Ultra Minimally Invasive Hysterectomy with 2.4 mm Needleoscopic Instruments Assistance: Reducing Invasiveness Maintaining the Technique

Abstract

Introduction: In the past 5 years, the constant technological improvement has determined a significant “revolution” in the philosophy of surgical approach. Riding the wave of minimal invasiveness, surgical procedures even less invasive than standard laparoscopy have been proposed. In this context it is possible to recognize the specific advantages of well-known ultra minimally invasive techniques such as Single Port and Mini-Laparoscopy.1,2 Nowadays, specific advantages and disadvantages of each approach are widely established: the possibility to maintain the laparoscopic ergonomy with the triangulation between instruments and tissues made Mini-Laparoscopy more suitable for hysterectomy. Based on this assumption, the reduction of instrument dimensions is better than reduction of number of instruments. On this background, the percutaneous technology, characterized by 2.4 mm of maximum diameter needlescopic instruments (MiniLap® System with MiniGrip® handle by Teleflex Ltd), represents, to the best of our knowledge, the ultimate and thinnest tool for minimally invasive gynecologic surgery.3 Our report shows the surgical feasibility and specific characteristics of total laparoscopic hysterectomy with bilateral salpingo-oophorectomy with the assistance of MiniLap percutaneous instruments. Materials and Methods: The patient was a 50-year-old women affected by complex atypical hyperplasia diagnosed by endometrial biopsy and radiologic examinations. She had no previous surgery and the body mass index was 24.91 kg/m2. Informed consent for abdominal or laparoscopic approach was obtained from the patient in accordance with the local legislation. Moreover, the patient signed an informed consent to use image and video of the procedure. IRB approval was not required for this kind of procedure. We performed total hysterectomy with bilateral salpingo-oophorectomy using a 5 mm HD 0° EndoEye camera (Olympus Winter GmBH) in a 5 mm transumbilical Hasson trocar. In place of two standard bilateral ancillary ports, 2.4 mm needleoscopic instruments percutaneously inserted were used. A multifunction device (Thunderbeat, Olympus Winter GmBH) was inserted through a 5 mm supra-pubic trocar. Results: The operation was effectively completed. Operative time was 53 minutes overall, skin-to-skin, and blood loss was 20 mL. No intraoperative complications were registered. The patient was discharged 18 hours after the end of surgery (day 1). Pathology report confirmed complex atypical hyperplasia. In accordance with Dindo classification,4 no early postoperative complications occurred. Conclusions: The needleoscopic assisted hysterectomy seems feasible and safe. The “noninvasive” needleoscopic approach mixed with only 10 mm overall laparoscopic incision allows, for the first time, to perform the “least” invasive hysterectomy. Despite the thinness of 2.4 mm could represent a limit in manipulating tissues in non-well-selected cases, the possibility to choose between three different tips and to make a fine dissection allows an expert laparoscopic surgeon to complete hysterectomy with an operative time similar to that of standard laparoscopy. However, the lack of any type of energy made essential the use of a multifunction instrument. Further studies are mandatory to define the benefits, advantages, and costs of this novel approach with respect to other ultra minimally invasive procedures. No competing financial interests exist. Minigrip Instruments were offered by the TELEFLEX company for the procedure. Runtime of video: 7 mins 36 secs