Single-port Access Subtotal Laparoscopic Hysterectomy: A Prospective Case-Control Study

Accepted Manuscript Single-Port Access Subtotal Laparoscopic Hysterectomy: A Prospective Case-Control Study Stefano Angioni, M.D.,Ph.D., Alessandro Pontis, M.D., Adolfo Pisanu, M.D., Liliana Mereu, M.D., Horace Roman, M.D.,Ph.D. PII:

S1553-4650(15)00275-7

DOI:

10.1016/j.jmig.2015.03.011

Reference:

JMIG 2527

To appear in:

The Journal of Minimally Invasive Gynecology

Received Date: 13 January 2015 Revised Date:

9 March 2015

Accepted Date: 13 March 2015

Please cite this article as: Angioni S, Pontis A, Pisanu A, Mereu L, Roman H, Single-Port Access Subtotal Laparoscopic Hysterectomy: A Prospective Case-Control Study, The Journal of Minimally Invasive Gynecology (2015), doi: 10.1016/j.jmig.2015.03.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Single-Port Access Subtotal Laparoscopic Hysterectomy: A Prospective CaseControl Study

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Stefano Angioni1 M.D.,Ph.D., Alessandro Pontis1 M.D., Adolfo Pisanu1 M.D., Liliana Mereu2 M.D.,. Horace Roman3 M.D.,Ph.D.,

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Department of Surgical Sciences, University of Cagliari, Italy;

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Department of Obstetric and Gynecology, Hospital Santa Maria Chiara, Trento, Italy

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Department of Obstetric and Gynecology, Rouen, France

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Correspondence, reprints and proofs to: Prof. Stefano Angioni M.D., Ph.D., Department of Surgical Sciences, Section of Obstetrics & Gynecology, University of Cagliari, Azienda Ospedaliero Universitaria, Blocco Q, 09124 Monserrato, Italy. Tel: +3907051093399, e-mail: [email protected]

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Abstract

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Study Objective: The objective was to evaluate the perioperative outcomes, safety, and patient acceptance of single-port access laparoscopic subtotal hysterectomy (SPAL-SH) in comparison with conventional multiport access laparoscopic subtotal hysterectomy (MPA-SH).

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Design: Case-control study.

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Design Classification: Canadian Task Force Classification II-2

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Setting: The study was conducted at university hospitals in Cagliari, Italy, and Rouen, France.

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Patients: A total of 61 women with metrorrhagia, abnormal uterine bleeding with uterine fibroids or symptomatic adenomyosis were included in the study.

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Interventions: Thirty-one patients underwent SPAL-SH, and 30 patients underwent conventional MPA-SH.

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Measurements and Main Results: We analyzed the data to compare the outcomes of SPAL-SH versus MPA-SH. Patients in the SPAL-SH group had longer operative times than those in the MPASH group (p<0.001) but a shorter hospital stays (p<0.001). Postoperative pain immediately after surgery, after 6 hours and after 24 hours was lower in the SPAL-SH group (p < 0.001). The SPALSH group reported significantly higher cosmetic satisfaction at 1, 4, and 24 weeks after surgery (p < 0.01).

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Conclusions: We conclude that SPAL-SH is a feasible and safe alternative to standard MPA-SH in selected patients. Ongoing refinement of the surgical technique and instrumentation is likely to expand its role in gynecologic surgery in the future. In addition, SPAL-SH has a definite benefit in relation to body image and cosmesis.

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Keywords: Single-port access laparoscopy, laparoscopic subtotal hysterectomy, SPAL

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Introduction

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Minimally invasive surgery has substantially decreased both the length of hospital stays and the

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need for postoperative analgesia as well as improving recovery times [1-2]. Although laparoscopy

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has decreased morbidity directly related to this surgical approach, each working port still carries a

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possible risk of bleeding, infection, concordant organ damage, hernia formation, and decreased

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cosmetic outcome [3].

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Advances in surgical instrumentation and design have led to the use of single-incision laparoscopic

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surgery (SILS), laparo-endoscopic single-site surgery (LESS), and single-port access laparoscopy

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(SPAL) in the field of gynaecology [4-7]. SPAL has also been proposed for total and subtotal

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hysterectomies in benign and malignant conditions [8-10].

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Laparoscopic subtotal hysterectomy (SLH) is a minimally invasive surgical procedure that was

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developed during the 1990s for the treatment of abnormal uterine bleeding. Three to five

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laparoscopic ports are required to complete a conventional SLH. Single-port access laparoscopy

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subtotal hysterectomy (SPAL-SH) was first introduced in 1992, when Pelosi et al. performed a

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subtotal hysterectomy with a single umbilical puncture [11], but this procedure did not gain wide

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acceptance by gynecologic surgeons right away because the available instruments were not

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adequate for some of the technical challenges. Since the early 2010s, however, SPAL-SH has been

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performed through an intra-umbilical incision using conventional laparoscopic instruments for the

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treatment of benign gynecologic pathologies.

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The aim of this study was to compare the surgical and cosmetic outcomes and complications of

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SPAL-SH and conventional multi-port access subtotal hysterectomy (MPA-SH).

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Materials and Methods

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This was a prospective case-control study of patients undergoing a subtotal hysterectomy for the

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treatment of symptomatic leiomyoma, adenomyosis or metrorrhagia resistant to medical therapy.

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The hysterectomies were performed between June 2011 and March 2014 in the Division of

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Obstetrics and Gynaecology of Cagliari University Hospital in Cagliari, Italy, and in the Division of

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Gynaecology and Obstetrics of Rouen University Hospital in Rouen, France. The eligibility criteria

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included having no evidence of gynecologic malignancy, normal cervical cytology, appropriate

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medical status for laparoscopic surgery (American Society of Anesthesiologists Physical Status

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classification system 1 or 2), and a uterus size ≤ 16 weeks. Major exclusion criteria were

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anaesthetic contraindications for laparoscopic surgery, a uterine size over 16 gestational weeks at

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pelvic examination, a diagnosis or suspicion of gynecologic cancer and/or deep infiltrating

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endometriosis (DIE) , a history of pelvic radiation therapy, more than three prior laparotomies or an

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inability to understand and provide written informed consent. After an accurate evaluation of their

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medical histories and routine blood tests, all patients underwent a preoperative pelvic examination,

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cervix cytology, transvaginal sonography evaluation, and an office diagnostic hysteroscopy with

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endometrial biopsy. The study was approved by the local ethics committees, and before entering

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the study, all eligible patients received oral and written information about the trial from the

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clinicians. Sixty-one out of 80 patients met the inclusion criteria and entered the study. The patients

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were informed about the two types of surgeries and were alternatively assigned to undergo a SPAL-

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SH or MPA-SH performed by two surgeons (S.A. and H.R.), both of whom had optimal

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laparoscopic experience and at least a year of training in the SPAL procedure Prospective data

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about these patients were collected until March 2014.

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These data included patient characteristics (age, BMI [kg/m²], indications for subtotal

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hysterectomy, type and duration of surgery, estimated blood loss (EBL), postoperative pain score,

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perioperative complications, length of hospital stay, body image and cosmesis. At the end of each

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procedure, intra-operative data were also registered regarding operative time, EBL, intra- and peri-

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operative complications, and conversion to standard multi-access laparoscopy or laparotomy.

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Operative time was defined as the time from umbilical skin incision to completion of skin closure.

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Postoperative abdominal pain intensity was rated at rest using the visual analog scale (VAS). The

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scale was presented as a 10-cm line, with a verbal descriptor anchored with “no pain” and “worst

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imaginable pain”. Patients were asked to rate their pain intensity immediately after surgery and

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again at 6, 24, and 48 hours after surgery. The body image questionaire (BIQ) was used to assess

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body image and cosmesis at 1, 4, and 24 weeks after surgery. The questionnaire consists of eight

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questions that are combined to form two scales: a body image scale and a cosmetic scale. Five

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questions regarding body image assess patients’ perception of and satisfaction with their own body

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and evaluate patients’ attitude toward their bodily appearance. The body image score ranges from 5

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(lowest body image score) to 20 (highest body image score). Three questions regarding the

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cosmetic result after the operation assess the degree of satisfaction with respect to the physical

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appearance of the incisional scar(s). First, patients were asked to give a rating for the appearance of

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their scar(s) on a scale from 1 (lowest score) to 10 (highest score). Then patients were asked to rate

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the extent to which they were satisfied with their scar on a scale ranging from 1 (very unsatisfied) to

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7(very satisfied). Finally, patients were asked to describe their scar on a scale ranging from 1 (very

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repulsive) to 7(very beautiful). The combined scores of these three questions resulted in the

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cosmetic scale ranging from 3 (lowest satisfaction) to 24 (highest satisfaction).Subjects were asked

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to complete the BIQ at each visit before seeing their clinician. Cronbach’s alpha for body image and

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cosmetic satisfaction were 0.81 and 0.70, respectively. The maximum scores for BIS and CS were

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20 and 24, respectively [12].

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Surgical Procedures

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All the patients were admitted to the hospital one day before surgery. Standard bowel preparation

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was indicated, and prophylactic antibiotic therapy (2 g of cefazolin) was administered 30 minutes

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preoperatively and again postoperatively. Both SPA-SH and MPA-SH were performed under

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general endotracheal anaesthesia with the patient in the dorsal lithotomy position. A Foley catheter

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was inserted into the bladder, and then a uterine manipulator was applied. To prevent or decrease

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the occurrence of postsurgical adhesions, 500 cc of warm lactated Ringer’s solution was instilled in

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the pelvis at the end of the procedures [13]. The extracted specimens were sent for histological

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examination. A Foley vesical catheter was maintained until the morning after surgery; in all

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patients, their haemoglobin concentration was determined 6 hours after surgery. All patients were

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permitted sips of water starting 6 hours after surgery, and a clear liquid diet was offered as the first

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meal after passing flatus. If pain control was needed, 30 mg of ketorolac was administered

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intravenously. The patients were encouraged to ambulate starting the first postoperative day.

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SPAL-SH (Group A)

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A 2-cm intra-umbilical vertical skin incision and a 2- to 2.5-cm rectus fasciotomy were performed

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to enter the peritoneal cavity. The single-port trocar (S-Portal X-Cone; Karl Storz, Tuttlingen,

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Germany) was inserted into the abdominal cavity, and the abdomen was insuflated to 12 mmHg.

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The single-port trocar device allows the simultaneous passage of various laparoscopic instruments

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through one small opening and has the added advantage of being reusable. Following placement of

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the X-Cone, the surgeon stood behind the patient’s left shoulder at the level of the patient’s right

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shoulder, and the monitor was positioned between the patient’s legs. A rigid, 30-degrees, 5-mm

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diameter, 50-cm length Hopkins high definition 3-chip camera (Karl Storz, Tuttlingen, Germany)

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was routinely used. For the subtotal hysterectomy, a rigid single curved forceps or scissors (Karl

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Storz, Tuttlingen ,Germany) monopolar loop (LiNA Gold Loop™, LiNA Medical, Glostrup,

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Denmark) and a standard straight bipolar dissector or multifunction device (En Seal: Ethicon

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Endosurgery, Cincinnati OH, or Ultracision Harmonic Scalpel: Ethicon, Cincinnati, OH) were used

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simultaneously. Removal of the uterus was performed in 20 cases by morcellation (Gynecare

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Morcellex: Ethicon, Cincinnati OH) through the umbilical trocar in vision after entering optic in the

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cervical canal and in 11 cases by morcellation through the cervical canal under an optical view from

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the umbilical trocar. Morcellation through the cervical canal requires cervix dilatation via the

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vaginal approach with a No. 15 Hegar dilator. The morcellator was then inserted through the dilated

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cervical os, and the uterus was removed using the transcervical morcellator with the assistance of

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the endoscopic grasper. After morcellation, bleeding at the cervical stump was controlled using a

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bipolar coagulator.

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MPA-SH (Group B)

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Pneumoperitoneum was induced by CO2 insufflation using a Veress needle that was passed through

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a 1-cm umbilical incision until the intra-abdominal pressure reached 12 mmHg. Following

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pneumoperitoneum, a 10-mm umbilical trocar for a 0-degree telescope was made. Three additional

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trocars (5-10 mm) were then inserted in the lower abdominal quadrants under direct laparoscopic

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vision. With traction of the distal portion of the fallopian tube, the tube pedicles, the utero-ovarian

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ligament or the infundibulo-pelvic ligament, and the round ligaments were coagulated with bipolar

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forceps and cut with scissors; the vesico-uterine peritoneum was dissected from the anterior portion

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of the uterus. Identification, coagulation and cutting of the uterine arteries bilaterally at the level of

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the ascending branch was performed with bipolar forceps and scissors or a multifunction device (En

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Seal: Ethicon Endosurgery or Ultracision Harmonic Scalpel: Ethicon Endosurgery); section at the

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level of isthmus using a monopolar hook or monopolar loop (Karl Storz). The uterus was removed

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using a transabdominal morcellator (Gynecare Morcellex: Ethicon, Cincinnati OH) through the

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sovrapubic trocar.

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Statistics

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The statistical analyses were performed using SPSS (version 13.0;SPSS Inc., Chicago, IL).

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Continuous variables across the two groups were compared using a one-way analysis of variance.

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Fischer’s test or chi-square analyses were used in the evaluation of categorical variables. A

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difference was considered significant when the p value was < 0.05.

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Results

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A total of 40 of the 61 patients that entered the study presented dysfunctional metrorrhagia by

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uterine myomas that were unresponsive to medical therapy, while 21 patients suffered from chronic

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pelvic pain and a diagnosis of adenomyosis using ultrasound. Deep endometriosis was excluded in

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the presurgical evaluation. Histology of the specimens confirmed the presurgical diagnoses for all

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cases. Patient characteristics are shown in Table 1. There were no differences in the demographic

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and preoperative data between the two groups.

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In our study, 61 surgical procedures were performed: 31 subtotal hysterectomies by SPAL (SPAL-

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SH) (Group A) and 30 subtotal hysterectomies by MPA (MPA-SH) (Group B) with or without a

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bilateral salpingo-oophorectomy. In Group A, a bilateral salpingo-oophorectomy was performed in

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5 cases (perimenopausal patients) and a bilateral salpingectomy without oophorectomy was

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performed in 26 cases (all patients under 50 years of age). In Group B, a bilateral salpino-

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oophorectomy was performed in 10 cases and a bilateral salpingectomy was performed in 20 cases.

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Port placement was successful in all patients, and there were no vascular or visceral injuries, loss of

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pneumoperitoneum or intraoperative port site bleeding. None of the patients were converted to a

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laparotomy, and none who received SPA-SH needed an additional port. There was one

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postoperative complication in Group A (bleeding of the cervical canal as a result of dilatation) and

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one in Group B (infection of the suprapubic skin incision)(Table2).

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The mean operative time was significantly different between the SPA-SH and conventional MPA-

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SH groups (89.58 minutes versus 67.26 minutes; p < 0.01). The estimated amount of operative

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blood was similar in the two groups, and no patient required a blood transfusion.

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The SPAL-SH group had a shorter postoperative hospital stays (2.06 days versus 2.65 days;

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F=5,226,df1, p < 0.001) compared with the conventional MPA-SH group (Table2).

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Pain measured immediately after surgery in the recovery unit was lower in the SPA-SH group than

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in the MPA-SH group. Moreover, postoperative pain scores after 6, 24, and 48 hours were lower in

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the SPA-SH group compared with the MPA-SH group (Table 3).

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The results of the BIQ questionnaire at 1, 4, and 24 weeks in the two groups are shown in Table 4.

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Patients operated on by single access showed a constant and higher perception of and satisfaction

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with their own body as evidenced by the body image score (BIS), which was significantly higher

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than in the MPA-SH group (19.61±0.49 vs. 14.42±0.88 respectively, at 24 weeks). Moreover,

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patients operated on by single access were significantly more satisfied with their scar as shown by

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the cosmetic score (CS), which was also constantly and significantly higher in the SPAL-SH group

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in comparison to the MPA-SH group (23.45±1.06 vs. 15.71±0.78 respectively at 24 weeks)

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(Table4).

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Discussion

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Recent important technical advances in the field of surgery have led to the development of new

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laparoscopic approaches, such as robotics and single-access laparoscopy [14]. The general trend is

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to make surgery as minimally invasive as possible. Most of the benefits of minimally invasive

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surgery are due to the reduced dimensions of incisions. Single-port access laparoscopy requires only

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one incision point, typically in the umbilical region. Therefore, single-incision laparoscopy may be

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considered a less invasive approach with fewer port site complications compared to conventional

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laparoscopy [15]. This reduction in the number of incisions can lead to a subsequent reduction in

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the level of postoperative pain. In agreement with other studies, we found a reduction in abdominal

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pain when single-access was compared with conventional multiport surgery. Chen et al. compared

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the immediate results of patients undergoing either a two-channel single-port laparoscopic-assisted

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vaginal hysterectomy or conventional multi-port laparoscopic-assisted vaginal hysterectomy. In this

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study, we observed no statistically significant differences in operative time, EBL, intraoperative and

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immediate postoperative complications or length of hospital stay between the two groups. In

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contrast, pain was significantly less in the single-port group compared with the conventional group,

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as evidenced by lower mean scores on the visual analog scale and a lower mean requirement for

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postoperative analgesics [16].

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In a retrospective study, Yim et al. compared surgical outcomes and postoperative pain between the

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single-port total laparoscopic hysterectomy and the conventional four-port total laparoscopic

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hysterectomy. The single-port group had less intraoperative blood loss, shorter hospital stays and

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faster recovery compared with the conventional group. The differences in the two groups were

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statistically significant. However, there was no difference in perioperative complications.

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Immediate postoperative pain scores and those at 6 hours and 24 hours after surgery were lower by

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a statistically significantly amount in the single-port group [17]. Conversely, a randomized

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prospective study of single-port and four-port approaches for hysterectomies did not demonstrate

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any reduction of postoperative pain with single-port access [18]. In our study we evidenced longer

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operative time in the SPA-SH group in comparison to the conventional multiport approach even if

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the uterine weight was significantly lower. In our opinion, SPAL has intrinsic difficulties related to

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the parallelism of instruments that could determine such results. Nevertheless, we did not

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experience any need for additional trocars.

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It is also believed that as the number of incisions decreases with single-incision surgery, local trocar

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site complications may also be reduced. Although in traditional laparoscopy the secondary trocars

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are inserted under direct vision, complications such as epigastric vessel injury are still frequent. The

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umbilicus itself lacks significant blood vessels and nerves in this location, hence reducing local

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incision site complications. The incidence of trocar site hernia may be low because of the decreased

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number of incisions, but an umbilical hernia may be slightly more common. We noted only one

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trocar site complication in the MPA group. However, one limiting factor in our study could be the

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low number of recruited patients and the short follow-up time. In fact, a larger number of patients

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and a longer follow-up could provide more evidence regarding the possible occurrence of late

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complications such as laparocele, particularly in the SPAL group, even though this complication

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has been shown previously to be rare [19]. We had one early complication in the SPAL group after

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transcervical morcellation; however, we believe that even if other surgeons choose this approach to

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extract the uterus in SPAL-SH [10,20], the transumbilical morcellation under vision with

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endocervical optic is a more elegant and safe method for uterus extraction. Moreover, hospital stays

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were significantly shorter for patients that underwent SPAL.

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Although the cosmetic benefit is supposed to be one advantage of single-incision laparoscopic

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surgery, this is still not proven. Most studies have not shown any superiority of the single-port

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access over conventional laparoscopic procedures. Some investigators believe that further studies

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are required to establish the superiority of this approach over traditional multiport laparoscopy.

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Cosmesis is definitely a benefit if the reconstruction of the umbilicus is carefully performed. Care

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must be taken to preserve the integrity of the umbilicus stalk. If the umbilicus stalk has been cut, it

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should be reattached to its fascial attachment. For the best cosmetic results, the scar should not

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extend outside the perimeter of the umbilical crater and should not disfigure the natural

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configuration of the umbilicus.

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satisfaction with laparo-endoscopic single-site surgery compared with multiport surgery; the two

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surgery groups did not differ in clinical demographic data. Compared with the multi-port group, the

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LESS group reported significantly higher cosmetic satisfaction at 1, 4 and 24 weeks after surgery

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[21]. In our study, we used validated questionnaires to determine that perceived body image and

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cosmetic satisfaction were higher by a statistically significant amount in the SPAL group in

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comparison with the MPA group and that these results were maintained at the 24-week follow-up.

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Subtotal hysterectomy is a minimally invasive surgical option that we can propose to patients with

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symptomatic adenomyosis or dysfunctional uterine bleeding not responsive to medical treatment.

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Once surgery is decided upon, the presurgical evaluation should exclude any suspicion of malignant

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disease to minimize the possible risk related to morcellation as recently recommended by many

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scientific societies [22]. In these patients it is mandatory to perform an office hysteroscopy and an

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endometrial biopsy to rule out endometrial carcinoma [23]. Moreover, we believe that patients with

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deep endometriosis are not suitable for SPAL surgery since pelvic adhesions increase surgical

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difficulties and time. Consequently, we excluded these patients in our study in the presurgical

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evaluation as previously described [24].

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Conclusion

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Our case-control study has shown that a subtotal hysterectomy can be performed successfully

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through a single umbilical incision and can provide some benefits to the patient. We believe that the

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SPAL subtotal hysterectomy can be performed in patients with symptomatic benign uterine

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pathology. In the hands of a surgeon accomplished in the skills and techniques of single-incision

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surgery, it can reduce patient morbidity and may become a preferred technique. Still, additional

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randomized control studies are needed to prove this. If both multiport and single-port approaches

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are feasible for a particular patient, in the hands of a skilled surgeon, patient preference may

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become a deciding factor in the future. Nevertheless, the recent debate about uterus morcellation

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and the risk of dissemination and subsequent implant of a preoperatively unexpected malignant

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condition should limit the indications of subtotal hysterectomy to low-risk cases in accordance with

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national guidelines, and the development of devices dedicated to intracavitary morcellation in a

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closed system should be encouraged to minimize the risk of tissue dispersion [22].

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Conflict of interest

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The authors have no commercial, proprietary, or financial interest in the products or companies

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described in this article.

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14. Pluchino N, Litta P, Freschi L, Russo M, Simi G, Santoro AN, Angioni S,

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Gadducci A, Cela V. Comparison of the initial surgical experience with robotic and

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laparoscopic myomectomy. Int J Med Robot.2014;10(2):208-12.

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15. Mencaglia L, Mereu L, Carri G, Arena I, Khalifa H, Tateo S, Angioni S. Single

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port entry-are there any advantages? Best Pract Res Clin Obstet

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Gynaecol.2013;27(3);441-55.

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16. Chen YJ, Wang PH, Ocampo EJ, Twu NF, Yen MS, Chao KC. Single-port

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randomized controlled trial. Obstet Gynecol.2011;117(4):906-12.

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17. Yim GW, Jung YW, Paek J, et al. Transumbilical single port versus conventional

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total laparoscopic hysterectomy: surgical outcomes. Am J Obstet

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Gynecol,2010;203(1):26.e1-6.

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18. Jung YW, Lee M, Yam GW et al. A randomized prospective study of single-port

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20. Yoon G, Kim TJ, Lee YY, Kim CJ, et al. Single-port access subtotal hysterectomy

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randomized controlled trial. J Minim Invasive Gynecol.2013;20(4):460-7.

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Tables and Figure Legend.

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Table 1: Patients characteristics.

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Table 2: Comparison of surgical outcomes between SPAL-SH and MPA-SH.

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Table 3: Comparison of postoperative pain between SPAL-SH and MPA-SH.

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Table 4: Body Image Questionnaire (BIQ) scores at 1, 4 and 24 weeks after surgery in SPAL-SH group and MPA-SH group.

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Table 1: Patients characteristics

Age,y;mean (SD)

47,9±6,52

BMI, kg/m²

23,89±2,2

Main symptom for surgery Metrorrhagia

19 (61,29 %)

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Dysmenorrhea/ Chronic pelvic pain 12 (38,71%)

MPA-SH (N:30)

Main pathology

p Value

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SPAL-SH (N:31)

49±7,23

NS

22,2±1,7

NS

SC

Characteristic

21 (70%)

NS

9 (30%)

NS

Leiomyoma

19 (61,29%)

21 (70%)

NS

Adenomyosis

12 (38,71%)

9 (30%)

NS

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SD standard deviation, BMI body mass index, SPAL-SH single port access laparoscopic subtotal hysterectomy, MPA-SH multi port access subtotal hysterectomy

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Table 2: Comparison of surgical outcomes between SPAL-SH and MPA-SH SPAL-SH (n:31)

MPA-SH(n:30)

P value

Operative time (min)

89,58 ±11,71

67,26±10,90

<0,001

EBL (ml)

63,84±12,49

56,26±11,39

0,15

Hospital stay

2,06±0,25

2,65±0,60

<0,001

Uterine weight (corpus)(gm)

259,16±44,67

296,77±59,18

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Transfusion

0

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NS

NS

0

NS

SPAL-SH= single port access laparoscopy subtotal hysterectomy; MPA-SH= multi port access laparoscopy subtotal hysterectomy; EBL= estimated blood loss,

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0,006

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Postoperative complication

0

SC

Perioperative complication rate, total 0

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Outcomes

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Table 3: Comparison of postoperative pain scores (VAS) between SPAL-SH and conventional

Postoperative pain score, mean (SD) Postoperative time

SPAL-SH (n:31)

RI PT

MPA-SH

MPA-SH(n:30)

P-value

4,01±0,55

5,22 ±0,83

6h

3,77±0,56

4,24±1

<0,001

24 h

2,35±0,48

4,03±0,94

<0,001

48 h

1,42±0,56

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Mean ±SD

SC

Immediate postoperative

2,48±0,62

<0,001

<0,001

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Table 4: Body Image Questionnaire (BIQ) scores at 1, 4 and 24 weeks after surgery in SPAL-SH group and MPA-SH group.

MPA-SH (30)

SC

SPAL-SH (31)

P-value

17,94±0,63

13,81±2,05

<0,001

BIS 4 weeks

18,68±0,54

14,68±1,14

<0,001

BIS 24 weeks

19,61 ±0,49

CS 1 week

21,68±0,90

CS 4 weeks

22,87±0,95

CS 24 weeks

23,45±1,06

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BIS 1 week

14,42 ±0,88

<0,001

15,32±0,94

<0,001

15,81±1,04

<0,001

15,71±0,78

<0,001

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SPAL-SH= single port access laparoscopy subtotal hysterectomy; MPA-SH= multi port access laparoscopy subtotal hysterectomy; BIS= body image score; CS= cosmetic score.

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http://www.AAGL.org/jmig-22-5-JMIG-D-15-00016

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PRECIS: Single port laparoscopy is a safe approach to perform subtotal hysterectomies with better outcomes in comparison to conventional laparoscopy.