Laparoendoscopic single-site surgery in gynecology: LESS is actually how much less?

The Learning Curve of Laparoendoscopic Single-Site Surgery in Benign Gynecological Diseases

OBJECTIVE

To analyze and draw the learning curve of laparoendoscopic single-site surgery (LESS) in various benign gynecological diseases, so as to provide a reference for applying this cutting-edge technique.

METHODS

A retrospective analysis of LESS was conducted. Factors influencing the LESS learning process were assessed using Cox's proportional hazards regression. The cumulative sum (CUSUM) value and the learning curve were calculated and visualized based on operation time (OT), blood loss (BL), conventional laparoscopic surgery (CLS), conversion rate (CV), and complications (CP). The CUSUM value was defined as the sum of CUSUM_OT, CUSUM_BL, CUSUM_CV, and CUSUM_CP.

RESULTS

A total of 445 cases, including adnexectomies (n = 147), ovarian cystectomies (n = 175), and myomectomies (n = 123) were analyzed. Multivariate regression analysis indicated that adhesion grade (HR, 1.462; 95% CI, 1.016-1.994; p = .045), surgical type (HR, 1.283; 95% CI, 1.042-1.429; p = .024), and surgeon CLS experience (HR, 1.372; 95% CI, 1.097-2.246; p = .012) were independent factors predicting surgeons' mastery of the LESS technique. Among gynecologists with CLS experience, the cutoff points were 17, 20, and 27 cases for adnexectomy, ovarian cystectomy, and myomectomy, respectively. For those without CLS experience, the corresponding cutoff values were 19, 27, and 35 cases.

CONCLUSION

The learning curve of LESS for benign gynecological diseases indicates a stepwise process, during which the surgeon's CLS experience is the key, especially in ovarian cystectomy and myomectomy. For the training of young gynecologists, CLS should be emphasized in the early stage, and LESS should be introduced gradually.

Percutaneous-assisted vs mini-laparoscopic hysterectomy: comparison of ultra-minimally invasive approaches

To assess the feasibility and the safety of the ultra-minimally invasive (U-MIS) approaches in gynecology, we compared our experience in percutaneous assisted hysterectomy (PSS-H) with a series of 3 mm mini-laparoscopy hysterectomy (m-LPS-H). 126 patients affected by benign and malignant gynecological conditions were considered eligible for minimally invasive hysterectomy: 80 patients received PSS approach and 46 m-LPS approach. For both groups, we evaluated intra and perioperative outcomes, post-operative pain and cosmetic outcomes. The baseline characteristics were comparable between the two study groups. As well, no differences were reported in the clinical indications for hysterectomy, principally fibroids/adenomyosis, endometrial hyperplasia and early stage endometrial cancer. The median operative time was 88.5 (40-190) minutes for PSS-H group and 95.0 (42-231) minutes in m-LPS-H group (p = 0.131). No differences were detected in median estimated blood loss (p = 0.104) as well, in the uterine manipulator usage (p = 0.127) between the two different surgical approaches. Only 1 (2.2%) conversion to standard laparoscopy occurred in m-LPS-H group (p = 0.691). One intra-operative complication was recorded 1 (1.3%) in the PSS-H group (p = 0.367). The post-operative early complication was recorded in five cases of PSS-H group (p = 0.158), none for m-LPS-H procedures. The results in post-operative pain detection was statistically significant after 4 h in favor of m-LPS-H group (p = 0.001). After 30 days no differences in cosmetic satisfaction were detected between the two groups (p = 0.206). PSS-H and m-LPS-H are two valid U-MIS alternatives for benign gynecological conditions and low/intermediate risk endometrial cancer.

A Novel System for Single-Port Laparoscopic Surgery: Preliminary Experience

AIMS

To present preliminary data of single-access laparoscopic surgery with a new device for the treatment of benign adnexal pathologies.

METHODS

Ten women with benign adnexal pathologies underwent salpingectomy (n = 4) and ovarian/para-ovarian cyst enucleation (n = 6) using a laparo-endoscopic single-port approach with an innovative advanced multiport reusable trocar inserted transumbilically through a small wound retractor. Trocar introduction time, operative time, estimated blood loss, conversion to standard laparoscopy, peri- and postoperative complications, hospital stay and Visual Analog Scale score (as assessment of pain and cosmesis) were analyzed.

RESULTS

Port placement was successful in all patients. Mean trocar introduction time was 4.4 min (range 3.4-5.3 min) and no intra or postoperative complication occurred. The mean operating time was 50.0 ± 9.2 min and mean blood loss was 28.5 ± 8.8 ml. The mean hospital stay following surgery was 1.6 ± 0.5 days and convalescence was complete in 1 week. Neither scores for postoperative incisional pain nor cosmesis side effects have been observed in any subjects.

CONCLUSION

We concluded that adnexal single-port surgery performed with this innovative advanced surgical instrumentation is a feasible, safe, and effective technique that drastically reduces postoperative pain and does not compromise cosmetic appearance. The isolation of the operative field by means of the drape prevents the contamination of the port site that occurs frequently, and mainly in adnexal pathologies of uncertain etiology. In addition, the ease of insertion and the conformation of the new port access also make the procedure feasible in obese patients.

Perioperative outcomes of three-port robotically assisted hysterectomy: a continuous series of 53 cases

This study evaluated the feasibility and safety of 3-port robotically assisted laparoscopic hysterectomy (RALH), using a consecutive series of women who underwent 3-port RALH in a university hospital. From November 2010 until June 2013 we operated on 53 women, whose mean age was 48.4 ± 7.7 years (range 35-68 years), and mean body mass index was 27.1 ± 5.1 kg/m(2) (range 19.5-42.9 kg/m(2)). The indications for hysterectomy were myoma in 31 (58.5 %), adenomyosis in 10 (18.9 %), cervical dysplasia in 4 (7.5 %), neoplasia in 4 (7.5 %), and recurrent polyps or postmenopausal bleeding in the remaining 4 women (7.5 %). We performed total RALH in 50 cases (94.3 %) and subtotal in the others. The median duration of total intervention was 169 min (interquartile range 147.5-206.5 min). The mean weight of the uterus was 209.8 ± 166.6 g (range 36-790 g) and mean estimated blood loss was 72.3 ± 75.9 ml (range 0-300 ml). There were no perioperative complications, in particular no blood transfusions nor conversions to laparotomy. The median hospital stay was 4 days (interquartile range 3-4 days). One patient was reoperated 1 month later for vaginal vault hematoma and another was readmitted 3 weeks post-operatively due to vaginal vault dehiscence after premature intercourse, but did not require reoperation. Three-port RALH is feasible and safe for simple hysterectomy. We believe this experience using minimum ports to be useful to prepare for robotically assisted single-port hysterectomy.