- Email: [email protected]
Single-Port Access Subtotal Hysterectomy with Transcervical Morcellation: A Pilot Study
Instruments and Techniques
Single-Port Access Subtotal Hysterectomy with Transcervical Morcellation: A Pilot Study Gun Yoon, MD1, Tae-Joong Kim, MD1, Yoo-Young Lee, MD, Chul-Jung Kim, MD, Chel Hun Choi, MD, Jeong-Won Lee, MD, Byoung-Gie Kim, MD, PhD, and Duk-Soo Bae, MD, PhD* From the Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea (all authors).
ABSTRACT We evaluated the feasibility, safety, and operative outcome of management of myomas and adenomyosis using single-port access subtotal hysterectomy with transcervical morcellation using a wound retractor and a surgical glove. We conclude the single-port access subtotal hysterectomy is safe and effective and results in almost no visible scar. With more experience and advanced instruments, this surgical procedure can offer a safe and effective option to hysterectomy with an excellent cosmetic outcome. Journal of Minimally Invasive Gynecology (2010) 17, 78–81 Ó 2010 AAGL. All rights reserved. Keywords:
Laparoscopy; One port; Minimally invasive surgery; Single-port access; Subtotal hysterectomy
The 2 common types of hysterectomy performed in patients with benign uterine disease such as symptomatic myomas or adenomyosis are total hysterectomy and subtotal (or supracervical) hysterectomy. It is usually not easy for the gynecologist to decide definitively which procedure is best in a given patient. Selection of the type of surgery may depend on surgeon preference or patient choice. There are no generally accepted recommendations on which type of hysterectomy to perform in patients with benign disease. There is limited information available on research related to the attitudes of gynecologists about the type of hysterectomy to perform in patients with benign disease [1]. In 2007, a meta-analysis of 34 randomized clinical trials and observational studies that compared total and subtotal abdominal hysterectomy for benign indications was reported. Fewer women had urinary incontinence, prolapse, and cervical stump problems (bleeding and abnormal smear) after total hysterectomy compared with subtotal hysterectomy. How-
The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. 1 Both authors contributed equally to this work. Corresponding author: Duk-Soo Bae, MD, PhD, Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Gangnam-gu, Seoul 135 710, Korea. E-mail: [email protected] Submitted June 30, 2009. Accepted for publication September 24, 2009. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2010 AAGL. All rights reserved. doi:10.1016/j.jmig.2009.09.018
ever, subtotal hysterectomy was performed more quickly, resulted in less perioperative bleeding, fewer intraoperative and postoperative complications, and is considered a good surgical option in selected patients [2]. Laparoscopic subtotal hysterectomy (LSH) is a minimally invasive surgical procedure that was developed during the 1990s for treatment of abnormal uterine bleeding [3,4]. In 1991, Semm [5] reported the first case of LSH. Three or 5 laparoscopic ports are required to complete a conventional LSH. One is inserted through the infraumbilicus, and the others are usually inserted through the lateral abdominal wall muscles or the suprapubic area [6]. These ports require small abdominal incisions ranging from 5 to 12 mm. For morcellation of the uterus, a sheath larger than 12 mm is needed. Single-port access surgery (SPA), also known as embryonic natural orifice transumbilical endoscopic surgery, is minimally invasive surgery that reduces morbidity and improves the cosmetic outcome [7]. The SPA subtotal hysterectomy was first introduced in 1992 [8]. However, this procedure has not gained wide acceptance by gynecologic surgeons because available instruments are not adequate for some of the technical challenges. With the recent development of advanced laparoscopic equipment and multichannel ports, SPA laparoscopy has been more widely used [9–11]. Ongoing refinement of the surgical technique and instrumentation is likely to expand its role in gynecologic surgery in the future. Herein we report our initial experience in 7 patients who underwent successful SPA subtotal hysterectomy because
Yoon et al.
Single-Port Access Subtotal Hysterectomy
of symptomatic myomas or adenomyosis, with a detailed description of our technique using a wound retractor and a surgical glove. Patients and Methods From January 2009 through May 2009, SPA subtotal hysterectomy was performed in 7 patients with symptomatic myoma or adenomyosis identified at transvaginal ultrasound. This prospective study was approved by our institutional review board. After receiving information about the advantages and disadvantages of SPA subtotal hysterectomy at our outpatient clinic, 7 patients agreed to undergo the procedure. Informed consent was provided by all 7 patients. The surgical technique used was the same in all patients and was performed by 1 surgeon (T.J.K.). All patients had myoma or adenomyosis with gynecologic symptoms such as dysmenorrhea or menorrhagia. Patient characteristics are given in Table 1.
79 Table 1
Patient Characteristics* Characteristic
Value
Age, yr Parity History of vaginal delivery, No. (%) Body mass indexy History of abdominal surgery, No. (%) Uterine dimensions, cmz Longitudinal Anteroposterior Primary indication for surgery, No. (%) Menorrhagia Dysmenorrhea Pathologic entity, No. Myoma Adenomyosis
43 (40–50) 2 (1–3) 4/7 (57.1) 24.9 (19.7–30.7) 5 (62.5) 10 (8.1–13.1) 6 (5.3–9.0) 4/7 (57.1) 3/7 (42.8) 6 1
* Unless otherwise indicated, values are given as median (range). y Calculated as weight in kilograms divided by height in meters squared. z Uterine size was measured at ultrasonography, and the longest longitudinal dimension with the thickest depth (anteroposterior) was measured in a sagittal view preoperatively.
Instruments and Techniques Under general anesthesia, the patient was placed in the dorsal lithotomy position. The surgeon stood on the left side of the patient. The patient’s left arm was tied to her right shoulder to secure the surgeon’s space. The first assistant stood on the right side of the patient to manipulate the scope. The second assistant was positioned between the legs of the patient and used the uterine elevator. Using the open Hasson technique, a 2-cm vertical incision was made in the umbilicus. An extra-small wound retractor (ALEXIS; Applied Medical Resources Corp, Rancho Santa Margarita, California) was inserted into the wound opening transumbilically. Three fingers were inserted into the surgical glove with a sheath that was draped around the rim of the wound retractor (Fig 1). The fingers of the glove functioned as a multiport system for the laparoscopic instruments and the scope. We used a rigid 0-degree, 5-mm laparoscope, standard laparoscope instruments (Harmonic Ace, Ethicon Endo-Surgery, Inc, Cincinnati, Ohio; and Roticulator, Covidien, Norwalk, Connecticut). The Harmonic scalpel has characteristics of both the unipolar and bipolar coagulator, which could decrease time for inserting or removing the instruments. In addition, it can cut through thicker tissue, creates less smoke, causes less lateral thermal damage, and may offer greater precision. As a result, we decided to use this instrument in most of the surgery. Once the laparoscope and instruments were in place, both round ligaments, fallopian tubes, and ovarian ligaments were cut and coagulated using the Harmonic Ace and Roticulator instruments. With sharp dissection using the Roticulator shear, the vesicouterine peritoneum was dissected off the anterior portion of the uterus. Both uterine vessels were coagulated and cut using a bipolar coagulator and the Roticulator shear. At the level of the cervical isthmus, a supracervical hysterectomy was performed using the Harmonic Ace and Roticulator instruments. The cervix was di-
lated via the vaginal approach with a No. 15 Hegar dilator. Then, the Semm morcellator (15-mm serrated blade; Wisap, Sauerlach-Munchen, Germany) was inserted through the dilated cervical os, and the uterus was removed using the transcervical morcellator with the assistance of the endoscopic grasper to hold the removed uterus. After morcellation, bleeding at the cervical stump was controlled using a bipolar coagulator. The cervical stump was covered with peritoneum using 1 or 2 intracorporeal stitches. The peritoneum and fascia were approximated and closed layer by layer with 2-0 polyglactin 910 (Vicryl) sutures. For closing the skin, we used skin adhesive (Dermabond; Ethicon, Inc, Somerville, New Jersey), which provided a good cosmetic outcome and eliminated the need to remove the stitches. Estimated blood loss was calculated as difference between total amount of suction and irrigation during the surgery. In all patients, hemoglobin concentration was determined on postoperative day 1. A Foley vesical catheter was maintained until the morning after surgery. Patients were
Fig. 1. Surgical glove around rim of wound retractor.
80
discharged when they could tolerate food. All patients were followed up in the outpatient clinic at 1 week and at 1 month after discharge. Results SPA subtotal hysterectomy was successfully completed in all 7 patients. Patient median (range) age was 43 (40–50) years, and body mass index was 24.9 (19.7–30.7) kg/m2. Six patients had a uterine myoma, and 1 had adenomyosis. Operative outcomes are given in Table 2. Tumor weight was 300 (168–427) g. Operative time was 157 (140–233) minutes. Estimated blood loss was 200 (100–300) mL. At postoperative day 1, hemoglobin concentration was (0.8– 3.8) g/dL; no patient required a transfusion after surgery. The visual analog scale score at 24 hours after surgery was 3 (1–4). The postoperative course was uneventful in all patients. Most patients were discharged according to the clinical guidelines of our hospital. Postoperative hospital stay was 4 (3–4) days. All final pathologic reports were consistent with the preoperative diagnosis. No intraoperative or postoperative complications were observed, and there have been no umbilical complications to date. Discussion To our knowledge, this is the first study to report SPA subtotal hysterectomy with transcervical morcellation using a wound retractor and a surgical glove. We achieved success in all cases without any serious complications during surgery. Several studies have compared perioperative outcome with LSH with that of various types of laparoscopic hysterectomy. In 1 study, blood loss, operative time, complication rate, and sexual function were substantially better with LSH compared with laparoscopy-assisted vaginal hysterectomy (LAVH) [12]. Compared with total laparoscopic hysterectomy (TLH), the complication rate was significantly lower, and mean operative time, blood loss, hospital stay, use of analgesia, and uterus weight were not significantly different [13]. Except for the number of ports, SPA subtotal hysterectomy is similar to LSH insofar as surgical technique. Thus, SPA subtotal hysterectomy is expected to have similar advantages as LSH in perioperative outcomes over LAVH or TLH. One report suggests that LSH may be better than LAVH, depending on the duration of operations [12]. However, SPA subtotal hysterectomy takes a little more time than SPA LAVH [14]. Median operative time was 157 minutes, and the time required for morcellation was 35 (28–100) minutes. The difference in the direction of the scope and morcellator likely adds time to the procedure because of difficulty with orientation of the operator. And more time was required for resection of the cervix at the level of the isthmus because of the visual field and angulation issues with SPA. However, with more experience, operative time, and in particular, morcellation time, may be reduced. This prediction is supported by previous reports of the learning curve associated with LSH [15].
Journal of Minimally Invasive Gynecology, Vol 17, No 1, January/February 2010 Table 2
Operative Outcomes with Single-Port Access Subtotal Hysterectomy* Operative outcome
Value
Operative time, min Morcellation time, min Uterus weight, g Estimated blood loss, mL Hospital stay, d Hb decrease at postoperative day 1 VAS score at postoperative day 1 Transfusion Operative complication
157 (140–233) 35 (28–100) 300 (168–427) 200 (100–300) 4 (3–4) 1.7 (0.8–3.8) 3 (1–4) 0 0
Hb, hemoglobin; VAS, visual analog scale. * Unless otherwise indicated, values are given as median (range).
Free movement is difficult with the current SPA platform because the morcellator (15 mm), scope, and laparoscopic grasper are inserted together into a small opening. However, with subtotal hysterectomy, the cervical canal may be used as another port, which enables morcellation without limiting range of motion. In addition, infectious complications with LSH are low because the vagina is not entered [3]. However, for SPA subtotal hysterectomy, transcervical morcellation may be considered a potential source of infection, although no infectious complications have been reported to date. Compared with transabdominal morcellation, transcervical morcellation may have no advantage in conventional laparoscopic procedures. However, in SPA procedures, the transcervical route can reduce crowding around the umbilical wound. In addition, the transumbilical morcellator with the serrated entrance could damage the glove during insertion into the umbilical wound, which could result in air leakage. Therefore, transcervical morcellation can be important in SPA subtotal hysterectomy. As noted in Table 1, 42.9% of patients had no history of vaginal delivery. Our data show that SPA subtotal hysterectomy can be performed successfully in nulliparous women. The dilated cervix was shortened to less than 1 cm on postoperative day 1. At the first outpatient follow-up visit after hospital discharge, the cervix was nearly closed, with no difference from the preoperative state. Most patients who undergo subtotal hysterectomy are young and wish to preserve sexual function; in addition, the cosmetic and emotional outcomes of surgery are important to this group. The SPA subtotal hysterectomy is a surgical procedure that is almost scarless without the need for suturing of the skin. Subtotal hysterectomy is preferred to total hysterectomy insofar as postoperative sexual function and dyspareunia [16,17], and may improve emotional outcome after surgery [18]. The limitations of this study include the following. First, our data are for procedures performed by a single surgeon and, therefore, may not be applicable to the wider group of gynecologists. Second, the average uterus weight was relatively small (median, 300 g). With a larger uterus or a laterally
Yoon et al.
Single-Port Access Subtotal Hysterectomy
expanding uterus, it could be difficult to perform this type of surgery, primarily because of limitation of the visual field as well as technical difficulties. To overcome these problems, a flexible or angled scope may be useful. In conclusion, SPA LHS is safe and effective and provides excellent cosmetic outcomes with only 1 small incision in the umbilicus. As experience with this technique increases and improved instruments become available, this surgery will provide a promising option in patients with benign gynecologic disease who are candidates for hysterectomy. References 1. Persson P, Hellborg T, Brynhildsen J, Fredrikson M, Kjolhede P. Attitudes to mode of hysterectomy: a survey-based study among Swedish gynecologists. Acta Obstet Gynecol Scand. 2009;88:267–274. 2. Gimbel H. Total or subtotal hysterectomy for benign uterine diseases? a meta-analysis. Acta Obstet Gynecol Scand. 2007;86:133–144. 3. Jenkins TR. Laparoscopic supracervical hysterectomy. Am J Obstet Gynecol. 2004;191:1875–1884. 4. Lyons T. Laparoscopic supracervical versus total hysterectomy. J Minim Invasive Gynecol. 2007;14:275–277. 5. Semm K. Hysterectomy via laparotomy or pelviscopy: a new CASH method without colpotomy [in German]. Geburtshilfe Frauenheilkd. 1991;51:996–1003. 6. 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. 7. Canes D, Desai MM, Aron M, et al. Transumbilical single-port surgery: evolution and current status. Eur Urol. 2008;54:1020–1029. 8. Pelosi MA, Pelosi MA III. Laparoscopic supracervical hysterectomy using a single-umbilical puncture (mini-laparoscopy). J Reprod Med. 1992;37:777–784.
81 9. Moreno Sanz C, Herrero Bogajo MA, Manzanera Diaz M, Pascual Pedreno A, Tadeo Ruiz G. Single port laparoscopic surgery. Widening the spectrum of use. Cir Esp. 2009, Jun 2 [Epub ahead of print]. 10. Romanelli JR, Earle DB. Single-port laparoscopic surgery: an overview[published online ahead of print April 4, 2009]. Surg Endosc. 2009;23:1419–1427. 11. White WM, Goel RK, Kaouk JH. Single-port laparoscopic retroperitoneal surgery: initial operative experience and comparative outcomes. Urology. 2009;73:1279–1282. 12. El-Mowafi D, Madkour W, Lall C, Wenger JM. Laparoscopic supracervical hysterectomy versus laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol Laparosc. 2004;11:175–180. 13. Mueller A, Renner SP, Haeberle L, et al. Comparison of total laparoscopic hysterectomy (TLH) and laparoscopy-assisted supracervical hysterectomy (LASH) in women with uterine leiomyoma. Eur J Obstet Gynecol Reprod Biol. 2009;144:76–79. 14. 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 [published online ahead of print May 31, 2009]. J Minim Invasive Gynecol. 2009;16:450–453. 15. Ghomi A, Littman P, Prasad A, Einarsson JI. Assessing the learning curve for laparoscopic supracervical hysterectomy. JSLS. 2007;11: 190–194. 16. Kilkku P. Supravaginal uterine amputation vs. hysterectomy: effects on coital frequency and dyspareunia. Acta Obstet Gynecol Scand. 1983;62: 141–145. 17. Kilkku P. Supravaginal uterine amputation versus hysterectomy with reference to subjective bladder symptoms and incontinence. Acta Obstet Gynecol Scand. 1985;64:375–379. 18. Thakar R, Ayers S, Georgakapolou A, Clarkson P, Stanton S, Manyonda I. Hysterectomy improves quality of life and decreases psychiatric symptoms: a prospective and randomised comparison of total versus subtotal hysterectomy. BJOG. 2004;111:1115–1120.
Single-Port Access Subtotal Hysterectomy with Transcervical Morcellation: A Pilot Study Gun Yoon, MD1, Tae-Joong Kim, MD1, Yoo-Young Lee, MD, Chul-Jung Kim, MD, Chel Hun Choi, MD, Jeong-Won Lee, MD, Byoung-Gie Kim, MD, PhD, and Duk-Soo Bae, MD, PhD* From the Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea (all authors).
ABSTRACT We evaluated the feasibility, safety, and operative outcome of management of myomas and adenomyosis using single-port access subtotal hysterectomy with transcervical morcellation using a wound retractor and a surgical glove. We conclude the single-port access subtotal hysterectomy is safe and effective and results in almost no visible scar. With more experience and advanced instruments, this surgical procedure can offer a safe and effective option to hysterectomy with an excellent cosmetic outcome. Journal of Minimally Invasive Gynecology (2010) 17, 78–81 Ó 2010 AAGL. All rights reserved. Keywords:
Laparoscopy; One port; Minimally invasive surgery; Single-port access; Subtotal hysterectomy
The 2 common types of hysterectomy performed in patients with benign uterine disease such as symptomatic myomas or adenomyosis are total hysterectomy and subtotal (or supracervical) hysterectomy. It is usually not easy for the gynecologist to decide definitively which procedure is best in a given patient. Selection of the type of surgery may depend on surgeon preference or patient choice. There are no generally accepted recommendations on which type of hysterectomy to perform in patients with benign disease. There is limited information available on research related to the attitudes of gynecologists about the type of hysterectomy to perform in patients with benign disease [1]. In 2007, a meta-analysis of 34 randomized clinical trials and observational studies that compared total and subtotal abdominal hysterectomy for benign indications was reported. Fewer women had urinary incontinence, prolapse, and cervical stump problems (bleeding and abnormal smear) after total hysterectomy compared with subtotal hysterectomy. How-
The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. 1 Both authors contributed equally to this work. Corresponding author: Duk-Soo Bae, MD, PhD, Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Gangnam-gu, Seoul 135 710, Korea. E-mail: [email protected] Submitted June 30, 2009. Accepted for publication September 24, 2009. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2010 AAGL. All rights reserved. doi:10.1016/j.jmig.2009.09.018
ever, subtotal hysterectomy was performed more quickly, resulted in less perioperative bleeding, fewer intraoperative and postoperative complications, and is considered a good surgical option in selected patients [2]. Laparoscopic subtotal hysterectomy (LSH) is a minimally invasive surgical procedure that was developed during the 1990s for treatment of abnormal uterine bleeding [3,4]. In 1991, Semm [5] reported the first case of LSH. Three or 5 laparoscopic ports are required to complete a conventional LSH. One is inserted through the infraumbilicus, and the others are usually inserted through the lateral abdominal wall muscles or the suprapubic area [6]. These ports require small abdominal incisions ranging from 5 to 12 mm. For morcellation of the uterus, a sheath larger than 12 mm is needed. Single-port access surgery (SPA), also known as embryonic natural orifice transumbilical endoscopic surgery, is minimally invasive surgery that reduces morbidity and improves the cosmetic outcome [7]. The SPA subtotal hysterectomy was first introduced in 1992 [8]. However, this procedure has not gained wide acceptance by gynecologic surgeons because available instruments are not adequate for some of the technical challenges. With the recent development of advanced laparoscopic equipment and multichannel ports, SPA laparoscopy has been more widely used [9–11]. Ongoing refinement of the surgical technique and instrumentation is likely to expand its role in gynecologic surgery in the future. Herein we report our initial experience in 7 patients who underwent successful SPA subtotal hysterectomy because
Yoon et al.
Single-Port Access Subtotal Hysterectomy
of symptomatic myomas or adenomyosis, with a detailed description of our technique using a wound retractor and a surgical glove. Patients and Methods From January 2009 through May 2009, SPA subtotal hysterectomy was performed in 7 patients with symptomatic myoma or adenomyosis identified at transvaginal ultrasound. This prospective study was approved by our institutional review board. After receiving information about the advantages and disadvantages of SPA subtotal hysterectomy at our outpatient clinic, 7 patients agreed to undergo the procedure. Informed consent was provided by all 7 patients. The surgical technique used was the same in all patients and was performed by 1 surgeon (T.J.K.). All patients had myoma or adenomyosis with gynecologic symptoms such as dysmenorrhea or menorrhagia. Patient characteristics are given in Table 1.
79 Table 1
Patient Characteristics* Characteristic
Value
Age, yr Parity History of vaginal delivery, No. (%) Body mass indexy History of abdominal surgery, No. (%) Uterine dimensions, cmz Longitudinal Anteroposterior Primary indication for surgery, No. (%) Menorrhagia Dysmenorrhea Pathologic entity, No. Myoma Adenomyosis
43 (40–50) 2 (1–3) 4/7 (57.1) 24.9 (19.7–30.7) 5 (62.5) 10 (8.1–13.1) 6 (5.3–9.0) 4/7 (57.1) 3/7 (42.8) 6 1
* Unless otherwise indicated, values are given as median (range). y Calculated as weight in kilograms divided by height in meters squared. z Uterine size was measured at ultrasonography, and the longest longitudinal dimension with the thickest depth (anteroposterior) was measured in a sagittal view preoperatively.
Instruments and Techniques Under general anesthesia, the patient was placed in the dorsal lithotomy position. The surgeon stood on the left side of the patient. The patient’s left arm was tied to her right shoulder to secure the surgeon’s space. The first assistant stood on the right side of the patient to manipulate the scope. The second assistant was positioned between the legs of the patient and used the uterine elevator. Using the open Hasson technique, a 2-cm vertical incision was made in the umbilicus. An extra-small wound retractor (ALEXIS; Applied Medical Resources Corp, Rancho Santa Margarita, California) was inserted into the wound opening transumbilically. Three fingers were inserted into the surgical glove with a sheath that was draped around the rim of the wound retractor (Fig 1). The fingers of the glove functioned as a multiport system for the laparoscopic instruments and the scope. We used a rigid 0-degree, 5-mm laparoscope, standard laparoscope instruments (Harmonic Ace, Ethicon Endo-Surgery, Inc, Cincinnati, Ohio; and Roticulator, Covidien, Norwalk, Connecticut). The Harmonic scalpel has characteristics of both the unipolar and bipolar coagulator, which could decrease time for inserting or removing the instruments. In addition, it can cut through thicker tissue, creates less smoke, causes less lateral thermal damage, and may offer greater precision. As a result, we decided to use this instrument in most of the surgery. Once the laparoscope and instruments were in place, both round ligaments, fallopian tubes, and ovarian ligaments were cut and coagulated using the Harmonic Ace and Roticulator instruments. With sharp dissection using the Roticulator shear, the vesicouterine peritoneum was dissected off the anterior portion of the uterus. Both uterine vessels were coagulated and cut using a bipolar coagulator and the Roticulator shear. At the level of the cervical isthmus, a supracervical hysterectomy was performed using the Harmonic Ace and Roticulator instruments. The cervix was di-
lated via the vaginal approach with a No. 15 Hegar dilator. Then, the Semm morcellator (15-mm serrated blade; Wisap, Sauerlach-Munchen, Germany) was inserted through the dilated cervical os, and the uterus was removed using the transcervical morcellator with the assistance of the endoscopic grasper to hold the removed uterus. After morcellation, bleeding at the cervical stump was controlled using a bipolar coagulator. The cervical stump was covered with peritoneum using 1 or 2 intracorporeal stitches. The peritoneum and fascia were approximated and closed layer by layer with 2-0 polyglactin 910 (Vicryl) sutures. For closing the skin, we used skin adhesive (Dermabond; Ethicon, Inc, Somerville, New Jersey), which provided a good cosmetic outcome and eliminated the need to remove the stitches. Estimated blood loss was calculated as difference between total amount of suction and irrigation during the surgery. In all patients, hemoglobin concentration was determined on postoperative day 1. A Foley vesical catheter was maintained until the morning after surgery. Patients were
Fig. 1. Surgical glove around rim of wound retractor.
80
discharged when they could tolerate food. All patients were followed up in the outpatient clinic at 1 week and at 1 month after discharge. Results SPA subtotal hysterectomy was successfully completed in all 7 patients. Patient median (range) age was 43 (40–50) years, and body mass index was 24.9 (19.7–30.7) kg/m2. Six patients had a uterine myoma, and 1 had adenomyosis. Operative outcomes are given in Table 2. Tumor weight was 300 (168–427) g. Operative time was 157 (140–233) minutes. Estimated blood loss was 200 (100–300) mL. At postoperative day 1, hemoglobin concentration was (0.8– 3.8) g/dL; no patient required a transfusion after surgery. The visual analog scale score at 24 hours after surgery was 3 (1–4). The postoperative course was uneventful in all patients. Most patients were discharged according to the clinical guidelines of our hospital. Postoperative hospital stay was 4 (3–4) days. All final pathologic reports were consistent with the preoperative diagnosis. No intraoperative or postoperative complications were observed, and there have been no umbilical complications to date. Discussion To our knowledge, this is the first study to report SPA subtotal hysterectomy with transcervical morcellation using a wound retractor and a surgical glove. We achieved success in all cases without any serious complications during surgery. Several studies have compared perioperative outcome with LSH with that of various types of laparoscopic hysterectomy. In 1 study, blood loss, operative time, complication rate, and sexual function were substantially better with LSH compared with laparoscopy-assisted vaginal hysterectomy (LAVH) [12]. Compared with total laparoscopic hysterectomy (TLH), the complication rate was significantly lower, and mean operative time, blood loss, hospital stay, use of analgesia, and uterus weight were not significantly different [13]. Except for the number of ports, SPA subtotal hysterectomy is similar to LSH insofar as surgical technique. Thus, SPA subtotal hysterectomy is expected to have similar advantages as LSH in perioperative outcomes over LAVH or TLH. One report suggests that LSH may be better than LAVH, depending on the duration of operations [12]. However, SPA subtotal hysterectomy takes a little more time than SPA LAVH [14]. Median operative time was 157 minutes, and the time required for morcellation was 35 (28–100) minutes. The difference in the direction of the scope and morcellator likely adds time to the procedure because of difficulty with orientation of the operator. And more time was required for resection of the cervix at the level of the isthmus because of the visual field and angulation issues with SPA. However, with more experience, operative time, and in particular, morcellation time, may be reduced. This prediction is supported by previous reports of the learning curve associated with LSH [15].
Journal of Minimally Invasive Gynecology, Vol 17, No 1, January/February 2010 Table 2
Operative Outcomes with Single-Port Access Subtotal Hysterectomy* Operative outcome
Value
Operative time, min Morcellation time, min Uterus weight, g Estimated blood loss, mL Hospital stay, d Hb decrease at postoperative day 1 VAS score at postoperative day 1 Transfusion Operative complication
157 (140–233) 35 (28–100) 300 (168–427) 200 (100–300) 4 (3–4) 1.7 (0.8–3.8) 3 (1–4) 0 0
Hb, hemoglobin; VAS, visual analog scale. * Unless otherwise indicated, values are given as median (range).
Free movement is difficult with the current SPA platform because the morcellator (15 mm), scope, and laparoscopic grasper are inserted together into a small opening. However, with subtotal hysterectomy, the cervical canal may be used as another port, which enables morcellation without limiting range of motion. In addition, infectious complications with LSH are low because the vagina is not entered [3]. However, for SPA subtotal hysterectomy, transcervical morcellation may be considered a potential source of infection, although no infectious complications have been reported to date. Compared with transabdominal morcellation, transcervical morcellation may have no advantage in conventional laparoscopic procedures. However, in SPA procedures, the transcervical route can reduce crowding around the umbilical wound. In addition, the transumbilical morcellator with the serrated entrance could damage the glove during insertion into the umbilical wound, which could result in air leakage. Therefore, transcervical morcellation can be important in SPA subtotal hysterectomy. As noted in Table 1, 42.9% of patients had no history of vaginal delivery. Our data show that SPA subtotal hysterectomy can be performed successfully in nulliparous women. The dilated cervix was shortened to less than 1 cm on postoperative day 1. At the first outpatient follow-up visit after hospital discharge, the cervix was nearly closed, with no difference from the preoperative state. Most patients who undergo subtotal hysterectomy are young and wish to preserve sexual function; in addition, the cosmetic and emotional outcomes of surgery are important to this group. The SPA subtotal hysterectomy is a surgical procedure that is almost scarless without the need for suturing of the skin. Subtotal hysterectomy is preferred to total hysterectomy insofar as postoperative sexual function and dyspareunia [16,17], and may improve emotional outcome after surgery [18]. The limitations of this study include the following. First, our data are for procedures performed by a single surgeon and, therefore, may not be applicable to the wider group of gynecologists. Second, the average uterus weight was relatively small (median, 300 g). With a larger uterus or a laterally
Yoon et al.
Single-Port Access Subtotal Hysterectomy
expanding uterus, it could be difficult to perform this type of surgery, primarily because of limitation of the visual field as well as technical difficulties. To overcome these problems, a flexible or angled scope may be useful. In conclusion, SPA LHS is safe and effective and provides excellent cosmetic outcomes with only 1 small incision in the umbilicus. As experience with this technique increases and improved instruments become available, this surgery will provide a promising option in patients with benign gynecologic disease who are candidates for hysterectomy. References 1. Persson P, Hellborg T, Brynhildsen J, Fredrikson M, Kjolhede P. Attitudes to mode of hysterectomy: a survey-based study among Swedish gynecologists. Acta Obstet Gynecol Scand. 2009;88:267–274. 2. Gimbel H. Total or subtotal hysterectomy for benign uterine diseases? a meta-analysis. Acta Obstet Gynecol Scand. 2007;86:133–144. 3. Jenkins TR. Laparoscopic supracervical hysterectomy. Am J Obstet Gynecol. 2004;191:1875–1884. 4. Lyons T. Laparoscopic supracervical versus total hysterectomy. J Minim Invasive Gynecol. 2007;14:275–277. 5. Semm K. Hysterectomy via laparotomy or pelviscopy: a new CASH method without colpotomy [in German]. Geburtshilfe Frauenheilkd. 1991;51:996–1003. 6. 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. 7. Canes D, Desai MM, Aron M, et al. Transumbilical single-port surgery: evolution and current status. Eur Urol. 2008;54:1020–1029. 8. Pelosi MA, Pelosi MA III. Laparoscopic supracervical hysterectomy using a single-umbilical puncture (mini-laparoscopy). J Reprod Med. 1992;37:777–784.
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