Ectopic pregnancy: laparoendoscopic single-site surgery—laparoscopic surgery through a single cutaneous incision

The learning curve of laparoscopic single-site salpingectomy with conventional laparoscopic instruments: A retrospective cohort study

Tubal pregnancy is a common cause of maternal mortality in early pregnancy. Transumbilical laparoendoscopic single-site surgery (TU-LESS) has gained popularity due to its safety and aesthetic advantages. However, the lack of affordable disposable entry platforms hinders its widespread adoption. This study aimed to investigate the learning curve of tubal pregnancy removal using single-incision multiport (SIMP) laparoscopy and provide guidance for novice gynecologists. A retrospective analysis was conducted on cases of ectopic pregnancy (EP) diagnosed at Dongguan Songshan Lake Central Hospital from June 2020 to June 2022. The analysis included 50 cases, with 25 undergoing single-port laparoscopy and 25 undergoing conventional laparoscopy (CL). Various indicators, including body mass index (BMI), previous pregnancies, mass size, hemoglobin levels, surgical duration, and complications, were collected. Learning curve analysis using the cumulative sum (CUSUM) technique was performed to assess procedural proficiency. There were no significant differences in patient characteristics or complications between the 2 groups. However, the single-port laparoscopy group exhibited a statistically significant longer average surgical time (41.60 ± 13.38 minutes) compared to the conventional laparotomy group (32.96 ± 7.32 minutes). The CUSUM analysis demonstrated a decline in surgical time after the completion of approximately 11 cases, indicating an improvement in SIMP laparoscopy surgical proficiency. SIMP laparoscopy for tubal pregnancy removal achieved similar safety outcomes as CL. Notably, the CUSUM analysis revealed that proficiency in single-port laparoscopy could be achieved after approximately 11 cases, leading to stable surgical times. These findings serve as valuable guidance for novice gynecologists interested in adopting single-incision laparoscopy.

Development of Pelvic Inflammatory Disease after Ectopic Removal

Although ectopic pregnancy and pelvic inflammatory disease (PID) are separately commonly seen in practice, development of PID after surgical removal is rare. Here, we present the case of a 41-year-old female who was admitted for pelvic inflammatory disease diagnosed after laparoscopic salpingectomy for a ruptured ectopic pregnancy. Treatment required drainage of TOAs with interventional radiology and antibiotic treatment. This case report demonstrates how treatment of PID following ectopic pregnancy is complex and may require surgical- or radiology-guided drainage of infection in addition to common antibiotic treatment. Follow-up and duration of treatment are highlighted.

Laparoendoscopic single-site surgery for management of ovarian endometriomas

BACKGROUND AND OBJECTIVES

To compare our initial experience in laparoscopic surgery for ovarian endometriomas performed through an umbilical incision using a single 3-channel port and flexible laparoscopic instrumentation versus traditional laparoscopy.

METHODS

This study was conducted in 3 tertiary care referral centers. Since September 2009, we have performed laparoendoscopic single-site surgery in 24 patients diagnosed with ovarian endometriomas. A control group of patients with similar diagnoses who underwent traditional operative laparoscopy during the same period was included (n = 28). In the laparoendoscopic single-site surgery group, a multichannel port was inserted into the peritoneum through a 1.5- to 2.0-cm umbilical incision.

RESULTS

Patients in the laparoendoscopic single-site surgery group were significantly older (P = .04) and had a higher body mass index (P = .005). Both groups were comparable regarding history of abdominal surgery, lateral pelvic side wall involvement, and cul-de-sac involvement. After we controlled for age and body mass index, the size of the resected endometriomas, duration of surgery, and amount of operative blood loss were comparable in both groups. When required, an additional 5-mm port was inserted in the right or left lower quadrant in the laparoendoscopic single-site surgery group to allow the use of a third instrument for additional tissue retraction or manipulation (10 of 24 patients, 41.6%). However, adhesiolysis was performed more frequently in the conventional laparoscopy group. The duration of hospital stay was <24 hours in both groups. No intraoperative complications were encountered. All incisions healed and were cosmetically satisfactory.

CONCLUSION

The laparoendoscopic single-site surgery technique is a reasonable initial approach for the treatment of endometriomas. In our experience, an additional side port is usually needed to treat pelvic side wall and cul-de-sac endometriosis that often accompanies endometriomas.

Laparoendoscopic single-site surgery in gynecology: a review of the literature, tools, and techniques

Recent decades have witnessed a tremendous shift from laparotomy to laparoscopy as the surgical approach of choice in gynecology. Completion of increasingly complicated procedures has been facilitated by technical advances in instrumentation. Lately, increasing attention has been paid to reducing both the number and size of laparoscopic incisions, with the ultimate goal being the absence of any visible scar. Laparoendoscopic single-site surgery (LESS), or single-incision laparoscopy, describes the use of 1 small skin incision to complete laparoscopic surgical procedures where traditionally multiple incisions were created. In addition to examining the developing literature related to LESS in gynecology, the aims of this review were to describe the technical challenges encountered during performance of LESS and to provide practical solutions for instrumentation and surgical techniques that allow them to be overcome.

TARGET AUDIENCE

Obstetricians and gynecologists, family physicians

LEARNING OBJECTIVES

After completing this CME activity, physicians should be better able to identify potential benefits of LESS, and implement practical solutions for instrumentation and surgical techniques to overcome technical challenges faced during LESS.

Comparison of tubal sterilization procedures performed by keyless abdominal rope-lifting surgery and conventional CO2 laparoscopy: a case controlled clinical study

Objective. To evaluate the safety and efficacy of Keyless Abdominal Rope-Lifting Surgery (KARS), for tubal sterilization procedures in comparison with the conventional CO₂ laparoscopy. Material and Methods. During a one-year period, 71 women underwent tubal ligation surgery. Conventional laparoscopy (N = 38) and KARS (N = 33) were used for tubal sterilization. In KARS, an abdominal access pathway through a single intra-abdominal incision was used to place transabdominal sutures that elevated the abdominal wall, and the operations were performed through the intraumbilical entry without the use of trocars. In CO₂ laparoscopy, following the creation of the CO₂ pneumoperitoneum a 10 mm trocar and two 5 mm trocars were introduced into the abdominal cavity. Tubal sterilizations were performed following the creation of the abdominal access pathways in both groups. The groups were compared with each other. Results. All operations could be performed by KARS without conversion to CO₂ laparoscopy or laparotomy. The mean operative time of the two groups was not significantly different (P > 0.05). Intra- and postoperative findings including complications, bleeding, and hospital stay time did not differ between groups (P > 0.05). Conclusion. KARS for tubal sterilization seems safe and effective in terms of cosmesis, postoperative pain, and early hospital discharge.

Single-incision pediatric endosurgery for ovarian pathology

BACKGROUND AND OBJECTIVES

Despite being pioneered by gynecologists, single-incision endosurgery has not been widely reported for the treatment of ovarian and adnexal pathology in neonates, children, and adolescents. We describe our initial experience using single-incision pediatric endosurgery (SIPES) for these indications and discuss advantages and drawbacks.

SUBJECTS AND METHODS

All children who underwent SIPES with a preoperative diagnosis of ovarian or adnexal pathology were included in the study. Data on age, operative time, complications, length of hospital stay, and outcomes were collected.

RESULTS

From January 2010 until January 2012, 19 girls (mean age, 11.4 years; range, 6 days-17 years; weight range, 4.0-90 kg) underwent SIPES procedures for ovarian or adnexal diagnoses, including hemorrhagic/follicular/paratubal cysts (n=8), torsion (n=7), tumor (n=3), and parauterine cyst (n=1). The operations included cyst unroofing (n=4), detorsion and oophoropexy (n=7), (salpingo)oophorectomy (n=5), marsupialization of cyst (n=2), and cyst aspiration (n=1). Median operative time was 42 ± 29 minutes; there were no conversions to conventional laparoscopy or open surgery. Fifteen patients (79%) were discharged within 24 hours after the procedure. There were no peri- or postoperative complications. Histopathology showed hemorrhagic/follicular/paratubal cyst (n=7), necrotic/calcified ovarian tissue after torsion (n=6), cystadenofibroma (n=1), granulosa cell tumor (n=1), and mature teratoma (Grade 0) (n=1).

CONCLUSIONS

SIPES is an excellent alternative to conventional laparoscopy for the treatment of adnexal pathology. Using a single umbilical incision that can be enlarged instead of three smaller trocar sites facilitates the resection and extraction of ovarian masses without compromising cosmesis.

[Feasibility of laparoendoscopic single-site surgery in gynecology with conventional laparoscopic instruments]

OBJECTIVES

To describe the safety and efficacy of single-port access for laparoscopic surgery in gynecology with conventional laparoscopic instruments.

PATIENTS AND METHODS

In this prospective study, we report our experience with 90 patients who underwent Single Port Access (SPA) laparoscopic surgery for gynecologic pathology with the use of the SILS(®) Port Multiple Instrument Access Port (Covidien(®), Mansfield, MA).

RESULTS

We realised 15 ovarian cystectomies, 30 salpingo-oophrectomies with 14 one side, 9 lysis of adhesions, 7 distal tubal repairs, 6 salpingectomy, 8 other procedures. The mean surgical time is 47 min (25-120). One conversion to conventional laparoscopy and one in laparotomy were performed. The mean duration stay is 2 days [1-3].

DISCUSSION AND CONCLUSION

SPA in gynecology is feasible with conventional laparoscopic instruments. SPA surgery represents the newest frontier in minimally invasive surgery.

Management of benign ovarian cysts by a novel, gasless, single-incision laparoscopic technique: keyless abdominal rope-lifting surgery (KARS)

BACKGROUND

To find the most efficacious method to minimize the side effects and maximize the advantages of laparoscopic surgery, this study aimed to define and document a gasless, single-incision abdominal access technique for the management of benign ovarian cysts.

METHODS

During a 1½ year period, 55 women underwent surgery for a benign ovarian cyst. Conventional carbon dioxide (CO(2)) laparoscopy was used for 33 of the women, and 22 of the women underwent a novel, gasless, single-incision laparoscopic surgery. An abdominal access pathway through a single intraabdominal incision was used to place transabdominal sutures that elevated the abdominal wall, and the operations were performed through the intra-umbilical entry without the use of trocars. Thus, the new technique was called keyless abdominal rope-lifting surgery (KARS). Two operative groups were compared to assess the feasibility of the new technique.

RESULTS

All the operations could be performed by KARS without conversion to CO(2) laparoscopy or laparotomy. However, for two patients in the conventional laparoscopy group, minilaparotomy had to be performed for tissue retrieval. Although the two techniques had many similar results, the total operative times and the abdominal access times in the KARS group were significantly longer than in the conventional laparoscopy group (p < 0.05). Simple oral analgesics were adequate for postoperative pain relief in both groups.

CONCLUSIONS

The KARS technique is a gasless, single-incision laparoscopic procedure that can be performed safely and effectively in terms of cosmesis, postoperative pain, and fertility preservation for the management of benign adnexal pathologies.

A clinical review of single-incision laparoscopic surgery

Laparoscopic surgery is one of the most significant surgical advances of the twentieth century. Recently, the focus has been on the development of minimally invasive techniques in the form of single-incision laparoscopic surgery. The single-incision technique provides a less invasive alternative to conventional laparoscopic surgery, requiring only one incision disguised within the umbilical folds in contrast to the three to five incisions in conventional laparoscopic surgery. The availability of a number of specialised ports has aided the development of single-incision laparoscopic surgery, and led to its widespread use. The successful use of single-incision laparoscopic surgery has been reported for a number of surgical procedures, and offers several potential benefits versus conventional laparoscopic surgery, including reduced pain, reduced time to recovery and improved cosmesis. This review of international literature assesses the current status, as well as the experience, of single-incision laparoscopic surgery within general, colorectal, bariatric, metabolic, gynaecological and urological surgery. The challenges faced with single-incision laparoscopic surgery are discussed, as well as the clinical studies that are required in order to establish single-incision surgery as a significant improvement to conventional laparoscopic surgery in terms of reduced pain and improved cosmesis.

Laparoendoscopic single-site combined cholecystectomy and hysterectomy

Laparoendoscopic single-site (LESS) surgery has gained increased acceptance among surgeons in various specialties. The universal nature of port placement in the umbilicus during LESS surgery may enable concomitant procedures to be performed in these surgical specialties via this single incision. This case report presents a 37-year-old woman who underwent concomitant LESS cholecystectomy and hysterectomy to treat a symptomatic fibroid uterus and symptoms of cholelithiasis. The surgical procedure was performed in approximately 3 hours without any complications, and the patient was discharge to home 18 hours after the procedure. This case demonstrates that increasingly complex concomitant procedures can be performed using a LESS surgical approach.

Perioperative Outcomes of Laparoendoscopic Single-Site Surgery (LESS) Versus Conventional Laparoscopy for Adnexal Disease: A Case—Control Study

Objective: This study aimed to evaluate the potential advantages of laparoendoscopic single-site surgery (LESS) approach with respect to conventional laparoscopy. Methods: Thirty LESS patients were matched 2:1 with a previous cohort of 58 patients undergoing conventional laparoscopy for the same type of surgery (controls). Results: Median operative time (38.5 vs 54 minutes; P = .09) and estimated blood loss (20 vs 30 mL; P = .008) were more favorable in patients undergoing LESS treatment compared with those undergoing conventional laparoscopy. Rupture of the cyst was observed in 11 out of 30 cases (36.6%) and 26 of 58 controls (44.8%; P = .46). Median length of stay was 1 day in the cases and 2 in the controls ( P = .03). Conclusions: Decreases in operative time, estimated blood loss, or length of stay should not be considered a benefit attributable to LESS; rather it seems there are no differences between these 2 surgical approaches after an adequate selection of patients.

Laparoendoscopic single-site surgery in gynaecology: A new frontier in minimally invasive surgery

REVIEW OBJECTIVE: To review the recent developments and published literature on laparoendoscopic single-site (LESS) surgery in gynaecology.

RECENT FINDINGS

Minimally invasive surgery has become a standard of care for the treatment of many benign and malignant gynaecological conditions. Recent advances in conventional laparoscopy and robotic-assisted surgery have favorably impacted the entire spectrum of gynaecological surgery. With the goal of improving morbidity and cosmesis, continued efforts towards refinement of laparoscopic techniques have lead to minimization of size and number of ports required for these procedures. LESS surgery is a recently proposed surgical term used to describe various techniques that aim at performing laparoscopic surgery through a single, small-skin incision concealed within the umbilicus. In the last 5 years, there has been a surge in the developments in surgical technology and techniques for LESS surgery, which have resulted in a significant increase in utilisation of LESS across many surgical subspecialties. Recently published outcomes data demonstrate feasibility, safety and reproducibility for LESS in gynaecology. The contemporary LESS literature, extent of gynaecological procedures utilising these techniques and limitations of current technology will be reviewed in this manuscript.

CONCLUSIONS

LESS surgery represents the newest frontier in minimally invasive surgery. Comparative data and prospective trials are necessary in order to determine the clinical impact of LESS in treatment of gynaecological conditions.

Early experience with isobaric laparoendoscopic single-site surgery using a wound retractor for the management of ectopic pregnancy

OBJECTIVE

To report our initial experience with isobaric (gasless) transumbilical laparoendoscopic single-site (LESS) surgery using a wound retractor for the management of ectopic pregnancy.

STUDY DESIGN

Twelve consecutive cases of ectopic pregnancy were managed by isobaric LESS surgery with the subcutaneous abdominal wall-lift method. In each case, a wound retractor was used as a transumbilical working port with insertion into the peritoneal cavity through a 2.5-cm vertical umbilical incision. Subsequent surgical procedures were performed with multiple conventional laparoscopic instruments through single umbilical port.

RESULTS

All cases of ectopic pregnancy were successfully managed by isobaric LESS surgery. Procedures included salpingectomy in eight cases of ampullary pregnancy and two cases of isthmic pregnancy, salpingectomy and local methotrexate injection in one case of isthmic pregnancy, and salpingo-oophorectomy for one case of ovarian pregnancy. Neither extraumbilical incisions nor conversion to laparotomy was required. In a case of ruptured ampullary pregnancy with massive hemoperitoneum, intraoperative autologous blood salvage and donation avoided the need for the transfusion of bank blood. Although postsurgical umbilical seroma was noted in one case and systemic methotrexate administration was required for persistent ectopic pregnancy in one case of isthmic pregnancy respectively, there were no major surgical complications in this series. The technique yielded excellent cosmetic results with minimum postoperative scar concealed within umbilicus. Retrospective comparison of surgical parameters including surgical duration, estimated blood loss, frequency of postoperative analgesic use, time of bowel recanalization, postoperative inflammatory response and postoperative hospital stay did not show any significant differences between isobaric LESS surgery group and conventional isobaric multiport laparoscopic surgery group.

CONCLUSIONS

Based on the satisfactory outcome achieved in these initial 12 cases of ectopic pregnancy treated by isobaric LESS surgery, the wound retraction system combined with the subcutaneous abdominal wall-lift method appears to contribute favorably to LESS surgery for the management of ectopic pregnancy because the device permits free circumferential access and retraction during procedures without the closed condition required during pneumoperitoneum.

Single-incision laparoscopic right colectomy: experience with 17 consecutive cases and comparison with multiport laparoscopic right colectomy

BACKGROUND

Recently, single-incision laparoscopic surgery has begun to develop as an extension of standard laparoscopic minimally invasive procedures. However, there have been a limited number of reports of single-incision procedures in colorectal disease.

PURPOSE

The aim of this study is to describe our initial experience with single-incision laparoscopic right colectomy and to make comparisons with the current standard of care, multiport laparoscopic right colectomy.

METHODS

Data from consecutive patients undergoing single-incision laparoscopic right colectomy were analyzed and compared with case-matched multiport laparoscopic right colectomies. Indications for surgery, type of port used, operative time, number of nodes harvested, length of hospital stay, and complications were the outcomes measured.

RESULTS

During the study period, 17 patients underwent single-incision laparoscopic colectomy. Of the planned single-incision laparoscopic cases, 15 (88%) were completed with a single incision, whereas 2 required an additional port placement. There were no conversions to open surgery during any of the cases. Indications for surgery were similar between the 2 groups. Operative time was not significantly different in single-incision laparoscopic right colectomy compared with multiport laparoscopic right colectomy (139 min vs 134 min, respectively; P = .61). Length of stay and number of nodes harvested also had no significant differences between the 2 groups. There was one death after discharge to home secondary to pulmonary embolism and one delayed thermal injury in the single-incision laparoscopic group.

CONCLUSION

Single-incision laparoscopic right colectomy is feasible, and appears to have results similar to standard multiport right colectomy in our initial comparisons. Ongoing development in instrumentation may help to further shorten operative time and minimize complications, and may make this an equivalent or preferred method for minimally invasive colorectal surgery. Large, prospective, randomized, controlled trials should be conducted to further compare the safety and efficacy of this approach.

Hysterectomy and Bilateral Salpingoovariectomy in a Transsexual Subject without Visible Scaring

Objective. To report on the use of laparoendoscopic single-site surgery (LESS) for the management of total hysterectomy (TH) with bilateral salpingoovariectomy (BSO) in a subject affected by gender identity disorder. Design. Case report. Setting. University Hospital. Patient(s). A 27-year-old affected by Gender Identity Disorder underwent a hysterectomy and BSO as part of surgical sex reassignment. Intervention(s). Laparoendoscopic single-site surgery access for TH and BSO. Main Outcome Measure(s). The procedure was performed without incident. The trocar placement was easy and safe, without inadvertent port removal. No vascular or visceral injuries, loss of pneumoperitoneum, or intraoperative port site bleeding occurred. Result(s). A detailed description of the technique of a single-site surgery for management of hysterectomy and BSO. Conclusion. Our case presents the first report of single-site surgery for surgical treatment of subjects affected by GID.