Original Article
Laparoendoscopic Single-site Myomectomy Versus Conventional Laparoscopic Myomectomy: A Comparison of Surgical Outcomes Seul Ki Kim, MD, Ji Hyun Lee, MD, Jung Ryeol Lee, MD, PhD*, Chang Suk Suh, MD, PhD, and Seok Hyun Kim, MD, PhD From the Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea (Drs. S.K. Kim, J.H. Lee, J.R. Lee, and C.S. Suh), and Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seongnam, Korea (Drs. J.R. Lee, C.S. Suh, and S.H. Kim).
ABSTRACT Study Objective: The objective of this study was to evaluate laparoendoscopic single-site myomectomy (LESS-M) for the surgical treatment of fibroids and to compare surgical outcomes and postoperative pain with conventional laparoscopic myomectomy (CLM). Design: Retrospective study. Setting: University-based hospital. Patients: Data were obtained from medical records of patients who underwent LESS-M between August 2011 and June 2012. Considering the surgeon’s learning curve for LESS-M, we collected the data after 100 LESS-M procedures were performed. The cases were compared with a historic cohort of patients who underwent CLM performed by the same surgeon between July 2008 and May 2009. A single experienced surgeon performed both procedures in all patients. A total of 118 patients who underwent LESS-M or CLM were included in the study (59 in the LESS-M group and 59 in the CLM group). Interventions: None. Measurements and Main Results: We analyzed and compared patient basal characteristics and surgical outcomes between the 2 groups. There were no statistically significant differences in basal characteristics (i.e., age, body mass index, number and size of myomas, and type of the largest myoma) between the 2 groups. The surgical outcomes (i.e., operative time, estimated blood loss, postoperative hemoglobin drop, postoperative hospital stay, and postoperative pain scores) were not different statistically between the 2 groups. Moreover, patients did not experience major intraoperative complications. Postoperative complications were wound infections that occurred in 3 patients (2 in the LESS-M and 1 in the CLM groups). Conclusion: LESS-M is feasible for less than 5 myomas and offers comparable surgical outcomes with those of CLM after the surgeon’s initial learning curve. Journal of Minimally Invasive Gynecology (2014) -, -–- Ó 2014 AAGL. All rights reserved. Keywords:
DISCUSS
Laparoendoscopic single-site surgery; Single port; Laparoscopic myomectomy; Myomectomy; Myoma
You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-21-4-JMIG-D-13-00691
Use your Smartphone to scan this QR code and connect to the discussion forum for this article now* * Download a free QR Code scanner by searching for ‘‘QR scanner’’ in your smartphone’s app store or app marketplace.
Supported by a grant from the Korea Healthcare Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (grant no. HI12C0055). The authors declare no conflict of interest. Corresponding author: Jung Ryeol Lee, MD, PhD, Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-Gu, Seongnam, Gyeonggi-do, 463-707, Korea. E-mail: [email protected] Submitted December 20, 2013. Accepted for publication March 4, 2014. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2014 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2014.03.002
Minimally invasive procedures such as laparoscopic surgery are becoming the current trend and are improving with advances in surgical instrumentation and technique. Laparoscopic myomectomy (LM) was first reported by Semm [1] in 1979. Henceforth, several studies showed that LM has various advantages over the laparotomic and minilaparotomic approaches, including less postoperative hemoglobin drop, shorter hospital stay, and less postoperative pain [2]. Nowadays, laparoendoscopic single-site surgery (LESS) has been applied to various gynecologic operations, and
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many reports describing this technique have been published [3–5]. LESS offers excellent cosmetic results compared with those obtained using conventional multiport laparoscopic surgery [6–8]. However, LESS has not been widely performed because of its technical difficulties such as limited motion and clashing between instruments. Moreover, laparoendoscopic single-site myomectomy (LESS-M) has more difficulties than other LESSs because it requires the tying of multiple sutures and the extraction of relatively large tissue specimens through the umbilical incision. After enucleation of myomas, the repair of uterine wall defects may be challenging for surgeons with limited experience in endoscopic suturing. Difficulties in maintaining adequate tension of the suture line while suturing and knot tying may increase the operative time and intraoperative blood loss [9]. Until now, there have been few reports in the literature about the application of LESS to myomectomy [10–14]. Only 1 study comparing surgical outcomes of LESS-M with those of conventional laparoscopic myomectomy (CLM) has been performed and reported [15]. However, most of the previous studies had small samples. To assess the exact feasibility and safety of LESS for myomectomy, we performed LESS-M with intracorporeal suture tying and morcellation and compared the surgical outcomes and postoperative pain with those of CLM.
Methods Subjects This study was approved by the Institutional Review Board of Seoul National University Bundang Hospital, Seongnam, Korea. Data were obtained from medical records of patients who underwent LESS-M between August 2011 and June 2012. Considering the surgeon’s learning curve for LESS-M, we collected data after the initial 100 LESS-M procedures were performed. Medical history questionnaires and pelvic examinations were conducted preoperatively; all patients underwent routine preoperative laboratory studies. Patients were included consecutively if their LESS-M was performed by a single experienced surgeon (J.R.L.) and if they had %4 myomas on the preoperative pelvic ultrasonography. LESS-M with other combined surgery was excluded. These cases were compared with a historic cohort of 59 consecutive patients who underwent CLM performed by the same surgeon between July 2008 and May 2009. A total of 118 patients who underwent LESS-M or CLM were included in the study (59 in the LESS-M group and 59 in the CLM group). We experienced 1 conversion to multiport surgery (1 additional 5-mm trocar) from LESS-M and 1 conversion to laparotomy from CLM. Both of the conversions were caused by the presence of severe pelvic adhesions because of previous pelvic surgery. In the CLM case, after confirming adhesion with a laparoscope through the umbilical incision, we per-
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formed conversion immediately without a second insertion of a trocar. We excluded these 2 conversion cases from this analysis. Operative Techniques The operative procedures were not different between the 2 groups with the exception of port placement, laparoscope, and the devices used for suture tying. After sterilization of the skin and draping of the patient, a uterine manipulator (Rumi System; Cooper Surgical, Trumbull, CT) was inserted into the uterine cavity. For LESS-M, single-port entry was established using a wound retractor (Alexis Wound Retractor XS; Applied Medical, Santa Margarita, CA) and a surgical glove. With the open Hasson technique, a vertical incision of 1.5 to 2 cm was made within the umbilicus, and a wound retractor was inserted into the incision. Two 5-mm trocars and one 12-mm trocar were inserted through the first, third, and fifth fingers of the surgical glove and fixed with silk ligatures; then, the glove was draped around the outer ring of the wound retractor (Fig. 1). A 12-mm trocar was inserted into the glove finger on the operator’s side and was then used for 10-mm devices, such as the myoma screw. A flexible 30 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 (Autonomy LaparoAngle; Cambridge Endo, Framingham, MA) was used for intracorporeal suture tying. When surgical preparation was completed, about 10 mL of a solution containing 6 IU (0.3 mL) vasoconstrictor agent (Vasopressin; Hanlim Pharma, Seoul, Korea) and 9.7 mL normal saline was injected into the tissue adjacent to the base and the capsule of the uterine myoma. The incision was made vertically to the myometrium using monopolar scissors or an ultrasonic cutting device (Harmonic Scalpel; Ethicon Endo-Surgery, Cincinnati, OH) and deepened until the myoma surface appeared. Myoma enucleation was performed with traction using a 10-mm myoma screw or claw forceps; the separation of the capsule from the myoma was achieved using 5-mm forceps. After enucleation of myomas, the uterine muscle was closed using either a 1- or 2-layer interrupted suturing technique (Fig. 2). Intracorporeal suture tying was performed using conventional and articulating laparoscopic instruments. The long end of the thread wrapped around the bent articulating device, and the short end was pulled through with the articulating device (Fig. 3). This suture technique is actually the same as the one used for conventional laparoscopic surgery consisting of a triangulation made by the vertically bent device tip. After repair of the myometrium was completed, enucleated myomas were extracted through the umbilical incision using a 15mm electromechanical morcellator (X-Tract; Ethicon Inc., Somerville, NJ), which was inserted through 1 free finger of the surgical glove. After irrigation with normal saline, an adhesion barrier (Interceed; Ethicon Inc., or Guardix;
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Fig. 1 An external view during an LESS-M procedure. (A) Single-port entry system using a wound retractor and a surgical glove. Two 5-mm trocars and one 12mm trocar are inserted through the first, third, and fifth fingers of the glove. (B) An external view during tissue morcellation. A 15-mm electromechanical morcellator is inserted through a free finger of the glove.
Genewel Inc.) was applied. The peritoneum and fascia of the umbilicus were closed with a 2-0 Vicryl suture, and the skin was closed with a vertical mattress suture using 3-0 nylon on 2 points. For CLM, the operative procedures were not different from LESS-M with the exception of trocar placement (three 5-mm trocars placed in the intraumbilical area, the suprapubic area, and the right lateral abdominal walls and one 12-mm trocar in the left lateral abdominal wall), the laparoscope (a 5-mm 0 laparoscope), and the rigid instrument for intracorporeal suture tying. The peritoneum and fascia of the
left lateral abdominal wall were closed with 2-0 Vicryl, and the skin was closed with a vertical mattress suture using 3-0 nylon on 2 points. The skin incisions of the 5-mm trocar sites were closed with a vertical mattress suture using 3-0 nylon on 1 point. Data Analysis We analyzed patient characteristics such as age, body mass index, number and size of myomas, type of the largest myoma, and weight of the enucleated myoma specimen.
Fig. 2 Techniques for LESS-M. (A) Enucleation of myoma with a 10-mm myoma screw and forceps, (B) suturing of the myometrium with a rigid needle holder, (C) knot tying using an articulating device, and (D) morcellation of the myoma with a 15-mm tissue morcellator.
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Fig. 3 The knot-tying technique using an articulating device. One end of the thread was wrapped around the vertically bended articulating device.
Surgical outcomes such as operative time, estimated blood loss, difference between preoperative and postoperative hemoglobin (postoperative hemoglobin drop), length of postoperative hospital stay, intraoperative or postoperative complications, and numeric rating scale of postoperative pain were evaluated. The operative time was defined as the interval between skin incision and closure. Intraoperative complications, including bladder, ureter, or bowel injuries, were carefully monitored. Postoperative complications included ileus, fever, wound infection, bleeding, and blood transfusion. Postoperative pain intensity was based on the patients’ subjective reports at 1, 6, and 24 hours after the operation using a numeric rating scale from 0 to 10 in which 0 represented the absence of pain and 10 represented the presence of the most severe pain. The patients were followed up 1 week after discharge for wound inspection and confirmation of the final pathology report. At this time, all patients were also evaluated for postoperative complications such as hematoma formation, hernia at the umbilical incision site, and infection. Pregnancy outcomes were confirmed by either medical chart review or by telephone in cases in which prenatal care was being delivered at another hospital. Statistical analysis was performed using the Student’s t test for continuous variables and the chi-square test for categoric variables where appropriate. The statistical software package SPSS version 18.0 (SPSS Inc, Chicago, IL) was used, and results were considered statistically significant at p , .05. Results Patient baseline characteristics are shown in Table 1. There were no statistically significant differences among patients with respect to age, body mass index, number and size
of myomas, type of the largest myoma, and weight of the enucleated myoma specimen. The mean size of the largest myoma was 7.3 cm (range, 2.9–14.0 cm) for the LESS-M group and 6.5 cm (range, 2.5–10.0 cm) for the CLM group. The surgical outcomes such as the operative time, estimated blood loss, postoperative hemoglobin drop, and postoperative hospital stay were not statistically different between the 2 groups (Table 2). There were no intraoperative complications such as bladder or bowel injuries or the administration of blood transfusions in either group. Wound infections occurred in 3 patients (2 in the LESS-M group and 1 in the CLM group), and these were the only complications reported. No other postoperative complications such as ileus, bleeding, or the administration of blood transfusion occurred in both groups. Postoperative pain scores assessed at 1, 6, and 24 hours were not significantly different between the 2 groups. Six patients became pregnant at least once after CLM, resulting in a total of 7 pregnancies. All 7 were delivered by cesarean section; 5 of them were delivered at term, and 2 of them were delivered by emergency cesarean section because of uncontrolled preterm labor at 35 1 1 weeks and 34 1 0 weeks. In the LESS-M group, there were 2 pregnancies. One woman had a cesarean section at term; the other woman was 30 weeks’ pregnant at the time of telephone contact. All the pregnancies were free of pre- and perinatal complications, including uterine rupture. Discussion Recently, many studies showed the feasibility of LESS in various gynecologic operations. Several retrospective comparative studies and randomized controlled trials showed that LESS has comparable and even better surgical outcomes compared with conventional multiport laparoscopic surgery [16–21]. In addition, in LESS-M, the cosmetic benefits are greater than in other operations. For instance, in CLM, a large (12–15 mm) scar on the lower abdomen may remain because of the large incision needed for tissue morcellation. Moreover, the large trocar insertion made on the lower abdomen could have a higher risk of trocar-related morbidity. For example, incisional hernias most frequently develop on larger extraumbilical trocar sites [22–24]. For advances in the single-port access technique, it is crucial to compare perioperative outcomes between LESS-M and CLM. However, there has been only 1 study comparing the surgical outcomes of LESS-M and CML with a small sample size [15]. To date, the present study represents the largest study. The surgical technique could be considered standardized because all surgeries were performed by 1 surgeon. Considering the surgeon’s learning curve for LESS-M, we collected the data after the initial 100 LESS-M procedures were performed. Paek et al [25] showed that the proficiency for LESS hysterectomy was achieved after performing 40
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Table 1 Patient characteristics of the LESS-M and CLM groups
Age (years) BMI (kg/m2) Number of myomas Size of the largest myoma (cm) Weight of specimen (g) Type of the largest myoma Intramural (%) Subserosal (%) Submucosal Intraligamentary (%)
LESS-M (n 5 59)
CLM (n 5 59)
p value
41.5 6 5.5 (30–52) 22.8 6 2.6 (17.8–27.7) 1.6 6 0.8 (1–4) 7.3 6 2.2 (2.9–14.0) 173.9 6 160.0 (12–902)
41.2 6 5.3 (25–53) 22.4 6 3.1 (17.9–30.6) 1.4 6 0.7 (1–5) 6.5 6 2.0 (2.5–10.0) 126.8 6 97.0 (10–342)
.758 .545 .149 .059 .073 .276
48 (81.4) 7 (11.9) 0 4 (6.8)
48 (81.4) 8 (13.6) 2 (3.4) 1 (1.7)
BMI 5 body mass index; CLM 5 conventional laparoscopic myomectomy; LESS-M 5 laparoendoscopic single-site surgery myomectomy. Data are shown as mean 6 standard deviation (range) or number (%).
procedures. In another study, proficiency in LESS ovarian cystectomy was evident after performing 33 procedures [26]. Thus, we infer that the surgeon had already reached a reasonable level of proficiency in LESS-M after performing 100 procedures, which can reduce the bias originated from the learning curve of LESS-M. For the CLM group, we retrospectively reviewed a historic cohort of 59 consecutive patients who underwent CLM by the same experienced laparoscopic surgeon before LESS-M was initiated in our institute. After the introduction of LESS in June 2009, most of the surgeries were performed by the technique instead of conventional multiport laparoscopic surgery. This can minimize the selection bias of the retrospective study because the same surgical indication was used for both groups. If we collected CLM cases in the same time period with that of the LESS-M, there would be a serious selection bias. Consequently, the basal characteristics of the 2 groups were not different. A possibility of bias could be expected because the technical capabilities of the single surgeon who performed all the procedures could be improved
during the period. However, the surgeon who performed CLM was an established surgeon who performed numerous CLMs before the study period; thus, the possibility of the bias appears minimal. Our results are different from those of Han et al [15], who showed that the operative time for LESS-M was significantly longer than that for the conventional technique. We speculate that the main reason for the difference between the previous and the present study may be the surgeon’s experience and learning curve. The study by Han et al was a report after an initial experience with 10 cases; thus, the initial learning curve may have not been overcome at the time of the analysis. Many studies showed that the operative times for LESS other than myomectomy were comparable with those for multiport laparoscopic surgery [17,18,27]. Some studies showed reduced postoperative pain in LESS compared with that in conventional laparoscopic surgery [17]. This could be explained by the smaller number of skin incisions or the shorter total length of the skin incision [28]. The umbilicus has no muscle layer beneath the skin; the
Table 2 Comparison of surgical outcomes between the LESS-M and CLM groups
Operative time (min) Estimated blood loss (mL) Postoperative Hb drop (g/dL) Postoperative hospital stay (d) No. of intraoperative complications No. of postoperative complications (%) NRS postoperative, 1 hour NRS postoperative, 6 hours NRS postoperative, 24 hours
LESS-M (n 5 59)
CLM (n 5 59)
p value
115.7 6 45.8 (56–282) 171.0 6 155.8 (20–800) 1.8 6 1.4 (20.2 to 7.6) 2.1 6 0.4 (1–5) 0 2 (3.4) 5.7 6 1.4 (3–9) 4.6 6 1.1 (2–7) 3.5 6 0.8 (2–6)
128.2 6 35.7 (65–207) 217.3 6 188.8 (30–500) 1.8 6 1.1 (20.8 to 5.9) 2.1 6 0.6 (1–5) 0 1 (1.7) 6.0 6 1.6 (2–10) 4.3 6 1.6 (3–10) 3.4 6 1.2 (2–7)
.102 .155 .973 .489 .559 .325 .235 .621
CLM 5 conventional laparoscopic myomectomy; Hb 5 hemoglobin; LESS-M 5 laparoendoscopic single-site surgery myomectomy; NRS 5 numeric rating scale. Data are shown as mean 6 standard deviation (range) or number (%).
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relatively tension-free umbilical incision in the LESS-M method could cause lesser pain than that of the 3 or 4 incisions used in the CLM method [17]. On the other hand, some studies showed that there were no differences in postoperative pain as in our study. This might be because visceral pain would be similar in both groups, and it was more dominant regardless of the reduced port site pain in the LESS-M group. Furthermore, although the number of ports was reduced, stretching of the umbilical fascia and subsequent extension of the length of the skin incision seemed inevitable because of crowding and passing of the laparoscopic instruments. This may explain why the pain scores were similar in both groups [18]. However, in the present study, the primary outcome was not postoperative pain. To analyze the difference in pain between groups, analgesic medication requests by the patients, which must be an important confounding factor, should have been considered. Therefore, randomized prospective studies with postoperative pain as the primary outcome are crucial to achieve a solid conclusion on the impact on postoperative pain. Several studies reported comparable pregnancy outcomes after CLM [29–31]. They concluded that spontaneous uterine rupture appears to be rare after CLM, and the risk should not deter the use of CLM if needed. Recently, Pistofidis et al [32] showed that they have performed more than 1100 CLMs without any reported uterine rupture in more than 250 subsequent pregnancies. In the present study, the 2-layer interrupted suturing technique was applied for women with plans to be pregnant in the future or myomectomies for submucosal myoma. The criteria were equally applied in both groups. Further studies with a larger number of subsequent pregnancies and with long-term follow-up periods are needed. Our study showed that the surgical outcomes and perioperative complications of LESS-M were comparable with those of CLM. In conclusion, even though this study was limited to cases with less than 5 myomas, LESS-M is safe and feasible for various sizes and types of myomas after the surgeon’s initial learning curve.
References 1. Semm K. New methods of pelviscopy (gynecologic laparoscopy) for myomectomy, ovariectomy, tubectomy and adnectomy. Endoscopy. 1979;11:85–93. 2. Jin C, Hu Y, Chen XC, et al. Laparoscopic versus open myomectomyda meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol. 2009;145:14–21. 3. Kim TJ, Lee YY, Kim MJ, et al. Single port access laparoscopic adnexal surgery. J Minim Invasive Gynecol. 2009;16:612–615. 4. 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;16:450–453. 5. Fader AN, Escobar PF. Laparoendoscopic single-site surgery (LESS) in gynecologic oncology: technique and initial report. Gynecol Oncol. 2009;114:157–161. 6. Song T, Cho J, Kim TJ, et al. Cosmetic outcomes of laparoendoscopic single-site hysterectomy compared with multi-port surgery:
7.
8.
9.
10.
11. 12.
13. 14. 15.
16.
17.
18.
19.
20. 21.
22.
23.
24.
25.
26. 27.
28.
randomized controlled trial. J Minim Invasive Gynecol. 2013;20: 460–467. Song T, Kim TJ, Cho J, et al. Cosmesis and body image after single-port access surgery for gynaecologic disease. Aust N Z J Obstet Gynaecol. 2012;52:465–469. Yoo EH, Shim E. Single-port access compared with three-port laparoscopic adnexal surgery in a randomized controlled trial. J Int Med Res. 2013;41:673–680. Yuen LT, Hsu LJ, Lee CL, Wang CJ, Soong YK. A modified suture technique for laparoscopic myomectomy. J Minim Invasive Gynecol. 2007; 14:318–323. 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;17:587–592. Einarsson JI. Single-incision laparoscopic myomectomy. J Minim Invasive Gynecol. 2010;17:371–373. 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;153:81–84. Yoshiki N, Okawa T, Kubota T. Single-incision laparoscopic myomectomy with intracorporeal suturing. Fertil Steril. 2011;95:2426–2428. Ramesh B, Vidyashankar M, Bharathi B. Single incision laparoscopic myomectomy. J Gynecol Endosc Surg. 2011;2:61–63. Han CM, Lee CL, Su H, Wu PJ, Wang CJ, Yen CF. Single-port laparoscopic myomectomy: initial operative experience and comparative outcome. Arch Gynecol Obstet. 2013;287:295–300. Lee YY, Kim TJ, Kim CJ, 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;151:181–184. Kim TJ, Lee YY, Cha HH, et al. Single-port-access laparoscopicassisted vaginal hysterectomy versus conventional laparoscopicassisted vaginal hysterectomy: a comparison of perioperative outcomes. Surg Endosc. 2010;24:2248–2252. 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.e1–26.e6. 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: 255–259.e2. Mencaglia L, Mereu L, Carri G, et al. Single port entry - are there any advantages? Best Pract Res Clin Obstet Gynaecol. 2013;27:441–455. Park JY, Kim TJ, Kang HJ, et al. Laparoendoscopic single site (LESS) surgery in benign gynecology: perioperative and late complications of 515 cases. Eur J Obstet Gynecol Reprod Biol. 2013;167:215–218. 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;172:1726–1731. discussion 31–33. Kadar N, Reich H, Liu CY, Manko GF, Gimpelson R. Incisional hernias after major laparoscopic gynecologic procedures. Am J Obstet Gynecol. 1993;168:1493–1495. 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;115:1316–1320. Paek J, Kim SW, Lee SH, et al. Learning curve and surgical outcome for single-port access total laparoscopic hysterectomy in 100 consecutive cases. Gynecol Obstet Invest. 2011;72:227–233. Song T, Kim TJ, Lee YY, et al. Learning curves for single-site laparoscopic ovarian surgery. J Minim Invasive Gynecol. 2012;19:344–349. Jung YW, Lee M, Yim GW, et al. A randomized prospective study of single-port and four-port approaches for hysterectomy in terms of postoperative pain. Surg Endosc. 2011;25:2462–2469. Ghezzi F, Cromi A, Colombo G, et al. Minimizing ancillary ports size in gynecologic laparoscopy: a randomized trial. J Minim Invasive Gynecol. 2005;12:480–485.
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29. Dubuisson JB, Fauconnier A, Deffarges JV, Norgaard C, Kreiker G, Chapron C. Pregnancy outcome and deliveries following laparoscopic myomectomy. Hum Reprod. 2000;15:869–873. 30. Campo S, Campo V, Gambadauro P. Reproductive outcome before and after laparoscopic or abdominal myomectomy for subserous or intramural myomas. Eur J Obstet Gynecol Reprod Biol. 2003;110: 215–219.
7 31. Li MH, Leng JH, Shi JH, Jia SZ, Lang JH. [Comparison of postoperative residue, recurrence and pregnancy outcome between laparoscopic and transabdominal myomectomy]. Zhonghua Fu Chan Ke Za Zhi. 2011;46:669–673. 32. Pistofidis G, Makrakis E, Balinakos P, Dimitriou E, Bardis N, Anaf V. Report of 7 uterine rupture cases after laparoscopic myomectomy: update of the literature. J Minim Invasive Gynecol. 2012;19:762–767.
Laparoendoscopic Single-site Myomectomy Versus Conventional Laparoscopic Myomectomy: A Comparison of Surgical Outcomes Seul Ki Kim, MD, Ji Hyun Lee, MD, Jung Ryeol Lee, MD, PhD*, Chang Suk Suh, MD, PhD, and Seok Hyun Kim, MD, PhD From the Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea (Drs. S.K. Kim, J.H. Lee, J.R. Lee, and C.S. Suh), and Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seongnam, Korea (Drs. J.R. Lee, C.S. Suh, and S.H. Kim).
ABSTRACT Study Objective: The objective of this study was to evaluate laparoendoscopic single-site myomectomy (LESS-M) for the surgical treatment of fibroids and to compare surgical outcomes and postoperative pain with conventional laparoscopic myomectomy (CLM). Design: Retrospective study. Setting: University-based hospital. Patients: Data were obtained from medical records of patients who underwent LESS-M between August 2011 and June 2012. Considering the surgeon’s learning curve for LESS-M, we collected the data after 100 LESS-M procedures were performed. The cases were compared with a historic cohort of patients who underwent CLM performed by the same surgeon between July 2008 and May 2009. A single experienced surgeon performed both procedures in all patients. A total of 118 patients who underwent LESS-M or CLM were included in the study (59 in the LESS-M group and 59 in the CLM group). Interventions: None. Measurements and Main Results: We analyzed and compared patient basal characteristics and surgical outcomes between the 2 groups. There were no statistically significant differences in basal characteristics (i.e., age, body mass index, number and size of myomas, and type of the largest myoma) between the 2 groups. The surgical outcomes (i.e., operative time, estimated blood loss, postoperative hemoglobin drop, postoperative hospital stay, and postoperative pain scores) were not different statistically between the 2 groups. Moreover, patients did not experience major intraoperative complications. Postoperative complications were wound infections that occurred in 3 patients (2 in the LESS-M and 1 in the CLM groups). Conclusion: LESS-M is feasible for less than 5 myomas and offers comparable surgical outcomes with those of CLM after the surgeon’s initial learning curve. Journal of Minimally Invasive Gynecology (2014) -, -–- Ó 2014 AAGL. All rights reserved. Keywords:
DISCUSS
Laparoendoscopic single-site surgery; Single port; Laparoscopic myomectomy; Myomectomy; Myoma
You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-21-4-JMIG-D-13-00691
Use your Smartphone to scan this QR code and connect to the discussion forum for this article now* * Download a free QR Code scanner by searching for ‘‘QR scanner’’ in your smartphone’s app store or app marketplace.
Supported by a grant from the Korea Healthcare Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (grant no. HI12C0055). The authors declare no conflict of interest. Corresponding author: Jung Ryeol Lee, MD, PhD, Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-Gu, Seongnam, Gyeonggi-do, 463-707, Korea. E-mail: [email protected] Submitted December 20, 2013. Accepted for publication March 4, 2014. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2014 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2014.03.002
Minimally invasive procedures such as laparoscopic surgery are becoming the current trend and are improving with advances in surgical instrumentation and technique. Laparoscopic myomectomy (LM) was first reported by Semm [1] in 1979. Henceforth, several studies showed that LM has various advantages over the laparotomic and minilaparotomic approaches, including less postoperative hemoglobin drop, shorter hospital stay, and less postoperative pain [2]. Nowadays, laparoendoscopic single-site surgery (LESS) has been applied to various gynecologic operations, and
2
many reports describing this technique have been published [3–5]. LESS offers excellent cosmetic results compared with those obtained using conventional multiport laparoscopic surgery [6–8]. However, LESS has not been widely performed because of its technical difficulties such as limited motion and clashing between instruments. Moreover, laparoendoscopic single-site myomectomy (LESS-M) has more difficulties than other LESSs because it requires the tying of multiple sutures and the extraction of relatively large tissue specimens through the umbilical incision. After enucleation of myomas, the repair of uterine wall defects may be challenging for surgeons with limited experience in endoscopic suturing. Difficulties in maintaining adequate tension of the suture line while suturing and knot tying may increase the operative time and intraoperative blood loss [9]. Until now, there have been few reports in the literature about the application of LESS to myomectomy [10–14]. Only 1 study comparing surgical outcomes of LESS-M with those of conventional laparoscopic myomectomy (CLM) has been performed and reported [15]. However, most of the previous studies had small samples. To assess the exact feasibility and safety of LESS for myomectomy, we performed LESS-M with intracorporeal suture tying and morcellation and compared the surgical outcomes and postoperative pain with those of CLM.
Methods Subjects This study was approved by the Institutional Review Board of Seoul National University Bundang Hospital, Seongnam, Korea. Data were obtained from medical records of patients who underwent LESS-M between August 2011 and June 2012. Considering the surgeon’s learning curve for LESS-M, we collected data after the initial 100 LESS-M procedures were performed. Medical history questionnaires and pelvic examinations were conducted preoperatively; all patients underwent routine preoperative laboratory studies. Patients were included consecutively if their LESS-M was performed by a single experienced surgeon (J.R.L.) and if they had %4 myomas on the preoperative pelvic ultrasonography. LESS-M with other combined surgery was excluded. These cases were compared with a historic cohort of 59 consecutive patients who underwent CLM performed by the same surgeon between July 2008 and May 2009. A total of 118 patients who underwent LESS-M or CLM were included in the study (59 in the LESS-M group and 59 in the CLM group). We experienced 1 conversion to multiport surgery (1 additional 5-mm trocar) from LESS-M and 1 conversion to laparotomy from CLM. Both of the conversions were caused by the presence of severe pelvic adhesions because of previous pelvic surgery. In the CLM case, after confirming adhesion with a laparoscope through the umbilical incision, we per-
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formed conversion immediately without a second insertion of a trocar. We excluded these 2 conversion cases from this analysis. Operative Techniques The operative procedures were not different between the 2 groups with the exception of port placement, laparoscope, and the devices used for suture tying. After sterilization of the skin and draping of the patient, a uterine manipulator (Rumi System; Cooper Surgical, Trumbull, CT) was inserted into the uterine cavity. For LESS-M, single-port entry was established using a wound retractor (Alexis Wound Retractor XS; Applied Medical, Santa Margarita, CA) and a surgical glove. With the open Hasson technique, a vertical incision of 1.5 to 2 cm was made within the umbilicus, and a wound retractor was inserted into the incision. Two 5-mm trocars and one 12-mm trocar were inserted through the first, third, and fifth fingers of the surgical glove and fixed with silk ligatures; then, the glove was draped around the outer ring of the wound retractor (Fig. 1). A 12-mm trocar was inserted into the glove finger on the operator’s side and was then used for 10-mm devices, such as the myoma screw. A flexible 30 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 (Autonomy LaparoAngle; Cambridge Endo, Framingham, MA) was used for intracorporeal suture tying. When surgical preparation was completed, about 10 mL of a solution containing 6 IU (0.3 mL) vasoconstrictor agent (Vasopressin; Hanlim Pharma, Seoul, Korea) and 9.7 mL normal saline was injected into the tissue adjacent to the base and the capsule of the uterine myoma. The incision was made vertically to the myometrium using monopolar scissors or an ultrasonic cutting device (Harmonic Scalpel; Ethicon Endo-Surgery, Cincinnati, OH) and deepened until the myoma surface appeared. Myoma enucleation was performed with traction using a 10-mm myoma screw or claw forceps; the separation of the capsule from the myoma was achieved using 5-mm forceps. After enucleation of myomas, the uterine muscle was closed using either a 1- or 2-layer interrupted suturing technique (Fig. 2). Intracorporeal suture tying was performed using conventional and articulating laparoscopic instruments. The long end of the thread wrapped around the bent articulating device, and the short end was pulled through with the articulating device (Fig. 3). This suture technique is actually the same as the one used for conventional laparoscopic surgery consisting of a triangulation made by the vertically bent device tip. After repair of the myometrium was completed, enucleated myomas were extracted through the umbilical incision using a 15mm electromechanical morcellator (X-Tract; Ethicon Inc., Somerville, NJ), which was inserted through 1 free finger of the surgical glove. After irrigation with normal saline, an adhesion barrier (Interceed; Ethicon Inc., or Guardix;
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Fig. 1 An external view during an LESS-M procedure. (A) Single-port entry system using a wound retractor and a surgical glove. Two 5-mm trocars and one 12mm trocar are inserted through the first, third, and fifth fingers of the glove. (B) An external view during tissue morcellation. A 15-mm electromechanical morcellator is inserted through a free finger of the glove.
Genewel Inc.) was applied. The peritoneum and fascia of the umbilicus were closed with a 2-0 Vicryl suture, and the skin was closed with a vertical mattress suture using 3-0 nylon on 2 points. For CLM, the operative procedures were not different from LESS-M with the exception of trocar placement (three 5-mm trocars placed in the intraumbilical area, the suprapubic area, and the right lateral abdominal walls and one 12-mm trocar in the left lateral abdominal wall), the laparoscope (a 5-mm 0 laparoscope), and the rigid instrument for intracorporeal suture tying. The peritoneum and fascia of the
left lateral abdominal wall were closed with 2-0 Vicryl, and the skin was closed with a vertical mattress suture using 3-0 nylon on 2 points. The skin incisions of the 5-mm trocar sites were closed with a vertical mattress suture using 3-0 nylon on 1 point. Data Analysis We analyzed patient characteristics such as age, body mass index, number and size of myomas, type of the largest myoma, and weight of the enucleated myoma specimen.
Fig. 2 Techniques for LESS-M. (A) Enucleation of myoma with a 10-mm myoma screw and forceps, (B) suturing of the myometrium with a rigid needle holder, (C) knot tying using an articulating device, and (D) morcellation of the myoma with a 15-mm tissue morcellator.
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Fig. 3 The knot-tying technique using an articulating device. One end of the thread was wrapped around the vertically bended articulating device.
Surgical outcomes such as operative time, estimated blood loss, difference between preoperative and postoperative hemoglobin (postoperative hemoglobin drop), length of postoperative hospital stay, intraoperative or postoperative complications, and numeric rating scale of postoperative pain were evaluated. The operative time was defined as the interval between skin incision and closure. Intraoperative complications, including bladder, ureter, or bowel injuries, were carefully monitored. Postoperative complications included ileus, fever, wound infection, bleeding, and blood transfusion. Postoperative pain intensity was based on the patients’ subjective reports at 1, 6, and 24 hours after the operation using a numeric rating scale from 0 to 10 in which 0 represented the absence of pain and 10 represented the presence of the most severe pain. The patients were followed up 1 week after discharge for wound inspection and confirmation of the final pathology report. At this time, all patients were also evaluated for postoperative complications such as hematoma formation, hernia at the umbilical incision site, and infection. Pregnancy outcomes were confirmed by either medical chart review or by telephone in cases in which prenatal care was being delivered at another hospital. Statistical analysis was performed using the Student’s t test for continuous variables and the chi-square test for categoric variables where appropriate. The statistical software package SPSS version 18.0 (SPSS Inc, Chicago, IL) was used, and results were considered statistically significant at p , .05. Results Patient baseline characteristics are shown in Table 1. There were no statistically significant differences among patients with respect to age, body mass index, number and size
of myomas, type of the largest myoma, and weight of the enucleated myoma specimen. The mean size of the largest myoma was 7.3 cm (range, 2.9–14.0 cm) for the LESS-M group and 6.5 cm (range, 2.5–10.0 cm) for the CLM group. The surgical outcomes such as the operative time, estimated blood loss, postoperative hemoglobin drop, and postoperative hospital stay were not statistically different between the 2 groups (Table 2). There were no intraoperative complications such as bladder or bowel injuries or the administration of blood transfusions in either group. Wound infections occurred in 3 patients (2 in the LESS-M group and 1 in the CLM group), and these were the only complications reported. No other postoperative complications such as ileus, bleeding, or the administration of blood transfusion occurred in both groups. Postoperative pain scores assessed at 1, 6, and 24 hours were not significantly different between the 2 groups. Six patients became pregnant at least once after CLM, resulting in a total of 7 pregnancies. All 7 were delivered by cesarean section; 5 of them were delivered at term, and 2 of them were delivered by emergency cesarean section because of uncontrolled preterm labor at 35 1 1 weeks and 34 1 0 weeks. In the LESS-M group, there were 2 pregnancies. One woman had a cesarean section at term; the other woman was 30 weeks’ pregnant at the time of telephone contact. All the pregnancies were free of pre- and perinatal complications, including uterine rupture. Discussion Recently, many studies showed the feasibility of LESS in various gynecologic operations. Several retrospective comparative studies and randomized controlled trials showed that LESS has comparable and even better surgical outcomes compared with conventional multiport laparoscopic surgery [16–21]. In addition, in LESS-M, the cosmetic benefits are greater than in other operations. For instance, in CLM, a large (12–15 mm) scar on the lower abdomen may remain because of the large incision needed for tissue morcellation. Moreover, the large trocar insertion made on the lower abdomen could have a higher risk of trocar-related morbidity. For example, incisional hernias most frequently develop on larger extraumbilical trocar sites [22–24]. For advances in the single-port access technique, it is crucial to compare perioperative outcomes between LESS-M and CLM. However, there has been only 1 study comparing the surgical outcomes of LESS-M and CML with a small sample size [15]. To date, the present study represents the largest study. The surgical technique could be considered standardized because all surgeries were performed by 1 surgeon. Considering the surgeon’s learning curve for LESS-M, we collected the data after the initial 100 LESS-M procedures were performed. Paek et al [25] showed that the proficiency for LESS hysterectomy was achieved after performing 40
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Table 1 Patient characteristics of the LESS-M and CLM groups
Age (years) BMI (kg/m2) Number of myomas Size of the largest myoma (cm) Weight of specimen (g) Type of the largest myoma Intramural (%) Subserosal (%) Submucosal Intraligamentary (%)
LESS-M (n 5 59)
CLM (n 5 59)
p value
41.5 6 5.5 (30–52) 22.8 6 2.6 (17.8–27.7) 1.6 6 0.8 (1–4) 7.3 6 2.2 (2.9–14.0) 173.9 6 160.0 (12–902)
41.2 6 5.3 (25–53) 22.4 6 3.1 (17.9–30.6) 1.4 6 0.7 (1–5) 6.5 6 2.0 (2.5–10.0) 126.8 6 97.0 (10–342)
.758 .545 .149 .059 .073 .276
48 (81.4) 7 (11.9) 0 4 (6.8)
48 (81.4) 8 (13.6) 2 (3.4) 1 (1.7)
BMI 5 body mass index; CLM 5 conventional laparoscopic myomectomy; LESS-M 5 laparoendoscopic single-site surgery myomectomy. Data are shown as mean 6 standard deviation (range) or number (%).
procedures. In another study, proficiency in LESS ovarian cystectomy was evident after performing 33 procedures [26]. Thus, we infer that the surgeon had already reached a reasonable level of proficiency in LESS-M after performing 100 procedures, which can reduce the bias originated from the learning curve of LESS-M. For the CLM group, we retrospectively reviewed a historic cohort of 59 consecutive patients who underwent CLM by the same experienced laparoscopic surgeon before LESS-M was initiated in our institute. After the introduction of LESS in June 2009, most of the surgeries were performed by the technique instead of conventional multiport laparoscopic surgery. This can minimize the selection bias of the retrospective study because the same surgical indication was used for both groups. If we collected CLM cases in the same time period with that of the LESS-M, there would be a serious selection bias. Consequently, the basal characteristics of the 2 groups were not different. A possibility of bias could be expected because the technical capabilities of the single surgeon who performed all the procedures could be improved
during the period. However, the surgeon who performed CLM was an established surgeon who performed numerous CLMs before the study period; thus, the possibility of the bias appears minimal. Our results are different from those of Han et al [15], who showed that the operative time for LESS-M was significantly longer than that for the conventional technique. We speculate that the main reason for the difference between the previous and the present study may be the surgeon’s experience and learning curve. The study by Han et al was a report after an initial experience with 10 cases; thus, the initial learning curve may have not been overcome at the time of the analysis. Many studies showed that the operative times for LESS other than myomectomy were comparable with those for multiport laparoscopic surgery [17,18,27]. Some studies showed reduced postoperative pain in LESS compared with that in conventional laparoscopic surgery [17]. This could be explained by the smaller number of skin incisions or the shorter total length of the skin incision [28]. The umbilicus has no muscle layer beneath the skin; the
Table 2 Comparison of surgical outcomes between the LESS-M and CLM groups
Operative time (min) Estimated blood loss (mL) Postoperative Hb drop (g/dL) Postoperative hospital stay (d) No. of intraoperative complications No. of postoperative complications (%) NRS postoperative, 1 hour NRS postoperative, 6 hours NRS postoperative, 24 hours
LESS-M (n 5 59)
CLM (n 5 59)
p value
115.7 6 45.8 (56–282) 171.0 6 155.8 (20–800) 1.8 6 1.4 (20.2 to 7.6) 2.1 6 0.4 (1–5) 0 2 (3.4) 5.7 6 1.4 (3–9) 4.6 6 1.1 (2–7) 3.5 6 0.8 (2–6)
128.2 6 35.7 (65–207) 217.3 6 188.8 (30–500) 1.8 6 1.1 (20.8 to 5.9) 2.1 6 0.6 (1–5) 0 1 (1.7) 6.0 6 1.6 (2–10) 4.3 6 1.6 (3–10) 3.4 6 1.2 (2–7)
.102 .155 .973 .489 .559 .325 .235 .621
CLM 5 conventional laparoscopic myomectomy; Hb 5 hemoglobin; LESS-M 5 laparoendoscopic single-site surgery myomectomy; NRS 5 numeric rating scale. Data are shown as mean 6 standard deviation (range) or number (%).
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relatively tension-free umbilical incision in the LESS-M method could cause lesser pain than that of the 3 or 4 incisions used in the CLM method [17]. On the other hand, some studies showed that there were no differences in postoperative pain as in our study. This might be because visceral pain would be similar in both groups, and it was more dominant regardless of the reduced port site pain in the LESS-M group. Furthermore, although the number of ports was reduced, stretching of the umbilical fascia and subsequent extension of the length of the skin incision seemed inevitable because of crowding and passing of the laparoscopic instruments. This may explain why the pain scores were similar in both groups [18]. However, in the present study, the primary outcome was not postoperative pain. To analyze the difference in pain between groups, analgesic medication requests by the patients, which must be an important confounding factor, should have been considered. Therefore, randomized prospective studies with postoperative pain as the primary outcome are crucial to achieve a solid conclusion on the impact on postoperative pain. Several studies reported comparable pregnancy outcomes after CLM [29–31]. They concluded that spontaneous uterine rupture appears to be rare after CLM, and the risk should not deter the use of CLM if needed. Recently, Pistofidis et al [32] showed that they have performed more than 1100 CLMs without any reported uterine rupture in more than 250 subsequent pregnancies. In the present study, the 2-layer interrupted suturing technique was applied for women with plans to be pregnant in the future or myomectomies for submucosal myoma. The criteria were equally applied in both groups. Further studies with a larger number of subsequent pregnancies and with long-term follow-up periods are needed. Our study showed that the surgical outcomes and perioperative complications of LESS-M were comparable with those of CLM. In conclusion, even though this study was limited to cases with less than 5 myomas, LESS-M is safe and feasible for various sizes and types of myomas after the surgeon’s initial learning curve.
References 1. Semm K. New methods of pelviscopy (gynecologic laparoscopy) for myomectomy, ovariectomy, tubectomy and adnectomy. Endoscopy. 1979;11:85–93. 2. Jin C, Hu Y, Chen XC, et al. Laparoscopic versus open myomectomyda meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol. 2009;145:14–21. 3. Kim TJ, Lee YY, Kim MJ, et al. Single port access laparoscopic adnexal surgery. J Minim Invasive Gynecol. 2009;16:612–615. 4. 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;16:450–453. 5. Fader AN, Escobar PF. Laparoendoscopic single-site surgery (LESS) in gynecologic oncology: technique and initial report. Gynecol Oncol. 2009;114:157–161. 6. Song T, Cho J, Kim TJ, et al. Cosmetic outcomes of laparoendoscopic single-site hysterectomy compared with multi-port surgery:
7.
8.
9.
10.
11. 12.
13. 14. 15.
16.
17.
18.
19.
20. 21.
22.
23.
24.
25.
26. 27.
28.
randomized controlled trial. J Minim Invasive Gynecol. 2013;20: 460–467. Song T, Kim TJ, Cho J, et al. Cosmesis and body image after single-port access surgery for gynaecologic disease. Aust N Z J Obstet Gynaecol. 2012;52:465–469. Yoo EH, Shim E. Single-port access compared with three-port laparoscopic adnexal surgery in a randomized controlled trial. J Int Med Res. 2013;41:673–680. Yuen LT, Hsu LJ, Lee CL, Wang CJ, Soong YK. A modified suture technique for laparoscopic myomectomy. J Minim Invasive Gynecol. 2007; 14:318–323. 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;17:587–592. Einarsson JI. Single-incision laparoscopic myomectomy. J Minim Invasive Gynecol. 2010;17:371–373. 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;153:81–84. Yoshiki N, Okawa T, Kubota T. Single-incision laparoscopic myomectomy with intracorporeal suturing. Fertil Steril. 2011;95:2426–2428. Ramesh B, Vidyashankar M, Bharathi B. Single incision laparoscopic myomectomy. J Gynecol Endosc Surg. 2011;2:61–63. Han CM, Lee CL, Su H, Wu PJ, Wang CJ, Yen CF. Single-port laparoscopic myomectomy: initial operative experience and comparative outcome. Arch Gynecol Obstet. 2013;287:295–300. Lee YY, Kim TJ, Kim CJ, 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;151:181–184. Kim TJ, Lee YY, Cha HH, et al. Single-port-access laparoscopicassisted vaginal hysterectomy versus conventional laparoscopicassisted vaginal hysterectomy: a comparison of perioperative outcomes. Surg Endosc. 2010;24:2248–2252. 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.e1–26.e6. 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: 255–259.e2. Mencaglia L, Mereu L, Carri G, et al. Single port entry - are there any advantages? Best Pract Res Clin Obstet Gynaecol. 2013;27:441–455. Park JY, Kim TJ, Kang HJ, et al. Laparoendoscopic single site (LESS) surgery in benign gynecology: perioperative and late complications of 515 cases. Eur J Obstet Gynecol Reprod Biol. 2013;167:215–218. 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;172:1726–1731. discussion 31–33. Kadar N, Reich H, Liu CY, Manko GF, Gimpelson R. Incisional hernias after major laparoscopic gynecologic procedures. Am J Obstet Gynecol. 1993;168:1493–1495. 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;115:1316–1320. Paek J, Kim SW, Lee SH, et al. Learning curve and surgical outcome for single-port access total laparoscopic hysterectomy in 100 consecutive cases. Gynecol Obstet Invest. 2011;72:227–233. Song T, Kim TJ, Lee YY, et al. Learning curves for single-site laparoscopic ovarian surgery. J Minim Invasive Gynecol. 2012;19:344–349. Jung YW, Lee M, Yim GW, et al. A randomized prospective study of single-port and four-port approaches for hysterectomy in terms of postoperative pain. Surg Endosc. 2011;25:2462–2469. Ghezzi F, Cromi A, Colombo G, et al. Minimizing ancillary ports size in gynecologic laparoscopy: a randomized trial. J Minim Invasive Gynecol. 2005;12:480–485.
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29. Dubuisson JB, Fauconnier A, Deffarges JV, Norgaard C, Kreiker G, Chapron C. Pregnancy outcome and deliveries following laparoscopic myomectomy. Hum Reprod. 2000;15:869–873. 30. Campo S, Campo V, Gambadauro P. Reproductive outcome before and after laparoscopic or abdominal myomectomy for subserous or intramural myomas. Eur J Obstet Gynecol Reprod Biol. 2003;110: 215–219.
7 31. Li MH, Leng JH, Shi JH, Jia SZ, Lang JH. [Comparison of postoperative residue, recurrence and pregnancy outcome between laparoscopic and transabdominal myomectomy]. Zhonghua Fu Chan Ke Za Zhi. 2011;46:669–673. 32. Pistofidis G, Makrakis E, Balinakos P, Dimitriou E, Bardis N, Anaf V. Report of 7 uterine rupture cases after laparoscopic myomectomy: update of the literature. J Minim Invasive Gynecol. 2012;19:762–767.
