Laparoendoscopic Single-Site Surgery for Management of Adnexal Masses in Pregnancy: Case Series

TU-LESS procedure for acute abdomen in late pregnancy: a retrospective study

BACKGROUND

Acute abdominal conditions during pregnancy are significant risks to maternal and fetal health, necessitating timely diagnosis and intervention. The choice of surgical approach is a major concern for obstetricians.

OBJECTIVE

To evaluate the safety and efficacy of the TU-LESS procedure for acute abdomen in late pregnancy.

METHODS

We retrospectively analyzed 12 patients who underwent TU-LESS for acute abdominal conditions in the third trimester from 2020 to 2023. We reviewed medical records for clinical characteristics, surgical interventions, postoperative complications, and pregnancy outcomes.

RESULTS

The study included patients with a median age of 27 (range 20-35) and a BMI of 24.33 kg/m2 (range 21.34-31.96). The median gestational age at surgery was 30 weeks (range, 28 + 3-32 + 4 weeks), with surgeries lasting an average of 60 min (range, 30-163 min). Blood loss was 2-20 mL, and the median hospital stay post-surgery was 6 days (range, 2-16 days). There were no significant complications. The median time to delivery after TU-LESS was 56 days (range, 26-66 days), resulting in 8 full-term deliveries, 2 preterm cesareans, and 2 preterm vaginal deliveries. All newborns were healthy, with no fetal losses or neonatal deaths.

CONCLUSION

TU-LESS, performed by experienced obstetricians and gynecologists with proper preoperative preparation, is safe and effective for managing acute abdomen in late pregnancy, without the need to delay surgery due to gestational age.

Successful use of single-port laparoscopic surgery for ovarian cyst removal during pregnancy: a case series of three cases

Pregnant patients have an increased risk of torsion compared to that seen in nonpregnant patients, and those with larger cysts undergo torsion more frequently, which can cause obstructions during labor. The risks associated with emergent surgery are higher than those with elective surgery. Laparoscopic surgery can be safely performed during pregnancy. Single-port laparoscopic surgery is reported to be a minimally invasive laparoscopic technique. We report three cases of ovarian dermoid cysts, which were successfully removed during pregnancy through elective single-port laparoscopic surgery. In all cases, imaging showed a dermoid cyst and the cyst size was greater than 6 cm. All patients requested the surgery. The ovarian cysts were successfully removed by single-port laparoscopy without additional ports and without intra- or postoperative complications. All pregnancies progressed well and delivered vaginally at full term. The single-port laparoscopic approach is useful for removing ovarian cysts during pregnancy.

Single-port laparoscopy versus conventional laparoscopy of benign adnexal masses during pregnancy: a retrospective case-control study

OBJECTIVE

To compare operative outcomes between single-port laparoscopy (SPL) and conventional laparoscopy (CL) to remove adnexal masses during pregnancy.

METHODS

This retrospective case-control study included all patients who had undergone laparoscopic removal of benign adnexal masses during pregnancy between October 2010 and January 2020. Multiple clinical characteristics and operative outcomes were retrospectively analysed and compared between patients who had undergone SPL versus CL, including cosmetic satisfaction with the scar, measured on a 10-point scale (10 indicating very satisfied).

RESULTS

A total of 64 patients were included (SPL, n = 22; and CL, n = 42). Overall scar satisfaction scores significantly favoured SPL versus CL (9.1 ± 1.7 versus 8.1 ± 1.3, respectively), however, surgery duration was significantly longer for SPL than CL (69.2 ± 21.0 min versus 54.7 ± 20.7 min). No incisional hernia was detected in the study. Operative blood loss, decrease in estimated haemoglobin level, length of hospital stay, and hospitalization expenses were comparable between the two groups. Pregnancy and fetal outcomes were not remarkably different.

CONCLUSION

For removal of benign adnexal masses during pregnancy, SPL may offer superior cosmetic satisfaction versus CL, and was not associated with additional perioperative danger, economic burden, or adverse pregnancy and neonatal outcomes.

Laparoendoscopic single-site surgery for adnexal disease during pregnancy: A single-center preliminary experience

Purpose

This study aimed to evaluate the safety and efficacy of laparoendoscopic single-site surgery (LESS) in treating adnexal disease during pregnancy.

Methods

Medical records of included patients were retrospectively reviewed and follow-ups of all the patients were performed until the delivery of the fetus. The clinical characteristics, surgical interventions, postoperative complications, and pregnancy outcomes were analyzed.

Results

Six cases were included, with the gestational age ranging from 19 to 31 weeks 1 day. Procedures included salpingo-oophorectomy (n = 3), ovarian or paratubal cystectomy with detorsion (n = 2), and adnexal detorsion (n = 1). The median duration of surgery was 35 min (range, 20–60 min), and the estimated blood loss ranged from 5 to 50 ml. No major intraoperative or postoperative complications were noted. The final pathologic results included high-grade serous ovarian carcinoma, ovarian borderline serous cystadenoma, ovarian simple cyst, endometrioma, and mesosalpinx cyst. Five patients had a spontaneous vaginal delivery at full-term, and one patient had a cesarean section preterm followed by comprehensive staging surgery of ovarian cancer.

Conclusion

Based on the data we included, LESS performed by experienced surgeons appeared to be a safe and feasible alternative to multiport laparoscopic surgery for the management of selected patients with adnexal disease during pregnancy. More studies with large sample sizes at multiple centers are warranted.

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.

Single-Port Laparoscopic Surgery for Adnexal Mass Removal During Pregnancy: The Initial Experience of a Single Institute

OBJECTIVE

Single-port laparoscopy has become a feasible and safe approach for the management of benign adnexal masses during pregnancy. To our knowledge, there are few reports on the feasibility and safety of single-port laparoscopy for adnexal mass removal during pregnancy. Our study reports the use of single-port laparoscopy in adnexal mass removal during pregnancy in our hospital.

METHODS

We included 10 cases of single-port laparoscopic surgery for adnexal mass removal during pregnancy in the West China Second University Hospital between January 2017 and March 2020. Median values were found using SPSS20. When the p-value was <0.05, the median and interquartile range were used. All patients provided informed consent.

RESULTS

The following median values were recorded: surgical time, 112.50 min; blood loss, 25 ml; postoperative hospital stay, 3 days; postoperative pain [visual analog scale (VAS)] at 6 h, 3; and postoperative pain (VAS) at 24 h, 2. Our study reported no postoperative spontaneous abortions. There was one preterm birth.

CONCLUSION

Single-port laparoscopy appears to be safe for both the mother and the fetus.

Laparoendoscopic single-site compared with conventional laparoscopic surgery for gynaecological acute abdomen in pregnant women

Objective

To estimate the safety and feasibility of laparoendoscopic single-site surgery (LESS) in pregnant patients with acute abdomen.

Methods

Baseline characteristics, surgical results, and obstetric and neonatal outcomes were retrospectively compared between single and multiport procedures in patients who underwent laparoscopic surgery during pregnancy between 2017 and 2021.

Results

Fifty-four pregnant patients were included: 26 who underwent LESS (salpingectomy, 11 cases/cystectomy, 15 cases) and 28 who underwent conventional laparoscopic surgeries (salpingectomy, 12 cases/cystectomy, 16 cases) during pregnancy. One patient in the single-port group required additional ports. No patients converted to laparotomy. In patients undergoing salpingectomy, the single-port group showed lower 8- and 24-h postoperative pain scores, shorter hospital stays, and lower Self-rating Anxiety Scale scores prior to discharge versus conventional laparoscopy. One patient experienced postoperative vaginal bleeding and a missed abortion during follow-up. In patients receiving cystectomy, 8- and 24-h pain scores, postoperative hospital stay, and anxiety scores were lower in the single-port versus multiport group. Other outcomes were comparable between the groups.

Conclusion

The feasibility and efficacy of laparoscopic surgery during pregnancy is similar between single- or multiport routes, however, the single-port route may be associated with less postoperative pain, shorter hospital stay, and lower anxiety.

Laparoscopic Single-site "In-bag" Ovarian Dermoid Cystectomy in a 16-week- pregnant Patient

STUDY OBJECTIVE

To demonstrate a novel "in-bag" ovarian cystectomy technique for a large adnexal mass in pregnancy.

DESIGN

Stepwise demonstration with narrated video.

SETTING

An academic tertiary care hospital. The patient was a 26-year-old woman, gravida 1, para 0, at gestational age of 7 weeks and 3 days who presented to the emergency department with persistent left pelvic pain and was diagnosed with a 16 cm × 10 cm × 12 cm dermoid cyst. She re-presented at gestational age of 16 weeks and 3 days with worsening pelvic pain, and the decision was made to proceed with surgical intervention.

INTERVENTIONS

Laparoscopic transumbilical single-site surgery for the surgical management of adnexal masses in pregnancy has been demonstrated to be feasible and safe [1-3]. However, single-site laparoscopic ovarian cystectomy can be very challenging in pregnancy, especially when the need for suturing arises. Exteriorizing the ovary and cyst after intraperitoneal drainage may allow for extracorporeal suturing that is faster and easier; however, it may increase the probability of spillage of cystic contents if it is not performed in a bag, which can then cause peritonitis in cases of dermoid cysts. A combination of in-bag and extracorporeal ovarian cystectomy is a novel alternative minimally invasive approach that is cosmetic, safe, and effective. Several helpful techniques in this novel combination technique include the following: • Creating an umbilical incision of at least 2 cm or one that is large enough for better manipulation of both the surgical bag and adnexal mass. • Tightening the bag appropriately around the infundibulopelvic ligament so that it is not too tight leading to compromised blood supply and tissue necrosis, yet not too loose resulting in leakage of cystic contents. • Ensuring that the infundibulopelvic ligament is stabilized within the surgical bag. • Inserting small-sized wound retractor into the bag for better exposure during cystectomy. • Having a double-suction irrigation setup for large adnexal masses, as demonstrated in this patient, to reduce the spillage of cystic contents. The procedure was successfully performed in approximately 110 minutes, and the fetal heart rate postprocedure was 128 bpm through bedside transabdominal ultrasound. Estimated blood loss was 5 mL, and the patient was discharged the same day with an uneventful 4-week postoperative follow-up.

CONCLUSION

Laparoscopic single-site "in-bag" ovarian dermoid cystectomy is feasible, effective, and safe in pregnant patients with a large adnexal mass. This technique results in better stabilization of the ovarian cyst and reduction of cystic content spillage.

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.