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Patient Preferences of Cosmesis for Abdominal Incisions in Gynecologic Surgery
Original Article
Patient Preferences of Cosmesis for Abdominal Incisions in Gynecologic Surgery Patrick P. Yeung Jr., MD*, Carlos R. Bolden, MD, Daniel Westreich, PhD, and Craig Sobolewski, MD From the Department of Obstetrics, Gynecology, and Women’s Health (Dr. Yeung), Minimally Invasive Gynecologic Surgery, Saint Louis University, St. Louis, Missouri, Department of Obstetrics and Gynecology (Drs. Bolden and Westreich), and Duke Center for Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology (Dr. Sobolewski), Duke University, Durham, North Carolina.
ABSTRACT Study Objective: To estimate patient preferences insofar as the cosmetic appeal of abdominal incisions used for hysterectomy. We hypothesized that the laparoendoscopic single-site surgery (LESS) incision would be preferred cosmetically to traditional multiport laparoscopic incisions and open abdominal incisions via Pfannenstiel, vertical midline, or horizontal mini-laparotomy. Design: Prospective comparative study (Canadian Task Force classification II-2). Setting: Two gynecology clinics at Duke University Medical Center in Durham, North Carolina. Patients: Seventy-three women including 50 consecutive women from a private specialty clinic and 23 consecutive women from a resident indigent care clinic. Interventions: A brief questionnaire was distributed that assessed preferences via ranking and by using a visual analog scale. Patients were also asked to rate the importance of 4 factors in their decision making: size, location, and number of incisions, and perceived recovery time. Descriptive statistics, t tests, Wilcoxon rank-sum tests, and c2 tests were used to compare continuous or categorical values. Measurements and Main Results: Overall, the LESS incision was the most preferred incision according to most common choice and visual analog scale scores. In the private clinic, the LESS incision was preferred most often, with 53% of women (39/73) ranking it as their first choice. In the resident clinic, the horizontal mini-laparotomy incision was preferred most often, with 27% of women (20/73) ranking it their first choice. Neither the demographic factors nor any of the factors in decision making explained the difference between the clinics. Conclusion: The LESS incision was most preferred in this study. However, the horizontal mini-laparotomy incision and the traditional laparoscopic with low lateral incisions were also highly preferred. Patient perception of the ‘‘visibility’’ of abdominal incisions may be the distinguishing issue to explain the difference in the preferences between the clinics and the differences between the present study and previously published studies of cosmetic preferences. Journal of Minimally Invasive Gynecology (2013) 20, 79–84 Ó 2013 AAGL. All rights reserved. DISCUSS
You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-20-1-12-00335
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.
The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Patrick P. Yeung Jr., MD, Department of Obstetrics, Gynecology, and Women’s Health, Minimally Invasive Gynecologic Surgery, St. Louis University Medical School, 6420 Clayton Rd., Ste 290, St. Louis, MO 63117. E-mail: [email protected] Submitted July 5, 2012. Accepted for publication September 22, 2012. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2013 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2012.09.008
As surgical techniques have become more advanced, minimally invasive approaches to hysterectomy have become increasingly commonplace. Indeed, the American Association of Gynecologic Laparoscopists, in their latest position statement on hysterectomy, recommend a minimally invasive approach when possible [1]. A number of factors are taken into consideration when discussing possible methods of hysterectomy with a surgical candidate and deciding which option is best. From the surgeon’s perspective, one must consider the suitability of the
80
patient for a particular approach, technical difficulty in performing the surgery, anticipated operative time, likelihood of complications, and patient satisfaction with the surgical result. From the patient’s perspective, surgeon skill, postoperative pain, postoperative recovery time, and the cosmetic appearance of the resulting incision(s) are important factors. Insofar as cosmesis, as a factor important to both surgeon and patient, it is important to assess whether patient preferences coincide with the intuitive notion that surgeries resulting in smaller or fewer abdominal incisions are more cosmetically preferred. Moreover, should the cosmetic appeal of the postoperative scars resulting from a particular surgical approach be discussed during presurgical counseling, and, if so, how much weight should it be given? The present study was designed as an update and modification of a 1996 study from the United Kingdom by Currie et al [2] that examined the cosmetic appeal of laparoscopic-assisted vaginal hysterectomy (LAVH) incisions as compared with 3 other incisions commonly used for abdominal hysterectomy. That study concluded that most women (68%) preferred a Pfannenstiel incision as the incision of first choice, and only about one-third (31%) chose the LAVH incision. This was an unexpected result because the authors had hypothesized that, on the basis of length and size, the LAVH incision (3–4 cm total length) should be cosmetically more appealing than the Pfannenstiel incision (10–15 cm total length). Thus, they concluded that gynecologists should not use cosmetic appeal in counseling women about LAVH. The objective of the present study was to estimate whether the laparoendoscopic single-site surgery (LESS) incision, as a single incision in the umbilicus, is cosmetically more appealing than other incisions commonly used in abdominal hysterectomy. Inasmuch as the LESS incision is a single 2-cm incision hidden in the umbilical fold, on the basis of incision length and that it is within the umbilicus, which is a natural scar, we hypothesized that this incision would be cosmetically more appealing to patients than other laparoscopic or open abdominal incisions. Materials and Methods Sixty-two patients were interviewed for the study, and 60 provided rankings for the illustrated incisions. Of the 60 patients, 37 attended the Duke Center for Minimally Invasive Gynecologic Surgery (MIGS) clinic, a private gynecologic clinic that provides services to patients with private insurance and Medicare patients with supplemental private insurance. Twenty-three participants attended the Duke University Medical Center Resident Gynecology clinic, an indigent-care clinic that provides gynecologic services to patients with state-sponsored insurance and those lacking insurance entirely. Women were selected consecutively in each clinic. Participants were recruited from the lists of patients for specified days in the MIGS and resident clinics who were scheduled for annual visits. The research subjects
Journal of Minimally Invasive Gynecology, Vol 20, No 1, January/February 2013
were not compensated for their study participation. The study was introduced to potential participants by their caregivers and were approached by the study team only if interested in participation. The study received approval from the Institutional Review Board at Duke University. Inclusion criteria for the study were as follows: (1) patients visiting the clinic for a scheduled annual visit, (2) patients aged R18 years and able to given legally effective consent, (3) patients for whom hysterectomy would likely be discussed as a treatment option during their visit, and (4) patients who were willing to participate in a study pertaining to the appearance of surgical incisions. Exclusion criteria included the following: (1) patients visiting the office for a reason other than an annual visit, (2) patients aged ,18 years or those not able to give legally effective consent, and (3) patients who believed that hysterectomy might be discussed as a treatment option during their visit. A 5-page questionnaire was distributed to willing participants that obtained historical information (age, race/ethnicity, height, weight, marital status, and occupation; and history of previous abdominal surgical procedures, including any complications) and included illustrations of 6 different abdominal incisions (labeled A–F) used for hysterectomy. If patients reported previous surgery, they were asked to elaborate on any postoperative complications. Short-term complications were specified to include wound infection and/or breakdown, and long-term complications were specified to include puckering, nodularity, keloid formation, or thickening along the scar line. Six diagrams of the female abdomen were presented, with 6 different incisional choices for hysterectomy. Diagrams with accompanying descriptions (Fig. 1A–F) corresponded, respectively, with a Pfannenstiel incision (14-cm incision at the ‘‘bikini line’’), a vertical midline incision (14-cm incision from midline symphysis to the umbilicus), multi-port laparoscopy with lateral port placement in the lower abdomen (two 0.5-cm lateral incisions in the lower abdomen and a 1-cm incision hidden in the umbilical fold), multiport laparoscopy with lateral port placement in the midabdomen (two 0.5-cm lateral incisions in the mid-abdomen and a 1-cm incision hidden in the umbilical fold), a LESS surgery incision (one 2-cm incision hidden in the umbilical fold), and a mini-laparotomy horizontal incision (6-cm incision at the bikini line). The relative sizes of the incisions were portrayed to scale. It is important to note that the 2 laparoscopic configurations could also represent robotic cosmetic results. Each participant was asked to rank the cosmetic appeal of each incision or group of incisions on a 10-cm visual analog scale (VAS) in the hypothetical situation that they would require hysterectomy and that all of the presented surgical approaches were equally safe and effective. All 6 incisions were ranked and rated on the same VAS line. The 10-cm marks represented the most desirable incision on the basis of cosmetic appeal alone. Participants were then asked to rank on a separate 10-cm VAS line how important each of
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Fig. 1 Illustrations used in the study questionnaire for cosmetic assessment. A: Pfannenstiel incision. B: Vertical midline incision. C: Multi-port laparoscopy with lateral incisions in lower abdomen. D: Multi-port laparoscopy with lateral incisions in mid-abdomen. E: Laparoendoscopic single-site surgery incision. F: Mini-laparotomy incision. Illustrations were 48 ! 52 mm and were presented in black and white.
4 factors were in making their decision: size and appearance of the incision(s), location of the incision(s), number of incisions, and perceived recovery time or time off from work. All 4 factors were ranked and rated on the same VAS line. There were no available data at the time of study design by which to calculate a sample size for the study because our hypothesis was that the LESS incision would be preferred. However, as an update to the study by Currie et al [2], it was decided that the objective should be to recruit 100 subjects. Descriptive statistics including ranks, means, and medians were used to characterize patient responses. Values for p (for comparison of VAS scores) were obtained using t tests to analyze differences in means of continuous variables; Wilcoxon rank-sum tests were used for differences in medians; and c2 tests were used for differences in distributions of categorical and dichotomous variables. Univariate linear and linear-risk (a generalized linear model under an identity link and with a binomial error distribution), and log-binomial regressions were used to test associations of continuous variables with outcomes. Results Seventy-five subjects were recruited into the study, of whom 73 provided rankings for surgery scar patterns. Sequential analyses of the subjects recruited (at 60 and then at 75 subjects) indicated a significant preference of incision,
which did not change with continued recruitment. Thus, the number of subjects recruited was adequate to prove our hypothesis, and it was not believed necessary to reach our initial goal of 100 subjects. Overall, subjects had a median age of 35 years (range, 18–68 years; interquartile range, 27–43 years) and a median body mass index (BMI) of 25.4 (range, 18.8–49.7; interquartile range, 22.0–30.0). Approximately equal numbers of women were partnered (n 5 37) and single (n 5 36), including 10 patients divorced or separated and 1 widowed. Most women (n 5 58) reported some form of employment. Most women self-reported race as white, non-Hispanic (n 5 39), or black non-Hispanic (n 5 28). Somewhat less than half of the women self-reported previous surgery (n 5 33), with half of those (n 5 17) reporting multiple previous surgical procedures. Compared with women in the resident clinic, patients in the MIGS group were significantly older (median age, 40 vs 27 years; p 5 .002) and more likely to be white (66% vs 26%; p 5 .002). Patients in the MIGS group also had a somewhat lower BMI (median, 25.2 vs 28.2; p 5 .19) and were slightly more likely to have undergone previous surgery (48% vs 39%; p 5 .48); however, these differences were not statistically significant. The clear overall most preferred choice was the LESS incision (Table 1). It had the highest mean VAS score, was selected as most preferred most often, and had nonoverlapping 95% confidence interval (CI) around the highest
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Table 1 Overall choice of incision Incision
VAS Score, mean (SD)
Times selected as first choice
Times selected as first choice, % (95% CI)
A: Pfannenstiel B: Vertical midline C: Multi-port laparoscopy with lateral ports in lower abdomen D: Multi-port laparoscopy with lateral incisions in mid-abdomen E: LESS F: Mini-laparotomy
2.83 (2.1) 1.41 (1.1) 6.48 (1.9)
1 0 12
0.01 (0–0.07) 0 (0–0.04) 0.16 (0.10–0.27)
5.33 (2.1)
1
7.22 (2.3) 5.90 (2.3)
39 20
0.01 (0–0.07) 0.53 (0.42–0.64) 0.27 (0.18–0.39)
CI 5 confidence interval; LESS 5 laparoendoscopic single-site surgery; VAS 5 visual analog scale.
proportion of most preferred incision. The second most preferred incision overall on the basis of mean VAS score was that of multi-port laparoscopy with the lateral incisions in the lower abdomen. However, the mini-laparotomy horizontal incision, which was third on the basis of mean VAS score, was the second most common incision selected as the most preferred incision overall. The clear overall least preferred was the vertical midline incision; no patients selected this incision as most preferred. When the data were examined according to clinic population, there was a difference in most preferred incision (Table 2). In the MIGS clinic group, 32 of 50 patients chose the LESS incision as their first choice. However, in the resident clinic group, the most preferred was the mini-laparotomy
incision, garnering 10 of 23 first-choice selections. The mean VAS scores for the LESS and mini-laparotomy incisions were, respectively, 7.8 and 5.7 in the MIGS clinic group, and 6.0 and 6.3 in the resident clinic group. The mean VAS score for the LESS incision differed between the 2 clinics (p 5 .01, pooled t test with unequal variances) but did not differ for the mini-laparotomy incision (p 5 .37). White patients most often preferred the LESS incision (mean VAS score, 7.4), followed in order by the minilaparotomy incision (mean VAS score, 5.8) and multi-port laparoscopy with lateral incisions in the lower abdomen (mean VAS score, 7.0). Nonwhite patients preferred the LESS incision (mean VAS score, 7.0), followed in order by the mini-laparotomy incision (mean VAS score, 6.0)
Table 2 Number of times each incision was chosen as first-choice preference and patient demographic characteristicsa Type of incision, No. (%) Variable Clinic group MIGS (n 5 50) Resident (n 5 23) Age, yr %35 (n 5 37) .35 (n 5 36) Race/ethnicity White (n 5 39) Nonwhite (n 5 34) Previous surgery Any (n 5 33) None (n 5 40) Body mass index %25 (n 5 32) 25–30 (n 5 24) .30 (n 5 17)
A: Pfannenstiel
C: Multi-port laparoscopy
D: Multi-port laparoscopy
LESS
Mini-laparotomy
p value (c2 test)
0 1 (4)
7 (14) 5 (22)
1 (2) 0
32 (64) 7 (30)
10 (20) 10 (44)
.05
1 (3) 0
6 (16) 6 (17)
0 1 (3)
20 (54) 19 (53)
10 (27) 10 (28)
.73
0 1 (3)
9 (23) 3 (9)
0 1 (3)
20 (51) 19 (56)
10 (26) 10 (29)
.32
0 1 (3)
5 (15) 7 (18)
1 (3) 0
20 (61) 19 (48)
7 (21) 13 (33)
.47
1 (3) 0 0
4 (13) 4 (17) 4 (24)
0 0 1 (6)
14 (44) 18 (75) 7 (41)
13 (41) 2 (8) 5 (29)
.09
LESS 5 laparoendoscopic single-site surgery; MIGS 5 minimally invasive gynecologic surgery. a Incisions A through F correspond to illustrations in Figure 1. B: Vertical midline incision is omitted because no patient chose this as first-choice option.
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Patient Preferences of Cosmesis for Abdominal Incisions
Table 3 Factors in decision making
Variable
VAS score, mean (SD)
Times ranked most important, No.a
Size and appearance of incisions Location of incisions No. of incisions Perceived recovery time
7.6 (2.0) 7.5 (1.9) 6.3 (2.3) 6.5 (2.9)
27 17 11 24
VAS 5 visual analog scale. a Total times ranked most important is greater than number of participants because 7 patients ranked R2 qualities as equally important.
and multi-port laparoscopy with lateral incisions in the lower abdomen (mean VAS score, 5.9). Patients who had undergone previous surgery most often chose the LESS incision (mean VAS score, 7.0), followed in order by multi-port laparoscopy with lateral incisions in the lower abdomen (mean VAS score, 6.7) and the minilaparotomy incision (mean VAS score, 6.0). Those with no previous abdominal surgery chose incisions in the same order, with mean VAS scores of 6.8, 6.1, and 6.1, respectively. At linear regression analysis, there was no effect of a unit of continuous age or a unit of continuous BMI on these ratings. In looking at the dichotomous outcome of ‘‘LESS as first choice’’ vs ‘‘an incision other than LESS as first choice,’’ there was no effect of white race, history of previous surgery, continuous age, or continuous BMI on this decision at linear regression analysis. Insofar as factors patients considered in making their decisions, size and appearance were believed to be most important, and were ranked as most important the greatest number of times and with the highest VAS scores (Table 3). Location was the second most important factor on the basis of mean VAS score, although it tied perceived recovery time as second in the number of times it was selected as the most important factor. Perceived recovery time was least important on the basis of mean VAS score. The mean scores of all 4 factors in decision making were all within 1 SD of each other. Multivariable regression analysis comparing the MIGS with the non-MIGS groups controlling for these 4 factors yielded an estimate of risk difference of 0.42 (95% CI, 0.13–0.70) and a risk ratio of 1.5 (95% CI, 1.0–2.2) for the outcome of choosing the LESS incision as first choice vs other possible first choices, which suggests that differences between clinics are not well explained by any one of these decision-making factors. Discussion The results of the present study are simultaneously expected and novel. Overall, the LESS incision was the most preferred incision for cosmesis. This is the intuitive choice
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because the LESS incision is a single small incision hidden within the umbilicus, itself a natural scar. Indeed, the LESS approach is being called ‘‘scarless’’ surgery [3] and can result in a virtually imperceptible scar when performed in experienced hands. For the best cosmetic result, the scar should not extend outside the perimeter of the umbilical crater and should not disfigure the natural configuration of the umbilicus [4]. When separating out the clinic populations, one sees that the resident clinic patients most often preferred the horizontal mini-laparotomy incision. The mini-laparotomy incision is larger than any of the laparoscopic (including LESS) configurations; note that the laparoscopic incision configurations also represent robotic incision configurations. This result is interesting because it simulates the results of the 1996 study by Currie et al [2] in which they found that patients preferred a Pfannenstiel incision to the LAVH incisions. Clearly, size alone is not the only factor that determines cosmetic preferences. When comparing the demographic characteristics of the 2 populations, the MIGS group was significantly older and more likely white; however, neither these nor any of the demographic differences explained the difference in the most common preference of incision between the clinic populations. Similarly, none of the factors in decision making inquired about explained the difference, at least not individually. That is, neither size, location, nor number of incisions alone explained why the resident population most commonly preferred the horizontal mini-laparotomy incision, whereas the MIGS group most commonly preferred the LESS incision. A reasonable explanation for the different most common preferences in the clinic populations, and perhaps one that encompasses the factors that were asked about and which were all rated equivalently high in importance, is something that was not asked about and that we refer to as ‘‘visibility.’’ Visibility can be thought of as the patient’s perception of whether the incisions are visible when the mid-abdomen (above the hip bones or the anterior superior iliac spine) is exposed. Although the LESS incision and the horizontal mini-laparotomy incision differ greatly in size, they are both potentially not visible when the mid-abdomen is exposed, as long as the LESS incision is hidden in the umbilicus. It is possible that the MIGS group had the perception or understanding that the LESS incision was hidden within the boundaries of the umbilical crater. It is notable that the graphic depiction of the LESS incision extends beyond the umbilicus. The incisions in the present study were mathematically scaled to size, making it impossible to visually depict that the LESS incision was completely confined within the margins of the umbilical crater, thus making it not visible. In practice, however, this is routinely accomplished. In a recent study by Bush et al [5], traditional laparoscopic incisions were considerably preferred over the LESS incision, a finding that contrasts with those presented herein. In the present study, traditional laparoscopic incisions were chosen third most commonly. It is noteworthy that the LESS incision, traditional laparoscopic incisions
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(with low lateral incisions), and the horizontal minilaparotomy incision are all potentially not visible when the mid-abdomen is exposed above the level of the hip bones. Again, the perceived visibility of the incisions, or lack thereof, may explain the differences between the results for cosmetic preferences of the studies by Currie et al [1], Bush et al [5], and the present study. Strengths of the present study included that 2 distinct populations were studied, 1 that specializes in minimally invasive gynecologic surgery and one that does not. In addition, our study is unique in that all possible open, laparoscopic, and robotic incisions were represented. Another unique aspect of the present study compared with previous studies of cosmetic preferences was inclusion of questions that related to the factors involved in patients’ decision making. Weaknesses included that the graphic depiction of incisions does not necessarily correlate well with actual cosmetic results, the lack of postoperative assessment as to whether patient’s were satisfied with their cosmetic result, and whether the actual cosmetic result correlated well with the anticipated cosmetic result.
Journal of Minimally Invasive Gynecology, Vol 20, No 1, January/February 2013
Larger, multi-center, prospective trials are needed. Future research on cosmetic preferences should examine this concept of the visibility of incisions, may need to include actual photos of cosmetic results, and should include postoperative assessments of whether the actual cosmetic result correlated with the patient’s anticipated cosmetic result. References 1. AAGL Advancing Minimally Invasive Gynecology Worldwide. AAGL Position Statement: route of hysterectomy to treat benign uterine disease. J Minim Invasive Gynecol. 2011;18:1–3. 2. Currie I, Onwude JL, Jarvis GJ. A comparative study of the cosmetic appeal of abdominal incisions used for hysterectomy. Br J Obstet Gynaecol. 1996;103:252–254. 3. Autorino R, White WM, Gettman MT, et al. Public perception of ‘‘scarless’’ surgery: a critical analysis of the literature. Urology. 2012;80: 495–502. 4. de Armas IA, Garcia I, Pimpalwar A. Laparoscopic single port surgery in children using Triport: our early experience. Pediatr Surg Int. 2011;27: 985–989. 5. Bush AJ, Morris SN, Millham FH, Isaacson KB. Women’s preferences for minimally invasive incisions. J Minim Invasive Gynecol. 2011;18: 640–643.
Patient Preferences of Cosmesis for Abdominal Incisions in Gynecologic Surgery Patrick P. Yeung Jr., MD*, Carlos R. Bolden, MD, Daniel Westreich, PhD, and Craig Sobolewski, MD From the Department of Obstetrics, Gynecology, and Women’s Health (Dr. Yeung), Minimally Invasive Gynecologic Surgery, Saint Louis University, St. Louis, Missouri, Department of Obstetrics and Gynecology (Drs. Bolden and Westreich), and Duke Center for Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology (Dr. Sobolewski), Duke University, Durham, North Carolina.
ABSTRACT Study Objective: To estimate patient preferences insofar as the cosmetic appeal of abdominal incisions used for hysterectomy. We hypothesized that the laparoendoscopic single-site surgery (LESS) incision would be preferred cosmetically to traditional multiport laparoscopic incisions and open abdominal incisions via Pfannenstiel, vertical midline, or horizontal mini-laparotomy. Design: Prospective comparative study (Canadian Task Force classification II-2). Setting: Two gynecology clinics at Duke University Medical Center in Durham, North Carolina. Patients: Seventy-three women including 50 consecutive women from a private specialty clinic and 23 consecutive women from a resident indigent care clinic. Interventions: A brief questionnaire was distributed that assessed preferences via ranking and by using a visual analog scale. Patients were also asked to rate the importance of 4 factors in their decision making: size, location, and number of incisions, and perceived recovery time. Descriptive statistics, t tests, Wilcoxon rank-sum tests, and c2 tests were used to compare continuous or categorical values. Measurements and Main Results: Overall, the LESS incision was the most preferred incision according to most common choice and visual analog scale scores. In the private clinic, the LESS incision was preferred most often, with 53% of women (39/73) ranking it as their first choice. In the resident clinic, the horizontal mini-laparotomy incision was preferred most often, with 27% of women (20/73) ranking it their first choice. Neither the demographic factors nor any of the factors in decision making explained the difference between the clinics. Conclusion: The LESS incision was most preferred in this study. However, the horizontal mini-laparotomy incision and the traditional laparoscopic with low lateral incisions were also highly preferred. Patient perception of the ‘‘visibility’’ of abdominal incisions may be the distinguishing issue to explain the difference in the preferences between the clinics and the differences between the present study and previously published studies of cosmetic preferences. Journal of Minimally Invasive Gynecology (2013) 20, 79–84 Ó 2013 AAGL. All rights reserved. DISCUSS
You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-20-1-12-00335
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.
The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Patrick P. Yeung Jr., MD, Department of Obstetrics, Gynecology, and Women’s Health, Minimally Invasive Gynecologic Surgery, St. Louis University Medical School, 6420 Clayton Rd., Ste 290, St. Louis, MO 63117. E-mail: [email protected] Submitted July 5, 2012. Accepted for publication September 22, 2012. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2013 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2012.09.008
As surgical techniques have become more advanced, minimally invasive approaches to hysterectomy have become increasingly commonplace. Indeed, the American Association of Gynecologic Laparoscopists, in their latest position statement on hysterectomy, recommend a minimally invasive approach when possible [1]. A number of factors are taken into consideration when discussing possible methods of hysterectomy with a surgical candidate and deciding which option is best. From the surgeon’s perspective, one must consider the suitability of the
80
patient for a particular approach, technical difficulty in performing the surgery, anticipated operative time, likelihood of complications, and patient satisfaction with the surgical result. From the patient’s perspective, surgeon skill, postoperative pain, postoperative recovery time, and the cosmetic appearance of the resulting incision(s) are important factors. Insofar as cosmesis, as a factor important to both surgeon and patient, it is important to assess whether patient preferences coincide with the intuitive notion that surgeries resulting in smaller or fewer abdominal incisions are more cosmetically preferred. Moreover, should the cosmetic appeal of the postoperative scars resulting from a particular surgical approach be discussed during presurgical counseling, and, if so, how much weight should it be given? The present study was designed as an update and modification of a 1996 study from the United Kingdom by Currie et al [2] that examined the cosmetic appeal of laparoscopic-assisted vaginal hysterectomy (LAVH) incisions as compared with 3 other incisions commonly used for abdominal hysterectomy. That study concluded that most women (68%) preferred a Pfannenstiel incision as the incision of first choice, and only about one-third (31%) chose the LAVH incision. This was an unexpected result because the authors had hypothesized that, on the basis of length and size, the LAVH incision (3–4 cm total length) should be cosmetically more appealing than the Pfannenstiel incision (10–15 cm total length). Thus, they concluded that gynecologists should not use cosmetic appeal in counseling women about LAVH. The objective of the present study was to estimate whether the laparoendoscopic single-site surgery (LESS) incision, as a single incision in the umbilicus, is cosmetically more appealing than other incisions commonly used in abdominal hysterectomy. Inasmuch as the LESS incision is a single 2-cm incision hidden in the umbilical fold, on the basis of incision length and that it is within the umbilicus, which is a natural scar, we hypothesized that this incision would be cosmetically more appealing to patients than other laparoscopic or open abdominal incisions. Materials and Methods Sixty-two patients were interviewed for the study, and 60 provided rankings for the illustrated incisions. Of the 60 patients, 37 attended the Duke Center for Minimally Invasive Gynecologic Surgery (MIGS) clinic, a private gynecologic clinic that provides services to patients with private insurance and Medicare patients with supplemental private insurance. Twenty-three participants attended the Duke University Medical Center Resident Gynecology clinic, an indigent-care clinic that provides gynecologic services to patients with state-sponsored insurance and those lacking insurance entirely. Women were selected consecutively in each clinic. Participants were recruited from the lists of patients for specified days in the MIGS and resident clinics who were scheduled for annual visits. The research subjects
Journal of Minimally Invasive Gynecology, Vol 20, No 1, January/February 2013
were not compensated for their study participation. The study was introduced to potential participants by their caregivers and were approached by the study team only if interested in participation. The study received approval from the Institutional Review Board at Duke University. Inclusion criteria for the study were as follows: (1) patients visiting the clinic for a scheduled annual visit, (2) patients aged R18 years and able to given legally effective consent, (3) patients for whom hysterectomy would likely be discussed as a treatment option during their visit, and (4) patients who were willing to participate in a study pertaining to the appearance of surgical incisions. Exclusion criteria included the following: (1) patients visiting the office for a reason other than an annual visit, (2) patients aged ,18 years or those not able to give legally effective consent, and (3) patients who believed that hysterectomy might be discussed as a treatment option during their visit. A 5-page questionnaire was distributed to willing participants that obtained historical information (age, race/ethnicity, height, weight, marital status, and occupation; and history of previous abdominal surgical procedures, including any complications) and included illustrations of 6 different abdominal incisions (labeled A–F) used for hysterectomy. If patients reported previous surgery, they were asked to elaborate on any postoperative complications. Short-term complications were specified to include wound infection and/or breakdown, and long-term complications were specified to include puckering, nodularity, keloid formation, or thickening along the scar line. Six diagrams of the female abdomen were presented, with 6 different incisional choices for hysterectomy. Diagrams with accompanying descriptions (Fig. 1A–F) corresponded, respectively, with a Pfannenstiel incision (14-cm incision at the ‘‘bikini line’’), a vertical midline incision (14-cm incision from midline symphysis to the umbilicus), multi-port laparoscopy with lateral port placement in the lower abdomen (two 0.5-cm lateral incisions in the lower abdomen and a 1-cm incision hidden in the umbilical fold), multiport laparoscopy with lateral port placement in the midabdomen (two 0.5-cm lateral incisions in the mid-abdomen and a 1-cm incision hidden in the umbilical fold), a LESS surgery incision (one 2-cm incision hidden in the umbilical fold), and a mini-laparotomy horizontal incision (6-cm incision at the bikini line). The relative sizes of the incisions were portrayed to scale. It is important to note that the 2 laparoscopic configurations could also represent robotic cosmetic results. Each participant was asked to rank the cosmetic appeal of each incision or group of incisions on a 10-cm visual analog scale (VAS) in the hypothetical situation that they would require hysterectomy and that all of the presented surgical approaches were equally safe and effective. All 6 incisions were ranked and rated on the same VAS line. The 10-cm marks represented the most desirable incision on the basis of cosmetic appeal alone. Participants were then asked to rank on a separate 10-cm VAS line how important each of
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Patient Preferences of Cosmesis for Abdominal Incisions
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Fig. 1 Illustrations used in the study questionnaire for cosmetic assessment. A: Pfannenstiel incision. B: Vertical midline incision. C: Multi-port laparoscopy with lateral incisions in lower abdomen. D: Multi-port laparoscopy with lateral incisions in mid-abdomen. E: Laparoendoscopic single-site surgery incision. F: Mini-laparotomy incision. Illustrations were 48 ! 52 mm and were presented in black and white.
4 factors were in making their decision: size and appearance of the incision(s), location of the incision(s), number of incisions, and perceived recovery time or time off from work. All 4 factors were ranked and rated on the same VAS line. There were no available data at the time of study design by which to calculate a sample size for the study because our hypothesis was that the LESS incision would be preferred. However, as an update to the study by Currie et al [2], it was decided that the objective should be to recruit 100 subjects. Descriptive statistics including ranks, means, and medians were used to characterize patient responses. Values for p (for comparison of VAS scores) were obtained using t tests to analyze differences in means of continuous variables; Wilcoxon rank-sum tests were used for differences in medians; and c2 tests were used for differences in distributions of categorical and dichotomous variables. Univariate linear and linear-risk (a generalized linear model under an identity link and with a binomial error distribution), and log-binomial regressions were used to test associations of continuous variables with outcomes. Results Seventy-five subjects were recruited into the study, of whom 73 provided rankings for surgery scar patterns. Sequential analyses of the subjects recruited (at 60 and then at 75 subjects) indicated a significant preference of incision,
which did not change with continued recruitment. Thus, the number of subjects recruited was adequate to prove our hypothesis, and it was not believed necessary to reach our initial goal of 100 subjects. Overall, subjects had a median age of 35 years (range, 18–68 years; interquartile range, 27–43 years) and a median body mass index (BMI) of 25.4 (range, 18.8–49.7; interquartile range, 22.0–30.0). Approximately equal numbers of women were partnered (n 5 37) and single (n 5 36), including 10 patients divorced or separated and 1 widowed. Most women (n 5 58) reported some form of employment. Most women self-reported race as white, non-Hispanic (n 5 39), or black non-Hispanic (n 5 28). Somewhat less than half of the women self-reported previous surgery (n 5 33), with half of those (n 5 17) reporting multiple previous surgical procedures. Compared with women in the resident clinic, patients in the MIGS group were significantly older (median age, 40 vs 27 years; p 5 .002) and more likely to be white (66% vs 26%; p 5 .002). Patients in the MIGS group also had a somewhat lower BMI (median, 25.2 vs 28.2; p 5 .19) and were slightly more likely to have undergone previous surgery (48% vs 39%; p 5 .48); however, these differences were not statistically significant. The clear overall most preferred choice was the LESS incision (Table 1). It had the highest mean VAS score, was selected as most preferred most often, and had nonoverlapping 95% confidence interval (CI) around the highest
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Journal of Minimally Invasive Gynecology, Vol 20, No 1, January/February 2013
Table 1 Overall choice of incision Incision
VAS Score, mean (SD)
Times selected as first choice
Times selected as first choice, % (95% CI)
A: Pfannenstiel B: Vertical midline C: Multi-port laparoscopy with lateral ports in lower abdomen D: Multi-port laparoscopy with lateral incisions in mid-abdomen E: LESS F: Mini-laparotomy
2.83 (2.1) 1.41 (1.1) 6.48 (1.9)
1 0 12
0.01 (0–0.07) 0 (0–0.04) 0.16 (0.10–0.27)
5.33 (2.1)
1
7.22 (2.3) 5.90 (2.3)
39 20
0.01 (0–0.07) 0.53 (0.42–0.64) 0.27 (0.18–0.39)
CI 5 confidence interval; LESS 5 laparoendoscopic single-site surgery; VAS 5 visual analog scale.
proportion of most preferred incision. The second most preferred incision overall on the basis of mean VAS score was that of multi-port laparoscopy with the lateral incisions in the lower abdomen. However, the mini-laparotomy horizontal incision, which was third on the basis of mean VAS score, was the second most common incision selected as the most preferred incision overall. The clear overall least preferred was the vertical midline incision; no patients selected this incision as most preferred. When the data were examined according to clinic population, there was a difference in most preferred incision (Table 2). In the MIGS clinic group, 32 of 50 patients chose the LESS incision as their first choice. However, in the resident clinic group, the most preferred was the mini-laparotomy
incision, garnering 10 of 23 first-choice selections. The mean VAS scores for the LESS and mini-laparotomy incisions were, respectively, 7.8 and 5.7 in the MIGS clinic group, and 6.0 and 6.3 in the resident clinic group. The mean VAS score for the LESS incision differed between the 2 clinics (p 5 .01, pooled t test with unequal variances) but did not differ for the mini-laparotomy incision (p 5 .37). White patients most often preferred the LESS incision (mean VAS score, 7.4), followed in order by the minilaparotomy incision (mean VAS score, 5.8) and multi-port laparoscopy with lateral incisions in the lower abdomen (mean VAS score, 7.0). Nonwhite patients preferred the LESS incision (mean VAS score, 7.0), followed in order by the mini-laparotomy incision (mean VAS score, 6.0)
Table 2 Number of times each incision was chosen as first-choice preference and patient demographic characteristicsa Type of incision, No. (%) Variable Clinic group MIGS (n 5 50) Resident (n 5 23) Age, yr %35 (n 5 37) .35 (n 5 36) Race/ethnicity White (n 5 39) Nonwhite (n 5 34) Previous surgery Any (n 5 33) None (n 5 40) Body mass index %25 (n 5 32) 25–30 (n 5 24) .30 (n 5 17)
A: Pfannenstiel
C: Multi-port laparoscopy
D: Multi-port laparoscopy
LESS
Mini-laparotomy
p value (c2 test)
0 1 (4)
7 (14) 5 (22)
1 (2) 0
32 (64) 7 (30)
10 (20) 10 (44)
.05
1 (3) 0
6 (16) 6 (17)
0 1 (3)
20 (54) 19 (53)
10 (27) 10 (28)
.73
0 1 (3)
9 (23) 3 (9)
0 1 (3)
20 (51) 19 (56)
10 (26) 10 (29)
.32
0 1 (3)
5 (15) 7 (18)
1 (3) 0
20 (61) 19 (48)
7 (21) 13 (33)
.47
1 (3) 0 0
4 (13) 4 (17) 4 (24)
0 0 1 (6)
14 (44) 18 (75) 7 (41)
13 (41) 2 (8) 5 (29)
.09
LESS 5 laparoendoscopic single-site surgery; MIGS 5 minimally invasive gynecologic surgery. a Incisions A through F correspond to illustrations in Figure 1. B: Vertical midline incision is omitted because no patient chose this as first-choice option.
Yeung Jr. et al.
Patient Preferences of Cosmesis for Abdominal Incisions
Table 3 Factors in decision making
Variable
VAS score, mean (SD)
Times ranked most important, No.a
Size and appearance of incisions Location of incisions No. of incisions Perceived recovery time
7.6 (2.0) 7.5 (1.9) 6.3 (2.3) 6.5 (2.9)
27 17 11 24
VAS 5 visual analog scale. a Total times ranked most important is greater than number of participants because 7 patients ranked R2 qualities as equally important.
and multi-port laparoscopy with lateral incisions in the lower abdomen (mean VAS score, 5.9). Patients who had undergone previous surgery most often chose the LESS incision (mean VAS score, 7.0), followed in order by multi-port laparoscopy with lateral incisions in the lower abdomen (mean VAS score, 6.7) and the minilaparotomy incision (mean VAS score, 6.0). Those with no previous abdominal surgery chose incisions in the same order, with mean VAS scores of 6.8, 6.1, and 6.1, respectively. At linear regression analysis, there was no effect of a unit of continuous age or a unit of continuous BMI on these ratings. In looking at the dichotomous outcome of ‘‘LESS as first choice’’ vs ‘‘an incision other than LESS as first choice,’’ there was no effect of white race, history of previous surgery, continuous age, or continuous BMI on this decision at linear regression analysis. Insofar as factors patients considered in making their decisions, size and appearance were believed to be most important, and were ranked as most important the greatest number of times and with the highest VAS scores (Table 3). Location was the second most important factor on the basis of mean VAS score, although it tied perceived recovery time as second in the number of times it was selected as the most important factor. Perceived recovery time was least important on the basis of mean VAS score. The mean scores of all 4 factors in decision making were all within 1 SD of each other. Multivariable regression analysis comparing the MIGS with the non-MIGS groups controlling for these 4 factors yielded an estimate of risk difference of 0.42 (95% CI, 0.13–0.70) and a risk ratio of 1.5 (95% CI, 1.0–2.2) for the outcome of choosing the LESS incision as first choice vs other possible first choices, which suggests that differences between clinics are not well explained by any one of these decision-making factors. Discussion The results of the present study are simultaneously expected and novel. Overall, the LESS incision was the most preferred incision for cosmesis. This is the intuitive choice
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because the LESS incision is a single small incision hidden within the umbilicus, itself a natural scar. Indeed, the LESS approach is being called ‘‘scarless’’ surgery [3] and can result in a virtually imperceptible scar when performed in experienced hands. For the best cosmetic result, the scar should not extend outside the perimeter of the umbilical crater and should not disfigure the natural configuration of the umbilicus [4]. When separating out the clinic populations, one sees that the resident clinic patients most often preferred the horizontal mini-laparotomy incision. The mini-laparotomy incision is larger than any of the laparoscopic (including LESS) configurations; note that the laparoscopic incision configurations also represent robotic incision configurations. This result is interesting because it simulates the results of the 1996 study by Currie et al [2] in which they found that patients preferred a Pfannenstiel incision to the LAVH incisions. Clearly, size alone is not the only factor that determines cosmetic preferences. When comparing the demographic characteristics of the 2 populations, the MIGS group was significantly older and more likely white; however, neither these nor any of the demographic differences explained the difference in the most common preference of incision between the clinic populations. Similarly, none of the factors in decision making inquired about explained the difference, at least not individually. That is, neither size, location, nor number of incisions alone explained why the resident population most commonly preferred the horizontal mini-laparotomy incision, whereas the MIGS group most commonly preferred the LESS incision. A reasonable explanation for the different most common preferences in the clinic populations, and perhaps one that encompasses the factors that were asked about and which were all rated equivalently high in importance, is something that was not asked about and that we refer to as ‘‘visibility.’’ Visibility can be thought of as the patient’s perception of whether the incisions are visible when the mid-abdomen (above the hip bones or the anterior superior iliac spine) is exposed. Although the LESS incision and the horizontal mini-laparotomy incision differ greatly in size, they are both potentially not visible when the mid-abdomen is exposed, as long as the LESS incision is hidden in the umbilicus. It is possible that the MIGS group had the perception or understanding that the LESS incision was hidden within the boundaries of the umbilical crater. It is notable that the graphic depiction of the LESS incision extends beyond the umbilicus. The incisions in the present study were mathematically scaled to size, making it impossible to visually depict that the LESS incision was completely confined within the margins of the umbilical crater, thus making it not visible. In practice, however, this is routinely accomplished. In a recent study by Bush et al [5], traditional laparoscopic incisions were considerably preferred over the LESS incision, a finding that contrasts with those presented herein. In the present study, traditional laparoscopic incisions were chosen third most commonly. It is noteworthy that the LESS incision, traditional laparoscopic incisions
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(with low lateral incisions), and the horizontal minilaparotomy incision are all potentially not visible when the mid-abdomen is exposed above the level of the hip bones. Again, the perceived visibility of the incisions, or lack thereof, may explain the differences between the results for cosmetic preferences of the studies by Currie et al [1], Bush et al [5], and the present study. Strengths of the present study included that 2 distinct populations were studied, 1 that specializes in minimally invasive gynecologic surgery and one that does not. In addition, our study is unique in that all possible open, laparoscopic, and robotic incisions were represented. Another unique aspect of the present study compared with previous studies of cosmetic preferences was inclusion of questions that related to the factors involved in patients’ decision making. Weaknesses included that the graphic depiction of incisions does not necessarily correlate well with actual cosmetic results, the lack of postoperative assessment as to whether patient’s were satisfied with their cosmetic result, and whether the actual cosmetic result correlated well with the anticipated cosmetic result.
Journal of Minimally Invasive Gynecology, Vol 20, No 1, January/February 2013
Larger, multi-center, prospective trials are needed. Future research on cosmetic preferences should examine this concept of the visibility of incisions, may need to include actual photos of cosmetic results, and should include postoperative assessments of whether the actual cosmetic result correlated with the patient’s anticipated cosmetic result. References 1. AAGL Advancing Minimally Invasive Gynecology Worldwide. AAGL Position Statement: route of hysterectomy to treat benign uterine disease. J Minim Invasive Gynecol. 2011;18:1–3. 2. Currie I, Onwude JL, Jarvis GJ. A comparative study of the cosmetic appeal of abdominal incisions used for hysterectomy. Br J Obstet Gynaecol. 1996;103:252–254. 3. Autorino R, White WM, Gettman MT, et al. Public perception of ‘‘scarless’’ surgery: a critical analysis of the literature. Urology. 2012;80: 495–502. 4. de Armas IA, Garcia I, Pimpalwar A. Laparoscopic single port surgery in children using Triport: our early experience. Pediatr Surg Int. 2011;27: 985–989. 5. Bush AJ, Morris SN, Millham FH, Isaacson KB. Women’s preferences for minimally invasive incisions. J Minim Invasive Gynecol. 2011;18: 640–643.