A different technique in gasless, laparoendoscopic, single-site myomectomy

All the procedures were performed successfully using our technique. A uterine manipulator was used in three procedures. The demographic characteristics of the patients are shown in Table 1. The mean age of the patients was 41.27 ± 8.58. The mean BMI was 22.72 ± 2.27 kg/m². 5 patients had a history of previous abdominal surgery: one had a traditional myomectomy, and the remaining four had one caesarean delivery each. The operative findings of the patients are shown in Table 2. The average myoma size 5.79 ± 3.12 cm, and the mean number of myomas removed was 3.87 ± 6.02 (range, 1–25), excluding those smaller than 1 cm. The average blood loss volume was 57.33 ± 72.35 ml. The largest number of myomas was 25, the longest operative duration was 280 min, and the most blood loss volume was 300 ml. None of the patients were treated with blood transfusions. The mean operative duration was 156.47 ± 62.19 min, and the average time of bowel activity was 27.67 ± 10.06 h. The postoperative hospitalization duration was 3.4 ± 0.74 days. The postoperative VAS pain score after 1, 6, and 24 h was 2.07 ± 0.26, 2.07 ± 0.59 and 1.87 ± 1.36, respectively. Three patients used analgesic drugs after the operation.

There were no surgical or wound complications in any patient, and the histopathological result was leiomyoma in all cases.

The present study demonstrates that GLESS myomectomy with our technique is a safe and effective alternative to conventional laparoscopic myomectomy. It is very low in cost compared to the use of trocars in conventional multiport laparoscopy or other gasless, laparoscopic techniques. In addition, the tools are reusable after sterilization and disinfection and could easily be promoted. Since the late 1980s, laparoscopic technology, with a laparoscope, CO₂ gas and several trocar ports as the main elements, has developed rapidly because of the reduced pain, faster recovery and more cosmetic incision. The desire to develop more minimally invasive surgical techniques has led to a transition from multiple-port surgery to port-less or single-port surgery, known as natural orifice transluminal endoscopic surgery (NOTES) and LESS techniques. In traditional laparoscopic surgery, the pressure of CO₂ is used to push away the surrounding tissues in the body cavity and provide a satisfactory surgical space. However, CO₂ can enter the circulatory system through the peritoneum, abdominal organs and broken vessels, resulting in adverse effects on the circulatory system, the respiratory system, and the nervous system, as well as leading to postoperative shoulder pain, nausea and vomiting [7]. Therefore, an increasing number of surgeons are focusing on gasless laparoendoscopic surgery to avoid the detrimental effects of pneumoperitoneum in high-risk patients who have cardiopulmonary or metabolic disorders, and high American Society of Anesthesiologist (ASA) status(≥ II) [8, 9]. In recent years, GLESS has been reported in the treatment of various gynaecologic diseases, including in hysterectomy and adnexal surgery [5, 6, 10‐12]. However, GLESS is not widely performed for other gynaecologic conditions because it requires much suturing and knot tying. The major drawback to LESS or GLESS is the frequent collisions of laparoscopic instruments extra- and intracorporeally, ascribed to the lack of triangulation and the limited operating area. Advances in technology have led to the development of special access devices and instruments, providing potential solutions to these problems. Using conventional, rigid, straight instruments, it is difficult to roll threads around an instrument with another instrument to tie intracorporeal knots because these instruments are nearly parallel in single-port laparoscopic surgery.

Single-port laparoscopic myomectomy (SP-LM) is difficult to apply because it is inevitably accompanied by technical difficulties, particularly in suturing and knotting. In our study, there was no need to establish a pneumoperitoneum, and a small incision of 2.5 cm was made in the umbilicus to facilitate the suture needle entering, leaving, suturing and knotting which can be performed with a common long-handle needle holder, with a method similar to that applied in conventional laparoscopic surgery (Fig. 3). Choi et al. did continuous suturing tied with a Hem-o-lok clip or suturing by barbed suture to overcome the limitations [13]. By our surgical access platform and instruments, we can easily complete the continuous suturing by pulling the suture extracorporeal which can maintain the tension without instruments collisions, shorten the operation time and reduce bleeding (as shown in the supplementary surgery video). Nearly 30% of patients still need an additional hole to complete the operation as knotting is another difficulty in surgery [14]. Some researchers proposed perform single-port surgery by suturing with robotic surgery, which undoubtedly increase the cost of surgery [15]. Single-port laparoscopically assisted-transumbilical ultraminilaparotomic myomectomy (SPLA-TUM) is another way to reduce the surgery difficult, but it was unsuitable for fibroid which located on the lower posterior wall of the uterus or lateral pelvic wall [16]. In addition, an enlarged umbilical incision may increase the incidence of hernias. Our study showed that GLESS can easily tie a knot extracorporeal, which undoubtedly greatly reduces the difficulty of surgery (as shown in the Online video). We can also easily place gauze though umbilical holder to improve the surgical field of vision which is not possible with traditional gas less laparoscopy.

In our study, we used a gasless, single-port system created with an abdominal wall lifting system and an umbilical fixation system that made transumbilical myoma extraction possible. The umbilical fixation system widens the umbilical incision, and the lifting system completely converts the incision space into the operative space, thereby improving the operative efficiency. In addition, we have designed some special laparoscopic instruments, such as bent separation forceps and myoma-grasping forceps. The unique bent design is useful in preventing crowding and making more room for triangulation.

Although minimally invasive laparoscopic surgery has many advantages when compared to traditional surgery, some difficulty remains in removing large tissue specimens through small incisions. To achieve this, morcellation using either a mechanical power morcellator or a surgical scalpel in the peritoneal cavity should be considered [17]. However, power morcellation-related complications, such as injury to blood vessels and adjacent organs, can occur [18]. This method also carries the risk of unintentional dissemination of the removed tissue in the open peritoneal cavity, which could lead to the recurrence of benign tumours, and even more worrying, the spread of malignant tumours, such as uterine sarcoma, which may cause a decrease in overall survival [19, 20]. In April 2014, the U.S. Food and Drug Administration issued a safety communication warning that power morcellation should not be used due to the risk of intraperitoneal malignant tumour dissemination during laparoscopic surgery [21].

Our homemade, single-port device can be used to easily remove specimens. Small myoma specimens less than 2 cm can be removed directly to avoid omission. Larger myomas can be placed into a sample bag and then removed through the umbilical incision after being cut into small pieces, similar to peeling an apple, to avoid the risk of myoma dissemination under laparoscopy (Fig. 4). In addition, the abdominal lifting system used two lifting clamps to grasp the abdominal wall tissue, avoiding the vascular injury caused by Kirschner wires passing through the subcutaneous tissue of the abdomen.

Although the technique has some advantages, it also has some shortcomings, including a longer operative duration and the use of specialized instruments. Intracorporeal suturing is a significant component of laparoscopic myomectomy and presents an even greater challenge in GLESS surgery; thus, there is a learning curve involved in mastering this technology. Whilst it is difficult to lift the anterior abdominal wall mechanically in obese patients, the abdominal wall can easily be lifted in normal- or low-weight patients. In our study, the patients’ BMI ranged from 19.62 to 25.96. The present study is a pilot study with a small sample and no controls. Prospective controlled studies are needed to determine the safety, advantages and disadvantages of this technique.

The current study demonstrates that our new technique overcomes many disadvantages of the conventional laparoendoscopic single-site myomectomy technique; it is safe, feasible and inexpensive. However, it represents only the retrospective results of a limited number of cases, and further studies with adequate samples are needed to illustrate its long-term safety.