Laparoendoscopic Single-Site Salpingectomy in Isthmic and Ampullary Ectopic Pregnancy: Preliminary Report and Technique

Pregnancy-preserving Laparoendoscopic Single-site Surgery for Gynecologic Disease: A Case Series

STUDY OBJECTIVE

The study objective was to assess the feasibility of laparoendoscopic single-site surgery (LESS) for the management of nonobstetric, gynecologic disease processes in pregnant patients.

DESIGN

A retrospective case series of 13 pregnant women aged 21 to 42 years who underwent LESS for various gynecologic pathology. If able to be contacted, the patients were followed up until the delivery of the fetus.

SETTING

The surgeries were performed in a single institution between January 2015 and June 2019.

PATIENTS

The patients were selected if a laparoscopic intervention was indicated.

INTERVENTIONS

The cases included 6 ovarian cystectomies and 2 salpingo-oophorectomies for adnexal masses; 1 myomectomy for a degenerated myoma; 1 salpingectomy for a heterotopic pregnancy; 2 cerclage placements for recurrent pregnancy loss and cervical insufficiency; and 1 paratubal cystectomy. The patients underwent LESS through a 2.5-cm umbilical incision. The masses were exteriorized using a laparoscopic specimen retrieval bag, with the exception of 2 large adnexal masses, which were aspirated at the incision site, exteriorized after content drainage, and cystectomies performed extracorporeally. The fascial incision was repaired with a permanent suture.

MEASUREMENTS AND MAIN RESULTS

Various data were collected from patients, including age, surgical and obstetric history, gestational age at surgery, and ultrasonic imaging results. The outcomes measured were operative duration, intraoperative bleeding, postoperative symptoms, fetal monitoring before and after surgery, pathologic findings, conversions, intraoperative complications, and pregnancy outcomes. Eight cases were performed in the first trimester, 4 in the second trimester, and 1 in the third trimester, with the surgeries lasting between 45 minutes and 298 minutes. The blood loss ranged from 5 mL to 300 mL, and postoperative symptoms of mild pelvic or abdominal pain were reported. There were 2 conversions to traditional multiport laparoscopic surgery for the 2 cerclage cases, and there were no open surgery conversions or intraoperative complications. The fetal heart rate ranged between 130 beats per minute and 167 beats per minute postoperatively. Of the 9 patients who were able to be contacted for follow-up, all had successful deliveries. One patient was healthy at 31 weeks and 5 days without complication at the time of her last follow-up.

CONCLUSION

LESS may be performed by experienced surgeons on gravid patients in any trimester for adnexal masses, myomas, heterotopic pregnancy, and cervical incompetence. Future multiple-center studies may provide further evidence that LESS is a feasible and safe option for gynecologic surgery during pregnancy.

Laparoscopy-assisted suprapubic salpingectomy 'Kaya technic' - a low-cost treatment of ectopic pregnancy

We aimed to demonstrate the feasibility and total cost of laparoscopy-assisted suprapubic salpingectomy (LASS), which utilises conventional open surgery equipment without any sealing or coagulation devices and reduces port sites compared to conventional laparoscopy (CL). Fifty-seven consecutive, age-matched patients presenting with a tubal pregnancy were enrolled. In the LASS group, a 10 mm reusable umbilical optical trocar and a 10 mm suprapubic trocar was used. The other 30 patients were managed with multiport CL. All of the patients were asked to use the visual analogue scale and Patient and Observer Scar Assessment Scale to evaluate their cosmetic satisfaction. The duration of surgery was 21.19 ± 2.33 minutes for the LASS group and 36.9 ± 4.9 minutes for the CL group (p < .001). The postoperative 6th-hour VAS score was 2.44 ± 0.5 for the LASS group and 3.03 ± 0.8 for the CL group (p: .005). All of the PSAS and OSAS parameter scores were significantly lower in LASS group than CL group. In conclusion, the LASS procedure is a feasible method for treating ectopic pregnancies with a shorter surgical duration, lower VAS scores, and better cosmetic scores than CL. Impact statement What is already known on this subject? Laparoscopy or laparotomy may be performed for the surgical management of ectopic pregnancy. Conventional laparoscopy has some advantages such as shorter hospital stay and recovery time and the better cosmetic results. However, the equipment used in conventional laparoscopy and single incision laparoscopy are more expensive than conventional open surgery equipment. What the results of this study add? Laparoscopy-assisted suprapubic salpingectomy (LASS) method has shorter operation time, lower VAS scores, better cosmetic scores and cheaper than conventional laparoscopy. What the implications are of these findings for clinical practice and/or further research? The LASS procedure looks like a feasible method for treating ectopic pregnancies and the feasibility of this procedure should be confirmed by a larger series of patients and randomised trials.

Temporal trends in severe morbidity and mortality associated with ectopic pregnancy requiring hospitalisation in Washington State, USA: a population-based study

OBJECTIVE

To examine temporal trend in maternal mortality/severe morbidity associated with hospitalisation due to ectopic pregnancy.

DESIGN

A population-based observational study.

SETTING AND PARTICIPANTS

All women hospitalised for ectopic pregnancy in Washington State, USA, 1987-2014 (n=20 418). The main composite outcome of severe morbidity/mortality included death, sepsis, need for transfusion, hysterectomy and systemic or organ failure, identified by diagnostic and procedure codes from hospitalisation files. Severe morbidity/mortality due to ectopic pregnancy were expressed as incidence ratios among women of reproductive age (15-64 years) and among women hospitalised for ectopic pregnancy. Comparisons were made between 1987-1991 (reference) and 2010-2014 using ratios of incidence ratios (RR) and ratio differences (RD). The Cochran-Armitage test for trend assessed statistical significance; logistic regression was used to obtain adjusted OR (AOR) and 95% CI, adjusted for demographic factors and comorbidity.

RESULTS

Hospitalisation for ectopic pregnancy declined from 0.89 to 0.16 per 1000 reproductive age women between 1987-1991 and 2010-2014 (p<0.001). Among reproductive age women, ectopic pregnancy mortality remained stable (0.03 per 100 000); and mortality/severe morbidity increased among women aged 25-34 years (p=0.022). Among women hospitalised for ectopic pregnancy, mortality increased from 0.29 to 1.65 per 1000 between 1987-1991 and 2010-2015 (p=0.06); severe morbidity/mortality increased from 3.85% to 19.63% (RR=5.10, 95% CI 4.36 to 5.98; RD=15.78 per 100 women, 95% CI 13.90 to 17.66; AOR for 1-year change was 1.08, 95% CI 1.07 to 1.08).

CONCLUSIONS

Hospitalisation for ectopic pregnancy declined in Washington State, USA, between 1987 and 2014; however, mortality/severe morbidity associated with ectopic pregnancy increased in female population aged 25-34 years.

Laparoendoscopic Single-Site Surgery for Management of Heterotopic Pregnancy: A Case Report and Review of Literature

BACKGROUND

Heterotopic pregnancy occurs when two pregnancies occur simultaneously in the uterus and an ectopic location. Treatment includes removal of the ectopic pregnancy with preservation of the intrauterine pregnancy. Treatment is done laparoscopically with either a Laparoendoscopic Single-Site Surgery (LESS) or a multiport laparoscopic surgery.

CASE

We present a case of a first trimester heterotopic pregnancy in a 42-year-old gravida 5, para 0-1-3-1 female with previous history of left salpingectomy, who underwent laparoscopic right salpingectomy and lysis of adhesions (LOA) via Single-Incision Laparoscopic Surgery (SILS).

CONCLUSION

Although LESS for benign OB/GYN cases is feasible, safe, and equally effective compared to the conventional laparoscopic techniques, studies have suggested no clinically relevant advantages in the frequency of perioperative complications between LESS and conventional methods. No data on the cost effectiveness of LESS versus conventional methods are available. LESS utilizes only one surgical incision which may lead to decreased pain and better cosmetic outcome when compared to multiport procedure. One significant undesirable aspect of LESS is the crowding of the surgical area as only one incision is made. Therefore, all instruments go through one port, which can lead to obstruction of the surgeon's vision and in some cases higher rate of procedure failure resulting in conversion to multiport procedure.

Laparoendoscopic single-site adnexal surgery: Preliminary Indian experience

INTRODUCTION:

Laparoendoscopic single-site surgery (LESS) is an emerging technique in gynaecology. The proposed advantages of the LESS include better cosmesis and reduction in pain. We report our preliminary experience with LESS in the treatment of adnexal pathology.

MATERIALS AND METHODS:

After a preoperative workup, LESS was offered to 37 patients between July 2009 and April 2015. All the procedures were carried out through a 2–2.5 cm transumbilical incision using conventional laparoscopic instruments. A single-incision, multiport (SIMP) approach (utilising one 7 mm and two 5 mm ports) was used in 27 patients and a homemade glove port (HMGP) was utilised in ten patients. All the specimens were extracted after placement in a plastic bag or inside the glove port avoiding contact with the wound. Umbilical fascial incisions were meticulously closed with non-absorbable sutures.

RESULTS:

Two patients with a history of previous abdominal surgery required omental adhesiolysis. Seventeen patients with breast cancer underwent bilateral salpingo-oophorectomy, ten had ovarian cystectomy (6 had cystadenoma, 2 had endometriotic cysts and 2 had dermoid cyst), six had excision of paraovarian cysts (one along with partial salpingectomy) and four with ruptured ectopic pregnancy underwent salpingectomy. LESS was completed in all but one patient, who required insertion of an additional 5 mm port. There were no intra- or post-operative complications.

CONCLUSIONS:

Our experience confirms the feasibility and safety of LESS in a variety of benign adnexal pathology. Both the SIMP and HMGP approaches seem comparable. Performing LESS without the use of specialised access ports or instruments makes it cost effective and suitable for wider application.

The effectiveness of laparoendoscopic single-site surgery (LESS) compared with conventional laparoscopic surgery for ectopic pregnancy with hemoperitoneum

OBJECTIVE

The purpose of this study was to compare clinical outcomes of conventional laparoscopic surgery and laparoendoscopic single-site surgery (LESS) in the surgical treatment of tubal ectopic pregnancy.

MATERIAL AND METHODS

A total of 156 patients were diagnosed with ectopic pregnancies by ultrasonography and serum β-human chorionic gonadotrophin (β-hCG) levels at Pusan National University Yangsan Hospital from January 2009 through December 2013. We excluded 28 patients who only received medical treatment, 15 patients who underwent surgery by laparotomy for severe hypovolemic shock, and 30 patients who presented with less than 1 L of hemoperitoneum. Of the 83 patients with massive hemoperitoneum, 38 patients had LESS performed while the remaining 45 patients underwent conventional laparoscopic surgery.

RESULTS

In this study, there were no statistically significant differences in clinical outcomes in either surgical method except for operative time. Operative time of LESS was significantly shorter than conventional surgery for patients with more than 500 mL of hemoperitoneum.

CONCLUSION

LESS is a safe and feasible surgical approach in the treatment of tubal ectopic pregnancy. At the same time, LESS has been shown to be more effective than conventional laparoscopic surgery in handling massive hemoperitoneum of more than 1 L, which is a common complication of ectopic pregnancy.

Single-port laparoscopic surgery for benign salpingo-ovarian pathology: a single-center experience from Saudi Arabia

BACKGROUND

There are limited data and few solid conclusions on the use of single-port laparoscopic surgery (SPLS) in gynecologic procedures.

OBJECTIVE

The objective of our descriptive study was to review our single-center experience with benign salpingo-ovarian conditions (feasibility, safety and surgical outcomes).

DESIGN

A retrospective cross-sectional study from January-2012 to October-2014.

SETTING

King Faisal Specialist Hospital & Research Center--a referral tertiary healthcare center.

PATIENTS AND METHODS

All gynecologic patients who underwent SPLS procedures for benign adnexal pathologies were analyzed for pre-, intra-and postoperative details. SPLS was done using a single multi-port trocar and standard laparoscopic instruments.

MAIN OUTCOME MEASURES

Perioperative complications and conversion rate.

RESULTS

Eighty (n=80) patients underwent SPLS interventions. the median age and BMi were 37 years and 24.6 kg/m2, respectively. Thirty-one patients (38.8%) had >=1 previous abdominopelvic surgeries. Of 104 SPLS procedures conducted, the three most common procedures were unilateral ovarian cystectomy (n=21/104; 20.2%), bilateral ovarian transposition (n=20/104; 19.2%), and unilateral salpingo-oophorectomy (n=16/104; 15.4%). No patient required addition of extra ports or conversion to conventional multi-port laparoscopy or laparotomy. The median operative time, estimated blood loss and hospital stay were 66 min, 10 mL and 1 day, respectively. No patient experienced major intraoperative or postoperative complications. the median postoperative pain grade using the visual analogue scale was 2 (examined in 74 of 80 patients). At six-weeks postoperatively, the median wound scar length (measured at outpatient clinic) was 1.2 cm.

CONCLUSION

SPLS in the management of benign salpingo-ovarian conditions is generally feasible, potentially safe, and associated with satisfactory operative and postoperative outcomes.

LIMITATIONS

Retrospective and non-comparative design. Single-center experience. Subjective scores of the patients' self-reported satisfaction about post-operative pain, subject to recall bias.

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.

Cosmesis and body image after single-port access surgery for gynaecologic disease

BACKGROUND

Little is known about patient satisfaction with single-port access (SPA) surgery for gynaecologic disease related to body image and cosmesis.

AIMS

This study aimed to determine cosmetic satisfaction with SPA surgery.

METHODS

Postal questionnaires, including the Body Image Questionnaire, were sent to 159 women who had undergone SPA surgery between May 2008 and April 2010.

RESULTS

Hundred and forty-six women participated in this study. Most of the women reported a relatively high body image and cosmetic score. The mean scores were 19.6 ± 1.1 and 21.9 ± 2.5, respectively. More than 67% of the women (N = 98) reported that the scar was invisible, and 97.3% of the women said that they would recommend SPA surgery to others.

CONCLUSION

Single-port access surgery is a good option for the management of gynaecologic disease with respect to patient satisfaction.

Laparo endoscopic single site balloon vaginoplasty (LESS-BV)

OBJECTIVE

To evaluate feasibility, advantages, and disadvantages of the laparo-endoscopic single site surgery (LESS) technique for balloon vaginoplasty (BV).

STUDY DESIGN

Cohort study.

SETTING

Tertiary care facility.

RESULTS

LESS-BV was successfully performed in 6 patients with Mullerian aplasia and one with androgen insensitivity syndrome (AIS). Patients presented with failure of intravaginal intercourse and/or dyspareunia. The procedure was performed successfully in conjunction with gonadectomy for the AIS case. The total operative time was 50-75 minutes. No operative complications were reported. Postoperative pain scores ranged from 0 to 2 points at rest and from 20 to 60 points during dressing change, increasing distension, and traction. The depths of the constructed neovaginas measured up to 12.8 cm. Sexual intercourse was initiated on the day of catheter removal. Penetrations and satisfactions scores increased to up 90 points for both partners.

CONCLUSIONS

LESS-BV is technically feasible. LESS-BV allows better, stronger midline and long traction pass along the anatomic longitudinal axis of the hypoplastic vagina. Surgical outcomes should be compared prospectively to conventional laparoscopic BV.

Cosmetic outcomes of laparoendoscopic single-site hysterectomy compared with multi-port surgery: randomized controlled trial

STUDY OBJECTIVE

To compare cosmetic satisfaction with laparoendoscopic single-site surgery (LESS) compared with multi-port surgery.

DESIGN

Randomized controlled trial (Canadian Task Force classification I).

SETTING

University hospital.

PATIENTS

Twenty women who underwent laparoscopically-assisted vaginal hysterectomy (LAVH) via LESS or multi-port surgery.

INTERVENTIONS

Laparoendoscopic single-site surgery or multi-port surgery.

MEASUREMENT AND MAIN RESULTS

Cosmetic satisfaction was assessed using the Body Image Questionnaire at baseline and at 1, 4, and 24 weeks after surgery. Of the 20 LESS procedures, 1 was converted to multi-port surgery because of severe adhesions, and 1 woman assigned to undergo multi-port surgery was lost to follow-up. The 2 surgery groups did not differ in clinical demographic data and surgical results or postoperative pain scores at 12, 24, and 36 hours. Compared with the multi-port group, the LESS group reported significantly higher cosmetic satisfaction at 1, 4, and 24 weeks after surgery (p < .01).

CONCLUSION

Compared with multi-port surgery, LESS is not only a feasible approach with comparable operative outcomes but also has an advantage insofar as cosmetic outcome.

[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.