La laparoscopie par incision unique en gynécologie : état des lieux en 2013

Minilaparoscopic Total Hysterectomy in Current Practice Feasibility and Benefits: A Unicentric, Randomized Controlled Trial

STUDY OBJECTIVE

To investigate whether mini-instrumentation may be used for hysterectomy (HT) by all surgeons (assistants and seniors) without increasing the operative time or altering surgeon working conditions.

DESIGN

A unicenter, randomized controlled, single blind, parallel, noninferiority trial comparing 2 surgical techniques.

SETTING

A tertiary referral center.

PATIENTS

Thirty-two patients undergoing HT for a benign gynecologic disease were enrolled in this study in our center between April 2, 2015, and June 1, 2018. Sixteen patients were randomized in group A and 16 patients in group B.

INTERVENTIONS

HT with bilateral annexectomy or ovarian conservation using 3-mm instruments (group A) or conventional 5-mm instruments (group B).

MEASUREMENTS AND MAIN RESULTS

Concerning the primary outcome, the operative time for the HT 3-mm group was 128 minutes (range, 122-150 minutes) versus 111 minutes (range, 92-143 minutes) for the HT 5-mm group (i.e., δ = 17 [90% confidence interval, -6 to 39]), with rejection of the noninferiority threshold at 35 minutes. Thirty-one percent of HTs initially performed using 3-mm instruments were completed with conventional instruments. HTs performed with mini-instruments required more concentration (p = .02) with surgeons reporting higher levels of frustration (p = .009) and sense of failure (p = .006). Patients tend to experience greater satisfaction regarding scars with a significant difference noted during the postoperative visit both for scar pain (1 vs 4 patients with moderate pain [30-50 mm on the Patient Scar Assessment Scale) in the HT 3-mm group and the HT 5-mm group, respectively) and scar firmness (p = .021; 3 vs 7 patients with moderate firmness [30-50 mm on the Patient Scar Assessment Scale] in the HT 3-mm group and the HT 5-mm group, respectively).

CONCLUSION

Total minilaparoscopic HT appears inferior to standard laparoscopy in terms of operative time and surgeon working conditions; only the short-term cosmetic appearance was in favor of the 3-mm approach.

Single port laparoscopy (SPL): Retrospective study evaluating postoperative pain in comparison with conventional laparoscopy (CL)

OBJECTIVE

To compare postoperative pain after single port laparoscopy (SPL) approach with conventional laparoscopy (CL) in case of adnexectomy.

MATERIAL AND METHODS

This is a retrospective monocentric study involving patients who underwent adnexal surgery by SPL or CL for a suspected benign disease or as a preventive measure. The main outcome measure was the level of postoperative pain.

RESULTS

A total of 87 patients were enrolled. Within 2h, the numerical scale (NS) was 1.9 in SPL group and 2.0 in the CL group (P=0.85). The next day, the NS was 1.8 in SPL group and 1.5 in CL group (P=0.55). The operating time was significantly shorter in SPL group (33 versus 56min, 95% CI [-31; -15], P<0.001) and no rupture of ovarian cysts occurred in this group. There was no significant difference concerning complications, length of hospital stay, general satisfaction and POSAS (Patient and Observer Scar Assessment Scale) score.

CONCLUSION

This study confirms the feasibility of single-port laparoscopic adnexectomy. We have not shown significant difference in postoperative pain but the operating time was significantly reduced under the guise of an experienced surgeon.

[Influencing factors on surgical duration of ovarian cystectomy by single-port access]

OBJECTIVES

To evaluate the factors influencing the operative duration of ovarian cystectomy by single-port access (SPA).

MATERIALS AND METHODS

Observational monocentric study from June 2010 to September 2012. Inclusive patients were patients with an indication of ovarian cystectomy may be done by laparoscopy. The procedures were performed by the SPA system LESS®. Factors evaluated were BMI of the patient, histological nature and size of the cyst.

RESULTS

We performed 54 cystectomy in 49 patients. SPA surgery was successfully completed in 53 patients. The median operative time was statistically longer for endometriotic cysts than dermoid cysts or serous-mucinous cysts (P=0.003). Cases exceeding 60minutes were significantly higher in the endometriosis group (P=0.005). There wasn't correlation found between the BMI of the patient and operative time (P=0.5). The operating time wasn't increased according to the size of the cyst (P=0.9).

CONCLUSION

Endometriotic cysts nature appears to be the only limiting factor of cystectomy by SPA. Further studies are needed to evaluate the factors that may limit the SPA actions.