First single-incision type 7 total laparoscopic hysterectomy, adnexectomy, and appendectomy
© Springer-Verlag 2009
Received: 18 May 2009
Accepted: 9 July 2009
Published: 24 July 2009
We report two cases of use of a single umbilical skin incision for a type 7 total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and appendectomy. This study is a retrospective chart review and discussion of two patients who underwent a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and appendectomy (Canadian Task Force Level III). Both patients underwent a type 7 total laparoscopic hysterectomy for benign indications in July 2007 and sustained no complications. The evidence from these two cases suggests that advanced laparoscopic procedures are possible using a single skin incision for multiple ports. Technological advances, including those in port structure, are needed to enable surgeons to employ strategies that effectively enhance instrument coordination and suturing. Benefits to the patient need to be documented prospectively before this procedure can be recommended widely.
Type 7 total laparoscopic hysterectomy (TLH), bilateral salpingo-oophorectomy (BSO) is a hysterectomy in which every step is performed via the laparoscopic ports, including suturing of the vaginal cuff . TLH/BSO and incidental appendectomy are now performed routinely at community and university hospitals worldwide for both malignant and benign indications. The standard of four 5-mm ports in a diamond configuration has been reported to be effective for both pelvic and abdominal procedures ; however, there has been much interest in single-incision laparoscopic surgery. Pelosi and colleagues used a single umbilical port to facilitate a type 3 laparoscopic-assisted vaginal hysterectomy/BSO, a supracervical hysterectomy/BSO, and an appendectomy [3–5]. These authors summarized: “The results suggest single-puncture (minilaparoscopy) operative endoscopy as the ultimate goal in the progression of minimally invasive surgery” . However, widespread interest lagged until recent technological advances in laparoscopic equipment allowed for easier applications of standard laparoscopic surgical techniques through very closely placed ports. King (Stephanie A. King, personal communication) with Curcillo and other colleagues, has been performing single-incision BSO and other procedures since 2007 [6, 7].
Patients and methods
A 48-year-old nulligravid women with a body mass index of 43 kg/m2 had large fibroids, with menorrhagia, pelvic pressure, and urinary frequency. Exam suggested that the uterus was about 16 weeks in gestational size, and ultrasound demonstrated uterine fibroids, with normal ovaries. The TLH/BSO/appendectomy took 176 min, with 200 cm3 of measured blood loss. The uterus weighed 535 g and contained only benign leiomyomata uteri. The patient was discharged home the following day and recovered without complication.
Single-incision laparoscopic surgery may theoretically result in less pain for the patient, but prospective data are needed to justify the extra challenges to the surgeons. Multiple challenges to success of this technique exist.
Patient selection for the first cases should include only those who could be completed as a standard four-port TLH. These two patients were comparable to those in the series of 830 patients published by the author in 2006. Their mean age was 50 years, parity was 1.3, body mass index was 28 kg/m2, duration of surgery was 132 min, estimated blood loss was 130 cm3, uterine weight was 160 g, hospital stay was 1 day, and serious complication rate was 4.7% in series (none in these two patients) were similar .
The procedure is technically much more difficult to perform due to motion limitations of the laparoscopic equipment at the port sites. Surgeons in both cases above noted that their hands on the instrument and scope handles frequently competed for optimal functional locations during the surgery due to the proximity of the three ports in the umbilical incision. They devised a collaboration that allowed the visual focus of the surgery on the monitor to be at the side of the large picture, instead of in the middle of the monitor picture, allowing the operative hands slightly more room to operate.
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