperative outcomes of RLM, AM, and LM.

SEARCH STRATEGY

We searched PubMed, Web of Science, Embase, and Clinical Trials for relevant literature published between January 2000 and January 2023.

SELECTION CRITERIA

We included all studies reporting peri- and postoperative outcomes of myomectomy in patients with uterine myomas. Surgical treatments were classified as RLM, LM, or AM.

DATA COLLECTION AND ANALYSIS

Two or more authors selected studies independently, assessed risk of bias, and extracted data. We derived mean difference (MD) or odds ratio (OR) with 95% confidence intervals (CIs) for each outcome, subgrouping trials by the patient characteristics and myoma characteristics. We used the I2 statistic to quantify heterogeneity and the random-effects model for meta-analysis when appropriate. We used the funnel plot to assess the publication bias.

MAIN RESULTS

A total of 32 studies with 6357 patients were included, of which 1982 women had undergone RLM. The operating time was significantly longer (MD = 43.58, 95% confidence interval [CI]: 25.22-61.93, P < 0.001), and the incidence of cesarean section after myomectomy was significantly lower (OR = 0.27, 95% CI: 0.10-0.78, P = 0.02) in RLM than in LM. Compared with AM, the operation time, blood loss, blood transfusion rate, complication rate, total cost, length of hospital stay, and pregnancy rate of patients with RLM were significantly different.

CONCLUSIONS

The safety and effectiveness of RLM are superior to those of AM but inferior to those of LM.

Currently Available Treatment Modalities for Uterine Fibroids

Uterine fibroids (leiomyomas and myomas) are the most common benign gynecological condition in patients presenting with abnormal uterine bleeding, pelvic masses causing pressure or pain, infertility and obstetric complications. Almost a third of women with fibroids need treatment due to symptoms.

OBJECTIVES

In this review we present all currently available treatment modalities for uterine fibroids.

METHODS

An extensive search for the available data regarding surgical, medical and other treatment options for uterine fibroids was conducted.

REVIEW

Nowadays, treatment for fibroids is intended to control symptoms while preserving future fertility. The choice of treatment depends on the patient's age and fertility and the number, size and location of the fibroids. Current management strategies mainly involve surgical interventions (hysterectomy and myomectomy hysteroscopy, laparoscopy or laparotomy). Other surgical and non-surgical minimally invasive techniques include interventions performed under radiologic or ultrasound guidance (uterine artery embolization and occlusion, myolysis, magnetic resonance-guided focused ultrasound surgery, radiofrequency ablation of fibroids and endometrial ablation). Medical treatment options for fibroids are still restricted and available medications (progestogens, combined oral contraceptives andgonadotropin-releasing hormone agonists and antagonists) are generally used for short-term treatment of fibroid-induced bleeding. Recently, it was shown that SPRMs could be administered intermittently long-term with good results on bleeding and fibroid size reduction. Novel medical treatments are still under investigation but with promising results.

CONCLUSIONS

Treatment of fibroids must be individualized based on the presence and severity of symptoms and the patient's desire for definitive treatment or fertility preservation.

Comparison of learning curves for laparoendoscopic single-site myomectomy performed by 2 surgeons

We aimed to compare the learning curves of 2 surgeons with different endoscopic bases when performing laparoendoscopic single-site myomectomy (LESS-M). We retrospectively analyzed and compared 2 groups of patients who underwent LESS-M performed by 2 surgeons with different bases in multi-port laparoscopic surgery (MLS) from October 2019 to December 2020 at West China Second Hospital of Sichuan University. Patients' characteristics and related surgical indicators were compared, and surgeons' learning curves were analyzed using a cumulative sum analysis. All of the patients completed LESS-M without converting to MLS or laparotomy, despite Surgeon A being MLS-unqualified and Surgeon B being MLS-qualified. There were no significant differences in patients' characteristics or surgical indicators between the 2 groups (P > 0.05 for all). Surgeons A and B crossed the learning curve after 21 and 18 cases, respectively. LESS-M is safe and feasible. Approximately 20 cases are required for surgeons to achieve LESS-M proficiency, and surgeons without MLS experience can still master LESS-M.

Outcomes of robotic and laparoscopic surgery for benign gynaecological disease: a systematic review

Benign gynaecological diseases are usually treated with minimally invasive approaches. Robotic surgery seems an alternative to laparoscopic surgery. No definitive conclusions have yet been made regarding comparison of robotic versus laparoscopic surgery for benign diseases. In this scenario, we performed a systematic review in order to assess the advantages and disadvantages of laparoscopy versus robotic surgery and conclude whether laparoscopy should be replaced by robotic surgery for the treatment of benign gynaecological conditions, following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) Statement. We included 64 studies: no significant difference was observed regarding overall complication rate; no significant benefit of robotic approach was demonstrated regarding length of hospital stay and conversion to laparotomy; furthermore, robotic surgery is more easily used by non-experienced surgeons, while it is more expensive and characterised by longer operative time. In conclusion, current evidence indicates neither statistically significant nor clinically meaningful differences in surgical outcomes between robotic and laparoscopic surgeries for benign gynaecological diseases. Impact statementWhat is already known on this subject? Benign gynaecological diseases are usually treated with minimally invasive approaches. Nevertheless, no definitive conclusions have yet been made regarding comparison of robotic versus laparoscopic surgery for benign diseases.What do the results of this study add? No significant difference was observed regarding overall complication rate; no significant benefit of robotic approach was demonstrated regarding length of hospital stay and conversion to laparotomy; furthermore, robotic surgery is more easily used by non-experienced surgeon, while it is more expensive and characterised by longer operative time.What are the implications of these findings for clinical practice and/or further research? Robotic surgery should not replace laparoscopy for the treatment of benign gynaecological conditions; in addition, gynaecologic surgeon should offer robotic surgery for benign diseases only after a proper counselling and a balanced decision-making process involving the patient.

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.