Uterine myomectomy: Role of gasless laparoscopy in comparison with other minimally invasive approaches

Gasless Laparoscopic Myomectomy Using A J-shaped Retractor and Suture Technique

OBJECTIVE

This study aimed to compare gasless single-port access (SPA) laparoscopic myomectomy using a J-shaped retractor and conventional SPA laparoscopic myomectomy.

STUDY DESIGN

The medical records of 60 patients who underwent laparoscopic myomectomy between January 2016 and August 2019 were reviewed. Thirty patients underwent gasless SPA laparoscopic myomectomy using a J-shaped retractor, and 30 patients underwent conventional SPA laparoscopic myomectomy. The 2 groups were compared in terms of surgical outcomes. In gasless laparoscopic myomectomy, closure of the uterine defect after myomectomy was performed using an extracorporeal suture technique with a Kelly clamp and knot pusher.

RESULTS

On comparing gasless SPA and conventional SPA laparoscopic myomectomy, no significant differences were observed in age, body mass index, parity, previous abdominal surgery, and size of the dominant uterine myoma. The median retraction setup time from skin incision was 8 minutes (range, 5 to 15 min) with gasless SPA laparoscopic myomectomy. The median total operation times were 105 minutes (range, 62 to 210 min) with gasless SPA myomectomy and 110 minutes (range, 60 to 270 min) with conventional SPA myomectomy, and there was no significant difference (P=0.251). There was no difference between the groups in terms of estimated blood loss. None of the patients experienced laparotomy conversion in both groups. No major complications, such as urologic, bowel, and vessel injuries, were found in both groups.

CONCLUSION

Gasless SPA laparoscopic myomectomy using a J-shaped retractor is a safe and feasible approach, which allows for easy and convenient suturing of a uterine defect after myomectomy.

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.

Minimally Invasive Myomectomy: An Overview on the Surgical Approaches and a Comparison with Mini-Laparotomy

Uterine fibroids (UFs) are the most common benign solid tumors of the female genital tract manageable by surgical of pharmacological approach. When the medical management is ineffective or surgery is primarily requested, several surgical approaches can be used. Among these, minimally invasive surgery might be preferred. Myomectomy is the standard surgical treatment when fertility sparing is claimed. It can be performed via laparoscopy, robotic surgery and hysteroscopy and the choice depend on UFs features and surgeon's skill. Alongside these minimally invasive options, mini-laparotomy has been proposed as a less invasive surgical approach comparable to the well-established minimally invasive options. The aim of this review is to describe the most recent advances in minimally invasive techniques to perform myomectomy, comparing them with mini-laparotomy approach.

ACR Appropriateness Criteria® Radiologic Management of Uterine Leiomyomas

Uterine fibroids, also known as leiomyomas, are the most common benign tumor in women of reproductive age. When symptomatic, these patients can present with bleeding and/or bulk-related symptoms. Treatment options for symptomatic uterine leiomyomas include medical management, minimally invasive treatment such as uterine artery embolization, and surgical options, such as myomectomy. It is important to understand the role of these treatment options in various clinical scenarios so that appropriate consultation is performed. Furthermore, patients should be presented with the outcomes and complications of each of these treatment options. A summary of the data and clinical trials of the treatment options for symptomatic uterine leiomyomas is outlined in this article. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Response to comment on "Oestrogen-induced angiogenesis and implantation contribute to the development of parasitic myomas after laparoscopic morcellation"

According to the literature review, CO2 insufflation on parasitic myoma implantation is not well studied, and we concur that our study is related to "Morcellation-induced parasitic myomas." We did not compare CO2 insufflation to non-insufflation in our study. The reason is the efficacy of gasless laparoscopic myomectomy and morcellation is not well established and this modality is seldom performed. Moreover, the effects of pneumoperitoneum on mesothelial cells and the role of the entire peritoneal cavity as a cofactor in adhesion formation have become well established, the role of CO2 insufflation in the establishment of parasitic myomas has not yet been studied. As such, more in-depth and well-designed studies for the role of CO2 insufflation are needed.

Spindle-like abdominal wall-lifting device in gasless laparoscopic surgery in animal experiments

INTRODUCTION

CO2 pneumoperitoneum has been used to establish an operation space in laparoscopic surgery. It may have some bad consequences, such as respiratory and circulatory system changes, hypotension and hypoxia in infants and the release of free tumor cells into the abdominal cavity. Gasless laparoscopic technique can avoid these adverse effects. But present gasless laparoscopic techniques have their own disadvantages. The main shortcoming of gasless laparoscopic techniques is inadequate operative space.

MATERIAL AND METHODS

We herein describe a new technique. We used a self-designed spindle-like abdominal wall-lifting device to perform gasless laparoscopic cholecystectomy in seven pigs, recording the operation time, bleeding volume and unexpected occurrences during the operation.

RESULTS

Seven pigs underwent laparoscopic cholecystectomy using this technique with no conversion to open operation. The operation time was between 21 minutes and 65 minutes, with a mean operative time of 42.5 minutes. The range of bleeding volumes was 2 ml to 8 ml, with a mean operative bleeding volume of 4.3 ml. There were no massive hemorrhages, internal organ injuries or other complications during the operation.

CONCLUSIONS

These preliminary outcomes indicate that the spindle-like abdominal wall-lifting device is feasible and safe in gasless laparoscopic cholecystectomy, which can provide sufficient exposure of the operative filed.

Hybrid approach of retractor-based and conventional laparoscopy enabling minimally invasive hysterectomy in a morbidly obese patient: case report and review of the literature

Minimally invasive hysterectomy in obese patients may be limited by laparoscopic sight on the one hand and by intraoperative complications related to reduced ventilation due to pneumoperitoneum on the other. Retractor-based laparoscopy offers an operative technique reducing anesthesia risks. We report the case of laparoscopic hysterectomy in an obese patient of short stature. Laparoscopic supracervical hysterectomy was performed by a hybrid approach of a retractor system exerting its effects on lifting the abdominal wall through gravity and conventional laparoscopy, thus bypassing the adverse effects of pneumoperitoneum on ventilation.