Laparoendoscopic Single-site Radical Hysterectomy Research Articles

Learning curve for laparoendoscopic single-site radical hysterectomy using the “chopstick” technique: a retrospective cohort study

Laparoendoscopic single-site surgery (LESS), as a promising minimally invasive surgery, is confronted with the obstacle of the "chopstick effect" which limits its further application. The "chopstick" technique is characterized by the usage of instruments of parallel and equal length, and in operations relying on double-fulcrum and unique surgeon position can play a key role in overcoming the above disadvantage effect. This study sought to explore the learning curve for the use of the novel "chopstick" technique in laparoendoscopic single-site radical hysterectomy (LESS-RH) and evaluate the technique's practicability. Consecutive cervical cancer patients who underwent LESS-RH with the "chopstick" technique by a surgeon with rich experience in laparoscopy from November 2016 to September 2018 were included in the study. The learning curve of his surgeries with the "chopstick" technique was evaluated using the cumulative summation (CUSUM) method by analyzing operation time (OT) which was the surrogate indicator of surgical ability. The patients were divided into Phase I and Phase II based on the learning curve peak, whose demographic and perioperative characteristics, such as tumor Federation International of Gynecology and Obstetrics (FIGO) stage and histology, operation time, blood loss, and complications were collected and analyzed. The mean OT was 231.5 min (range, 115-355 min). The division of the learning curve based on OT occurred after the first 15 cases were finished, dividing Phase I and Phase II. The mean OT for Phase I (259 min) was significantly longer than that of Phase II (219 min) (P=0.02). Only 1 intraoperative complication occurred in Phase I, and none occurred in Phase II. Major postoperative complications occurred more frequently in Phase I (N=3) than in Phase II (N=0). No significant differences were observed in terms of lymph nodes, blood loss, or pathological features. The "chopstick" technique may help surgeons obtain stable LESS surgical performance through a relatively short learning curve, even in some complex surgeries, such as radical hysterectomy.

Vaginal-assisted gasless laparoendoscopic single-site radical hysterectomy for early cervical cancer: a retrospective pilot study

BackgroundMinimally invasive surgery for early cervical cancer is debated. We developed this new vaginal-assisted gasless laparoendoscopic single-site radical hysterectomy for early cervical cancer, and we aimed to evaluate the feasibility and safety of this surgical procedure and observe the early oncologic outcomes.MethodsFrom January 2019 to August 2020, patients with early cervical cancer who underwent vaginal-assisted gasless laparoendoscopic single-site radical hysterectomy were studied retrospectively. The clinical characteristics, pathologic outcomes, perioperative outcomes, and follow-up details of the patients were recorded.ResultsForty-eight patients underwent vaginal-assisted gasless laparoendoscopic single-site radical hysterectomy were included, 14 (29.2%) with stage IB1, 13 (27.1%) with stage IB2, 7 (14.6%) with stage IB3, 10 (20.8%) with stage IIA1, and 4 (8.3%) stage with IA2. The mean age at diagnosis was 50.4 (range 28–72) years old. The mean operative time was 237.3 min (range 162–393), and the mean estimated blood loss was 246.5 ml (range 80–800). No intraoperative complications occurred, and there were no patients who were readmitted. Histological types were distributed as follows: squamous cell carcinoma 72.9%, adenocarcinoma 10.4%, and adenosquamous cell carcinoma 16.7%. There were 2 patients (4.2%) with positive nodes, 20 patients (41.7%) with positive lymphovascular space invasion, and 2 patients (4.2%) with positive parametria. Twenty-eight patients (58.3%) received adjuvant therapy after the operation. With a mean follow-up of 17.7 months (range 6–26), there were no recurrent cases, and 11 patients (22.9%) suffered lower limb lymphoedema.ConclusionsThe vaginal-assisted gasless laparoendoscopic single-site radical hysterectomy might be a feasible technique for early cervical cancer, with promising short-term oncological outcomes and safety. A prospective study with more patients and longer follow-up periods should be performed to further evaluate the safety and oncological outcomes.

A Comparative Analysis of Robotic Single-Site Surgery and Laparoendoscopic Single-Site Surgery as Therapeutic Options for Stage IB1 Cervical Squamous Carcinoma

PurposeTo compare perioperative outcomes between robotic single-site surgical technique and conventional laparoendoscopic single-site surgical technique.MethodsThis was a retrospective cohort study involving 67 patients who received robotic single-site surgery or laparoendoscopic single-site surgery for the treatment of stage IB1 cervical squamous carcinoma. The robotic single-site radical hysterectomy technique combined with pelvic lymph node dissections were performed in 32 patients while the laparoendoscopic single-site radical hysterectomy technique combined with pelvic lymph node dissections were performed in 35 patients.ResultsThe enrolled patients had been diagnosed with stage IB1 cervical squamous carcinoma. The perioperative outcomes were mean age (51.63±8.32 years in the lymph node dissection (RSS group) and 53.14±8.14 years in the lymph node dissection (LESS group), p=0.453); BMIs (23.76±2.72 in the RSS group and 23.46±2.28 in the LESS group, p=0.629); shorter operative times (223.56±15.43 min in the RSS group and 248.61±20.89 min in the LESS group, p<0.01) and less estimated blood loss (217.25±16.77 mL in the RSS group and 294.74±24.00 mL in the LESS group, p<0.01). None of the study participants exhibited postoperative pain. There were no statistically significant differences in the length of hospital stay (p=0.865), perioperative complications (p=0.602), duration of closure and removal of catheter (p=0.518) as well as in pathological diagnoses between the two groups.ConclusionRobotic single-site surgery can be used in the treatment of early stage cervical cancer as it exhibits acceptable operative times and perioperative outcomes. This surgical technique is feasible and safe.

Chopstick technique used in laparoendoscopic single site radical hysterectomy for early stage cervical cancer

Laparoendoscopic single-site surgery (LESS) further minimizes the invasiveness of traditional laparoscopic surgery. However, the "chopstick" effect caused by the parallel arrangement of the instruments in the umbilicus is considered an obstacle indelicate operations. The purpose of this study was to introduce a new technique characterized by a double fulcrum formed by instruments, named the "chopstick" technique, which facilitates the expedient accomplishment of complicated surgeries such as LESS radical hysterectomy (LESS-RH). Seventy-three patients who underwent LESS-RH using the "chopstick" technique were retrospectively analyzed. The procedure was performed successfully in 72 patients. The median operative duration was 225 min, and the median intraoperative blood loss was 200 ml. Among the operations in the first 20 patients, intraoperative vascular injuries and bladder injury occurred in two patients and were repaired by LESS. Patients responded positively regarding minimal postoperative pain control. The score of satisfaction with the cosmetic outcome expressed by the patients was eight at discharge and nine 30 days later. In conclusion, this study presents the feasibility of accomplishing complicated procedures, such as radical hysterectomy, by LESS using the “chopstick” technique. This approach provides more options for both selected patients and surgeons.

Transumbilical Laparoendoscopic Single-Site Radical Hysterectomy without Uterine Manipulator and with Vaginal Closure

Study Objective Minimally invasive surgery (MIS) of radical hysterectomy (RH) was reported with inferior oncologic outcomes according to the New England Journal of Medicine (NEJM). Then some studies suggested that the no-touch technique may be a useful procedure to prevent tumor spillage as well as improve survival, and the procedures were improved continuously. Therefore, we performed RH targeting early-stage cervical cancer through laparoendoscopic single-site (LESS) approach with enclosed colpotomy and without uterine manipulator. Design A presentation of the surgery through this technical video. Setting A Hospital. Patients or Participants A 48-year-old postmenopausal woman was diagnosed as cervical cancer with stage IB1(FIGO 2018). Interventions After fully informed of the benefits and risks of different surgical approaches (open laparotomy and MIS), she agreed with the MIS. Measurements and Main Results The type C radical hysterectomy via LESS approach was performed successfully, the final pathologic findings confirmed stage IB1 cervical carcinoma. The patient recovered fast and well with slight pain, and the incision scar was hidden perfectly for cosmetic purpose. Conclusion This video demonstrated that LESS-RH with vaginal closure and without manipulator was feasible and safe. Suspension skills played a significant role in the LESS-RH. Besides, this surgery procedure also involved 4 specific techniques to prevent tumor spillage, including creation of a vaginal cuff, avoidance of interoperate uterine manipulator, standard extent and bagging of the specimen. These adaptations were meant to minimize tumor manipulation and disruption, for reducing the increased risk of recurrence. However, further verifications were still required.

Laparoendoscopic Single-site Radical Hysterectomy with Vaginal Closure and without Uterine Manipulator for FIGO IB1 Cervical Cancer

Minimally invasive surgery (MIS) for radical hysterectomy (RH) has been reported with inferior oncologic outcomes in the New England Journal of Medicine [1,2]. Some studies have suggested that the no-touch technique may be a useful procedure to prevent tumor spillage and improve survival. Therefore, we performed RH targeting early-stage cervical cancer using the laparoendoscopic single-site (LESS) approach with an enclosed colpotomy and without a uterine manipulator [3]. Video demonstration of the technique. A hospital. A 48-year-old postmenopausal woman received a diagnosis of stage IB1 (International Federation of Gynecology and Obstetrics, 2018) cervical cancer [4]. After being fully informed of the benefits and risks of different surgical approaches (laparotomy and MIS), she consented to the MIS. The type C RH through the LESS approach was performed successfully. The final pathologic findings confirmed stage IB1 cervical carcinoma. The patient recovered quickly, albeit with slight pain, and the incision scar was hidden perfectly for cosmetic purposes. This video demonstrates that LESS-RH with vaginal closure and without a manipulator is feasible and safe. Suspension skills played a significant role in LESS-RH. In addition, this surgical procedure involved 4 specific techniques to prevent tumor spillage: creation of a vaginal cuff, avoidance of a uterine manipulator, standard type C radical hysterectomy, and bagging of the specimen. These adaptations were meant to minimize tumor manipulation and disruption for reducing the increased risk of recurrence. However, further verifications are still required.

1704 Application of “Chopstick Technique” In Laparoendoscopic Single-Site Radical Hysterectomy: Initial Single-Institutional Experience for Early Stage Cervical Cancer

Study Objective This study aimed to describe the new “chopstick technique” in laparoendoscopic single-site radical hysterectomy (LESS-RH) and explore its feasibility, safety and perioperative outcomes in the treatment of early stage cervical cancer. Design Retrospective study. Setting The First Affiliated Hospital of Third Military Medical University, Chongqing, China. Patients or Participants Women with federation international of gynecology and obstetrics (FIGO) stage Ia1 with lymph vascular space invasion or stage Ia2-IIa2 cervical cancer. Interventions “Chopstick technique” was performed in LESS-RH and pelvic lymph node dissection. The demographic characteristics and perioperative efficacy of the patients were summarized and analyzed. Measurements and Main Results LESS-RH was attempted in 84 patients, and 83 (98%) patients underwent the procedure successfully. One patient underwent conversion to traditional laproscopic surgery secondary to phase IV endometriosis. “Chopstick technique” was used in all the 83 cases, wherein 40 cases used the single-incision three-channel laparoscopy platform, and 43 used the multichannel-tipped single port laparoscopy platform (HangT Port). The average operation time was 225.0±50.2min and the median intraoperative blood loss was 100mL. During the operations in the first 20 cases, 2 patients had intraoperative vascular injuries and 1 patient had bladder injury, and all were repaired under LESS. One case had ureterovaginal fistula 14 days after operation, and was successfully repaired by ureteroneocystostomy. The average number of pelvic lymph node dissections was 21, and the pathological examination of incisal edge was negative. Deep stromal invasion in 43 cases, LVSI in 16 cases,positive parametrium in 1 case, positive pelvic nodes in 15 cases. 33 patients were treated with postoperative chemotherapy and radiotherapy and 19 patients with intermediate risk factors were treated with radiotherapy postoperatively. Conclusion “Chopstick technique” under LESS was considered feasible for treating cervical cancer.

1155 Robotic Laparoendoscopic Single-Site Radical Hysterectomy and Pelvic Lymphadenectomy with Conventional Surgical Instruments in Cervical Cancer

Video Objective To describe and demonstrate the feasibility and safety of robotic laparoendoscopic single-site radical hysterectomy and pelvic lymphadenectomy with conventional robotic surgical instruments. Setting A university hospital. Interventions Robotic laparoendoscopic single-site radical hysterectomy and pelvic lymphadenectomy with conventional robotic surgical instruments. All of the interventions were performed using a da Vinci Si surgical system and all the surgery instrument was conventional robotic instruments. A uterine manipulator and an indwelling catheter (Foley catheter) were used. The patient was in the Trendelenburg position, and the robot was placed between her legs. By adopting the principle of the chopstick technique for R-LESS, a 30° robotic lens was placed in the upward configuration to reduce collision and achieve a better view. Conclusion Our preliminary experience has demonstrated that with experienced laparoscopic skills, R-LESS with the da Vinci Si system is a feasible and safe surgical approach for performance of radical hysterectomy and pelvic lymphadenectomy with conventional robotic surgical instruments. Further studies with greater number of patients in multiple settings will help us to fully elucidate the role of da Vinci Si surgical system in single-site gynecologic surgery.

The Application of Chopsticks Technique Single-Site Laparoscopic Surgery Technology in Cervical Cancer

Objective: To describe the new “chopsticks technique” single-site laparoscopic surgery technology, and to explore the feasibility, safety and perioperative outcome of Laparoendoscopic single-site radical hysterectomy and pelvic lymphadenectomy using “chopsticks technique”.

The application of "chopsticks technique" single-site laparoscopic surgery technology in cervical cancer

Objective To describe the new chopsticks technique single-site laparoscopic surgery technology, and to explore the feasibility, safety and peri operative outcome of laparoendoscopic single-site radical hysterectomy and pelvic lymphadenectomy using chopsticks technique . Methods From Oct.2016 to Oct. 2017, Patients diagnosed with cervical cancer were prospectively enrolled in obstetrics and Gynecology Department of Southwest Hospital, Third Military Medical University. The demographic characteristics of the patients and the effect of perioperative period were summarized and analyzed. Results 53 cases were operated on, and 52 cases(98%) were successfully completed , and 1 cases were converted to 3-port laparoscopy due stage Ⅳ endometriosis. All the 52 cases were used chopsticks technique , of which 40 cases were used incision three channel approach platform, and 12 cases were soft access platform. The median operation time was 212 min, and the average blood loss was 134 ml during the operation. 2 cases of vascular injury and 1 cases of bladder injury occurred in the first 20 cases, and all of them were repaired by single-site laparoscopy during the operation. 1 case of ureteral vaginal fistula occurred 14 days after the operation, and the ureterovesical reimplantation was successfully repaired. Conclusions The chopsticks technique single port laparoscopic surgery is feasible for the treatment of cervical cancer. Preliminary clinical observation shows that the perioperative clinical outcomes are similar to those reported by literature. However, in the initial stage of technology, we should pay attention to prevent intraoperative complications. Key words: Cervical cancer; Laparoendoscopic single-site surgery; Radical hysterectomy

75 - Single-Institutional Experience in Laparoendoscopic Single-Site Radical Hysterectomy with Pelvic Lymphadenectomy for Treatment of Cervical Cancer

Study Objective: To describe the feasibility, safety, and outcomes of women with cervical cancer treated with laparoendoscopic single-site surgery radical hysterectomy with pelvic lymphadenectomy (LESS-RH/PLND).

Robotic Laparoendoscopic Single Site Radical Hysterectomy With Sentinel Lymph Node Mapping and Pelvic Lymphadenectomy for Cervical Cancer

Objective. Laparoendoscopic single site (LESS) radical hysterectomy has been previously described but has not gained wide acceptance [1,2]. The role of sentinel lymph node (SLN) mapping in cervical cancer continues to evolve [3]. Recent advances in the single site robotic platform have made the performance of robotic LESS radical hysterectomy feasible [4]. The aim of this video is to demonstrate the feasibility of robotic LESS radical hysterectomy, with sentinel lymph node mapping and complete lymphadenectomy.

Robotic laparoendoscopic single site radical hysterectomy with sentinel lymph node mapping and pelvic lymphadenectomy for cervical cancer

Objective. Laparoendoscopic single site (LESS) radical hysterectomy has been previously described but has not gained wide acceptance [1,2]. The role of sentinel lymph node (SLN) mapping in cervical cancer continues to evolve [3]. Recent advances in the single site robotic platform have made the performance of robotic LESS radical hysterectomy feasible [4]. The aim of this video is to demonstrate the feasibility of robotic LESS radical hysterectomy, with sentinel lymph node mapping and complete lymphadenectomy.

Minilaparoscopic Radical Hysterectomy (mLPS-RH) vs Laparoendoscopic Single-Site Radical Hysterectomy (LESS-RH) in Early Stage Cervical Cancer: A Multicenter Retrospective Study

Study ObjectiveTo compare the perioperative outcomes of laparoendoscopic single-site radical hysterectomy (LESS-RH) and minilaparoscopic radical hysterectomy (mLPS-RH). DesignRetrospective study (Canadian Task Force classification II-2). SettingSeven institutions in Italy. PatientsForty-six patents with early cervical cancer (FIGO stage IA2-IB1/IIA1) were included in the study. Nineteen patients (41.3%) underwent LESS-RH, and 27 (58.7%) underwent mLPS-RH. Pelvic lymph node dissection was performed in all patients. InterventionsIn the LESS-RH group, all surgical procedures were performed through a single umbilical multichannel port. In the mLPS-RH group, the procedure was completed using a 5-mm umbilical optical trocar and 3 additional 3-mm ancillary trocars, placed suprapubically and in the left and right lower abdominal regions. Measurements and Main ResultsThere was no difference in clinicopathologic characteristics at the time of diagnosis between the LESS-RH and mLPS-RH groups. Median operative time was 270 minutes (range, 149–380 minutes) for LESS-RH, and was 180 minutes (range, 90–240 minutes) for mLPS-RH (p = .001). No further differences were detected between the 2 groups insofar as type of radical hysterectomy, number of lymph nodes removed, or perioperative outcomes. In the LESS-RH group, conversion to laparotomy was necessary in 1 patient (5.3%) because of external iliac vein injury, and in another patient, conversion to standard laparoscopy was required because of truncal obesity. In the mLPS-RH group, no conversions were observed; however, a repeat operation was performed to repair a ureteral injury. The percentage of patients discharged 1 day after surgery was significantly higher in the LESS-RH group (57.9%) compared with the mLPS-RH group (25.0%) (p = .03). After a median follow-up of 27 months (range, 9–73 months), only 1 patient, who had undergone mLPS-RH, experienced pelvic recurrence and died of the disease. ConclusionsBoth LESS-RH and mLPS-RH are feasible ultra-minimally invasive approaches for performance of radical hysterectomy plus pelvic lymph node dissection. Further technical improvements are required to enable wider use of these techniques for more complex procedures.

Laparoendoscopic Single-site Radical Hysterectomy With Pelvic Lymphadenectomy: Initial Multi-institutional Experience for Treatment of Invasive Cervical Cancer

Study ObjectiveTo describe the feasibility, safety, and outcomes of women with stage I cervical cancer treated with laparoendoscopic single-site surgery radical hysterectomy (LESS-RH). DesignA retrospective descriptive study (Canadian Task Force classification III). SettingMultiple academic teaching hospitals. PatientsWomen with Fédération Internationale de Gynécologie et d'Obstétrique FIGO stage IA1 to IB1 cervical cancer. InterventionsLESS-RH as the primary therapy for cervical cancer performed by a gynecologic oncologist with expertise in LESS. A multichannel, single-port access device; a flexible-tipped 5-mm laparoscope; and a multifunctional instrument were used in all cases. Clinicopathologic, surgical, and perioperative outcomes were analyzed. Measurements and Main ResultsTwenty-two women were identified in whom a LESS-RH was attempted; 20 (91%) successfully underwent the procedure, including 19 in whom pelvic lymphadenectomy (PLND) was completed. Of the 2 converted procedures, 1 patient underwent 2-port laparoscopy secondary to truncal obesity, and 1 patient underwent conversion to laparotomy secondary to external iliac vein laceration during PLND. The median age and body mass index were 46 years and 23.3 kg/m2, respectively. The median number of pelvic lymph nodes removed was 22. One patient experienced an intraoperative complication, and no patient required reoperation. The margins of excision were negative. One patient with 2 positive pelvic nodes and 1 patient with microscopic parametrial disease received adjuvant chemosensitized radiation; 3 additional patients received adjuvant radiation therapy secondary to an intermediate risk for recurrence. After a median follow up of 11 months, no recurrences were detected. ConclusionLESS-RH/PLND is feasible and safe for select patients with stage I cervical cancer. Larger studies are needed to confirm whether the increased technical difficulty of this procedure justifies its use in routine gynecologic oncology practice.

Laparoendoscopic Single-Site Radical Hysterectomy for Treatment of Early Stage Cervical Cancer

Laparoendoscopic Single-Site Radical Hysterectomy for Treatment of Early Stage Cervical Cancer

Laparoendoscopic single-site radical hysterectomy for treatment of early cervical cancer

Objective: Performance of radical hysterectomy via laparoendoscopic single- site surgery (LESS) demonstrates the potential of LESS to be safely used for completion of even the most technically challenging of gynecologic surgical procedures. We hope to spur further interest in the development of this exciting approach within minimally invasive surgery.

Laparoendoscopic single-site radical hysterectomy: The first report of LESS type III hysterectomy involves a woman with cervical cancer

Laparoendoscopic single-site surgery is a logical advance in the evolution of minimally invasive surgery and is being utilized to perform increasingly complex procedures. We report its use for completion of radical hysterectomy as treatment for cervical cancer.