European Journal of Obstetrics & Gynecology and Reproductive Biology 181 (2014) 200–204
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Single port laparoscopic myomectomy with intracorporeal suture-tying and transumbilical morcellation§ Jung Ryeol Lee a,b, Ji Hyun Lee a, Ju Yeong Kim a, Hye Jin Chang c, Chang Suk Suh a,b,*, Seok Hyun Kim b a
Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam 463-707, Republic of Korea Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul 110-744, Republic of Korea c Health Promotion Center, Seoul National University Bundang Hospital, Seongnam 463-707, Republic of Korea b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 14 September 2013 Received in revised form 23 March 2014 Accepted 30 July 2014
Objective: To evaluate the feasibility of single-port laparoscopic myomectomy (SPLM) with intracoporeal suture-tying and transumbilical morcellation. Study design: We retrospectively reviewed the medical records of 100 consecutive women who underwent SPLM without any combined surgery between January 2010 and July 2011. The medical records were reviewed and the clinical outcomes were analyzed. Single port entry was established using a wound retractor and a surgical glove. After myoma was enucleated from myometrium, intracorporeal suturing and knot tying was done for myometrium repair. Enucleated myoma was extracted through umbilicus using tissue morcellator. Factors investigated included operation time, blood loss, postoperative hospital stay and complications. Results: Mean patient age and BMI were 40.4 7.1 years and 23.1 3.5 kg/m2. Mean diameter of largest myoma and number of myomas were 6.6 2.2 (range 2–12) cm and 1.6 1.2 (range 1–7), respectively. Mean weight of myoma was 136.9 118.4 (range 4–684) g. Type of the main myomas were intramural (80/ 100), submucosal (5/100), subserosal (12/100), and intraligamentary (3/100). Location of the main myomas were anterior (36/100), posterior (24/100), fundal (30/100), and lateral (10/100). Mean operation time and estimated blood loss were 116.3 36.8 min and 94.6 74.5 mL. Mean hospital stay after the operation was 2 0.4 days. Conversion to double port surgery (one more trocar inserted on suprapubic site) was occurred in 1 patient due to severe pelvic adhesion. No patient experienced major complications, including bowel, ureter, or bladder injuries, or incisional hernia. Conclusion: SPLM is safe and acceptable for various myoma sites and sizes up to 12 cm. Intracorporeal suture-tying and transumbilical morcellation are key technical points of SPLM. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Single port laparoscopy Myomectomy Minimally invasive surgery Myoma
Introduction Uterine myomas, occurring in 20–40% of women of reproductive age, are the most common benign tumors of the female genital tract [1]. Careful pathological examination of surgical specimens suggests that the prevalence is as high as 77% [2]. Myomas can
§ This work was conducted at Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea. * Corresponding author at: Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam 463-707, Republic of Korea. Tel.: +82 31 787 7251; fax: +82 31 787 4054. E-mail address: [email protected] (C.S. Suh).
http://dx.doi.org/10.1016/j.ejogrb.2014.07.051 0301-2115/ß 2014 Elsevier Ireland Ltd. All rights reserved.
cause menorrhagia, pelvic pain, dysmenorrhea, dyspareunia, and urinary symptoms. They are also associated with infertility [3,4]. Surgical treatment is the main mode of therapy for symptomatic myomas despite the recent introduction of non-surgical treatments such as myolysis and uterine artery embolization Medical treatment can only temporarily reduce myoma size; thus, it usually used for preoperative management or for perimenopausal women for whom menopause is expected soon. Myomectomy is a treatment option for women who desire future fertility or wish to retain the uterus. Recently, various minimally invasive surgical techniques have been developed, resulting in an increased trend toward less invasive surgery. A reduced number of trocar insertion sites and scars in surgeries is an example of this trend. Single port
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laparoscopic surgery (SPLS) through one umbilical incision was also recently developed. This technique has been adopted to various adnexal and uterine surgeries, and initial reports on this novel technique have been published [5–9]. However, SPLS has not been widely performed because of its technical difficulties including limited motion and crashing between instruments. Moreover, single port laparoscopic myomectomy (SPLM) has more difficulties than other operations because it requires much suturing and knot tying as well as extraction of relatively larger tissue specimens through the umbilicus. There have been a few reports on SPLM [10–13], but most of those studies included small numbers of cases, and intracorporeal knot tying and transumbilical morcellation using an automated morcellator were partially performed in only one report [10]. We recently successfully performed SPLM with intracorporeal suturing and knot tying using the same technique as that in conventional multi-port laparoscopic myomectomy. Extracted myomas were removed through the umbilicus using an automated tissue morcellator. The objectives of this study were to evaluate the feasibility of SPLM using intracorporeal suturing, knot tying, and transumbilical morcellation and discuss the technical points of SPLM. Materials and methods Subjects A total of 100 consecutive women who underwent SPLM without any combined surgery from January 2010 to July 2011 were included. The medical records and recorded operation videos were reviewed and the clinical outcomes were analyzed. This study was approved by the institutional review board of Seoul National University Bundang Hospital. All SPLM procedures were performed by one of the two surgeons (J.R. Lee and C.S. Suh). Preoperative history taking, pelvic examinations, and routine preoperative studies including complete blood count, chemistry, electrolytes, and coagulation tests; chest radiography; and electrocardiography were performed in all patients. Indications for myomectomy included women with symptomatic myomas who were of reproductive age or wanted to conserve their uterus. Operative techniques Each operation was performed under general anesthesia with the patient in a lithotomy position. After skin sterilization and patient draping, a uterine manipulator (Rumi System; Cooper Surgical, Trumbull, CT, USA) was inserted into the uterine cavity. Single port entry was established using a wound retractor and a surgical glove (Fig. 1). Using the open Hassan technique, a 2-cm vertical incision was made within the umbilicus and a wound retractor (Alexis, X-small; Applied Medical, Rancho Santa Margarita, CA, USA) was inserted into the opened umbilicus. Two 5-mm trocars and one 11-mm trocar were inserted through first, third, and fifth fingers of the surgical glove and tied, and the glove was draped around the outer ring of the wound retractor. An 11-mm trocar was inserted into the finger on operator’s side and used for the 10-mm devices such as a myoma screw. A rigid 08 laparoscope was used and inserted through the 5-mm trocar on the assistant’s side. Most procedures were performed using conventional rigid laparoscopic instruments and an articulating device (Real Hand; Novare Surgical Systems, Cupertino, CA, USA or Autonomy LaparoAngle; Cambridge Endo, Framingham, MA, USA) was used to perform the intracorporeal knot-tying. The overall procedure was the same as the conventional multiport laparoscopic myomectomy (Fig. 2). After the injection of
Fig. 1. Single-port entry system using a wound retractor and a surgical glove.
a vasoconstricting agent, an incision was made vertically to the myometrium using monopolar scissors or an ultrasonic cutting device (Harmonic Scalpel; Ethicon Endo-Surgery, Cincinnati, OH, USA) and was deepened until the myoma surface appeared. Myoma enucleation was carried out with traction using a 10-mm myoma screw or claw forceps and the capsule was separated from the myoma using 5-mm forceps. After myoma enucleation, the myometrium was repaired with either 1 or 2 layers. Intracorporeal suture-tying was done using conventional and articulating laparoscopic instruments. The long end of the thread was wrapped around the bent articulating device and short end was pulled thorough with the articulating device. This technique is actually the same as that used for conventional laparoscopic surgery with a triangulation made by a vertically bent device tip (Fig. 3). After the myometrium repair was completed, the enucleated myomas were extracted through the umbilicus using the 15-mm electromechanical morcellator (X-Tract; Ethicon Inc., Somerville, NJ, USA) inserted through 1 free finger of the surgical glove. After irrigation with normal saline, an adhesion barrier (Interceed; Ethicon Inc.) was applied. The peritoneum and fascia were closed with a 2–0 Vicryl suture and the skin was closed by a vertical mattress suture using 3–0 Nylon on 2 points. Results Mean patient age and body mass index were 40.4 7.1 years and 23.1 3.5 kg/m2. Indications of myomectomy were symptoms due to myomas and increasing size. The mean diameter of the largest myoma and the mean number of myomas were 6.6 2.2 (range, 2– 12) cm and 1.6 1.2 (range, 1–7), respectively. Mean myoma weight was 136.9 118.4 (range, 4–684) g. Type of the main myomas were intramural (80/100), submucosal (5/100), subserosal (12/100), and intraligamentary (3/100). Location of the main myomas were anterior (36/100), posterior (24/100), fundal (30/100), and lateral (10/100).
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Fig. 2. Techniques for single-port laparoscopic myomectomy. (a) Incision of myometrium with ultrasonic cutting device, (b) enucleation of myoma with 10-mm myoma screw and forceps, (c) suturing of myometrium with rigid needle holder, (d) morcellation of myoma with 15-mm tissue morcellator.
Mean operation time and estimated blood loss were 116.3 36.8 min and 94.6 74.5 mL, respectively. No patient required an intraoperative transfusion. The mean decreases in hemoglobin concentration on postoperative day 1 and hospital stay after the operation were 1.8 1.1 g/dL and 2.0 0.4 days, respectively. Conversion to double port surgery (one more trocar inserted into the suprapubic site) was required in one patient because of severe pelvic adhesion. No patient experienced any major complications, including bowel, ureter, or bladder injuries, or incisional hernia. Other postoperative complications occurred in three patients (voiding difficulty on postoperative day 1, thigh numbness, and wound discharge) (Tables 1 and 2). Among 100 women, 3 women became pregnant after the operation. Each of these patients delivered their babies at full term by cesarean section without any complications. Comment Many studies have recently demonstrated the feasibility of SPLS in various gynecologic operations including ovarian cystectomy, salpingectomy, hysterectomy, and myomectomy [5–10]. In addition, several retrospective comparative studies and randomized controlled trials showed that SPLS has comparable and even better surgical outcomes than conventional laparoscopic myomectomy, with respect to postoperative pain, operation time, blood loss, and length of hospital stay [14–17]. In the present study, SPLM showed acceptable surgical outcomes for operation time, blood loss, length of hospital stay, and complications. Safe pregnancy outcomes were
also seen after the operations, although the number of pregnant women was small. According to the findings from previous studies on other gynecologic operations, SPLM presumably has more beneficial outcomes than conventional laparoscopic myomectomy, although comparative data are not yet available. SPLS is an attempt to further enhance the cosmetic benefits of conventional laparoscopic surgery while minimizing the potential morbidity associated with multiple incisions, such as bleeding, infection, concordant organ damage, and hernia formation [18]. One of the most certain and important advantages of SPLS is its cosmetic benefits [19]. The cosmetic benefit of SPLM exceeds that of other single port operations because conventional laparoscopic myomectomy results in a larger (12–15 mm) scar on the lower abdomen due to tissue morcellation. The larger trocar insertion on the lower abdomen could increase the potential morbidity associated with ancillary trocar insertion in laparoscopic myomectomy. For example, incisional hernias most frequently develop on larger extraumbilical trocar sites [20–22]. Therefore, SPLM has more advantages in addition to the other benefits of SPLS compared to conventional laparoscopic surgery. The two technical challenges of SPLM are suture-tying and the extraction of large amounts of tissue through the umbilicus. Several suture-tying techniques, such as the one-hand tying and the rolling threads technique, have been introduced for SPLS, however, their application is not easy because special techniques are necessary for this procedure, and making a double-turn tie is much more difficult [10,23]. In the present study, tying was performed using an articulating device; triangulation can be made between rigid and vertically bent instruments (Fig. 3). This
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Table 2 Operation outcomes of single-port laparoscopic myomectomy.
a
Operation time (min) Estimated blood loss (mL) Hb drop (g/dL)a Postoperative hospital stay (days) Conversion to multi-port surgery Intraoperative complications Postoperative complicationsb
Mean S.D.
Median (range)
116.3 36.8 94.6 74.5 1.8 1.1 2.0 0.4
114 (27–245) 100 (10–500) 1.8 ( 1.4–4.9) 2 (1–4) 1/100 (1%) 0 3
S.D.: standard deviation. a The data are normally distributed. b Post-op complications were: voiding difficulty on postoperative one day, thigh numbness, and wound discharge.
Fig. 3. (a) and (b) Knot-tying technique using articulating device. One end of thread wrapped around the vertically bended articulating device.
technique is actually the same as that used in conventional laparoscopic surgery with a triangulation made between devices from the lower quadrant and suprapubic ancillary ports. Morcellation and extraction of enucleated myoma were performed using a 15-mm tissue morcellator through a free finger of the surgical glove. Trocars were not used to insert devices with relatively large diameters in order to minimize crashing between the morcellator and the telescope. After the tissue is removed through a morcellator, the remaining myoma chips can be extracted though Table 1 Clinical characteristics of patients. Mean S.D. a
40.4 7.1 Age (years) BMI (kg/m2) 23.1 3.5 Number of myoma 1.6 1.2 Largest myoma size (cm) 6.6 2.2 Weight of specimen (g) 136.9 118.4 Type and size of largest myoma Intramural (80/100) 6.6 2.2 Subserosal (12/100) 8.1 1.7 Submucosal (5/100) 3.6 1.2 Intraligamentary (3/100) 5.7 1.2 Location and size of largest myoma Anterior (36/100) 6.2 2.1 Posterior (24/100) 6.1 2.1 Fundal (30/100) 7.6 2.2 Lateral (10/100) 6.3 2.3 S.D.: standard deviation, BMI: body mass index. a The data are normally distributed.
Median (range) 41 (21–55) 22.6 (17.1–39.5) 1 (1–7) 6.5 (2.0–12.0) 110 (4–684) 6.2 7.8 4.0 5.0
(3.0–12.0) (6.0–12.0) (2.0–5.0) (5.0–7.0)
6.0 6.0 7.3 5.9
(2.0–12.0) (3.0–11.0) (3.0–12.0) (4.0–12.0)
an 11-mm trocar or a free finger without detachment of the surgical glove. The free finger channel was clamped with a mosquito clamp for gas sealing after its use. Using this technique, even large myomas could be easily extracted another technical tip for SPLM involves making an incision into the myometrium and the myoma capsule that is deep enough to expose the myoma itself. After an adequately deep incision is made, strong traction using a 10mm myoma screw can help separate the myoma from the surrounding capsule to enable easy removal of the myoma from the peeling capsule using forceps. We used a wound retractor-glove system for single port entry. This system provides a more flexible fulcrum for inserting and manipulating a telescope and instruments with minimal clashing; thus it would make more difficult techniques such as suturetying easier to perform through a single port [13]. The multiple fingers of the glove functioned as multiport channels for device entry and tissue removal. Thus this system has five channels and two free fingers can be used for larger device entry and removal of larger tissue than diameter of trocars already attached. Additionally, in contrast with commercial systems, the fourth and fifth channels (free fingers) do not crash with the other channels when not in use because no trocar is used within them. In this system, the glove and trocars are located only outside of the body and there is nothing inside the body. This feature can minimize clashes between the devices because there is nothing to occupy space and to disturb movement of the devices inside of the body. This benefit is obvious if the wound retractor-glove system is compared with other commercial entry system such as SILS Port (Covidien, Norwalk, CT, USA) in which, foam sponge and trocars are located in umbilicus and inside of the body. This foam sponge and trocars can occupy space and reduce motion range of devices. Many commercial single port systems are currently available, but the wound retractor-glove system still has its benefits for SPLS, especially SPLM. There was no significant technical difference according to myoma location. In SPLM, all devices are inserted through umbilicus (usually above enough from the uterus) and this make the approaches of the devices similar in most cases even the myoma location is different. In other words, whether the location of myoma is anterior, posterior, left or right does not make significant difference unless the myoma size is huge and the highest part of the myoma is near or above umbilicus. In contrast, during conventional laparoscopic myomectomy, devices are inserted through ancillary trocar sites in lower abdomen and the operation procedure is more dependent on myoma location than SPLM. In conclusion, SPLM is safe and acceptable for various myoma sites and sizes up to 12 cm. Intracorporeal suture-tying and transumbilical morcellation are key technical points of SPLM. A comparative study with a control group of patients who underwent conventional laparoscopic myomectomy is necessary to confirm the comparability of SPLM.
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Acknowledgments This study was supported by a grant of the Korea Healthcare Technology R&D Project, Ministry of Health & Welfare, Republic of Korea. (Grant No.: HI12C0055) References [1] Wallach EE, Vlahos NF. Uterine myomas: an overview of development, clinical features, and management. Obstet Gynecol 2004;104:393–406. [2] Stewart EA. Uterine fibroids. Lancet 2001;357:293–8. [3] Parker WH. Etiology, symptomatology, and diagnosis of uterine myomas. Fertil Steril 2007;87:725–36. [4] Practice Committee of American Society for Reproductive Medicine. Society of Reproductive Surgeons. Myomas and reproductive function. Fertil Steril 2008;90:S125–30. [5] Yoon BS, Park H, Seong SJ, Park CT, Park SW, Lee KJ. Single-port laparoscopic salpingectomy for the surgical treatment of ectopic pregnancy. J Minim Invasive Gynecol 2010;17:26–9. [6] Kim TJ, Lee YY, Kim MJ, et al. Single port access laparoscopic adnexal surgery. J Minim Invasive Gynecol 2009;16:612–5. [7] Lee YY, Kim TJ, Kim CJ, et al. Single-port access laparoscopic-assisted vaginal hysterectomy: a novel method with a wound retractor and a glove. J Minim Invasive Gynecol 2009;16:450–3. [8] Fader AN, Escobar PF. Laparoendoscopic single-site surgery (LESS) in gynecologic oncology: technique and initial report. Gynecol Oncol 2009;114:157–61. [9] Escobar PF, Bedaiwy MA, Fader AN, Falcone T. Laparoendoscopic single-site (LESS) surgery in patients with benign adnexal disease. Fertil Steril 2010;93:2074.e7–2074.e10. [10] Kim YW, Park BJ, Ro DY, Kim TE. Single-port laparoscopic myomectomy using a new single-port transumbilical morcellation system: initial clinical study. J Minim Invasive Gynecol 2010;17:587–92. [11] Einarsson JI. Single-incision laparoscopic myomectomy. J Minim Invasive Gynecol 2010;17:371–3.
[12] Lee JH, Choi JS, Jeon SW, Son CE, Lee SJ, Lee YS. Single-port laparoscopic myomectomy using transumbilical GelPort access. Eur J Obstet Gynecol Reprod Biol 2010;153:81–4. [13] Yoshiki N, Okawa T, Kubota T. Single-incision laparoscopic myomectomy with intracorporeal suturing. Fertil Steril 2011;95:2426–8. [14] Lee YY, Kim TJ, Kim CJ, et al. Single port access laparoscopic adnexal surgery versus conventional laparoscopic adnexal surgery: a comparison of perioperative outcomes. Eur J Obstet Gynecol Reprod Biol 2010;151: 181–4. [15] Kim TJ, Lee YY, Cha HH, et al. Single-port-access laparoscopic-assisted vaginal hysterectomy versus conventional laparoscopic-assisted vaginal hysterectomy: a comparison of perioperative outcomes. Surg Endosc 2010;24: 2248–52. [16] Yim GW, Jung YW, Paek J, et al. Transumbilical single-port access versus conventional total laparoscopic hysterectomy: surgical outcomes. Am J Obstet Gynecol 2010;203:26 e1–e266. [17] Fagotti A, Bottoni C, Vizzielli G, 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. [18] Escobar PF, Starks D, Fader AN, Catenacci M, Falcone T. Laparoendoscopic single-site and natural orifice surgery in gynecology. Fertil Steril 2010;94:2497–502. [19] Eom JM, Ko JH, Choi JS, Hong JH, Lee JH. A comparative cross-sectional study on cosmetic outcomes after single port or conventional laparoscopic surgery. Eur J Obstet Gynecol Reprod Biol 2013;167:104–9. [20] Boike GM, Miller CE, Spirtos NM, et al. Incisional bowel herniations after operative laparoscopy: a series of nineteen cases and review of the literature. Am J Obstet Gynecol 1995;172:1726–31. discussion 31-3. [21] Kadar N, Reich H, Liu CY, Manko GF, Gimpelson R. Incisional hernias after major laparoscopic gynecologic procedures. Am J Obstet Gynecol 1993;168: 1493–5. [22] Ghezzi F, Cromi A, Uccella S, Siesto G, Bergamini V, Bolis P. Transumbilical surgical specimen retrieval: a viable refinement of laparoscopic surgery for pelvic masses. BJOG 2008;115:1316–20. [23] Thanakumar J, John PH. One-handed knot tying technique in single-incision laparoscopic surgery. J Minimal Access Surg 2011;7:112–5.
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Single port laparoscopic myomectomy with intracorporeal suture-tying and transumbilical morcellation§ Jung Ryeol Lee a,b, Ji Hyun Lee a, Ju Yeong Kim a, Hye Jin Chang c, Chang Suk Suh a,b,*, Seok Hyun Kim b a
Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam 463-707, Republic of Korea Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul 110-744, Republic of Korea c Health Promotion Center, Seoul National University Bundang Hospital, Seongnam 463-707, Republic of Korea b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 14 September 2013 Received in revised form 23 March 2014 Accepted 30 July 2014
Objective: To evaluate the feasibility of single-port laparoscopic myomectomy (SPLM) with intracoporeal suture-tying and transumbilical morcellation. Study design: We retrospectively reviewed the medical records of 100 consecutive women who underwent SPLM without any combined surgery between January 2010 and July 2011. The medical records were reviewed and the clinical outcomes were analyzed. Single port entry was established using a wound retractor and a surgical glove. After myoma was enucleated from myometrium, intracorporeal suturing and knot tying was done for myometrium repair. Enucleated myoma was extracted through umbilicus using tissue morcellator. Factors investigated included operation time, blood loss, postoperative hospital stay and complications. Results: Mean patient age and BMI were 40.4 7.1 years and 23.1 3.5 kg/m2. Mean diameter of largest myoma and number of myomas were 6.6 2.2 (range 2–12) cm and 1.6 1.2 (range 1–7), respectively. Mean weight of myoma was 136.9 118.4 (range 4–684) g. Type of the main myomas were intramural (80/ 100), submucosal (5/100), subserosal (12/100), and intraligamentary (3/100). Location of the main myomas were anterior (36/100), posterior (24/100), fundal (30/100), and lateral (10/100). Mean operation time and estimated blood loss were 116.3 36.8 min and 94.6 74.5 mL. Mean hospital stay after the operation was 2 0.4 days. Conversion to double port surgery (one more trocar inserted on suprapubic site) was occurred in 1 patient due to severe pelvic adhesion. No patient experienced major complications, including bowel, ureter, or bladder injuries, or incisional hernia. Conclusion: SPLM is safe and acceptable for various myoma sites and sizes up to 12 cm. Intracorporeal suture-tying and transumbilical morcellation are key technical points of SPLM. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Single port laparoscopy Myomectomy Minimally invasive surgery Myoma
Introduction Uterine myomas, occurring in 20–40% of women of reproductive age, are the most common benign tumors of the female genital tract [1]. Careful pathological examination of surgical specimens suggests that the prevalence is as high as 77% [2]. Myomas can
§ This work was conducted at Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea. * Corresponding author at: Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam 463-707, Republic of Korea. Tel.: +82 31 787 7251; fax: +82 31 787 4054. E-mail address: [email protected] (C.S. Suh).
http://dx.doi.org/10.1016/j.ejogrb.2014.07.051 0301-2115/ß 2014 Elsevier Ireland Ltd. All rights reserved.
cause menorrhagia, pelvic pain, dysmenorrhea, dyspareunia, and urinary symptoms. They are also associated with infertility [3,4]. Surgical treatment is the main mode of therapy for symptomatic myomas despite the recent introduction of non-surgical treatments such as myolysis and uterine artery embolization Medical treatment can only temporarily reduce myoma size; thus, it usually used for preoperative management or for perimenopausal women for whom menopause is expected soon. Myomectomy is a treatment option for women who desire future fertility or wish to retain the uterus. Recently, various minimally invasive surgical techniques have been developed, resulting in an increased trend toward less invasive surgery. A reduced number of trocar insertion sites and scars in surgeries is an example of this trend. Single port
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laparoscopic surgery (SPLS) through one umbilical incision was also recently developed. This technique has been adopted to various adnexal and uterine surgeries, and initial reports on this novel technique have been published [5–9]. However, SPLS has not been widely performed because of its technical difficulties including limited motion and crashing between instruments. Moreover, single port laparoscopic myomectomy (SPLM) has more difficulties than other operations because it requires much suturing and knot tying as well as extraction of relatively larger tissue specimens through the umbilicus. There have been a few reports on SPLM [10–13], but most of those studies included small numbers of cases, and intracorporeal knot tying and transumbilical morcellation using an automated morcellator were partially performed in only one report [10]. We recently successfully performed SPLM with intracorporeal suturing and knot tying using the same technique as that in conventional multi-port laparoscopic myomectomy. Extracted myomas were removed through the umbilicus using an automated tissue morcellator. The objectives of this study were to evaluate the feasibility of SPLM using intracorporeal suturing, knot tying, and transumbilical morcellation and discuss the technical points of SPLM. Materials and methods Subjects A total of 100 consecutive women who underwent SPLM without any combined surgery from January 2010 to July 2011 were included. The medical records and recorded operation videos were reviewed and the clinical outcomes were analyzed. This study was approved by the institutional review board of Seoul National University Bundang Hospital. All SPLM procedures were performed by one of the two surgeons (J.R. Lee and C.S. Suh). Preoperative history taking, pelvic examinations, and routine preoperative studies including complete blood count, chemistry, electrolytes, and coagulation tests; chest radiography; and electrocardiography were performed in all patients. Indications for myomectomy included women with symptomatic myomas who were of reproductive age or wanted to conserve their uterus. Operative techniques Each operation was performed under general anesthesia with the patient in a lithotomy position. After skin sterilization and patient draping, a uterine manipulator (Rumi System; Cooper Surgical, Trumbull, CT, USA) was inserted into the uterine cavity. Single port entry was established using a wound retractor and a surgical glove (Fig. 1). Using the open Hassan technique, a 2-cm vertical incision was made within the umbilicus and a wound retractor (Alexis, X-small; Applied Medical, Rancho Santa Margarita, CA, USA) was inserted into the opened umbilicus. Two 5-mm trocars and one 11-mm trocar were inserted through first, third, and fifth fingers of the surgical glove and tied, and the glove was draped around the outer ring of the wound retractor. An 11-mm trocar was inserted into the finger on operator’s side and used for the 10-mm devices such as a myoma screw. A rigid 08 laparoscope was used and inserted through the 5-mm trocar on the assistant’s side. Most procedures were performed using conventional rigid laparoscopic instruments and an articulating device (Real Hand; Novare Surgical Systems, Cupertino, CA, USA or Autonomy LaparoAngle; Cambridge Endo, Framingham, MA, USA) was used to perform the intracorporeal knot-tying. The overall procedure was the same as the conventional multiport laparoscopic myomectomy (Fig. 2). After the injection of
Fig. 1. Single-port entry system using a wound retractor and a surgical glove.
a vasoconstricting agent, an incision was made vertically to the myometrium using monopolar scissors or an ultrasonic cutting device (Harmonic Scalpel; Ethicon Endo-Surgery, Cincinnati, OH, USA) and was deepened until the myoma surface appeared. Myoma enucleation was carried out with traction using a 10-mm myoma screw or claw forceps and the capsule was separated from the myoma using 5-mm forceps. After myoma enucleation, the myometrium was repaired with either 1 or 2 layers. Intracorporeal suture-tying was done using conventional and articulating laparoscopic instruments. The long end of the thread was wrapped around the bent articulating device and short end was pulled thorough with the articulating device. This technique is actually the same as that used for conventional laparoscopic surgery with a triangulation made by a vertically bent device tip (Fig. 3). After the myometrium repair was completed, the enucleated myomas were extracted through the umbilicus using the 15-mm electromechanical morcellator (X-Tract; Ethicon Inc., Somerville, NJ, USA) inserted through 1 free finger of the surgical glove. After irrigation with normal saline, an adhesion barrier (Interceed; Ethicon Inc.) was applied. The peritoneum and fascia were closed with a 2–0 Vicryl suture and the skin was closed by a vertical mattress suture using 3–0 Nylon on 2 points. Results Mean patient age and body mass index were 40.4 7.1 years and 23.1 3.5 kg/m2. Indications of myomectomy were symptoms due to myomas and increasing size. The mean diameter of the largest myoma and the mean number of myomas were 6.6 2.2 (range, 2– 12) cm and 1.6 1.2 (range, 1–7), respectively. Mean myoma weight was 136.9 118.4 (range, 4–684) g. Type of the main myomas were intramural (80/100), submucosal (5/100), subserosal (12/100), and intraligamentary (3/100). Location of the main myomas were anterior (36/100), posterior (24/100), fundal (30/100), and lateral (10/100).
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Fig. 2. Techniques for single-port laparoscopic myomectomy. (a) Incision of myometrium with ultrasonic cutting device, (b) enucleation of myoma with 10-mm myoma screw and forceps, (c) suturing of myometrium with rigid needle holder, (d) morcellation of myoma with 15-mm tissue morcellator.
Mean operation time and estimated blood loss were 116.3 36.8 min and 94.6 74.5 mL, respectively. No patient required an intraoperative transfusion. The mean decreases in hemoglobin concentration on postoperative day 1 and hospital stay after the operation were 1.8 1.1 g/dL and 2.0 0.4 days, respectively. Conversion to double port surgery (one more trocar inserted into the suprapubic site) was required in one patient because of severe pelvic adhesion. No patient experienced any major complications, including bowel, ureter, or bladder injuries, or incisional hernia. Other postoperative complications occurred in three patients (voiding difficulty on postoperative day 1, thigh numbness, and wound discharge) (Tables 1 and 2). Among 100 women, 3 women became pregnant after the operation. Each of these patients delivered their babies at full term by cesarean section without any complications. Comment Many studies have recently demonstrated the feasibility of SPLS in various gynecologic operations including ovarian cystectomy, salpingectomy, hysterectomy, and myomectomy [5–10]. In addition, several retrospective comparative studies and randomized controlled trials showed that SPLS has comparable and even better surgical outcomes than conventional laparoscopic myomectomy, with respect to postoperative pain, operation time, blood loss, and length of hospital stay [14–17]. In the present study, SPLM showed acceptable surgical outcomes for operation time, blood loss, length of hospital stay, and complications. Safe pregnancy outcomes were
also seen after the operations, although the number of pregnant women was small. According to the findings from previous studies on other gynecologic operations, SPLM presumably has more beneficial outcomes than conventional laparoscopic myomectomy, although comparative data are not yet available. SPLS is an attempt to further enhance the cosmetic benefits of conventional laparoscopic surgery while minimizing the potential morbidity associated with multiple incisions, such as bleeding, infection, concordant organ damage, and hernia formation [18]. One of the most certain and important advantages of SPLS is its cosmetic benefits [19]. The cosmetic benefit of SPLM exceeds that of other single port operations because conventional laparoscopic myomectomy results in a larger (12–15 mm) scar on the lower abdomen due to tissue morcellation. The larger trocar insertion on the lower abdomen could increase the potential morbidity associated with ancillary trocar insertion in laparoscopic myomectomy. For example, incisional hernias most frequently develop on larger extraumbilical trocar sites [20–22]. Therefore, SPLM has more advantages in addition to the other benefits of SPLS compared to conventional laparoscopic surgery. The two technical challenges of SPLM are suture-tying and the extraction of large amounts of tissue through the umbilicus. Several suture-tying techniques, such as the one-hand tying and the rolling threads technique, have been introduced for SPLS, however, their application is not easy because special techniques are necessary for this procedure, and making a double-turn tie is much more difficult [10,23]. In the present study, tying was performed using an articulating device; triangulation can be made between rigid and vertically bent instruments (Fig. 3). This
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Table 2 Operation outcomes of single-port laparoscopic myomectomy.
a
Operation time (min) Estimated blood loss (mL) Hb drop (g/dL)a Postoperative hospital stay (days) Conversion to multi-port surgery Intraoperative complications Postoperative complicationsb
Mean S.D.
Median (range)
116.3 36.8 94.6 74.5 1.8 1.1 2.0 0.4
114 (27–245) 100 (10–500) 1.8 ( 1.4–4.9) 2 (1–4) 1/100 (1%) 0 3
S.D.: standard deviation. a The data are normally distributed. b Post-op complications were: voiding difficulty on postoperative one day, thigh numbness, and wound discharge.
Fig. 3. (a) and (b) Knot-tying technique using articulating device. One end of thread wrapped around the vertically bended articulating device.
technique is actually the same as that used in conventional laparoscopic surgery with a triangulation made between devices from the lower quadrant and suprapubic ancillary ports. Morcellation and extraction of enucleated myoma were performed using a 15-mm tissue morcellator through a free finger of the surgical glove. Trocars were not used to insert devices with relatively large diameters in order to minimize crashing between the morcellator and the telescope. After the tissue is removed through a morcellator, the remaining myoma chips can be extracted though Table 1 Clinical characteristics of patients. Mean S.D. a
40.4 7.1 Age (years) BMI (kg/m2) 23.1 3.5 Number of myoma 1.6 1.2 Largest myoma size (cm) 6.6 2.2 Weight of specimen (g) 136.9 118.4 Type and size of largest myoma Intramural (80/100) 6.6 2.2 Subserosal (12/100) 8.1 1.7 Submucosal (5/100) 3.6 1.2 Intraligamentary (3/100) 5.7 1.2 Location and size of largest myoma Anterior (36/100) 6.2 2.1 Posterior (24/100) 6.1 2.1 Fundal (30/100) 7.6 2.2 Lateral (10/100) 6.3 2.3 S.D.: standard deviation, BMI: body mass index. a The data are normally distributed.
Median (range) 41 (21–55) 22.6 (17.1–39.5) 1 (1–7) 6.5 (2.0–12.0) 110 (4–684) 6.2 7.8 4.0 5.0
(3.0–12.0) (6.0–12.0) (2.0–5.0) (5.0–7.0)
6.0 6.0 7.3 5.9
(2.0–12.0) (3.0–11.0) (3.0–12.0) (4.0–12.0)
an 11-mm trocar or a free finger without detachment of the surgical glove. The free finger channel was clamped with a mosquito clamp for gas sealing after its use. Using this technique, even large myomas could be easily extracted another technical tip for SPLM involves making an incision into the myometrium and the myoma capsule that is deep enough to expose the myoma itself. After an adequately deep incision is made, strong traction using a 10mm myoma screw can help separate the myoma from the surrounding capsule to enable easy removal of the myoma from the peeling capsule using forceps. We used a wound retractor-glove system for single port entry. This system provides a more flexible fulcrum for inserting and manipulating a telescope and instruments with minimal clashing; thus it would make more difficult techniques such as suturetying easier to perform through a single port [13]. The multiple fingers of the glove functioned as multiport channels for device entry and tissue removal. Thus this system has five channels and two free fingers can be used for larger device entry and removal of larger tissue than diameter of trocars already attached. Additionally, in contrast with commercial systems, the fourth and fifth channels (free fingers) do not crash with the other channels when not in use because no trocar is used within them. In this system, the glove and trocars are located only outside of the body and there is nothing inside the body. This feature can minimize clashes between the devices because there is nothing to occupy space and to disturb movement of the devices inside of the body. This benefit is obvious if the wound retractor-glove system is compared with other commercial entry system such as SILS Port (Covidien, Norwalk, CT, USA) in which, foam sponge and trocars are located in umbilicus and inside of the body. This foam sponge and trocars can occupy space and reduce motion range of devices. Many commercial single port systems are currently available, but the wound retractor-glove system still has its benefits for SPLS, especially SPLM. There was no significant technical difference according to myoma location. In SPLM, all devices are inserted through umbilicus (usually above enough from the uterus) and this make the approaches of the devices similar in most cases even the myoma location is different. In other words, whether the location of myoma is anterior, posterior, left or right does not make significant difference unless the myoma size is huge and the highest part of the myoma is near or above umbilicus. In contrast, during conventional laparoscopic myomectomy, devices are inserted through ancillary trocar sites in lower abdomen and the operation procedure is more dependent on myoma location than SPLM. In conclusion, SPLM is safe and acceptable for various myoma sites and sizes up to 12 cm. Intracorporeal suture-tying and transumbilical morcellation are key technical points of SPLM. A comparative study with a control group of patients who underwent conventional laparoscopic myomectomy is necessary to confirm the comparability of SPLM.
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