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 Table of Contents     
ORIGINAL ARTICLE
Year : 2017  |  Volume : 13  |  Issue : 3  |  Page : 170-175
 

Laparoendoscopic single-site adnexal surgery: Preliminary Indian experience


1 Department of Obstetrics and Gynecology, Rockland Hospital, Dwarka, New Delhi, India
2 Department of Minimal Access Surgery, Hinduja Hospital, Mumbai, Maharashtra, India
3 Department of Gynecology, Hinduja Hospital, Mumbai, Maharashtra, India

Date of Submission28-Sep-2016
Date of Acceptance20-Feb-2017
Date of Web Publication12-Jun-2017

Correspondence Address:
Deepraj S Bhandarkar
Department of Minimal Access Surgery, Room 2103, Hinduja Hospital, Veer Savarkar Road, Mahim, Mumbai - 400 016, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_206_16

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 ¤ Abstract 

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.


Keywords: Laparoendoscopic single-site surgery, salpingo-oophorectomy, single-incision laparoscopic surgery


How to cite this article:
Balusamy S, Salgaonkar HP, Behera RR, Bhalerao-Gandhi A, Bhandarkar DS. Laparoendoscopic single-site adnexal surgery: Preliminary Indian experience. J Min Access Surg 2017;13:170-5

How to cite this URL:
Balusamy S, Salgaonkar HP, Behera RR, Bhalerao-Gandhi A, Bhandarkar DS. Laparoendoscopic single-site adnexal surgery: Preliminary Indian experience. J Min Access Surg [serial online] 2017 [cited 2017 Jul 20];13:170-5. Available from: http://www.journalofmas.com/text.asp?2017/13/3/170/207839



 ¤ Introduction Top


Laparoscopic surgery has now become the standard of care in the treatment of patients with benign adnexal pathology as well as in haemodynamically stable patients with ectopic pregnancy. In 1992, Pelosi and Pelosi published the first case of a supracervical hysterectomy using laparoendoscopic single-site surgery (LESS).[1] However, it is only over the past few years that there has been a renewed interest in LESS and several series of hysterectomy, ovarian cystectomy, salpingo-oophorectomy as well as salpingectomy have been reported. As LESS is carried out through a single transumbilical incision, it is a virtually scarless procedure and is likely to lead to reduced pain, faster recovery and decreased analgesic requirement, although these benefits by no means are proven and the superiority of LESS over standard laparoscopic surgery remains to be established. In this series, which is believed to be the first of its kind reported from India, we review our experience with 37 patients who underwent LESS for benign adnexal pathology and compare the outcome with the two approaches utilised – single-incision multiport (SIMP) and homemade glove port (HMGP).


 ¤ Materials and Methods Top


This is a retrospective analysis of prospectively collected data of 37 patients who underwent LESS adnexal surgery at a tertiary care hospital between June 2009 and April 2015. Patients with cystic ovarian/paraovarian masses < 8 cm in diameter, haemodynamically stable patients with ruptured ectopic pregnancy and patients with breast cancers meriting adnexal excision as a hormonal adjunct were included in the study group. LESS was contraindicated in patients with masses >8 cm in size, elevated carcinoembryonic antigen 125 (CA-125) levels, obesity (body mass index [BMI] >30), American Society of Anesthesiologists Grade higher than III and haemodynamic instability. Previous abdominal surgery was not considered a contraindication. Preoperatively, all the patients underwent appropriate haematological and biochemical tests including CA-125 levels and abdominal and pelvic ultrasonography with a colour Doppler assessment. They were counselled and consented for a conversion to a multiport laparoscopic surgery or a laparotomy. For the outcome analysis, patients were subdivided into those undergoing LESS through a SIMP approach and those having it using a HMGP.

Surgical technique

All the LESS procedures were performed with the patient under general endotracheal anaesthesia in the supine position with a steep, Trendlenberg tilt and both arms adducted. An indwelling urinary catheter was placed after induction of anaesthesia. A 5 mm, 30°, 51 cm laparoscope connected to a high-definition endocamera and a Xenon light source (Karl Storz GmBH, Tuttlingen, Germany) were used in all the surgeries.

Two LESS approaches were utilised.

  1. SIMP: A 2–2.5 cm transumbilical incision was made down to the fascia, which was dissected from the subcutaneous fat for a distance of 3 cm. A stab incision was made at the cephalad corner for induction of pneumoperitoneum through a Veress needle. A 7 mm reusable, metal laparoscopic cannula was placed at this site. The pneumoperitoneum pressure was maintained at 12 mmHg. After preliminary survey of the peritoneal cavity, the skin edges were retracted and two low-profile, 5 mm laparoscopic sleeves were placed through the fascia [Figure 1]a for the introduction of laparoscopic instruments
  2. HMGP: This port was prepared using an Alexis wound retractor and a powder-free surgical glove. A glove was rolled up onto the upper ring of Alexis retractor. Small incisions were made in three of the fingers, and a 10 mm and two 5 mm trocars were introduced into the fingers and secured with silk ligatures. A single transumbilical, 2 cm incision was made through all the layers. The distal ring of the retractor was introduced intra-abdominally, and the proximal flexible ring was rolled up such that it retracted the linear incision into a circular one. The insufflation tubing was attached to one of the trocars, and the abdomen was insufflated. The gas filled up the glove and created a leak-proof system in continuity with the abdominal cavity. Laparoscope and instruments were introduced through the ports tied into the fingers of the glove [Figure 1]b.
Figure 1: (a) Multiple ports passed through a transumbilical incision (b) a handmade glove port in use

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Procedures undertaken varied as per the pathology. Salpingectomy and salpingo-oophorectomy involved coagulation of the ligaments/vessels with either bipolar or ultrasonic energy devices followed by excision [Figure 2]a. In the ovarian cystic lesions, an incision was made on the wall with a monopolar hook and the cyst was enucleated [Figure 2]b. Larger cysts were initially aspirated. Haemostasis on the residual ovarian substance was obtained with a bipolar forceps. Paraovarian cysts were excised with the help of an ultrasonic energy device. When using the SIMP approach, at the conclusion of the procedure, the 7 mm fascial incision was joined to one of the 5 mm ones and a 10 mm cannula was placed through this. A plastic bag was introduced through this cannula for capturing the specimen, which was retrieved under the visual guidance of the 5 mm telescope. When a HMGP was in place, the specimen was withdrawn into the glove, abdomen desufflated and the entire assembly removed along with the specimen/s. The fascial incisions were meticulously closed with non-absorbable sutures, local anaesthetic infiltrated and skin approximated with a fine subcuticular absorbable suture [Figure 3].
Figure 2: (a) A right salpingo-oophorectomy being performed (b) a left dermoid cyst being enucleated

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Figure 3: Small transumbilical incision after laparoendoscopic single-site surgery

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Data collection

The patients' age, BMI, type of access (SIMP or HMGP), type of energy source utilised, operative blood loss, operative time, post-operative hospital stay, necessity and reason for placement of additional port/s, intra- and post-operative complications and histopathological findings were recorded in an Excel (Microsoft Office, Cupertino, CA, USA) sheet.

Statistical analysis

Statistical analysis was performed with SPSS software version 15.0 (SPSS Inc., Chicago, IL, USA) using Student's t-test, Fisher's exact test and the Chi-square test. P<0.05 was considered statistically significant.


 ¤ Results Top


[Table 1] summarises the clinical characteristics of the 37 patients divided into two groups, which were comparable. Omental adhesiolysis was required in three patients with a history of previous abdominal surgery (caesarean delivery in one patient and two caesarean deliveries plus appendectomy in another). [Table 2] outlines the intraoperative variables. Procedures performed were ovarian cystectomy, paraovarian cystectomy, para-ovarian cystectomy with partial salpingectomy, bilateral salpingo-oophorectomy (BSO) and salpingectomy. Energy sources used were monopolar hook, bipolar forceps and ultrasonic device. Additional 5 mm port was required for achieving haemostasis and performing ovarian reconstruction in one patient with a large ovarian cyst (SIMP group). Blood loss of 100 ml in this patient was the only significant intraoperative event in the series. The operative time did not differ significantly between the two groups. There was no statistical difference in the approach (SIMP or HMGP) used in dealing with various pathologies except in those with ruptured tubal ectopic pregnancy, which were all treated with a SIMP approach. [Table 3] outlines the postoperative stay and the pathological diagnosis reached in the two groups. There were no early postoperative wound complications and no port-site hernias at a follow-up of 6 months.
Table 1: Characteristics of the patients

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Table 2: Intraoperative data

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Table 3: Post-operative outcome

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 ¤ Discussion Top


This is a single-institutional series, believed to be the first one from India, of patients undergoing LESS adnexal surgery. LESS seems ideally suited for adnexal surgery as fewer complex manoeuvres are required, and relatively smaller specimens need to be extracted. Although there are no data on the learning curve of LESS adnexal surgeries, it is likely to be shorter than more complex procedures such as LESS hysterectomy.

Selection of cases for LESS is paramount, especially during the learning curve. There are isolated reports of LESS being performed in patients with BMI over 30.[2] However, we avoided LESS in obese patients as a thick abdominal wall tends to grip the ports reducing their manoeuvreability. Like us, most reported series [3],[4],[5],[6] considered cysts below 8 cm suitable for LESS. Nevertheless, Scribner et al. have described a left LESS salpingo-oophorectomy in a patient with a 37 cm ovarian cyst.[7] They used a GelPort (Applied Medical Systems, Rancho Santa Margarita, CA, USA) LESS device and inserted a 12 mm trocar directly into the cyst to aspirate over 5 L of fluid. After excision, the large specimen required internal morcellation before retrieval. Like most authors reporting LESS adnexal surgeries, we did not consider previous lower abdominal surgery as a contraindication, and in three of our patients with previous surgery, omental adhesiolysis could be easily carried out. Nearly half of our LESS procedures were BSO in breast cancer patients. Two of these have been published previously as a case report.[8] The Oxford Review analysis showed that at 15 years of follow-up, premenopausal women treated with ovarian ablation had statistically significantly higher relapse-free survival as also overall survival rates.[9] In patients with ectopic pregnancy who do not meet the criteria for methotrexate therapy, surgical intervention, usually by laparoscopy, is performed. During the study period, four haemodynamically stable patients with suspected ruptured ectopic pregnancy were offered LESS, and a salpingectomy was performed in all. Bedaiwy et al. reported a series of LESS salpingectomy in 11 patients with ectopic pregnancy.[10] They used three trocars through a SILS port (Covidien, MA, USA) and a LigaSure device (Valleylab, Boulder, CO, USA) for dissection. None of the patients required additional ports, the median intraoperative blood loss was 30 (10–50) ml and operative time 35 (25–65) min. LESS salpingostomy, extraction of the products of conception and suturing of the incision on the tube, is a more challenging procedure. Kumakiri et al. have described a LESS salpingostomy with suturing for ampullary ectopic pregnancy in three patients.[11] They used a articulating forceps (Roticulator Endo Grasp, Covidien) in the left hand and an articulating suturing device (SILS-Stitch, Covidien) to allow closure of the linear salpingostomy.

As outlined by Ramirez, LESS is more challenging than multiport laparoscopic surgery due to reduced visualisation, loss of triangulation and clashing of the instruments with the laparoscope.[12] Authors undertaking LESS adnexal procedures have employed different strategies to overcome these handicaps. Fagotti et al.[3] used a single access port device (Olympus Winter and Ibe GmbH, Hamburg, Germany) and a 5 mm, 30° laparoscope with a long flexible handle (Olympus Winter and Ibe). Furthermore, they employed instruments of varying lengths (36 and 42 cm) to overcome the external clashing. Escobar et al. used a SILS port (Covidien) in conjunction with articulating or curved graspers in their series of nine patients.[13] In all our cases, we employed a rigid 5 mm, 30°, 51 cm laparoscope (Karl Storz) that moved the cameraperson's hand away from the abdominal wall and reduced clashing with the instruments. As indicated by Dursun et al.[4] after the preliminary step of introduction of the trocars/HMGP, the surgeon moved to the head end of the patient so as to get a coaxial vision and to place the surgeon's hands in a different axis from the laparoscope. Whenever possible, we used one instrument with a pistol handle and another with a straight handle. Finally, we deliberately carried out manoeuvres such as peeling off of the ovarian tissue from a cyst in a 'to and fro' manner rather than with a side-to-side movement. In one patient, we had to insert an additional 5 mm port to control the bleeding from the ovarian tissue and to facilitate underrunning of the wall. In two-thirds of our cases (24/37), we used a combination of a bipolar forceps and ultrasonic shears. A monopolar hook was used in a third of the patients (13/37), mostly for making the preliminary incision on the cyst wall.

Use of a HMGP has been described for general surgical procedures such as cholecystectomy and appendectomy.[14],[15] We used this approach in ten of our patients when dealing with a larger cyst or while performing a BSO in patients with bulky ovaries. The single incision through all the layers allowed for easier retrieval of the specimens. Overall, however, there was no statistically significant difference in any of the intra- or post-operative variables between the SIMP and HMGP groups. Cho et al. reported a randomised trial of sixty patients with adnexal pathology, in which forty undergoing traditional laparoscopic surgery were compared to thirty having LESS.[16] Although most parameters were comparable between the two groups, there was a statistically significant higher post-surgical drop in haemoglobin in the LESS group (2 ± 0.7 g/dL) versus the laparoscopic group (1.7 ± 0.6 g/dL). The authors stated that this could be improved with increasing experience.

Whenever a new technique such as LESS is introduced, increase in the operative time is a concern. In a study by Lee et al. comparing perioperative outcomes of LESS versus conventional laparoscopic adnexal surgery, there were no differences between the groups in median operation time.[6] Furthermore, Jung et al.[17] reported that mean duration of LESS adnexal surgery was 64.5 min (range 21–176 min) similar to our experience. Escobar et al. have suggested that duration of the operation decreases by the end of the learning curve and that in experienced hands, time taken for LESS is comparable to that of a standard laparoscopic procedure.[13]

The benefits of LESS in terms of post-operative pain and cosmesis have often been questioned. Fagotti et al. reported a prospective randomised trial comparing the LESS and multiport laparoscopic surgery in sixty patients undergoing ovarian cystectomy or unilateral or BSO.[18] Patients in the LESS group experienced less post-operative pain (assessed with a visual analogue score) at 20 min, 2, 4 and 8 h after surgery, though only the difference at 4 h was statistically significant. In addition, the patients undergoing LESS surgery had a statistically significant lower requirement for post-operative analgesic medication. Moreover, there was a statistically higher rate of satisfaction with the scars in the LESS group. A drawback of our series was the lack of comparison of pain and wound satisfaction scores between the two groups.

The issue of wound-related complications in patients undergoing LESS has been debated widely. It is felt that the multiple fascial incisions in the SIMP approach or a relatively longer fascial incision in the HMGP approach may result in higher incidence of port-site hernias. Gunderson et al. retrospectively reviewed the 211 women who had previously undergone gynaecological LESS through a single 1.5–2.0 cm umbilical incision.[19] Umbilical hernias were noticed in five (2.4%) patients at a median follow-up of 16 months. However, a closer look at the data revealed that four out of these five patients also had significant risk factors for fascial weakening such as requirement for a second abdominal surgery and postoperative chemotherapy. Upon elimination of these subjects from the analysis, the incidence of port-site hernia came to a more accep[Table 1]/207 (0.5%). The authors concluded that studies with larger sample size and longer follow-up were needed to reach a conclusion. None of our patients developed seroma or other early wound-related complications, but the long-term port-site hernia rates could not be determined. It has been our routine practice in all patients undergoing LESS to meticulously approximate the individual fascial incisions (SIMP approach) or the single fascial incision (HMGP approach) with non-absorbable suture.

We are mindful of the limitations of our study, namely, the small patient population and absence of a control group comprising patients undergoing laparoscopic procedures for adnexal pathology utilising the standard (multiport) approach. Furthermore, there was no comparison of pain scores between the two groups. Notwithstanding these, we feel the aspects of this study which make the technique reproducible are (a) performance of all LESS procedures using reusable instruments with certain modifications, (b) use of readily available energy sources and (c) teamwork between an experienced gynaecologist (AB-G) and a surgeon facile with LESS surgery (DB).


 ¤ Conclusions Top


This preliminary series confirms the technical feasibility and safety of the LESS in the management of adnexal pathology. Based on our limited experience, it is not possible to recommend either the SIMP or HMGP approach as being superior to the other. Furthermore, before accepting LESS as the standard of care in India, prospective studies with larger number of patients comparing the LESS and multiport approaches are necessary.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ¤ References Top

1.
Pelosi MA, Pelosi MA 3rd. Laparoscopic supracervical hysterectomy using a single-umbilical puncture (mini-laparoscopy). J Reprod Med 1992;37:777-84.  Back to cited text no. 1
    
2.
Escobar PF, Bedaiwy MA, Fader AN, Falcone T. Laparoendoscopic single-site (LESS) surgery in patients with benign adnexal disease. Fertil Steril 2010;93:2074.e7-10.  Back to cited text no. 2
    
3.
Fagotti A, Bottoni C, Vizzielli G, Rossitto C, Tortorella L, Monterossi G, et al. Laparoendoscopic single-site surgery (LESS) for treatment of benign adnexal disease: single-center experience over 3-years. J Minim Invasive Gynecol 2012;19:695-700.  Back to cited text no. 3
    
4.
Dursun P, Tezcaner T, Zeyneloglu HB, Alyazıci I, Haberal A, Ayhan A. Adnexal masses treated using a combination of the SILS port and non-curved straight laparoscopic instruments: Turkish experience and review of the literature. Minim Invasive Surg 2013;2013:836380.  Back to cited text no. 4
    
5.
Marocco F, Fanfani F, Rossitto C, Gallotta V, Scambia G, Fagotti A. Laparoendoscopic single-site surgery for fertility-sparing staging of border line ovarian tumors: initial experience. Surg Laparosc Endosc Percutan Tech 2010;20:e172-5.  Back to cited text no. 5
    
6.
Lee YY, Kim TJ, Kim CJ, Park HS, Choi CH, Lee JW, et al. Single port access laparoscopic adnexal surgery versus conventional laparoscopic adnexal surgery: a comparison of peri-operative outcomes. Eur J Obstet Gynecol Reprod Biol 2010;151:181-4.  Back to cited text no. 6
    
7.
Scribner DR Jr., Lara-Torre E, Weiss PM. Single-site laparoscopic management of a large adnexal mass. JSLS 2013;17:350-3.  Back to cited text no. 7
    
8.
Bhandarkar D, Katara A, Deshmane V, Mittal G, Udwadia TE. Single-incision bilateral laparoscopic oophorectomy. J Minim Access Surg 2011;7:87-9.  Back to cited text no. 8
    
9.
Ovarian ablation in early breast cancer: overview of the randomised trials. Early Breast Cancer Trialists' Collaborative Group. Lancet 1996;348:1189-96.  Back to cited text no. 9
    
10.
Bedaiwy MA, Escobar PF, Pinkerton J, Hurd W. Laparoendoscopic single-site salpingectomy in isthmic and ampullary ectopic pregnancy: preliminary report and technique. J Minim Invasive Gynecol 2011;18:230-3.  Back to cited text no. 10
    
11.
Kumakiri J, Kikuchi I, Kitade M, Matsuoka S, Tokita S, Takeda S. Linear salpingotomy with suturing by single incision laparoscopic surgery for tubal ectopic pregnancy. Acta Obstet Gynecol Scand 2010;89:1604-7.  Back to cited text no. 11
    
12.
Ramirez PT. Single-port laparoscopic surgery: is a single incision the next frontier in minimally invasive gynecologic surgery? Gynecol Oncol 2009;114:143-4.  Back to cited text no. 12
    
13.
Escobar PF, Starks DC, Fader AN, Barber M, Rojas-Espalliat L. Single-port risk-reducing salpingo-oophorectomy with and without hysterectomy: surgical outcomes and learning curve analysis. Gynecol Oncol 2010;119:43-7.  Back to cited text no. 13
    
14.
Hayashi M, Asakuma M, Komeda K, Miyamoto Y, Hirokawa F, Tanigawa N. Effectiveness of a surgical glove port for single port surgery. World J Surg 2010;34:2487-9.  Back to cited text no. 14
    
15.
Kim HJ, Lee JI, Lee YS, Lee IK, Park JH, Lee SK, et al. Single-port transumbilical laparoscopic appendectomy: 43 consecutive cases. Surg Endosc 2010;24:2765-9.  Back to cited text no. 15
    
16.
Cho YJ, Kim ML, Lee SY, Lee HS, Kim JM, Joo KY. Laparoendoscopic single-site surgery (LESS) versus conventional laparoscopic surgery for adnexal preservation: a randomized controlled study. Int J Womens Health 2012;4:85-91.  Back to cited text no. 16
    
17.
Jung YW, Choi YM, Chung CK, Yim GW, Lee M, Lee SH, et al. Single port transumbilical laparoscopic surgery for adnexal lesions: a single center experience in Korea. Eur J Obstet Gynecol Reprod Biol 2011;155:221-4.  Back to cited text no. 17
    
18.
Fagotti A, Bottoni C, Vizzielli G, Gueli Alletti S, Scambia G, Marana E, et al. Postoperative pain after conventional laparoscopy and laparoendoscopic single site surgery (LESS) for benign adnexal disease: a randomized trial. Fertil Steril 2011;96:255-9.e2.  Back to cited text no. 18
    
19.
Gunderson CC, Knight J, Ybanez-Morano J, Ritter C, Escobar PF, Ibeanu O, et al. The risk of umbilical hernia and other complications with laparoendoscopic single-site surgery. J Minim Invasive Gynecol 2012;19:40-5.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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