What is the learning curve for single-port access laparoscopic-assisted vaginal hysterectomy?

The Effects of a Laparoscopy by Single-Port Endoscopic Access in Benign Adnexal Surgery: A Randomized Controlled Trial

STUDY OBJECTIVE

To evaluate whether laparoendoscopic single-site surgery (LESS) offers advantages over conventional laparoscopy (CL) in benign adnexal surgery.

DESIGN

Randomized controlled study.

SETTING

Gynecology-Obstetrics Unit of the University Hospital of the Conception in Marseille, France.

PATIENTS

Patients older than 18 years requiring ovarian cystectomy or salpingo-oophorectomy by laparoscopy for symptomatic ovarian cysts requiring benign or prophylactic surgery.

INTERVENTIONS

In the case of ovarian cysts, premenopausal patients typically undergo a unilateral cystectomy, whereas postmenopausal patients undergo a unilateral or bilateral salpingo-oophorectomy upon a patient's request. In cases requiring prophylactic surgery, a bilateral salpingo-oophorectomy was performed. All participants were randomly assigned to either the LESS or the CL group.

MEASUREMENTS AND MAIN RESULTS

Patients in both groups reported similar levels of pain at 24 hours: Simple Numerical Scale was 1.3 (standard deviation, 1.5) in the LESS group vs 1.7 (standard deviation, 1.5) in the CL group (p = .12), and there were no significant differences in postoperative pain at 2 hours, 4 hours, 6 hours, and 7 days. Furthermore, there was no difference in analgesic consumption. Regarding intraoperative criteria, the only difference was the longer operating time in the LESS group than the CL group. We also found that patients' satisfaction with their scar at 1 month may be higher with LESS than with CL.

CONCLUSION

There was no significant difference between the 2 techniques in postoperative pain, although the LESS technique necessitated a longer operative time than the CL technique, while providing better aesthetic result patients.

Laparo-endoscopic single-site versus conventional laparoscopic surgery for early-stage endometrial cancer: A randomized controlled non-inferiority trial

OBJECTIVE

To evaluate the feasibility and safety of laparo-endoscopic single-site surgery (LESS) compared with conventional laparoscopic surgery (CLS) for early-stage endometrial cancer.

METHODS

Patients with clinical stage IA, IB, grade 1-3 endometrial cancer were randomly assigned to undergo LESS or CLS. The primary endpoint was the non-inferiority of LESS to CLS in terms of operation time and the number of resected pelvic lymph nodes. We set the non-inferior margin of the operation time as within 15% (24 min) and the number of resected pelvic lymph nodes as within 20% (5.2 lymph nodes).

RESULTS

There was no significant difference between the LESS group (n = 53) and the CLS group (n = 54) in terms of age, weight, body mass index, parity, menopausal status, history of abdominal surgery, and preoperative CA-125 levels. The total operation time was comparable between the two groups. On average, 4.6 fewer pelvic lymph nodes were retrieved in the LESS group, which was within the non-inferiority margin. There were no significant differences in the incidence of intra- and postoperative complications, estimated blood loss, and postoperative hospital stay between the two groups. After a median follow-up time of 34 months (range, 2-242), the progression-free survival rates were 96.2% and 98.1% (P = 0.55) in the LESS group and the CLS group, and the overall survival rates were 98.1% and 100.0% (P = 0.31), respectively.

CONCLUSION

LESS surgical staging was non-inferior to CLS and had acceptable feasibility, safety, and efficacy for the surgical management of early-stage endometrial cancer.

TRIAL REGISTRATION

Clinicaltrial.gov identifier number: NCT01679522.

Feasibility of Single-Port Access (SPA) Laparoscopy for Large Ovarian Tumor Suspected to Be Borderline Ovarian Tumor

Objectives

To compare the surgical, pathological and oncological outcomes of single-port access (SPA) laparoscopy against laparotomy for large ovarian tumor (>15 cm) suspected to be a borderline ovarian tumor (BOT) on preoperative imaging.

Methods

A retrospective review of the patients who underwent SPA laparoscopy (SPA Group) or laparotomy (Laparotomy Group) for suspected BOT was performed. Surgical outcomes, including the rates of iatrogenic spillage of tumor contents, and oncological outcomes, such as recurrence-free survival (RFS) and overall survival (OS), were compared between the two groups. Correlation between intraoperative frozen section analysis and permanent pathology results was also assessed.

Results

A total of 178 patients underwent surgical treatment for suspected large BOT. Among them, 105 patients with a mean tumor diameter of 20.9 ± 6.5 cm underwent SPA laparoscopy, and the other 73 patients, with a mean tumor diameter 20.2 ± 5.9 cm, underwent laparotomy. The mean operation time did not differ between the two groups (99.1 ± 41.9 min for SPA Group vs. 107.3 ± 35.7 min for Laparotomy Group, p = 0.085). There was no difference in the occurrence of iatrogenic spillage of tumor contents between the groups either (11.4% in the SPA Group vs. 6.8% in the Laparotomy Group, p = 0.381). However, the postoperative complication rates were significantly higher in the Laparotomy Group compared with SPA Group (16.4% vs. 5.7%, p = 0.025). The surgical approach was not associated with the misdiagnosis rates of frozen section analysis (19% in the SPA Group vs. 26% in the Laparotomy Group, p = 0.484). The most common histologic type of the tumors was mucinous in both groups.

Conclusion

SPA laparoscopy is feasible, safe, and not inferior to laparotomy for surgical treatment of large ovarian tumors that suspected to be BOT on preoperative imaging.

Learning curve analysis of transvaginal natural orifice transluminal endoscopic hysterectomy

Background

No data are available to assess the learning curve for transvaginal natural orifice transluminal endoscopic hysterectomy for non-prolapsed uteri in benign gynecologic diseases. The lack of exposure to transvaginal natural orifice transluminal endoscopic hysterectomy during training, in addition to a poorly defined learning curve, further deters interested physicians from applying this technique to daily practice. The aim of this study was to evaluate the learning curve and perioperative outcome of transvaginal natural orifice transluminal endoscopic hysterectomy by an experienced endoscopist.

Methods

A total of 240 cases of transvaginal natural orifice transluminal endoscopic hysterectomies with or without adnexectomy for various benign gynecologic diseases were included. Demographic data and various perioperative parameters were reviewed from the prospectively collected database. Operative time was set as a surrogate marker for surgical competency. The learning curve was evaluated using the cumulative sum method.

Results

The overall mean operative time (OT) was 76.5 min ± 22.4. Four unique phases of the learning curve were derived using cumulative sum analysis: the mean OT of phase I (the initial learning curve of 20 cases) was 86.3 ± 23.7 min, phase II (acquisition of competence of 80 cases) was 71.0 ± 21.4 min, phase III (proficiency and plateau of 80 cases) was 76.0 ± 20.4 min, and phase IV (post-learning in which more challenging cases were managed) was 81.3 ± 23.6 min. No major complications were encountered. One case in phase III converted to laparoscopy due to difficulty in performing anterior colpotomy.

Conclusion

Our data demonstrated four distinct phases of the learning curve of transvaginal natural orifice transluminal endoscopic hysterectomy. In a well-trained endoscopist, surgical competence in transvaginal natural orifice transluminal endoscopic hysterectomy can be reached after 20 cases.

Electronic supplementary material

The online version of this article (10.1186/s12893-019-0554-0) contains supplementary material, which is available to authorized users.

Robotic Single-Site Sacrocolpopexy with Retroperitoneal Tunneling

Introduction

This series of cases was an investigation of the safety and feasibility of robotic laparoendoscopic single-site surgery (R-LESS) as a method of performing sacrocolpopexy.

Case Presentation

This is a retrospective series of 15 cases of R-LESS sacrocolpopexy with the V-Loc (Medtronic, Minneapolis, Minnesota, USA) suture and a retroperitoneal tunneling technique performed by a single surgeon, combined with a literature review. Patient demographic information and perioperative data were analyzed. The standard robotic sacrocolpopexy steps were followed, but the surgeon used a combined technique of V-Loc suture and retroperitoneal tunneling to simplify the procedure. No additional ports were necessary in any of the patients.

Management and Outcome

Using the pelvic organ prolapse quantification (POP-Q) scoring method, the mean preoperative C-point of the 15 patients was +1.16 compared to the mean immediate postoperative C-point, which was -5.5. The mean total sacrocolpopexy time was 74.7 (range, 50-99) minutes and mean mesh anchoring time was 22.60 ± 3.85 minutes. The mean sacral promontory fixation and tunneling and mesh position times were 11.87 ± 3.02 and 5.80 ± 2.14 minutes, respectively. All 15 cases were performed without perioperative or long-term complications.

Discussion

R-LESS in combination with the V-Loc suture and the retroperitoneal tunneling technique can be safely and feasibly performed, especially in sacrocolpopexy and, potentially, in other POP surgeries. With adequate and systematic training, surgeons can acquire the necessary skills to perform this complex surgical procedure.

Total vaginal and single-port total laparoscopic hysterectomy for uterine benign diseases

OBJECTIVE

This study aimed to review the surgical outcomes and health-related quality of life (HRQOL) of total vaginal (TVH) and single-port total laparoscopic hysterectomy (SP-TLH) for uterine benign diseases.

STUDY DESIGN

This study included 121 patients who had undergone TVH or SP-TLH for uterine benign diseases between April 2011 and July 2012. Surgical outcomes, complications, and HRQOL were reviewed in the two groups. Preoperative and postoperative HRQOL data from the 36-item Short Form questionnaire (SF-36) were recorded for all patients.

RESULTS

TVH was performed more often for the patients who had fewer previous operations (p = 0.32). In the TVH, there were fewer combined surgical procedures (p < 0.01), shorter operation times (p < 0.01), shorter vaginal stump suture times (p = 0.03) and lower complication rates (p < 0.01) than in SP-TLH. Overall, all SF-36 scales improved after surgery, except for the Social Functioning scale. There was no significant difference in any of the scales between the two groups.

CONCLUSIONS

TVH has equivalent effects on HRQOL as SP-TLH. SP-TLH is preferred for the cases with complicated and combined procedures.

Single-port access total laparoscopic hysterectomy with Korean-made OCTO Port: Turkish surgeons' initial experience

We present our initial experience with single-port access total laparoscopic hysterectomy (TLH) surgery using a Korean-made laparoscopic port (OCTO™ Port). In a retrospective study, single-port access TLH (SPA-TLH) with the OCTO Port was performed on 34 patients with benign gynaecological indications from July 2013 to May 2014 by two surgeons (Ahmet Kale and Hasan Terzi). All patients were divided into two groups. The first 15 patients who underwent SPA-TLH were classified as Group 1, and the second 19 patients who underwent SPA-TLH were classified as Group 2. Patient data were analyzed for age, body mass index (BMI, kg/m(2)), weight of uterus, vaginal cuff suturation time, estimated blood loss, operation time, hysterectomy indications and operative outcomes. The median time needed for the surgery was 75 min in both groups. The duration of suturing of the vaginal cuff was shorter in Group 2 compared with that in Group 1. The estimated blood loss was less in Group 2 compared with Group 1: Four patients in Group 1 required blood transfusion while none of the patients in Group 2 required blood transfusion. The OCTO Port has soft and flexible instrumental movements, which can reduce crowding of instruments during surgery, and the cap rotates 360 degrees. The OCTO Port might facilitate the learning curve of single-port laparoscopic hysterectomy surgery.

Laparoendoscopic single-site surgery using conventional laparoscopic instruments and glove port technique in gynecology: a single surgeon's experience

STUDY OBJECTIVE

To report a single surgeon's experience with 120 laparoendoscopic single-site surgery (LESS) procedures using conventional laparoscopic instruments and a homemade glove port system to treat benign gynecologic diseases.

DESIGN

Retrospective chart analysis (Canadian Task Force classification III).

SETTING

Eulji University Hospital.

PATIENTS

One hundred twenty patients who underwent LESS performed by a single surgeon to treat benign gynecologic diseases between November 2010 and November 2012.

INTERVENTION

LESS using conventional instrumentation was performed using our specialized glove port technique, which consists of the combination of the homemade glove port system designed to minimalize collision of the trocar on the tip of the finger of the surgical glove, a sufficient rectus fasciotomy, the surgeon's position at the patient's head, and adequate positioning of the instruments.

MEASUREMENTS AND MAIN RESULTS

The LESS procedures performed were laparoscopically assisted vaginal hysterectomy (n = 50), ovarian cystectomy (n = 25), myomectomy (n = 14), oophorectomy (n = 11), salpingectomy (n = 9), fimbrioplasty or neosalpingstomy (n = 7), and adhesiolysis only (n = 4). Median patient age was 40 years, and median body mass index was 23. Median operative time was 100 minutes (range, 50-145 minutes) for laparoscopically assisted vaginal hysterectomy, 70 minutes (range, 30-150 minutes) for ovarian cystectomy, 107 minutes (range, 65-180 minutes) for myomectomy, 55 minutes (range, 25-130 minutes) for oophorectomy, 85 minutes (range, 35-110 minutes) for salpingectomy, 70 minutes (range, 25-140 minutes) for neosalpingostomy or fimbrioplasty, and 35 minutes (range, 30-60-minutes) for adhesiolysis only. All procedures were completed successfully without the need for additional ports or conversion to the standard laparoscopic approach. One perioperative complication occurred. The complication rate was 83% (1 of 120). Other postoperative complications were not observed at follow-up.

CONCLUSION

Our experience shows that LESS using conventional laparoscopic instruments and our glove port technique is a feasible and safe technique for the surgical management of various gynecologic conditions. Therefore, our homemade glove port laparoscopic system used in our specialized technique provides a simple, cost-effective approach to LESS and would probably make laparoscopic procedures using conventional instruments easier.

Virtual reality robotic surgical simulation: an analysis of gynecology trainees

STUDY OBJECTIVE

To analyze the learning curves of gynecology trainees on several virtual reality da Vinci Skills Simulator exercises.

DESIGN

Prospective cohort pilot study.

SETTING

Academic hospital-based gynecology training program.

PARTICIPANTS

Novice robotic surgeons from a gynecology training program.

METHODS

Novice robotic surgeons from an academic gynecology training program completed 10 repetitions of 4 exercises on the da Vinci Skills Simulator: matchboard, ring and rail, suture sponge, and energy switching. Performance metrics measured included time to completion, economy of instrument movement, excessive force, collisions, master workspace range, missed targets, misapplied energy, critical errors, and overall score. Statistical analyses were conducted to define the learning curve for trainees and the optimal number of repetitions for each exercise.

RESULTS

A total of 34 participants were enrolled, of which 9 were medical students, 22 were residents, and 3 were fellows. There was a significant improvement in performance between the 1st and 10th repetitions across multiple metrics for all exercises. Senior trainees performed the suture exercise significantly faster than the junior trainees during the first and last repetitions (p = 0.004 and p = 0.003, respectively). However, the performance gap between seniors and juniors narrowed significantly by the 10th repetition. The mean number of repetitions required to achieve performance plateau ranged from 6.4 to 9.3.

CONCLUSION

Virtual reality robotic simulation improves ability through repetition at all levels of training. Further, a performance plateau may exist during a single training session. Larger studies are needed to further define the most high-yield simulator exercises, the ideal number of repetitions, and recommended intervals between training sessions to improve operative performance.

Single-port vs. conventional multi-port access laparoscopy-assisted vaginal hysterectomy: comparison of surgical outcomes and complications

OBJECTIVE

To compare surgical outcomes and complications between single-port access (SPA) and multi-port access (MPA) laparoscopy-assisted vaginal hysterectomy (LAVH).

STUDY DESIGN

A retrospective review of medical records was performed in patients who underwent LAVH for non-malignant gynaecological diseases at Eun Hospital between April 2010 and April 2012. One hundred and twenty women underwent SPA LAVH using a transumbilical three-channel single-port system and 130 women underwent conventional MPA LAVH. Surgical outcomes and complications were compared between the two groups.

RESULTS

The outcomes of the SPA-LAVH group vs. the conventional MPA-LAVH group were as follows: mean±standard deviation total operative time (73.1±24.3 vs. 70.3±22.1min, p=0.349), largest dimension of uterus (10.7±2.3 vs. 10.8±2.8cm, p=0.847), weight of extirpated uterus (311±185 vs. 339±234g, p=0.298) and change in haemoglobin (1.7±0.8 vs. 2.0±0.9g/dl, p=0.025). The incidence of complications was similar in each group (20 vs. 16 patients, p=0.327). Unplanned intra-operative laparotomy was not necessary in either group, and there were no cases of bowel injury or main vessel injury in either group. In total, there were three bladder injuries: one in the SPA-LAVH group and two in the MPA-LAVH group. The postoperative course was uneventful in most patients, but six patients had a transient paralytic ileus (four in the SPA-LAVH group and two in the MPA-LAVH group) and 10 patients had a pelvic haematoma (five in each group), all of whom recovered following conservative management. Port-related complications were rare, but one patient in the SPA-LAVH group had a port-site umbilical hernia.

CONCLUSION

Use of SPA and MPA LAVH has similar results in terms of surgical outcomes and complications.

Single-port access laparoscopy-assisted vaginal hysterectomy: our initial experiences with 100 cases

Objectives. To present our initial experiences with laparoscopically assisted vaginal hysterectomy performed using homemade transumbilical single-port system. Materials and Methods. We reviewed the medical records of one hundred patients who underwent single-port access laparoscopically assisted vaginal hysterectomy (SPA-LAVH). SPA-LAVH was performed with homemade single port system and conventional rigid laparoscopic instruments. Results. All procedures were successfully completed through the single-port system and vagina without need for extraumbilical puncture or conversion to laparotomy. The median patient age was 48.2 ± 6.5 years. Thirty-three patients had history of past abdominopelvic surgery. The median total operative time, largest dimension of the uterus, and weight of the uterus were 73.1 ± 24.6 min, 10.5 ± 2.1 cm, and 300.8 ± 192.5 gram, respectively. The median decline in the hemoglobin from before surgery to postoperative day 1 was 1.8 ± 0.9 g/dL. Bladder injury in occurred one patient who was repaired through intraoperative laparoscopic suture. The postoperative course was uneventful in most patients except for three who had a transient paralytic ileus, five who had pelvic hematoma, but they were recovered following conservative managements. No port-related complications were noted, and the cosmetic results were excellent. Conclusions. SPA-LAVH is technically safe procedure, and the homemade single-port system offers reliable access for single-port surgery.

[Feasibility study about the single-port in gynecologic oncology surgery]

OBJECTIVES

To describe our single-port experience in gynecologic oncology surgery, and emphasize the feasibility to use the single-port in this surgery.

PATIENTS AND METHODS

It is a retrospective, feasibility study, monocentric. All patients who were operated by the single-port, between 1st January 2010 to 1st November 2011, were included.

RESULTS

We note that 107 patients were included. We made different interventions: uni- and bilateral salpingo-ovariectomy, hysterectomy, pelvic and para-aortic lymph node sampling or lymphadenectomy in gynecologic malignancies. The median age of the population and the body mass index were respectively 52 and 22.6 kg/m(2). In total, six interventions will be converted. The median hospital stay of patients, all procedures combined, was 2 days. We find low rate of postoperative complications.

CONCLUSION

Gynecological cancer surgery appears feasible for single-port. However, we need other studies to confirm a benefit of using the single-port compared to conventional laparoscopy.