Objective
The objective of the study was to compare surgical outcomes and postoperative pain between transumbilical single-port access total laparoscopic hysterectomy (SPA-TLH) and conventional 4-port total laparoscopic hysterectomy (TLH).
Study Design
We retrospectively reviewed 157 patients who underwent SPA-TLH (n = 52) or conventional TLH (n = 105). A single-port access system consisted of a wound retractor, surgical glove, 2 5 mm trocars, and 1 10/11 mm trocar.
Results
The SPA-TLH group had less intraoperative blood loss ( P < .001), shorter hospital stay ( P = .001), and earlier diet intake ( P < .001) compared with the conventional TLH group. There was no difference in perioperative complications. Immediate postoperative pain score was lower in the SPA-TLH group ( P < .001). Postoperative pain after 6 and 24 hours was lower in SPA-TLH with marginal statistical significance.
Conclusion
SPA-TLH is a feasible method for hysterectomy with lower immediate postoperative pain and better surgical outcomes with respect to recovery time compared with conventional TLH.
Laparoscopy has several advantages over laparotomy including improved cosmesis, shorter length of hospital stay, faster return to normal activities, lower cost, and reduced pain. Several investigators have demonstrated the feasibility of a laparoscopic approach for gynecologic procedures, the most common being laparoscopic hysterectomy. Minimally invasive procedures such as laparoscopy are becoming the current trend and are constantly improving with advances in surgical instrumentation and technique.
Recently single-port access (SPA) laparoscopic surgery has been introduced into the field of minimally invasive surgery and implemented in gynecologic procedures. In fact, a single-port approach had already been used in the gynecologic field; in the 1970s, laparoscopic tubal ligations were performed with Yoon’s ring through a single umbilical incision, and Pelosi and Pelosi performed total hysterectomy with bilateral salpingo-oophorectomy using the single-puncture technique in 1991. However, this procedure did not initially gain popularity because of technical challenges. Since then, technological innovations in the field of laparoscopic surgery have been remarkable, allowing complicated procedures such as cholecystectomy, appendectomy, nephrectomy, and sacrocolpopexy using single-port access.
The technology and techniques used in laparoscopic procedures are still evolving, yet there are limited numbers of studies demonstrating the feasibility of single-port access laparoscopic hysterectomy. Lee et al reported SPA-laparoscopic-assisted vaginal hysterectomy. However, there are no reports of total laparoscopic hysterectomy (TLH) using a single multichannel port. Since 2008, with the recent progression in laparoscopic skills and instrumentation, we have successfully performed SPA-TLH. In this study, we present our experience with SPA-TLH and a retrospective comparative analysis of surgical outcomes including postoperative pain for SPA-TLH and conventional TLH.
Materials and Methods
The study was approved by the Institutional Review Board at Yonsei University College of Medicine. We evaluated 157 patients who underwent SPA-TLH (n = 52) or conventional TLH (n = 105) for benign gynecological conditions from June 2004 to July 2009 at the Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine in Seoul, Korea. Conventional TLH using 4 ports was performed in our institution until August 2008 when SPA laparoscopic surgery was introduced for adnexal surgery and hysterectomy.
All hysterectomies were performed by 2-surgeon teams. After general anesthesia, patients were placed in the lithotomy position. A RUMI uterine manipulator was placed with a KOH Colpotomizer system (Cooper Surgical Inc, Trumbull, CT). Surgical instruments used were bipolar forceps, monopolar scissors, atraumatic forceps, toothed grasper, laparoscopic needle holder, and a suction-irrigation system.
Data pertaining to patient characteristics (age, parity, body mass index, and general health status), type and duration of surgery, presence of pelvic adhesion, estimated blood loss, uterine weight, postoperative pain scores, short-term postoperative complications, resumption of normal diet, and length of hospital stay were collected from medical records. Operative time was defined as the time from umbilical skin incision to completion of skin closure.
Inclusion criterion of the study was a planned hysterectomy for benign gynecologic conditions and healthy patients (American Society of Anesthesiologists classification I-II). Exclusion criteria were confirmed cervical, uterine, or ovarian malignancy; uterine size greater than 16 gestational weeks by pelvic examination; previous history of radiation therapy; and laparoscopic cases that were converted to abdominal hysterectomy.
Postoperative pain intensity was rated at rest using a visual analog scale. The scale was presented as a 10 cm line, with verbal descriptors anchored with “no pain” and “worst imaginable pain.” Patients were asked to rate their pain intensity immediately after surgery in the recovery unit and at 6, 24, and 48 hours after surgery. Intraoperative analgesia consisted of intravenous fentanyl (100 μg) and ketorolac tromethamine (60 mg).
Intravenous patient-controlled analgesia (IV-PCA) was part of the postoperative pain management protocol under consent and was commenced 30 minutes prior to the end of surgery and continued for 48 hours. The standard prescription for IV-PCA was 1000 μg fentanyl, 120 mg ketorolac tromethamine, and 16 mg ondansetron HCl in 100 mL 0.9% saline. This was given in a standard 2 mL per hour infusion set, and a patient bolus of 2 mL every 15 minutes was allowed. After surgery, intravenous analgesia (60 mg ketorolac tromethamine) was given on demand.
Oral nonsteroidal antiinflammatory drugs were given regularly during the hospital stay when the patient started diet intake around postoperative day 2. Five day discharge medication was dispensed. Patients were discharged from the hospital when they were mobile with well-controlled pain, tolerated an oral diet, and resumed normal bowel and urinary functions.
Surgical techniques
Conventional TLH: a 5 or 10 mm vertical intraumbilical incision was made and a 5 or 10 mm trocar was inserted bluntly through the umbilicus before CO 2 insufflation. After creating a CO 2 pneumoperitoneum, a rigid 30°, 5 or 10 mm laparoscope was introduced, depending on the surgeon’s preference. Two ancillary 5 mm trocars were placed at the McBurney and the counter-McBurney point, and another 5 mm trocar was inserted about 10 cm above the counter-McBurney point. After transvaginal specimen removal, the vaginal cuff was closed laparoscopically using 0 Polysorb sutures (Syneture, Mansfield, MA) and tied intracorporeally or extracorporeally using a Clarke-Reich knot pusher.
SPA-TLH
After making a 1.2-1.5 cm vertical intraumbilical skin incision, a 1.5-2 cm rectus fasciotomy was performed to enter the peritoneal cavity ( Figure 1 , A). For the SPA system, the Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA) was inserted into the peritoneal cavity through the umbilicus ( Figure 1 , B). The wrist portion of a size 7½ surgical glove was fixed to the outer ring of the wound retractor.
After making a small hole in one of the finger tip portions of the glove, a 5 mm trocar was inserted and advanced into the abdominal cavity. The abdomen was insufflated with CO 2 gas through this trocar to approximately 2 L, and a rigid 30°, 5 mm laparoscope was inserted.
After inspection of the pelvic cavity, 2 additional holes for accessory ports were made in the other finger tips of the glove and 1 conventional 5 mm and another 10-11 mm port were inserted through the holes. Laparoscopic forceps and graspers were inserted through these accessory ports as needed. Bipolar and monopolar electrocautery and the LigaSure system (Valleylab, Boulder, CO) were used ( Figure 1 , C).
After placing the SPA system, the overall procedure was similar to that of conventional TLH using 4 ports. Bilateral round ligaments and tuboovarian ligaments were securely ligated and cut with the LigaSure system ( Figure 2 , A and B). After completely detaching the uterus from the vagina, the uterus was transvaginally extracted. Pneumoperitoneum was maintained with a surgical glove filled with normal saline.
The vaginal cuff was laparoscopically repaired with 0 Polysorb sutures in 38 of 52 cases. A 40 mm round-bodied needle was introduced through the 10 or 11 mm port and tied intracorporeally or extracorporeally using a Clarke-Reich knot pusher ( Figure 2 , C). Four interrupted sutures were made in total ( Figure 2 , D).
Among the first 26 cases, the vaginal vault was repaired transvaginally with 0 Polysorb sutures in 14 patients who had sufficient vaginal space; however, the vaginal cuff was closed laparoscopically in all of the last 12 cases. After hemostasis, the single 3-channel port was removed and the umbilical fascia and subcutaneous tissue were approximated with 2-0 Vicryl sutures (Ethicon, Piscataway, NJ) ( Figure 1 , D).
Statistical methods
Statistical analysis was performed with SPSS version 12 for Windows (SPSS Inc, Chicago, IL). A P value of less than .05 was regarded as statistically significant. Student t test and Mann-Whitney U test were used for parametric and nonparametric variables, respectively. Differences between proportions were compared with the χ 2 test.
Results
In total, 157 patients were included in this study: 52 in the SPA-TLH group and 105 in the conventional TLH group ( Table 1 ). None of the patients were converted to laparotomy; however, 1 patient with a dense intestinouterine adhesion in the posterior cul-de-sac area who received SPA-TLH needed an additional port on the suprapubic area to complete the procedure.
