Problem: larger incisions cause more pain and scarring

Transvaginal ultrasonography revealed a 3-cm simple anechoic left ovarian cyst in a 61-year-old asymptomatic postmenopausal woman with a body mass index of 21.7 kg/m ² . She had recently learned that she carried a BRCA-2 mutation that raised her risk for ovarian cancer. Testing for CA 125 was negative. Nonetheless, it was suggested that she undergo microlaparosopic bilateral prophylactic adnexectomy. She had never had abdominal surgery.

Our solution

General anesthesia was administered through an endotracheal tube. With the patient in the Trendelenburg position, pneumoperitoneum was created with a Veress needle (Ethicon Endo-Surgery, Somerville, NJ) at 12 mm Hg of pressure, and a 3-mm laparoscope was introduced intraumbilically ( Video Clip ). Two 2-mm suprapubic ancillary trocars were then inserted in the abdominal cavity under direct vision. A 2-mm laparoscope and a 2-mm atraumatic grasper (Karl Storz Endoskope, Tuttlingen, Germany) were placed in the right and left suprapubic ports, respectively.

While the left adnexum was suspend with the grasper, the ipsilateral suspensory ligament, mesosalpinx, uteroovarian ligament, and fallopian tube were coagulated and cut by alternative use of a 3-mm bipolar forceps and a 3-mm bipolar scissors through the umbilical port (both instruments were powered by the Autocon II generator, Karl Storz Endoskope). The same steps were carried out for the right adnexum after the positioning of the 2-mm laparoscope, and the 2-mm grasper was reversed.

When the adnexa were completely freed from their supports, a 10-mm endobag was inserted transvaginally and pushed against the posterior vaginal fornix to delineate the cul-de-sac. Colpotomy was performed with a 2-mm monopolar hook, and the specimens were extracted through the vagina within the bag. Vaginal closure was accomplished transvaginally. The abdominal cavity was reinspected laparoscopically to ensure hemostasis. Suprapubic skin incisions were reapproximated with Steri-Strips (Nexcare; 3M Global Headquarters, St. Paul, MN).

The patient was discharged on the day of surgery, and no complications ensued during the following month. Because the surgical specimen was removed through the vagina, we did not have to enlarge the trocar incision as might have been necessary had the umbilical route been used; this reduced the potential for pain and scarring. The use of 2-mm ancillary instruments, combined with effective 3-mm intraumbilical coagulation, could open new perspectives in the field of ultraminimally invasive surgery.