Minimal-invasive, single-port laparoscopic surgery is a recent innovation that may improve surgical outcomes. In this chapter, we review published research on single-port surgery in gynaecology, and the different surgical instruments available. Challenges, advantages, indications and potential future rules of this new approach are also discussed. Sixty-five studies were available for review: 17 case reports, 32 case studies, 13 retrospective comparative studies, and three randomised-controlled trials (RCTs). The recent availability of advanced instruments has made single-port surgery safer and more feasible for most benign gynaecologic surgeries. Single-port surgery has many potential benefits, but comparative trials have found no differences between single-port surgery and conventional laparoscopy in postoperative complications, postoperative pain, hospital stay, and cosmetic results. Single-port surgery seems to provide another option in the area of minimal invasive surgery, and further development of this technique, along with robotics and natural orifice transgastric endoscopic surgery, will improve dissemination of this approach.
Introduction
One of the more recent advances in the field of minimally invasive gynaecology is the increasing use of single-port surgery (SPS). Single-port access laparoscopy (SPAL) is an attractive surgical approach because of its potential benefits and advantages. Trans-umbilical endoscopy has no additional abdominal incisions and, therefore, abdominal wound infections and incisional hernias could potentially be avoided. This could translate into less pain and improved cosmesis. Single-port surgery has developed rapidly in the past 3–4 years as an alternative to scarless natural orifice transluminal endoscopic surgery, which still remains experimental.
A recent systematic review by Ahmed et al. identified 102 clinical studies on SPAL in general, urologic, and gynecologic surgery, most of them conducted within the last 5 years.
Gynaecological surgeons pioneered pelvic SPS, as thousands of tubal ligation were carried out using single-incision laparoscopes with an offset eyepiece. In the 1970s, several gynaecologists carried out laparoscopic tubal sterilisation through a single umbilical incision. More advanced laparoscopic procedures using single-port surgery were reported years later, with the first single-port laparoscopic hysterectomy reported Pelosi and Pelosi in 1991. Improvement in traditional laparoscopic techniques, and availability of more advanced instruments, has made single-incision laparoscopy more feasible and safer. In this chapter, we review the published literature on SPS gynaecology ( Table 1 ), and present the different surgical instruments available. We also discuss challenges, advantages, indications and potential future rules of this new approach.
| Source, year | Study type | Surgery type | Indication (benign or malign) | Number of participants | Mean operative time (minutes) | Complications, including conversion to open procedure. | |
|---|---|---|---|---|---|---|---|
| 1 | Lambaudie et al., 2012 | CS | Extra peritoneal aortic lymphadenectomy | M | 13 | 180 | None. |
| 2 | Hoyer-Sorensen et al., 2012 | RCT | Adnexal surgery (SPL vs LPS) | B e M | 40 (20 v 20) | 42 v 31 | 2 (2 wound infections) v 1 (urinary retention). |
| 3 | Fagotti et al., 2012 | RC | TLH (SPL vs R-LPS) | M | 150 (75 v 75) | 122 v 175 | 5 (3 insertion additional port + 1 vaginal dehiscence + 1 wound infection) v 7 (2 conversion to mini-laparotomy access + 2 vaginal dehiscences + 1 intestinal volvulus + 1 suppurated lymphocyst + 1 late ureteral stenosis). |
| 4 | Fanfani et al., 2012 | RC | TLH (LPS vs M-LPS vs SPL) | B e M | 85 (30 v 25 v 30) | 80 v 90 v 105 | None v 2 (1 intraoperative haemorrhage + urinary infection) v 1 (intraoperative haemorrhage). |
| 5 | Li et al., 2012 | RC | TLH (SPL vs LPS) | B | 52 v 56 | 130 v 112 | 13 (1 wound infection + 12 fever) v 19 (5 wound infections + 14 fever). |
| 6 | Behnia-Willison et al., 2012 | CS | Endometriosis, OC adhesiolysis, TLH, PSP | B | 84/105 | 73 | 4 insertion of additional ports because of surgical difficulties, 1 intra-operative uterine perforation, 6 wound infections, 1 vault haematoma. |
| 7 | Song et al., 2012 | CS | Adnexal surgery | B | 115 | 83 | 1 (laparotomic conversion). |
| 8 | Kim et al., 2012 | RC | Adnexal surgery (SPL vs LPS) | B | 188 (94 v 94) | 78 v 69 | 6 insertion of additional ports v none. |
| 9 | Lin et al., 2012 | CR | Intraperitoneal chemotherapy port placement | 1 | NA | None. | |
| 10 | Wang et al., 2012 | RC | TLH (SPL vs LPS) | B | 56 (28 v 28) | 93 v 79 | 5 (1 bladder lesion; 2 ileus, 1 fever, 1 wound disruption) vs 3 (1 ileus, 1 fever, 1 voiding difficulty). |
| 11 | Koo et al., 2012 | CR | Mature cystic teratoma excision | B | 1 | NA | None. |
| 12 | Cho et al., 2012 | RCT | Adnexal surgery (SPL vs LPS) | B | 40 (20 v 20) | 42 v 36 | 2 (1 ileus, 1 delayed ovarian bleeding) v none. |
| 13 | Fagotti et al., 2012 | CS | TLH + BSO + Pelvic and paraortic lymph node dissection | M | 100 | 129 | 8 (1 transection of obturator nerve with laparotomic conversion, 1 small tear on the inferior vena cava with 1 additional trocar insertion, 1 superficial serosal injury on small bowel, 1 paravaginal bleeding, 1 wound cellulites, 2 partial vaginal cuff dehiscence, 1 ileus). |
| 14 | Wenger et al., 2012 | CS | SCH with endocervical resection | B | 2 | 134 | None. |
| 15 | Lee et al., 2012 | CS | TLH, SOB, myomectomy | B e M | 500 | 97 | 37 (3 bladder injury, 2 omental bleeding, 1 rectal serosa injury, 1 trocar site haematoma, 2 re-operation, 14 fever, 3 ileus, 5 vault bleeding/dehiscence, 3 wound infection, 3 other). |
| 16 | Roh et al., 2012 | RC | Adnexal surgery (SPL vs LPS) | B | 139 (96 v 43) | 70 v 75 | 11 (8 blood transfusions, 1 wound infection, 2 ileus) v none. |
| 17 | Lazard et al., 2011 | CS | Cornual resection for interstitial pregnancy | B | 2 | NA | None. |
| 18 | Yoon et al., 2011 | CR | TLH, BSO, omentectomy, pelvic lymphadenectomy, appendectomy | Borderline | 1 | 280 | None. |
| 19 | Gouy et al., 2011 | CS | Extraperitoneal para-aortic lymphadenectomy | M | 14 | 190 | None. |
| 20 | Im et al., 2011 | RC | Adnexal surgery (SPL vs LPS) | B | 33 (18 v 15) | 63 v 51 | None. |
| 21 | Song et al., 2011 | CS | LAVH | B e M | 100 | 115 | 9 (5 insertion of additional ports, 1 conversion to laparotomy, 1 bleeding, 1 vesicovaginal fistula, 1 cuff abscess). |
| 22 | Yoon et al., 2011 | RC | Ectopic pregnancy (SPL vs LPS) | B | 60 (30 v 30) | 53 v 47 | 1 (1 transfusion) vs 3 (3 transfusions). |
| 23 | Calcagno et al., 2012 | CS | Salpingectomy for ectopic pregnancy | B | 12 | 37 | None. |
| 24 | Gunderson et al., 2012 | CS | TLH, SCH, SO, Myomectomy, OC | B e M | 211 | 108 | 10 (4 laparotomic conversion, 6 insertion of additional port). |
| 25 | Lee et al., 2011 | RC | LAVH (SPL vs LPS) | B e M | 242 (80 v 162) | 93 v 90 | 3 (1 bladder injury, 1 transfusion, 1 fever) v 7 (2 subcutaneous emphysema, 2 bladder injury, 2 transfusions, 1 fever). |
| 26 | Kim et al., 2011 | CS | Adnexal surgery | B e M | 96 | 50 | 12 (6 cyst rupture, 2 fever, 2 insertion of additional ports, 2 conversion to laparotomy). |
| 27 | Chen et al., 2011 | RCT | LAVH (SPL vs LPS) | B | 100 (50 v 50) | 122 v 127 | 3 (1 vaginal cuff hematoma, 2 an additional trocar) vs 2 (1 post operative anemia with a blood transfusion, 1 wound infection). |
| 28 | Chua et al., 2011 | CR | 10 cm ovarian cyst | B | 1 | 73 | None. |
| 29 | Angioni et al., 2011 | CR | LAVH | B | 1 | 90 | None. |
| 30 | Bedaiwy et al., 2011 | CS | Salpingectomy | B | 11 | 35 | None. |
| 31 | Jung et al., 2011 | RCT | TLH (SPL vs LPS) | B | 68 (34 v 34) | 89 v 80 | 17(7 fever, 1 ileus, 1 other, 1 transfusion, 1 bladder injury, 4 conversion to 2 or 4 port) vs 4 (2 fever, 1 ileus, 1 other). |
| 32 | Kavallaris et al., 2011 | RC | Adnexal surgery (SPL vs LPS) | B | 48 (24 v 24) | 35 v 28 | None vs None. |
| 33 | Jung et al., 2011 | CS | Adnexal surgery | B | 86 | 64 | 6 (2 conversion to 2 or 3 port; 3 postoperative infections, 1 postoperative bleeding). |
| 34 | Ramesh et al., 2011 | CR | Myomectomy | B | 1 | 130 | None. |
| 35 | Mereu et al., 2011 | CR | Myomectomy | B | 1 | 94 | None. |
| 36 | Phongnarisorn and Chinthakanan, 2011 | CS | TLH | B | 10 | 163 | 2 (fever). |
| 37 | Kim and Know, 2010 | CR | OC during pregnancy | B | 1 | 25 | None. |
| 38 | Fagotti et al., 2010 | CR | Adnexal surgery | B | 30 | 40 | None. |
| 39 | Park et al., 2011 | CS | TLH; SCH; adnexal surgery, myomectomy; Adhesiolysis | B and M | 200 | 113 | 4 bleeding and 1 vescicovaginal fistula after hysterectomy, 1 hematoma after myomectomy, 1 conversion to open, 9 insertion additional port. |
| 40 | Boruta et al., 2011 | CS | Pelvic and para-aortic lymphadenectomy | M | 5 | 243 | None. |
| 41 | Hahn and Kim, 2010 | CS | Pelvic lymph node dissection + RVH | M | 2 | 178 | None. |
| 42 | Kumakiri et al., 2010 | CS | Salpingotomy + intracorporeal suturing | B | 3 | 56 | None. |
| 43 | Hart et al., 2010 | CR | TLH and cholecystectomy | B | 1 | 180 | None. |
| 44 | Perrone et al., 2010 | CR | TLH + BSO | B | 1 | 90 | None. |
| 45 | Escobar et al., 2010 | CS | Pelvic and para-aortic lymphadenectomy | M | 21 | 120 | 2 (1 insertion of additional trocars + 1 small vein injury). |
| 46 | Surico et al., 2010 | CR | OC and Cholecystectomy | B | 1 | 132 | None. |
| 47 | Lee et al., 2010 | CS | Myomectomy, cystectomy, appendectomy | B | 15 | 81 | None. |
| 48 | Fader et al., 2010 | CS | Adnexal surgery LH, BSO, RLH pelvic/Para aortic lymphadenectomy | B and M | 74 | 82 | 6 (3 minor; 1 conversion to conventional LPS; 2 conversion to open). |
| 49 | Kim et al, 2010 | CS | Myomectomy using transumbilical morcellator | B | 15 | 97 | None. |
| 50 | Song et al., 2010 | CS | LAVH (uterus > 500 g) | B | 15 | 125 | 2 insertion of additional trocar. |
| 51 | Yim et al., 2010 | RC | TLH (SPL vs LPS) | B and M | 157 (52 v 105) | 118 v 110 | 2 (1 urinary tract infection, 1 wound infection) vs 10 (2 urinary tract infection, 1 hematuria, 1 Upper respiratory infection, 1 wound infection, 2 ileus, 2 Vault bleeding, 1 Vault rupture). |
| 52 | Lee et al., 2010 | RC | Adnexal surgery (SPL vs LPS) | B | 51 (17 v 34) | 64 v 58 | None. |
| 53 | Kim et al., 2010 | RC | LAVH (SPL vs LPS) | B | 86 (43 v 43) | 119 v 124 | None. |
| 54 | Angioni et al., 2010 | CS | Endometrioma excision | B | 3 | 40 | None. |
| 55 | Mereu et al., 2010 | CS | Adnexal surgery | B | 16 | 42 | 1 wound infection. |
| 56 | Jung et al., 2010 | CS | TLH | B | 30 | 100 | 1 insertion of additional trocar. |
| 57 | Yoon et al., 2010 | CS | SCH with transcervical morcellation | B | 7 | 157 | None. |
| 58 | Langebrekk and Qvigstad, 2009 | CR | TLH | B | 1 | 60 | None. |
| 59 | Fanfani et al., 2009 | CR | TLH | M | 1 | 120 | None. |
| 60 | Gilabert-Estelles, 2010 | CR | TLH | B | 1 | 125 | None. |
| 61 | Lee et al., 2009 | CS | LAVH | B | 24 | 119 | 6 (3 transfusion, 2 insertion of additional trocar). |
| 62 | Lim et al., 2009 | CS | Adnexal surgery | B | 12 | 73 | None. |
| 63 | Ghezzi et al., 2005 | CS | Salpingectomy for tubal pregnancy | B | 10 | 27 | None. |
| 64 | Kosumi et al., 2001 | CR | Ovarian cystectomy | B | 1 | NA | None. |
| 65 | Pelosi, 1991 | CS | SCH | B | 4 | NA | None. |
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