Single-Port Laparoscopy vs Conventional Laparoscopy in Benign Adnexal Diseases: A Systematic Review and Meta-Analysis

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.

Comparing the efficacy and safety of three surgical approaches for total hysterectomy (TSATH): protocol for a multicentre, single-blind, parallel-group, randomised controlled trial

INTRODUCTION

Hysterectomy is the most common surgical procedure in the field of gynaecology. The traditional multiport laparoscopy, transumbilical laparoendoscopic single-site surgery (TU-LESS) and transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy approaches have been implemented to varying degrees in clinical practice. At present, although their feasibility has been proven, there are no large randomised controlled studies on postoperative rehabilitation. This study aims to evaluate postoperative recovery and assess the safety and effectiveness of these three surgical approaches for total laparoscopic hysterectomy.

METHOD AND ANALYSIS

This is a multicentre, randomised, single-blind, three-arm, parallel-group, interventional clinical trial. Recruitment will be carried out in five tertiary hospitals in China. Patients diagnosed with benign uterine disease or precancerous lesions will be assigned to the vNOTES group, TU-LESS group and conventional laparoscopy group at a 1:1:1 ratio. The achievement rate of comprehensive indices of enhanced recovery after surgery (ERAS) within 24 hours postoperatively will be considered the primary outcome (the comprehensive indicators of ERAS include fluid intake, passing flatus, urination after catheter removal, ambulation and a Visual Analogue Scale score ≤3.) This study will use a non-inferiority test, with a power (1-ß) of 80% and a margin of -0.15, at a one-sided α of 0.0125. The sample size will be 480 patients (including an assumed 15% dropout rate), calculated according to the primary outcome.

ETHICS AND DISSEMINATION

This study was approved on 25 April 2022 by the Medical Ethics Committee of West China Second University Hospital (2022(057)), Sichuan University, Chengdu, China. All participants will be required to provide informed consent before their participation in the study. The results of the trial will be submitted for publication in a peer-reviewed journal and presented at international conferences.

PROTOCOL VERSION

V.3.0, 31 August 2023.

TRIAL REGISTRATION NUMBER

ChiCTR2200057405.

Single-port robotic surgery using the EDGE SP1000 surgical system in gynaecology: Initial experience of a single institution

BACKGROUND

The EDGE SP1000 is a newly developed single-port (SP) robotic surgical system whose clinical evaluation in gynaecology has not yet been addressed.

METHODS

This is a single-arm clinical trial evaluating the perioperative outcomes of patients receiving EDGE SP1000 assisted surgeries. Patients with either benign or malignant gynaecological diseases suitable for robotic surgery were included, and their data were prospectively collected.

RESULTS

Eighteen patients were included and 8 of them had malignant conditions. The total operative time was 190.1 ± 83.3 min for benign diseases and 254.4 ± 59.4 min for malignant diseases. The mean estimated blood loss was 25 mL (range, 5-100). No assistant ports or conversions were required. No perioperative complications occurred. Overall satisfaction with the umbilical wounds was expressed at the 1-month follow-up.

CONCLUSION

EDGE SP1000 SP robotic surgical system is technically feasible and safe in various gynaecological surgeries with good cosmetic effects.

Application of single-port procedure and ERAS management in the laparoscopic myomectomy

OBJECTIVE

Advances in surgical techniques and perioperative management are the two major contributing factors to improved surgical outcomes. The purpose of the current study was to compare the efficacy of single-port surgery and perioperative enhanced recovery after surgery (ERAS) management in laparoscopic myomectomy.

METHODS

The present study included 120 patients undergoing laparoscopic myomectomy in the Gynecological Ward of Quzhou Affiliated Hospital of Wenzhou Medical University. According to the traditional perioperative management mode and ERAS management, multi-port and single-port procedures, all patients were assigned to the Conventional-SPLS (Single-Port Laparoscopic Surgery with conventional perioperative care) group (n = 34), Conventional-Multi (multi-port laparoscopic surgery with conventional perioperative care) group (n = 47), and ERAS (multi-port laparoscopic surgery with ERAS perioperative care) group (n = 39). The surgical outcomes of the three groups were compared operation time, intraoperative blood loss, variations in postoperative hemoglobin, postoperative walking time, postoperative flatus expelling time, postoperative hospital stay, and visual analog scale (VAS) scores at 6 and 12 h following surgery.

RESULTS

The ERAS group recovered the quickest in terms of postoperative walking time and flatus expelling duration. The ERAS group also recovered the shortest postoperative hospital stay (3.85 ± 1.14 days), which differed significantly from that in the Conventional-Multi group, but not significantly from that in the Conventional-SPLS group. In terms of VAS scores at 6 and 12 h after surgery, the ERAS group had the lowest pain intensity, which differed significantly from that of the other two groups. The effect of surgical procedures or postoperative care on hospital stay was assessed using multiple regression analysis. The results demonstrated that ERAS was an important independent contributor to reducing postoperative hospital stay (β = 0.270, p = 0.002), while single-port surgery did not affect this index (β = 0.107, p = 0.278).

CONCLUSION

In laparoscopic myomectomy, perioperative ERAS management could control postoperative pain and shorten hospital stay. Single-port surgery could speed up the recovery of gastrointestinal function and postoperative walking time, but it did not affect postoperative pain management or the length of hospital stay. Thus, the most effective approach to improving postoperative outcomes in laparoscopic myomectomy was the application of perioperative ERAS management.

Does Robot Assisted Laparoscopy (RAL) Have an Advantage in Preservation of Ovarian Reserve in Endometriosis Surgery? Comparison of Single-Port Access (SPA) RAL and SPA Laparoscopy

The purpose of this study was to compare single-port access (SPA) laparoscopy and SPA robot assisted laparoscopy (RAL) for endometriosis with respect to ovarian reserve preservation and surgical outcomes. Clinical factors affecting any reduction in ovarian function after surgery were also evaluated. Patients with endometriosis who underwent SPA laparoscopy (n = 87) or RAL (n = 78) were retrospectively reviewed. Patients' baseline characteristics, including the severity of endometriosis and surgical outcomes including surgical complexity, were collected. To assess the preservation of ovarian reserve after surgery, serum anti-Müllerian hormone (AMH) levels before surgery, at two weeks, and at three months after surgery were collected. Age, ovarian cyst size, location of cyst, complexity of surgery, and the severity of endometriosis were associated with the reduction in AMH levels after surgery. The severity of endometriosis was higher in the RAL group than in the SPA group. There were no significant differences in other clinical baseline characteristics, including preoperative AMH levels. For surgical outcomes, radical surgery was more frequently performed in the RAL group. In univariate and multivariate linear regression analyses, age, ovarian cyst size, location of cyst, complexity of surgery, and the severity of endometriosis were associated with the reduction in AMH levels after surgery. Incorporating surgical approaches and risk factors for postoperative ovarian function decrease, RAL was more beneficial than SPA laparoscopy for the preservation of ovarian reserve in patients with mild endometriosis (stage I/II) (postoperative 3 month AMH reduction rate (%), SPA laparoscopy vs. RAL, 33.51 ± 19.98 vs. 23.58 ± 14.98, p = 0.04) and in patients who underwent non-complex surgery (postoperative 3 month AMH reduction rate (%), SPA laparoscopy vs. RAL, 37.89 ± 22.37 vs. 22.37 ± 17.49, p = 0.022). SPA RAL may have advantages over SPA laparoscopy in ovarian function preservation, especially in patients with mild endometriosis and patients who have undergone a non-complex surgery.

Laparoendoscopic Single-Site Technique Contrasted with Conventional Laparoscopy in Cystectomy for Benign Ovarian Cysts

Objective

To compare the laparoendoscopic single-site (LESS) technique with conventional laparoscopy in cystectomy for benign ovarian cysts.

Materials and methods

A retrospective analysis was performed at Yixing People's Hospital from April 2020 until December 2021.

Results

Thirty-seven patients using the LESS technique were compared with a control group of 45 patients who underwent a traditional laparoscopic ovarian cystectomy. There was no statistically significant difference in the perioperative hemoglobin level changes, cyst rupture rate, postoperative recovery of exhausting time, or pain score at 24 hours after surgery between the 2 groups (P > 0.05). The mean operating time was significantly longer in the LESS group than that of the control group (88.38 ± 30.57 minutes vs 59.44 ± 24.22 minutes; P = 0.001). However, the length of postoperative hospital stay was significantly shorter in the LESS group (3.70 ± 0.57 days vs 4.38 ± 0.86 days; P = 0.001). In addition, total hospitalization expenses were higher in the LESS group (14,709.78 ± 1618.63 yuan vs 12,676.73 ± 1411.78 yuan; P = .001) and the satisfaction score was also significantly higher in the LESS group (z = -2.272; P = 0.023). After a follow-up time of 12 to 24 months, no patient in either group showed wound infection, umbilical hernia, or recurrent cysts.

Conclusions

The LESS technique for benign ovarian cystectomy is safe, feasible, and equally effective compared with the multiport laparoscopic oophorocystectomy. Although it currently costs more, patients with benign ovarian cysts are highly satisfied with the LESS technique.

Efficacy of a continuous wound infiltration system for postoperative pain management in gynecologic patients who underwent single-port access laparoscopy for adnexal disease

Introduction

Single-port access (SPA) laparoscopy requires only one incision, unlike conventional laparoscopy. However, its umbilical incision is larger than that of conventional laparoscopy and can be vulnerable to postoperative pain. This study aimed to evaluate whether simultaneous use of a continuous wound infiltration (CWI) system and intravenous patient-controlled analgesia (IV PCA) effectively decreases surgical site pain in patients who underwent SPA laparoscopy due to gynecologic adnexal disease.

Methods

A total of 371 patients who underwent SPA laparoscopy and who received IV PCA or CWI was retrospectively reviewed (combined group [CWI + IV PCA, n = 159] vs. PCA group [IV PCA only, n = 212]). To evaluate postoperative pain management, the numeric rating scale (NRS) pain score after surgery, total amount of fentanyl administered via IV PCA, and additional pain killer consumption were collected.

Results

The NRS scores at 12 h (1.90 ± 1.11 vs. 2.70 ± 1.08, p < 0.001) and 24 h (1.82 ± 0.82 vs. 2.11 ± 1.44, p = 0.026) after surgery were significantly lower in the combined group than in the PCA group. The total amount of PCA fentanyl was significantly smaller in the combined group than in the PCA group (p < 0.001). The total quantity of rescue analgesics was smaller in the combined group than in the PCA group (p < 0.05).

Conclusion

Combined use of the CWI system and IV PCA is an effective postoperative pain management strategy in patient who underwent SPA laparoscopy for adnexal disease.

Single-port laparoscopic surgery for parasitic cystic teratoma of the greater omentum and bilateral ovarian teratomas: a case report

Teratomas of extragonadal origin are extremely rare. The most common extragonadal site is the greater omentum. A 36-year-old woman was referred to our department for treatment of bilateral ovarian tumors. A 3- to 4-cm mass was observed in each ovary; bilateral ovarian mature cystic teratoma was diagnosed through imaging studies. The patient underwent single-port laparoscopic surgery, during which we found not only bilateral ovarian mature cystic teratomas but also an omental tumor macroscopically similar to the ovarian teratomas. The ovarian and omental teratomas were successfully removed through single-port laparoscopic surgery. The histopathological diagnosis of the omental tumor was parasitic mature cystic teratoma.

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.

Early return to work: Single-port vs. multiport laparoscopic surgery for benign ovarian tumor

Objective

To compare the return to work (RTW) time between single-port laparoscopic surgery (SPLS) and multiport laparoscopic surgery (MPLS) for benign ovarian tumors.

Methods

A cross-sectional cohort study was conducted, which consisted of 335 women of reproductive age with benign ovarian tumors and who were keen on returning to work as early as possible. Surgical outcomes, postoperative pain score, postoperative satisfaction with the cosmesis score (CS), and the RTW time of the SPLS group were compared with those of the MPLS group. Besides, the RTW time and CS were calculated from the questionnaire survey by a single specialized gynecologist.

Results

Women who met the inclusion criteria were included in the SPLS (n = 106) and MPLS groups (n = 229). The RTW time in the SPLS group (22.13 ± 27. 06 days) was significantly shorter than that in the MPLS group (46.08 ± 57.86 days) (P &lt; 0.001). The multivariate Cox analysis results showed that age (HR = 0.984, 95% CI, 0.971−0.997, P = 0.020), SPLS (HR = 3.491, 95% CI, 2.422−5. 032, P &lt; 0.001), and return to normal activity time (HR = 0.980, 95% CI, 0.961−0.998, P = 0.029) were independent factors of the RTW time.

Conclusions

SPLS may be advantageous in terms of shortening the RTW time for women with benign ovarian tumors.

First in-human trial and prospective case series of an articulated laparoscopic camera system in minimally invasive surgery in gynecology: an IDEAL stage 1 and 2a study

Objectives

Precision Robotics’ Sirius Robotic Flexible Endoscopic System is a new, fully integrated, compact three-dimensional laparoscopic camera system with a disposable single-use flexible tip that can change its viewing direction. This IDEAL Stage 1 and 2a study assessed its safety, reliability and potential efficacy particularly for single incision laparoscopic surgery and vaginal natural orifice transluminal endoscopic surgery.

Design

Prospective single-institution, single-surgeon study.

Setting

The study was conducted in a multispecialty hospital.

Participants

Women aged 18–70 years scheduled for gynecological laparoscopic surgery were invited to participate. An information sheet and consent was available for the women and an informed consent was obtained. Thirteen participants completed this study.

Interventions

The laparoscopic procedures were done in the usual manner. The only difference was the Sirius System was used in place of the conventional laparoscope. All other procedures and instruments remained the same.

Main outcome measures

Primary outcome was the proportion of women who successfully completed the intended procedure using the Sirius System without conversion to another camera system, camera users and surgeon’s view and experience, and iterations and modifications to the system. Secondary outcomes were the incidence of intraoperative and postoperative complications during the first 6 weeks following surgery, and duration of surgery.

Results

85% (11/13) of women had their procedure completed successfully using the Sirius System. Two women required immediate conversion to the conventional laparoscope due to technical issues. There were no intraoperative complications. Users agreed that the improved field of view was beneficial for laparoscopic surgery. Iterative improvements were made in the imaging quality, user interface and manufacturing quality.

Conclusions

Sirius System has early indications for safety and efficacy for intermediate and major minimally invasive laparoscopic procedures in gynecology. Further studies are needed to confirm it can replace a conventional laparoscope in the surgical workflow.

Trial registration number

NCT05048407.

Recent advances in benign gynecological laparoscopic surgery

Minimally invasive surgery continues to transform the field of gynecological surgery and is now the standard of care for the surgical treatment of many diseases in gynecology. Owing to minimally invasive surgery's clear advantages, new advances in technology are being employed rapidly and enabling even the most complicated procedures to be performed less invasively. We examine recent literature on minimally invasive surgical innovations, advances, and common practices in benign gynecology that, from our point of view, made an impact on the way laparoscopic surgery is performed and managed in the last decade.

An analysis of the surgical outcomes of laparoendoscopic single-site myomectomy and multi-port laparoscopic myomectomy

Background

This study sought to compare the surgical results of patients undergoing a laparoendoscopic single-site myomectomy (LESS-M) and a conventional laparoscopic myomectomy (CLM) at our hospital.

Methods

The basic data of 233 patients undergoing LESS-M and 233 patients undergoing CLM at the Obstetrics and Gynecology Hospital Affiliated to Fudan University were collected from January 2018 to January 2020, and the results of the operations were compared by evaluating a number of factors, including operation time, intraoperative bleeding, postoperative fever, and postoperative maximum body temperature.

Results

The operation times of the LESS-M and CLM groups were 83.9±33.4 and 75.2±26.7 min, respectively; the difference between the groups was statistically significant. The surgical blood loss of the LESS-M group was 86.1±76.9 mL, and that of the CLM group was 83.8±79.9 mL (P>0.05). When the diameter of a fibroid was ≥8 cm, a fibroid was located in the posterior wall or the number of fibroids was ≥4, the operation time of the CLM group was shorter than that of the LESS-M group. When the diameter of a fibroid was ≥8 cm, the blood loss of the CLM group was less than that of the LESS-M group.

Conclusions

LESS-M is safe and feasible. If the diameter of a fibroid is ≥8 cm, the fibroid is located in the posterior wall, or the number of fibroids is ≥4, the utility of single-port surgery should be carefully considered.

Single incision laparoscopic surgery using conventional laparoscopic instruments versus two-port laparoscopic surgery for adnexal lesions

Single incision laparoscopic surgery (SILS) has emerged as least invasive interventions for gynecologic disease. However, SILS is slow to gain in popularity due to difficulties in triangulation and instrument crowding. Besides, the costly instruments may influence patients' will to have this procedure, and limit other medical expense as well. To optimize outcome and reduce cost, the objective of this study is to evaluate the feasibility and safety for patients undergoing adnexal surgeries using conventional laparoscopic instruments with SILS (SILS-C), and to compare with those of patients subject to TP using conventional laparoscopic instruments (TP-C). This is a retrospective case-control study. The data dated from April 2011 to April 2018. Patients who received concomitant multiple surgeries, were diagnosed with suspected advanced stage ovarian malignancy, or required frozen sections for intraoperative pathologic diagnosis were excluded. Demographic data, including the age, body weight, height, previous abdominal surgery were obtained. The surgical outcomes were compared using conventional statistical methods. 259 patients received SILS-C. The operating time was 63.83 ± 25.31 min. Blood loss was 2.38 ± 6.09 c.c. 58 patients (24.38%) needed addition of port to complete surgery. 384 patients received TP-C. Compared with SILS-C, the operating time was shorter (57.32 ± 26.38 min, OR = 0.984, CI = 0.975-0.992). The patients were further divided into unilateral or bilateral adnexectomy, and unilateral or bilateral cystectomy. Other than the operating time in unilateral cystectomy (66.12 ± 19.5 vs. 58.27 ± 23.92 min, p = .002), no statistical differences were observed in the subgroup analysis. Single incision laparoscopic surgery using conventional laparoscopic instruments is feasible and safe as initial approach to adnexal lesions. In complex setting as unilateral cystectomy or pelvic adhesions, two-port access may be considered.

Comparison of single-port laparoscopy and laparotomy in early ovarian cancer surgical staging

OBJECTIVE

s The aims of this study were to assess the feasibility of single-port laparoscopic surgical staging (SPLS) in early ovarian cancer and to compare the surgical outcomes of SPLS with those of staging laparotomy.

METHODS

Between January 2014 and December 2018, 40 patients underwent SPLS and 41 patients underwent staging laparotomy at Yonsei Cancer Center. The patients were diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage I ovarian cancer. Variables such as patient age, body mass index (BMI), tumor size, FIGO stage, and perioperative surgical outcomes and survival outcomes of SPLS and laparotomy were compared.

RESULTS

The total operation time was similar between the 2 groups (SPLS: 201.4 vs. laparotomy: 203.0 minutes, P=0.806). The median tumor diameters in the SPLS and laparotomy groups were 11.0 (2.5-28 cm) and 15.4 (6-40 cm), respectively (P=0.001). The SPLS group had lower tumor spillage rate (5.0% vs. 19.5%, P=0.047), less intraoperative blood loss (102.0 vs. 371.5 mL, P<0.001), less postoperative pain, and shorter postoperative hospital stay (5 vs. 9.5 days, P<0.001). The intraoperative major complication rate was similar between groups (2.5% vs. 4.9%, P=0.571). There was no significant difference in progression-free survival between the 2 groups (P=0.945). There were no deaths in either group.

CONCLUSION

SPLS is feasible in early ovarian cancer and has better perioperative surgical outcomes, in some aspects, than staging laparotomy without compromising survival outcomes. SPLS could be performed in patients suspected to have early ovarian cancer.

Laparoscopic transvesical vesicovaginal fistula repair with the least invasive way: Only three trocars and a limited posterior cystotomy

Objective

Two conventional approaches for vesicovaginal fistula (VVF) repair are transabdominal repair for supratrigonal VVF and transvaginal approach for low lying fistulae. Laparoscopic surgery was introduced to duplicate the surgical steps of the transabdominal approach with reduction in morbidity. We report a series of patients treated with a modified laparoscopic technique which includes the use of only three trocars and a limited posterior cystotomy.

Methods

We retrospectively reviewed the data of eight patients who underwent laparoscopic VVF repair with our standardized technique from January 2015 to April 2018. Only cases with a supratrigonal fistula were included. We constantly used only three trocars. A limited 2 cm midline posterior cystotomy was performed using ultrasonic energy. A stay suture on a straight needle was passed percutaneously in the abdomen, then on either side of the cystotomy and finally was exteriorized to maintain countertraction. The cystotomy was extended downwards to include the fistula site. The fistula was dissected circumferentially to raise the bladder and vaginal flaps. The vaginal defect was closed in a transverse fashion and the cystotomy was closed vertically.

Results

Mean operative time was 178±31.6 min and estimated blood loss was 60±18.7 mL. Flap interposition was performed in six cases. No intraoperative complications were recorded. Mean hospital stay was 2.25±0.89 days. During hospitalization two patients experienced postoperative complications (Clavien grade I). Mean follow-up was 20.9±11.1 months (6.0–39.0 months). All patients remained continent during the follow-up period.

Conclusions

This minimally invasive laparoscopic approach with only three trocars and limited posterior cystotomy provides excellent results with minimum morbidity.

Gasless single-port access laparoscopy using a J-shaped retractor in patients undergoing adnexal surgery

OBJECTIVE

The aim of this study was to compare gasless single-port access (SPA) laparoscopy using a J-shaped retractor and conventional SPA laparoscopy in patients undergoing adnexal surgery. Study design The medical records of 80 patients who underwent laparoscopic adnexal surgery between May 2017 and April 2019 were reviewed. Of the 80 patients, 40 patients underwent gasless SPA laparoscopy using a J-shaped retractor and 40 underwent conventional SPA laparoscopy. All surgeries were performed by one laparoscopic surgeon. Surgical outcomes were compared between the two groups.

RESULTS

There are no significant differences in age, body mass index, parity, previous abdominal surgery, tumor marker, and tumor diameter between the gasless and conventional groups. The median retraction setup time from skin incision was 7 min (range 5-12 min) in gasless SPA laparoscopic adnexal surgery. The median total operation times were 55.5 min (range 30-155 min) in the gasless group and 55 min (range 30-165 min) in the conventional group without a significant difference. Additionally, there were no differences in operation type, conversion rate of laparotomy, use of an additional trocar, and pathological outcomes between the two groups. No major complications, such as urologic, bowel, and vessel injuries, were found in both groups.

CONCLUSIONS

Gasless SPA laparoscopy using a J-shaped retractor appears to offer a better alternative to conventional SPA laparoscopy that avoids the potential negative effects of carbon dioxide gas in selected cases.

A comparison of the oxidative stress response in single-incision laparoscopic versus multi-trocar laparoscopic totally extraperitoneal inguinal hernia repair

Introduction

Surgical treatment is always associated with tissue damage and the subsequent development of oxidative stress.

Aim

To compare the oxidative stress response in patients treated operatively for inguinal hernia with multi-trocar laparoscopic totally extraperitoneal technique (TEP) or single-incision laparoscopic totally extraperitoneal technique (TEP-SI).

Material and methods

A randomized group of 34 patients with one-sided inguinal hernia was enrolled in the study. Seventeen patients were treated with a standard TEP method (group 1) and the other 17 patients were treated with the TEP-SI technique (group 2). Thiobarbituric acid reactive substances (TBARS) and total antioxidant status (TAS) as the oxidative stress markers were measured before surgery (0), 1 day (1) and 4 days (2) after surgery.

Results

A decrease in TAS on the first day after surgery was observed in both groups. Sustained reduction on the fourth day after surgery was observed in group 1, whereas in group 2 an increase followed. A statistically significant difference was observed in TAS (2 : 0) ratio with a meaningful decrease in group 1. TBARS concentration was elevated 1 day after surgery in both groups. It remained at an elevated level on the fourth day after surgery in group 1, while it decreased in group 2. The duration of surgery was higher in group 2 (mean: 57.5 min) than in group 1 (mean: 50.0 min) (p = 0.0286).

Conclusions

Oxidative stress levels are lower in patients treated operatively by TEP-SI technique than by TEP. TEP-SI may be considered as a less invasive technique associated with less tissue injury.

Outcome of Gynecologic Laparoendoscopic Single-Site Surgery with a Homemade Device and Conventional Laparoscopic Instruments in a Chinese Teaching Hospital

OBJECTIVE

To demonstrate various benign gynecologic diseases that can be performed by laparoendoscopic single-site surgery (LESS) with conventional laparoscopic instruments.

METHOD

Patients with benign gynecologic diseases that need ovarian cystectomy, fallopian tube resection, or myomectomy were divided into experimental group and control group, and perioperative outcomes of these patients were analyzed.

RESULTS

From November 2017 to May 2018, 65 LESS gynecological surgeries were performed, among which there were 25 ovarian cystectomies, 28 unilateral fallopian tube resections, and 12 myomectomies. All the surgeries were completed smoothly, and only one surgery needed one more additional port. No patients have severe complications. Operative time, intraoperative blood loss, and perioperative complications have no difference between the two groups. The LESS laparoscopy group had less postoperative pain scores and longer bowel recovering time, compared with the conventional laparoscopy group (<0.05).

CONCLUSION

Compared with traditional laparoscopy, LESS surgery with conventional laparoscopic instruments is feasible and safe, but postoperative exhaust time is longer than the control group.

Cosmesis and Patient Satisfaction Following Laparoscopic Adnexal Surgery

Background and Objectives

Laparoendoscopic single site surgery (LESS), a minimally invasive procedure, is performed in many hospitals. Although its cosmetic superiority is widely touted, some authors have disputed this view. Here, we compare the surgical and long-term cosmetic outcomes of and patient satisfaction with postoperative wounds for LESS and over 2-port laparoscopy (OTPL), including 2-port laparoscopy (TPL) and standard laparoscopy (SL), after a 6-mo follow-up period.

Methods

A total of 125 patients who underwent adnexal surgery performed by the same surgeon at the same institution between March 2005 and May 2017 were included. The patients were divided into 2 groups: the LESS group and the OTPL group. The patients completed an evaluation using the Patient Scar Assessment Scale (PSAS, used to evaluate linear scars) and the Ultimate Question (UQ, used to determine overall patient satisfaction). We evaluated surgical scars using the Observer Scar Assessment Scale, which includes the Umbilical Scar Overall Shape Assessment Scale (USOSAS) and the Vancouver Scar Scale (VSS).

Results

There were no significant differences in the PSAS, UQ, USOSAS, and VSS results between the study groups. The USOSAS score was consistently correlated with VSS scores of 2, 3, and 4 and the total VSS score, indicating that the USOSAS score may be as effective as the VSS score.

Conclusions

Because the long-term patient satisfaction with and cosmetic wound outcomes of LESS were not significantly different from those achieved by OTPL, surgeons should consider performing LESS after weighing the pros and cons with regard to the patient's condition.

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.

Recent advances in minimally invasive surgery for gynecologic indications

Recently, an increasing interest in less invasive surgery has led to the advent of laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES). LESS and NOTES could be technically challenging, but available literature has demonstrated the feasibility and safety of LESS for benign gynecologic diseases. However, the evidence is not strong enough to recommend the use of LESS over that of conventional multiport laparoscopic surgery (MLS). As per the results of the most recently published meta-analysis, the majority of surgical outcomes are equivalent between LESS and MLS, except for the longer operative time in LESS for both adnexal surgery and hysterectomy. Although an increasing number of studies have reported on robotic LESS, NOTES, and LESS for gynecologic malignancy, definite conclusions have not been drawn owing to the lack of sufficient information.

Effect of laparoscopy by single-port endoscopic access in benign adnexal surgery: study protocol for a randomized controlled trial

Background

Laparoscopic surgery has become the preferred surgical approach due to a reduction in postoperative pain, better recovery, shorter hospitalization, and improved esthetic outcomes. Laparoscopic surgery with single-port laparoscopy (SPL) is a laparoscopic surgery technique that is based on making a single parietal incision using a single trocar specifically designed to allow introduction of several instruments. The level of evidence regarding the advantages of SPL in terms of postoperative pain has remained low despite several randomized studies. Adult patients exhibiting a surgical indication for an a priori benign ovarian pathology or for prophylactic purposes that can be performed by laparoscopy will be randomized to receive conventional laparoscopy (CL) or SPL. The aim of our study is to evaluate whether SPL offers advantages over CL in benign adnexal surgery.

Methods

The patients will be evaluated preoperatively to confirm their eligibility. The perioperative data up to 24 h after the intervention, as well as the postoperative data at day 7 and at one month from the intervention will be collected. The primary outcome for the study will be the postoperative pain at 24 h ± 2 h after the intervention. The pain will be assessed by a numeric rating scale of 0–10.

Other outcomes will also be assessed, such as pain at other times, the consumption of analgesics, the operative time, perioperative bleeding, the number of additional trocars in the two groups, the incidence of laparoconversion, the esthetic criteria of the scar at one month, the incidence of complications, and the quality of life at one month.

Discussion

If our hypothesis is confirmed, this study will provide evidence that the use of SPL can decrease postoperative pain in adnexal surgery. The standard surgical treatment of this condition would thus be modified.

Trial registration

ClinicalTrials.gov, NCT02739724. Registered on 12 April 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2429-y) contains supplementary material, which is available to authorized users.

Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) adnexectomy for benign pathology compared with laparoscopic excision (NOTABLE): a protocol for a randomised controlled trial

INTRODUCTION

Natural orifice transluminal endoscopic surgery (NOTES) uses natural orifices to access the cavities of the human body to perform surgical interventions. NOTES limits the magnitude of surgical trauma and potentially reduces postoperative pain. Our group published a protocol on a randomised study comparing transvaginal NOTES (vNOTES) versus laparoscopy for hysterectomy (HALON). We simultaneously designed a similar randomised controlled trial (RCT) comparing vNOTES with laparoscopy for adnexectomy. To the best of our knowledge, this is the first RCT comparing vNOTES with laparoscopy for adnexal surgery.

METHODS AND ANALYSIS

The methodology of the Notes Adnexectomy for Benign Indication versus Laparoscopic Excision (NOTABLE) study is similar to that of the HALON trial. Women aged 18-70 years with an indication for benign adnexal surgery will be eligible. We will use stratification according to adnexal size. Entrants will be randomised to the laparoscopic treatment (control) or vNOTES (intervention). Participants will be evaluated on days 0-7 and at 3 and 6 months. The primary outcome will be the proportion of women successfully treated by removing an adnexa by the allocated technique without conversion. We will collect the following data (secondary outcomes): proportion of women hospitalised on the day of surgery, postoperative pain scores measured two times per day from day 1 to 7, total dosage of pain killers used from day 1 to 7, hospital readmission during the first 6 weeks, dyspareunia and sexual well-being at baseline, 3 and 6 months using a validated questionnaire (Short Sexual Functioning Scale), health-related quality of life at baseline, 3 and 6 months after surgery using a validated questionnaire (EQ-5D-3L), duration of surgical intervention, infection or other surgical complications and direct costs up to 6 weeks following surgery. For the primary outcome measure, a one-sided 95% CI of the difference in the proportions of women with a successful removal of the uterus by the randomised technique will be estimated. Non-inferiority will be concluded when 15% lies above the upper limit of this 95% CI.

ETHICS AND DISSEMINATION

The study was approved on 1 December 2015 by the EthicsCommitteeof the Imelda Hospital (registration no: 689), Bonheiden, Belgium. We aim to present the final results of the NOTABLE trial in peer-reviewed journals and at scientific meetings within 4 years after the start of the recruitment.

TRIAL REGISTRATION NUMBER

NCT02630329.

Perioperative Outcomes of 3-Arm Versus 4-Arm Robotic Radical Hysterectomy in Patients with Cervical Cancer

STUDY OBJECTIVE

To investigate and compare surgical outcomes of the 3 versus 4 robotic arm approaches for robotic surgery in patients with cervical cancer.

DESIGN

A retrospective analysis of prospectively collected data (Canadian Task Force classification II-2).

SETTING

An academic tertiary hospital.

PATIENTS

A total of 142 patients with stage 1A1 to IIB cervical carcinoma who underwent robotic surgery were included for analysis. The subjects were divided according to the surgical approach (i.e., the number of robotic arms), and the 2 groups were compared in terms of intraoperative data and postoperative outcomes.

INTERVENTIONS

Robotic radical hysterectomy (RRH) with lymphadenectomy using 3 robotic arms (n = 101) versus 4 robotic arms (n = 41).

MEASUREMENTS AND MAIN RESULTS

Perioperative surgical outcomes. The 3-arm robotic approach consisted of a camera arm, 2 robotic arms, and 1 conventional assistant port. An additional robotic arm was placed on the right side of the patient's abdomen for the 4-arm robotic approach. The mean age, body mass index, cell type, Fédération Internationale de Gynécologie et d'Obstétrique stage, and type of surgery were not significantly different between the 2 cohorts. The 3-arm approach showed favorable outcomes over the 4-arm approach in terms of postoperative pain at 6 and 24 hours (3.8 ± 1.8 vs 4.5 ± 1.7 and 2.8 ± 1.7 vs 3.4 ± 1.6, respectively; p = .033 and .049) and postoperative hemoglobin difference (1.8 ± 0.9 vs 2.6 ± 1.3 and 1.9 ± 1.1 vs 2.4 ± 0.9 on days 1 and 3, respectively; p = .002 and .004). The median length of postoperative hospital stay, total operative time, docking time, lymph node yield, and intraoperative and postoperative complication rates were comparable between the 2 cohorts.

CONCLUSION

Surgical outcomes and complications rates of RRH for cervical cancer using the 4-arm approach were comparable with that of the 3-arm approach with decreased early postoperative pain in the 3-arm group. Cost-benefit analysis and the impact on surgical training are needed in the future.