Single-port access laparoscopic surgery in gynecologic oncology: outcomes and feasibility.

ORIGINAL STUDY

Single-Port Access Laparoscopic Surgery in Gynecologic Oncology Outcomes and Feasibility Justine Figurelli, MD, Lucie Bresson, MD, Fabrice Narducci, MD, Ninad Katdare, MD, Pascale Coulon, PhD, Charles Fournier, PhD, and Eric Leblanc, PhD Objectives: Single-port access laparoscopic surgery (SPALS) is supposed to simplify and improve the outcomes of current multiport laparoscopic procedures. This retrospective study was performed to assess the actual outcomes of SPALS in 2 simple gynecological oncology procedures, namely, diagnostic laparoscopy and bilateral adnexectomy. Methods: We conducted a retrospective monocentric study. Case files of only those women who underwent bilateral adnexectomies and diagnostic and/or staging laparoscopy were studied with respect to the operative room time, intraoperative and postoperative complications, postoperative pain, and lengths of hospital stays. The main objective was to assess the feasibility and utility of SPALS surgery in gynecology. The secondary objective was to compare this group with a cohort of patients with multiport conventional laparoscopic surgery (MPCLS) performed during the same period. Results: From December 2009 to March 2013, there were 134 patients who underwent these 2 procedures. Eighty adnexectomies were performed, 41 by SPALS and 39 by MPCLS. Fifty-four diagnostic laparoscopies were performed, with 27 patients in each group. In the group of adnexectomies, operative time was significantly lower in SPALS compared with MPCLS (36 vs 59 minutes, P G 10j4) and also compared with the postoperative stay (1 vs 2.2 nights, P G 10j4). By contrast, no significant difference was observed between the 2 methods of access in all the parameters studied in the group of diagnostic laparoscopies. Conclusions: Our experience demonstrates that SPALS is feasible and safe for simple gynecological procedures. This approach may result in a smooth postoperative course and shorter hospital stay and can thus be promoted to a day care procedure. Key Words: Single-port access laparoscopic surgery, Single site, Single incision, Gynecology, Oncology Received February 10, 2014, and in revised form March 18, 2014. Accepted for publication March 23, 2014. (Int J Gynecol Cancer 2014;24: 1126Y1132) access laparoscopic surgery (SPALS) (also S ingle-port called laparoendoscopic single-site surgery [LESS],

single-incision multiport laparoscopy, [SIMPL] and singleincision laparoscopic surgery [SILS]) has emerged as a

Department of Gynecologic Oncology, Oscar Lambret Center, Lille, France. Address correspondence and reprint requests to Justine Figurelli, MD, Oscar Lambret Center, 3 Rue Fre´de´ric Combemale, 59000 Lille, France. E-mail: [email protected]. The authors declare no conflicts of interest. Copyright * 2014 by IGCS and ESGO ISSN: 1048-891X DOI: 10.1097/IGC.0000000000000150

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potentially less invasive technique compared with conventional laparoscopic surgery. With this technique, only 1 trocar is inserted through an umbilical incision. This port is flexible and can accommodate several operative trocars, with variable diameters of 5 to 12 mm. Single-port surgery has been used in gynecological surgery for several years. The first single-port hysterectomy was reported in 1991, but this technique was not readily adopted at that time. Single-port surgery then resurfaced in general surgery in 2007 when Podolsky et al1 reported their experience with single-port cholecystectomy. This in turn has led to a renewed interest in gynecological single-port surgery in recent years.

International Journal of Gynecological Cancer

& Volume 24, Number 6, July 2014

Copyright © 2014 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited.



Several manufacturers provide different systems, which are available on the market today, all with various advantages and disadvantages. These devices, which are used in gynecological surgery, include but are not limited to the following: SILSPort (Covidien, Mansfield, Mass); TriPort+, TriPort15, QuadPort+ (Advanced Surgical Concepts, Inc, Bray, Co, Wicklaw, Ireland); GelPOINT (AppliedMedical, Rancho Santa Margarita, Calif ); and Uni-X (Pnavel Systems, Cleveland, Ohio). From an operative point of view, SPALS is definitely more challenging and technically difficult than multiport conventional laparoscopic surgery (MPCLS). First, because of the lack of assistance, a steep Trendelenburg position is necessary to clear the bowel from the pelvis and to display a good view of the pelvic organs. This can be a problem in the case of very obese patients or be unsuccessful if there are adhesions. Second, if regular straight laparoscopic instruments are used, the mobility is reduced with a tendency for the instruments to clash with each other or with the laparoscope (sword fighting effect), thus interfering with their free mobility and handling. Third, the instrument extremity is not always completely visible, which can be harmful when using thermal/energy devices for hemostasis. In contrast, SPALS may have some advantages; the most apparent benefit is that it improves cosmetic with the single surgical incision hidden in the umbilicus rather than having 2 to 4 small abdominal incisions. The second benefit is less pain at least owing to this unique small scar, which can result in a reduced need of analgesics and consequently in faster recovery and reduced hospital stay.2,3 Some previous reports have demonstrated the feasibility of using SPALS in many benign and oncological gynecology procedures. The main objectives of the present retrospective singlecenter study were to assess outcomes and to determine the feasibility of SPALS in 2 routine oncological gynecological procedures. The second objective was to compare the results of SPALS and MPCLS in terms of perioperative and postoperative parameters as discussed later. We have also enumerated certain techniques, which are used, at our hospital center to make the conduct of SPALS easier. This study was approved by our internal review board, and patients were informed and gave their consent.

Single-Port Access Surgery

the operative room time (skin incision to skin closure time), operation failures (failure of the procedure was defined as the use of additional ports or conversion to laparotomy), intraoperative and postoperative complications (until 2 postoperative months), hospital stay (defined by the number of nights spent in hospital), postoperative pain level using an analog 10-point pain scale at 2 and 24 hours after surgery (patients discharged on the same day of surgery were contacted by telephone on the next day). Bilateral adnexectomy and exploratory laparoscopy were compared with respect to these variables. The secondary objective was to compare these parameters with those of a cohort of patients who underwent MPCLS in the same period, and the same set of parameters was assessed from their files.

Surgical Procedures Single-Port Access Laparoscopic Surgery All procedures were performed under general anesthesia in the modified Trendelenburg position, legs slightly apart and arms along the body. For SPALs, the GelPOINT system (Applied Medical Society. Rancho Santa Margarita, Calif ) was always used (Fig. 1). The surgeons have chosen the gel point system because there is a wall retractor that protects the wound from eventual tumor seeding or port site metastasis. Besides this, the system also maximizes the internal wound diameter for instruments. The GelPOINT system is placed at the umbilical level or more laterally if previous laparoscopy has been performed. A 2- to 3-cm skin incision is performed and is placed within or just underneath the umbilicus (Fig. 2). Rectus sheath and peritoneum are incised vertically for 3 to 4 cm (to accommodate 2 fingerbreadths). A GelPOINT system equipped with 3 dedicated trocars was set up (1 for camera and 2 as working ports). The specific Alexis wound protector was inserted first, through the incision, and then covered by the GelSeal cap. A regular set of straight ancillary instruments was used, one or two 5-mm fenestrated forceps, one bipolar. As disposable instruments, we added disposable scissors or sometimes a LigaSure 5-mm blunt tip 37 cm (Covidien, Mansfield, Mass). Endoscopic bags were never used because specimen could be retrieved through the protected umbilical incision (specific gel point wound retractor).

MATERIALS AND METHODS This is a retrospective study, which was conducted at our department (Centre Oscar Lambret, Lille, France). The files of all patients who underwent SPALS for the 2 indications mentioned later between December 2009 and March 2013 were retrieved and analyzed. We focused only on those patients with indications of bilateral adnexectomy (prophylactic procedures for BRCA mutation carriers, treatment of suspicious ovarian mass, or surgical castration for breast cancer) or diagnostic laparoscopy (performed to assess peritoneal carcinomatosis and/or any suspicious pelvic/abdominal mass).

Data Collection For all procedures of interest, the details of the following parameters were retrieved: the patient characteristics,

FIGURE 1. GelPOINT system.

* 2014 IGCS and ESGO


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Figurelli et al

FIGURE 2. Umbilical skin incision. The laparoscopy was performed with a Trendelenburg position of 25 to 30 degrees, intra-abdominal CO2 pressure of 12 mm Hg, and a flow rate 6 L/min. At the end of the procedure, the device was disassembled, providing immediate exsufflation, and the wound retractor was extracted. Umbilical incision was closed in several layers using reabsorbable sutures, namely, the rectus, subcutaneous tissue, and a subcuticular layer.

Multiport Conventional Laparoscopic Surgery For the exploratory laparoscopy, a 10-mm trocar is placed within or laterally to the umbilicus (if previous laparotomy) for the camera. According to the internal aspect, one or two 5-mm operative working trocars are placed above the iliac crests or in the midline to enable bowel mobilization and fluid/tumor sampling. For bilateral adnexectomy, a 10-mm trocar is placed within the umbilicus for the laparoscope, two 5-mm operative trocars for the instruments are placed above each iliac crests and a last 10- to 12-mm trocar in the midline in the suprapubic area for instruments and specimen retrieval. A regular set of straight ancillary instruments was used, two 5-mm fenestrated forceps and one bipolar. As disposable instruments, we added disposable scissors or sometimes a LigaSure 5-mm blunt tip 37 cm (Covidien). Endoscopic bags were used to retrieve big specimens. The conditions of laparoscopy were as follows: Trendelenburg position 20 degrees, CO2 pressure of 12 mm Hg, and a flow rate of 6 L/min. At the end of the procedure, trocars are removed, and incisions are closed in 2 layers for the 10-mm and only the skin for the 5-mm port sites.

Data Analysis For calculations, a P G 0.05 was considered statistically significant. For normally distributed data, a 2-tailed Student t test was used to test for group differences. The Wilcoxon rank-sum test was used when the variables were not normally distributed. The W2 test and Fisher exact test were used to compare proportions. All the women were fully informed, and this study was approved by our local institutional review board.

RESULTS Sixty-eight patients had SPALS (bilateral adnexectomy, n = 41; exploratory laparoscopy, n = 27). The patient characteristics are reported in Table 1.

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The operative room time, operation failures, intraoperative and postoperative complications, hospital stay, and postoperative pain level for SPALS are reported in Table 2. The blood loss was in all the cases less than 50 mL. There was no need for blood transfusion in any procedure. We observed only 1 case of conversion from SPALS to conventional surgery because of pelvic adhesions. We did not observe any intraoperative or postoperative complications for SPALS in our study. We matched the patients evaluated before with the patients who underwent bilateral adnexectomy and exploratory laparoscopy by multiport conventional laparoscopy during the same period. Upon combining both the groups, a total of 134 women were included in the study. Eighty patients underwent bilateral adnexectomy, and 54 patients underwent exploratory laparoscopy. The characteristics of the patients from the single-port group (n = 68) and the multiport group (n = 66) were as follows: age, 55 years (n = 11) (SPALS) versus 58 years (n = 13) (MPCLS) (nonsignificant [NS]); body mass index, 26.5 (SPALS) versus 26.7 kg/m2 (MPCLS) (NS); and history of pelvic surgery, 39.5% (SPALS) versus 54% (MPCLS) (NS). The 2 groups were similar for indications. The comparative data between the single-port group and the multiport group are reported in Table 3 (exploratory laparoscopy) and Table 4 (bilateral adnexectomy). TABLE 1. Patient characteristics for SPALS in gynecological oncology

Characteristics Age, mean (SD), y Body mass index, mean (SD), kg/m2 History of pelvic surgery, % Indications BRCA1 mutation BRCA2 mutation Suspicious ovarian mass Surgical castration Prophylactic bilateral adnexectomy, BRCAFIGO IA, endometrial cancer (complementary bilateral adnexectomy after occult endometrial carcinoma at definitive results of total hysterectomy) Operability ovarian cancer Suspicion of peritoneal carcinomatosis

SPALS SPALS Bilateral Exploratory Adnexectomy Laparoscopy (n = 41) (n = 27) 49 (9) 25.5 (6.6)

62 (13) 27.4 (4.9)

37

42

24 4 7 2 2

6

2

8 13






TABLE 2. Operative data for SPALS in gynecological oncology SPALS Bilateral Adnexectomy (n = 41) Operative room time, min Mean (SD) Median (extremes) Operation failures Hospital stay, night Mean (SD) Median (extremes) 0 night, % (n) 1 night, % (n) 2 nights, % (n) 92 nights, % (n) Intraoperative complications Late postoperative complications

SPALS Exploratory Laparoscopy (n = 27)

36 (15) 33 (13Y76) 1/41 (pelvic adhesions)

31 (11) 30 (9Y51) 0/27

1.0 1 33 45 20 2

(1.0) (0Y5) (13/41) (18/41) (8/41) (1/41) 0/41 1/41 (suspicion of umbilical hernia)

For exploratory laparoscopy, the operative room time, the postoperative pain, and the hospital stay were, respectively (SPALS vs MPCLS), 31 versus 27 minutes (NS), 2.3 versus 2.6 (NS) (10-point scale), and 1.7 versus 2.4 nights (NS). There were no intraoperative and postoperative complications.

1.7 2 15 26 41 18

(1.2) (0Y5) (4/27) (7/27) (11/27) (5/27) 0/27 0/27

For bilateral adnexectomy, the operative room time, the postoperative pain, and the hospital stay were, respectively (SPALS versus MPCLS), 36 versus 59 minutes (P G 10j4), 2.9 versus 2.5 (NS) (10-point scale), and 1 versus 2.2 nights (P G 10j4). We observed only 1 case of conversion from

TABLE 3. Exploratory laparoscopy outcomes: SPALS versus MPCLS SPALS Exploratory Laparoscopy MPCLS Exploratory Laparoscopy (n = 27) (n = 27) Operative room time, min Mean (SD) Median (extremes) Hospital stay, night Mean (SD) Median (extremes) 0 night, % (n) 1 night, % (n) 2 nights, % (n) 92 nights, % (n) Postoperative pain (10-point scale) 2 h after surgery, mean (SD) 2 h after surgery, median (extremes) 24 h after surgery, mean (SD) 24 h after surgery, median (extremes) Mean (SD) Median (extremes) Maximum, mean (SD) Maximum, median (extremes) Intraoperative complications Late postoperative complications

31 (11) 30 (9Y51)

27 (16) 26 (9Y66)

t: 0.41 W:0.254

1.7 2 15 26 41 18

(1.2) (0Y5) (4/27) (7/27) (11/27) (5/27)

2.4 2 22 22 44 11

(3.6) (0Y15) (6/27) (6/27) (12/27) (3/27)

t: 0.34 W: 0.60

2.6 2 1.8 2 2.3 2 3.6 3

(2.1) (0Y8) (1.7) (0Y5) (1.3) (0Y5) (2.0) (0Y8) 0/27 0/27

3.0 3 1.6 1 2.6 2 3.8 4

(1.9) (0Y6) (1.4) (0Y4) (1.5) (0Y6) (2.3) (0Y10) 0/27 0/27

t: 0.55 W: 0.40 t: 0.72 W: 0.85 t: 0.51 W: 0.43 t: 0.71 W: 0.71

K: 0.80 F: 0.83

F, Fisher exact test; t, Student t test; W, Wilcoxon rank; /, W2. * 2014 IGCS and ESGO


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Figurelli et al


TABLE 4. Bilateral adnexectomy outcomes: SPALS versus MPCLS SPALS Bilateral Adnexectomy (N = 41)

MPCLS Bilateral Adnexectomy (n = 40)

Operative room time, min Mean (SD) 36 (15) 59 (25) Median (extremes) 33 (13Y76) 51 (29Y149) Hospital stay, night Mean (SD) 1.0 (1.0) 2.2 (0.8) Median (extremes) 1 (0Y5) 2 (1Y4) 0 night, % (n) 33 (13/41) 0 (0/39) 1 night, % (n) 45 (19/41) 21 (8/39) 2 nights, % (n) 20 (8/41) 46 (18/39) 92 nights, % (n) 2 (1/41) 33 (13/39) Postoperative pain (10-point scale) 2 h after surgery, mean (SD) 3.5 (2.4) 3.1 (2.7) 2 h after surgery, median (extremes) 4 (0Y8) 3 (0Y10) 24 h after surgery, mean (SD) 2.1 (1.4) 2.2 (1.7) 24 h after surgery, median (extremes) 2 (0Y5) 2 (0Y6) Mean (SD) 2.9 (1.5) 2.5 (1.4) Median (extremes) 3 (0Y6) 3 (0Y5) Maximum, mean (SD) 4.2 (2.1) 4.3 (2.4) Maximum, median (extremes) 4 (0Y8) 4 (0Y10) Intraoperative complications 0/41 2/40 Late postoperative complications 1/41 (suspicion of umbilical hernia) 1/40 (suspicion of umbilical hernia)

t: G10j4 W: G10j4 t: G10j4 W: G10j4 K: G10j4 F: G10j4

t: 0.47 W: 0.39 t: 0.82 W: 0.88 t: 0.26 W: 0.30 t: 0.78 W: 0.83

F, Fisher exact test; t, Student t test; W, Wilcoxon rank; /, W2.

SPALS to conventional surgery because of pelvic adhesions. In our study, the operative room time and the hospital stay were significantly shorter in the group SPALS for bilateral adnexectomy compared with the group MPCLS. We just observed 2 cases of delay of wound healing in the umbilical wound after surgery in the conventional bilateral adnexectomy group. During the postoperative follow-up, 2 cases of umbilical hernia were suspected 2 months later (1 case for the single-port bilateral adnexectomy group 1 one case in the conventional bilateral adnexectomy group), but the suspicion was allayed in each case after abdominal computed tomographic scan.

DISCUSSION Single-port access laparoscopic surgery is a relatively new procedure in gynecology, and the available literature on this subject is limited. Most authors have studied the feasibility of SPALS in gynecology with respect to the type of procedures performed4Y11 and their feasibility. However, few authors have focused on the comparison between SPALS and MPCLS. Lee et al12 demonstrated that single-port laparoscopic adnexal surgery resulted in operative outcomes comparable with those of conventional laparoscopy with respect to the length of the regarding hospital stay, operation time, transfusion, and postoperative pain. Some authors have compared postoperative pain between SPALS and MPCLS.13Y15 Hoyer-Sorensen et al13

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reported that women undergoing SPALS reported significantly more shoulder tip pain compared with those undergoing conventional laparoscopy. Kim et al14 have suggested that 1 advantage of SPALS over conventional laparoscopy might be decreased postoperative pain. However, Yim et al15 recently concluded in their study that there was no difference in the pain intensity between the SPALS and the MPCLS. Thus, there is no consensus on the effect of method of laparoscopy on the level of postoperative pain. In our study, we have failed to demonstrate that SPALS surgery was less painful than conventional laparoscopy. However, in our retrospective study, there was no established analgesic protocol (analgesia was dependent on the anesthesiologist). A prospective study with concomitant assessment of pain scores should be performed to answer the question in a better way. We have demonstrated that the hospital stay was significantly shorter for bilateral adnexectomy performed by SPALS surgery compared with MPCLS. However, this result may represent a bias in our study. Indeed, we increasingly tend to perform SPALS wherever it was possible, and we wanted to perform these types of procedures in ambulatory hospital stays. Thus, for each patient with a nonelevated body mass index (therefore better tolerance of Trendelenburg position), without a history of pelvic surgery, and who consented for this procedure, we proposed ambulatory SPALS (largely from 2011 onward because of the learning curve for SPALS in our department and the surgeons’ experience). * 2014 IGCS and ESGO




The reason for the operative time being significantly shorter for SPALS bilateral adnexectomy compared with MPCLS in our study could be caused by the positioning of the patient. The steep Trendelenburg position corrects several limitations of SPALS, including reduced visualization, loss of triangulation, and instrument interference. We also believe that we save time during trocar insertion, removal, and closure because we have to manage only a single access wound. The specimen can be retrieved easily from the single port without a specimen bag because the wound is already protected. This allows us to save more time compared with introducing a specimen retrieval bag through the lateral trocar and extracting the specimen. We have not evaluated the cosmetic outcomes of SPALS. Eom et al16 recently reported that SPALS offered better cosmetic and overall patient satisfaction and seemed to have a considerable cosmetic benefit in women with abdominal scars from previous surgeries. Song et al17 have studied cosmetic outcomes and body image after SPALS for gynecological diseases and have reported that SPALS was a good option for the management of gynecological disease with respect to patient satisfaction. Some patients have told us spontaneously during the postoperative visit that they were satisfied with the single scar. It may be possible to consider this parameter in another study. Similar to Park et al18 and compared with previous reports of SPALS, late postoperative complications were not increased in our study. We would also like to suggest some tips and tricks that we use for SPALS, which may play a role in making the procedure easier and in early postoperative discharge from hospital as well as in reducing postoperative mortality and morbidity. Patients are required to urinate before the operation. Therefore, as patients do not require bladder catheterization for the procedure, we restrict the risk of postoperative urinary infection, and we think the hospital stay can be reduced. To gain more space to operate, we place the arms of the patient along the body. In agreement with the anesthesiologists, we place the patient in steep Trendelenburg position, which displaces the bowel upwards, and it does not come in the way of the pelvic surgery, thus allowing the procedure to be completed in quick time. This position is generally well tolerated because of the short operation time (Fig. 3).

FIGURE 3. Patient installation.


The surgeon stands at the head of the patient, and the assistant is on the surgeon’s right but can easily move to the surgeon’s left during the procedure. We also think that the wall retractor protects the wound from tumor seeding in the wound compared with conventional laparoscopy.

CONCLUSIONS Single-port access laparoscopic surgery is a feasible, safe, and reproducible technique for short gynecological oncology procedures. We believe that the operative room time is shorter because of the position of the patient and the surgeons, and we save time on incision and closure of the single wound. It thus seems feasible to perform these procedures in ambulatory settings. We think that SPALS offers real benefit to explore abdominal cavity and reduce the risk of tumor seeding of the trocar sites. Even if we did not evaluate the cosmetic advantage of SPALS, the utility of the procedure seems obvious especially for prophylactic surgery.

REFERENCES 1. Podolsky ER, Rottman SJ, Poblete H, et al. Single port access (SPA) cholecystectomy: a completely transumbilical approach. J Laparoendosc Adv Surg Tech A. 2009;19:219Y222. 2. Chen YJ, Wang PH, Ocampo EJ, et al. Single-port compared with conventional laparoscopic-assisted vaginal hysterectomy: a randomized controlled trial. Obstet Gynecol. 2011;117: 906Y912. 3. Marks J, Tacchino R, Roberts K, et al. Prospective randomized controlled trial of traditional laparoscopic cholecystectomy versus single-incision laparoscopic cholecystectomy: report of preliminary data. Am J Surg. 2011;201:369Y372. 4. Behnia-Willison F, Foroughinia L, Sina M, et al. Single incision laparoscopic surgery (SILS) in gynaecology: feasibility and operative outcomes. Aust N Z J Obstet Gynaecol. 2012;52: 366Y370. 5. De Poncheville L, Smirnoff A, Me´nard J, et al. Feasibility of laparoendoscopic single-site surgery in gynecology with conventional laparoscopic instruments [in French]. Gynecol Obstet Fertil. 2012;40:729Y733. 6. Park HS, Kim TJ, Song T, et al. Single-port access (SPA) laparoscopic surgery in gynecology: a surgeon’s expe´rience with an initial 200 cases. Eur J Obstet Gynecol Reprod Biol. 2011;154:81Y84. 7. Nickles Fader A, Rojas-Espaillat L, Ibeanu O, et al. Laparoendoscopic single-site surgery (LESS) in gynecology: a multi-institutional evaluation. Am J Obstet Gynecol. 2010;203:501.e1Y501.e6. 8. Lee M, Kim SW, Kim YT, et al. Single-port laparoscopic surgery is applicable to most gynecologic surgery: a single surgeon’s experience. Surg Endosc. 2012;26:1318Y1324. 9. Jackson T, Einarsson J. Single-port gynecologic surgery. Rev Obstet Gynecol. 2010;3:133Y139. 10. Kim TJ, Lee YY, Kim CJ, Bae DS, et al. Single port access laparoscopic adnexal surgery. J Minim Invasive Gynecol. 2009;16:612Y615. 11. Jung YW, Choi YM, Chung CK, et al. Single port transumbilical laparoscopic surgery for adnexal lesions: a single center experience in Korea. Eur J Obstet Gynecol Reprod Biol. 2011;155:221Y224.



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12. 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;151:181Y184. 13. Hoyer-Sorensen C, Vistad I, Ballard K. Is single-port laparoscopy for benign adnexal disease less painful than conventional laparoscopy ? A single-center randomized controlled trial. Fertil Steril. 2012;98:973Y979. 14. Kim TJ, Lee YY, An JJ, et al. Does single-port access (SPA) laparoscopy mean reduced pain ? A retrospective cohort analysis between SPA and conventional laparoscopy. Eur J Obstet Gynecol Reprod Biol. 2012;162:17Y74. 15. Yim GW, Lee M, Nam EJ, et al. Is single-port access laparoscopy less painful than conventional laparoscopy for

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adnexal surgery? A comparison of postoperative pain and surgical outcomes. Surg Innov. 2013;20:46Y54. 16. Eom JM, Ko JH, Choi JS, et al. A comparative cross-sectional study on cosmetic outcomes after single port or conventional laparoscopic surgery. Eur J Obstet Gynecol Reprod Biol. 2013;167:104Y109. 17. 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;52:465Y469. 18. 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;167:215Y218.



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