Original Article
Single-port Access Subtotal Laparoscopic Hysterectomy: A Prospective Case-Control Study Stefano Angioni, MD, PhD*, Alessandro Pontis, MD, Adolfo Pisanu, MD, Liliana Mereu, MD, and Horace Roman, MD, PhD From the Department of Surgical Sciences (Drs. Angioni, Pontis, and Pisanu), University of Cagliari, Cagliari, Italy, Department of Obstetrics and Gynaecology (Dr. Mereu), Hospital Santa Maria Chiara, Trento, Italy, and Department of Obstetrics and Gynaecology (Dr. Roman), University of Rouen, Rouen, France.
ABSTRACT Study Objective: The objective was to evaluate the perioperative outcomes, safety, and patient acceptance of single-port access laparoscopic subtotal hysterectomy (SPAL-SH) in comparison with conventional multiport access laparoscopic subtotal hysterectomy (MPAL-SH). Design: Case-control study. Canadian Task Force Classification II-2. Setting: The study was conducted at university hospitals in Cagliari, Italy, and Rouen, France. Patients: Sixty-one women with metrorrhagia, abnormal uterine bleeding with uterine myomas, or symptomatic adenomyosis were included in the study. Interventions: Thirty-one patients underwent SPAL-SH, and 30 patients underwent conventional MPAL-SH. Measurements and Main Results: We analyzed the data to compare the outcomes of SPAL-SH versus MPAL-SH. Patients in the SPAL-SH group had longer operative times than those in the MPAL-SH group (p , .001) but shorter hospital stays (p , .001). Postoperative pain immediately after surgery, after 6 hours, and after 24 hours were lower in the SPAL-SH group (p , .001). The SPAL-SH group reported significantly higher cosmetic satisfaction at 1, 4, and 24 weeks after surgery (p , .01). Conclusion: We conclude that SPAL-SH is a feasible and safe alternative to standard MPAL-SH in selected patients. Ongoing refinement of the surgical technique and instrumentation is likely to expand its role in gynecologic surgery in the future. In addition, SPAL-SH has a definite benefit in relation to body image and cosmesis. Journal of Minimally Invasive Gynecology (2015) 22, 807–812 Ó 2015 AAGL. All rights reserved. Keywords:
DISCUSS
Single-port access laparoscopy; Laparoscopic subtotal hysterectomy; SPAL
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Minimally invasive surgery has substantially decreased both the length of hospital stays and the need for postoperative analgesia and has improved recovery times [1,2]. Although laparoscopy has decreased morbidity directly related to this surgical approach, each working port still The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Stefano Angioni, MD, PhD, Section of Obstetrics & Gynaecology, Department of Surgical Sciences, University of Cagliari, Azienda Ospedaliero Universitaria, Blocco Q, 09124 Monserrato, Italy. E-mail:
[email protected] Submitted January 13, 2015. Accepted for publication March 13, 2015. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2015 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2015.03.011
carries a possible risk of bleeding, infection, concordant organ damage, hernia formation, and decreased cosmetic outcome [3]. Advances in surgical instrumentation and design have led to the use of single-incision laparoscopic surgery, laparoendoscopic single-site surgery, and singleport access laparoscopy (SPAL) in the field of gynecology [4–7]. SPAL has also been proposed for total and subtotal hysterectomies in benign and malignant conditions [8–10]. Laparoscopic subtotal hysterectomy (SH) is a minimally invasive surgical procedure developed during the 1990s for the treatment of abnormal uterine bleeding. Three to 5 laparoscopic ports are required to complete a conventional laparoscopic SH. Single port access laparoscopy subtotal
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hysterectomy (SPAL-SH) was first introduced in 1992, when Pelosi and Pelosi [11] performed a SH with a single umbilical puncture, but this procedure did not gain wide acceptance by gynecologic surgeons right away because the available instruments were not adequate for some of the technical challenges. Since the early 2010s, however, SPAL-SH has been performed through an intraumbilical incision using conventional laparoscopic instruments for the treatment of benign gynecologic pathologies. The aim of this study was to compare the surgical and cosmetic outcomes and complications of SPAL-SH and conventional multiport access laparoscopic (MPAL) SH.
The body image questionnaire (BIQ) was used to assess body image and cosmesis at 1, 4, and 24 weeks after surgery. The questionnaire consists of 8 questions that are combined to form 2 scales: a body image scale and a cosmetic scale. Five questions regarding body image assess patients’ perception of and satisfaction with their own body and evaluate patients’ attitude toward their bodily appearance. The body image scores range from 5 (lowest body image score) to 20 (highest body image score). Three questions regarding the cosmetic result after the operation assess the degree of satisfaction with respect to the physical appearance of the incisional scar(s). First, patients were asked to give a rating for the appearance of their scar(s) on a scale from 1 (lowest score) to 10 (highest score). Patients were then asked to rate the extent to which they were satisfied with their scar on a scale ranging from 1 (very unsatisfied) to 7 (very satisfied). Finally, patients were asked to describe their scar on a scale ranging from 1 (very repulsive) to 7 (very beautiful). The combined scores of these 3 questions resulted in the cosmetic scale ranging from 3 (lowest satisfaction) to 24 (highest satisfaction). Subjects were asked to complete the BIQ at each visit before seeing their clinician. Cronbach’s alpha for body image and cosmetic satisfaction were.81 and .70, respectively. The maximum scores for the body image scale and the cosmetic scale were 20 and 24, respectively [12].
Methods This was a prospective case-control study of patients undergoing a SH for the treatment of symptomatic leiomyoma, adenomyosis, or metrorrhagia resistant to medical therapy. Hysterectomies were performed between June 2011 and March 2014 in the Divisions of Obstetrics and Gynaecology of Cagliari University Hospital (Cagliari, Italy) and of Rouen University Hospital (Rouen, France). Eligibility criteria were no evidence of gynecologic malignancy, normal cervical cytology, appropriate medical status for laparoscopic surgery (American Society of Anesthesiologists Physical Status classification system 1 or 2), and a uterus size % 16 weeks. Major exclusion criteria were anesthetic contraindications for laparoscopic surgery, a uterine size over 16 gestational weeks at pelvic examination, a diagnosis or suspicion of gynecologic cancer and/or deep infiltrating endometriosis, a history of pelvic radiation therapy, more than 3 prior laparotomies, or an inability to understand and provide written informed consent. After an accurate evaluation of their medical histories and routine blood tests, all patients underwent a preoperative pelvic examination, cervix cytology, transvaginal sonography evaluation, and an office diagnostic hysteroscopy with endometrial biopsy. The study was approved by the local ethics committees, and before entering the study, all eligible patients received oral and written information about the trial from the clinicians. Sixty-one of 80 patients met the inclusion criteria and entered the study. Patients were informed about the 2 types of surgeries and were alternatively assigned to undergo a SPAL-SH or MPAL-SH performed by 2 surgeons (S.A. and H.R.), both of whom had optimal laparoscopic experience and at least a year of training in the SPAL procedure. Prospective data about these patients were collected until March 2014. These data included patient characteristics (age, body mass index in kg/m2, indications for SH, type and duration of surgery, estimated blood loss, postoperative pain score, perioperative complications, length of hospital stay, body image, and cosmesis. At the end of each procedure, intraoperative data were also registered regarding operative time, estimated blood loss, intra- and perioperative complications, and conversion to standard MPA laparoscopy or laparotomy. Operative time was defined as the time from umbilical skin incision to completion of skin closure. Postoperative abdominal pain intensity was rated at rest using the visual analog scale. The scale was presented as a 10-cm line, with a verbal descriptor anchored with ‘‘no pain’’ and ‘‘worst imaginable pain.’’ Patients were asked to rate their pain intensity immediately after surgery and again at 6, 24, and 48 hours after surgery.
Surgical Procedures All patients were admitted to the hospital 1 day before surgery. Standard bowel preparation was indicated, and prophylactic antibiotic therapy (2 g cefazolin) was administered 30 minutes preoperatively and again postoperatively. Both SPAL-SH and MPAL-SH were performed under general endotracheal anesthesia with the patient in the dorsal lithotomy position. A Foley catheter was inserted into the bladder, and then a uterine manipulator was applied. To prevent or decrease the occurrence of postsurgical adhesions, 500 cc of warm lactated Ringer’s solution was instilled in the pelvis at the end of the procedures [13]. The extracted specimens were sent for histologic examination. A Foley vesical catheter was maintained until the morning after surgery; hemoglobin concentration was determined in all patients 6 hours after surgery. All patients were permitted sips of water starting 6 hours after surgery, and a clear liquid diet was offered as the first meal after passing flatus. If pain control was needed, 30 mg ketorolac was administered intravenously. The patients were encouraged to ambulate starting the first postoperative day. SPAL-SH (Group A) A 2-cm intraumbilical vertical skin incision and a 2- to 2.5-cm rectus fasciotomy were performed to enter the peritoneal cavity. The single-port trocar (S-Portal X-Cone; Karl Storz, Tuttlingen, Germany) was inserted into the abdominal cavity, and the abdomen was insufflated to 12 mm Hg. The single-port trocar device allows the simultaneous passage of various laparoscopic instruments through 1 small opening and has the added advantage of being reusable. After placement of the X-Cone, the surgeon stood behind the patient’s left shoulder at the level of the patient’s right shoulder, and the monitor was positioned between the patient’s legs. A rigid, 30-degree, 5-mm diameter, 50-cm length Hopkins high-definition 3-chip camera (Karl Storz) was routinely used. For the SH, a rigid single curved forceps or scissors (Karl Storz) monopolar loop (LiNA Gold LoopÔ; LiNA Medical, Glostrup, Denmark) and a standard straight bipolar dissector or multifunction device (En Seal or Ultracision Harmonic Scalpel; Ethicon Endosurgery,
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Cincinnati, OH) were used simultaneously. Removal of the uterus was performed in 20 cases by morcellation (Gynecare Morcellex; Ethicon) through the umbilical trocar under vision with the optic introduced in the cervical canal and in 11 cases by morcellation through the cervical canal under an optical view from the umbilical trocar. Morcellation through the cervical canal requires cervix dilatation via the vaginal approach with a no. 15 Hegar dilator. The morcellator was then inserted through the dilated cervical os and the uterus removed using the transcervical morcellator with the assistance of the endoscopic grasper. After morcellation, bleeding at the cervical stump was controlled using a bipolar coagulator. MPAL-SH (Group B) Pneumoperitoneum was induced by CO2 insufflation using a Veress needle passed through a 1-cm umbilical incision until the intra-abdominal pressure reached 12 mm Hg. After pneumoperitoneum, a 10-mm umbilical trocar for a 0-degree telescope was made. Three additional trocars (5–10 mm) were then inserted in the lower abdominal quadrants under direct laparoscopic vision. With traction of the distal portion of the fallopian tube, the tube pedicles, the utero-ovarian ligament or the infundibulopelvic ligament, and the round ligaments were coagulated with bipolar forceps and cut with scissors; the vesicouterine peritoneum was dissected from the anterior portion of the uterus. Identification, coagulation, and cutting of the uterine arteries bilaterally at the level of the ascending branch was performed with bipolar forceps and scissors or a multifunction device (En Seal or Ultracision Harmonic Scalpel; Ethicon); section at the level of isthmus was performed using a monopolar hook or monopolar loop (Karl Storz). The uterus was removed using a transabdominal morcellator (Gynecare Morcellex; Ethicon) through the sovrapubic trocar.
Statistics Statistical analyses were performed using SPSS (version 13.0; SPSS Inc., Chicago, IL). Continuous variables across the 2 groups were compared using a 1-way analysis of variance. Fischer’s test or c2 analyses were used in the evaluation of categorical variables. A difference was considered significant when the p , .05.
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Table 1 Patient characteristics
Characteristic Age, yr, mean 6 SD BMI, kg/m2 Main symptom for surgery Metrorrhagia Dysmenorrhea/chronic pelvic pain Main pathology Leiomyoma Adenomyosis
SPAL-SH (n 5 31)
MPAL-SH (n 5 30)
p
47.9 6 6.52 23.89 6 2.2
49 6 7.23 22.2 6 1.7
NS NS
19 (61.29%) 12 (38.71%)
21 (70%) 9 (30%)
NS NS
19 (61.29%) 12 (38.71%)
21 (70%) 9 (30%)
NS NS
SD 5 standard deviation; NS 5 not significant; BMI 5 body mass index.
Port placement was successful in all patients, and there were no vascular or visceral injuries, loss of pneumoperitoneum, or intraoperative port site bleeding. None of the patients was converted to a laparotomy, and none who received SPAL-SH needed an additional port. There was 1 postoperative complication in group A (bleeding of the cervical canal as a result of dilatation) and 1 in group B (infection of the suprapubic skin incision) (Table 2). The mean operative time was significantly different between the SPAL-SH and conventional MPAL-SH groups (89.58 minutes vs 67.26 minutes; p , .01). The estimated amount of operative blood was similar in the 2 groups, and no patient required a blood transfusion. The SPAL-SH group had shorter postoperative hospital stays (2.06 days vs 2.65 days; F 5 5226, df 5 1, p , .001) compared with the conventional MPAL-SH group (Table 2). Pain measured immediately after surgery in the recovery unit was lower in the SPAL-SH group than in the MPAL-SH group. Moreover, postoperative pain scores after 6, 24, and 48 hours
Results Forty of 61 patients who entered the study presented dysfunctional metrorrhagia by uterine myomas that were unresponsive to medical therapy, whereas 21 patients suffered from chronic pelvic pain and a diagnosis of adenomyosis using ultrasound. Deep endometriosis was excluded in the presurgical evaluation. Histology of the specimens confirmed the presurgical diagnoses for all cases. Patient characteristics are shown in Table 1. There were no differences in the demographic and preoperative data between the 2 groups. In our study, 61 surgical procedures were performed: 31 SPAL-SH (group A) and 30 MPAL-SH (group B) with or without a bilateral salpingo-oophorectomy. In group A, a bilateral salpingo-oophorectomy was performed in 5 cases (perimenopausal patients) and a bilateral salpingectomy without oophorectomy was performed in 26 cases (all patients , 50 years old). In group B, a bilateral salpinooophorectomy was performed in 10 cases and a bilateral salpingectomy in 20 cases.
Table 2 Comparison of surgical outcomes between SPAL-SH and MPAL-SH
Outcomes Operative time, min EBL, mL Hospital stay Uterine weight (corpus), g Perioperative complication rate, total Postoperative complication Transfusion
SPAL-SH (n 5 31)
MPAL-SH (n 5 30)
p
89.58 6 11.71 63.84 6 12.49 2.06 6 .25 259.16 6 44.67
67.26 6 10.90 56.26 6 11.39 2.65 6 .60 296.77 6 59.18
,.001 .15 ,.001 .006
0
0
NS
1
1
NS
0
0
NS
EBL 5 estimated blood loss; NS 5 not significant.
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Table 3 Comparison of postoperative pain scores (visual analog scale) between SPAL-SH and conventional MPAL-SH Postoperative pain score (mean 6 SD) Postoperative time
SPAL-SH (n 5 31)
MPAL-SH (n 5 30)
p
Immediate postoperative After 6 h After 24 h After 48 h
4.01 6 .55 3.77 6 .56 2.35 6 .48 1.42 6 .56
5.22 6 .83 4.24 6 1 4.03 6 .94 2.48 6 .62
,.001 ,.001 ,.001 ,.001
SD 5 standard deviation.
were lower in the SPAL-SH group compared with the MPAL-SH group (Table 3). The results of the BIQ questionnaire at 1, 4, and 24 weeks in the 2 groups are shown in Table 4. Patients operated on by single access showed a constant and higher perception of and satisfaction with their own body as evidenced by the body image score, which was significantly higher than in the MPAL-SH group (19.61 6 .49 vs 14.42 6 .88, respectively, at 24 weeks). Moreover, patients operated on by single access were significantly more satisfied with their scar as shown by the cosmetic score, which was also constantly and significantly higher in the SPAL-SH group compared with the MPAL-SH group (23.45 6 1.06 vs 15.71 6 .78, respectively, at 24 weeks) (Table 4). Discussion Recent important technical advances in the field of surgery have led to the development of new laparoscopic approaches, such as robotics and single-access laparoscopy [14]. The general trend is to make surgery as minimally invasive as possible. Most of the benefits of minimally invasive surgery are due to the reduced dimensions of incisions. SPAL requires only 1 incision point, typically in the umbilical region. Therefore, single-incision laparoscopy may be Table 4 BIQ scores at 1, 4 and 24, weeks after surgery in SPAL-SH and MPAL-SH groups
BIS 1 week BIS 4 weeks BIS 24 weeks CS 1 week CS 4 weeks CS 24 weeks
SPAL-SH (n 5 31)
MPAL-SH (n 5 30)
p
17.94 6 .63 18.68 6 .54 19.61 6 .49 21.68 6 .90 22.87 6 .95 23.45 6 1.06
13.81 6 2.05 14.68 6 1.14 14.42 6 .88 15.32 6 .94 15.81 6 1.04 15.71 6 .78
,.001 ,.001 ,.001 ,.001 ,.001 ,.001
BIS 5 body image score; CS 5 cosmetic score.
considered a less invasive approach with fewer port site complications compared with conventional laparoscopy [15]. This reduction in the number of incisions can lead to a subsequent reduction in the level of postoperative pain. In agreement with other studies, we found a reduction in abdominal pain when single-access surgery was compared with conventional multiport surgery. Chen et al [16] compared the immediate results of patients undergoing either a 2-channel single-port laparoscopic-assisted vaginal hysterectomy or a conventional multiport laparoscopicassisted vaginal hysterectomy. In this study, we observed no statistically significant differences in estimated blood loss, intraoperative and immediate postoperative complications, or length of hospital stay between the 2 groups. In contrast, pain was significantly less in the single-port group compared with the conventional group, as evidenced by lower mean scores on the visual analog scale and a lower mean requirement for postoperative analgesics. In a retrospective study, Yim et al [17] compared surgical outcomes and postoperative pain between the single-port total laparoscopic hysterectomy and the conventional 4-port total laparoscopic hysterectomy. The single-port group had less intraoperative blood loss, shorter hospital stays, and faster recovery compared with the conventional group. The differences in the 2 groups were statistically significant. However, there was no difference in perioperative complications. Immediate postoperative pain scores and those at 6 and 24 hours after surgery were lower by a statistically significantly amount in the single-port group [17]. Conversely, a randomized prospective study of single-port and 4-port approaches for hysterectomies did not demonstrate any reduction of postoperative pain with single-port access [18]. In our study we showed longer operative time in the SPAL-SH group in comparison with the conventional multiport approach, even if the uterine weight was significantly lower. In our opinion, SPAL has intrinsic difficulties related to the parallelism of instruments that could determine such results. Nevertheless, we did not experience any need for additional trocars. It is also believed that as the number of incisions decreases with single-incision surgery, local trocar site complications may also be reduced. Although in traditional laparoscopy the secondary trocars are inserted under direct vision, complications such as epigastric vessel injury are still frequent. The umbilicus itself lacks significant blood vessels and nerves in this location, hence reducing local incision site complications. The incidence of trocar site hernia may be low because of the decreased number of incisions, but an umbilical hernia may be slightly more common. We noted only 1 trocar site complication in the MPAL group. However, 1 limiting factor in our study could be the low number of recruited patients and the short follow-up time. In fact, a larger number of patients and a longer follow-up could provide more evidence regarding the possible occurrence of late complications such as laparocele, particularly in the SPAL group, even though this complication has been shown
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previously to be rare [19]. We had 1 early complication in the SPAL group after transcervical morcellation; however, we believe that even if other surgeons choose this approach to extract the uterus in SPAL-SH [10,20], the transumbilical morcellation under vision with endocervical optics is a more elegant and safe method for uterus extraction. Moreover, hospital stays were significantly shorter for patients who underwent SPAL. Although the cosmetic benefit is believed to be an advantage of single-incision laparoscopic surgery, this is still not proven. Most studies have not shown any superiority of the single-port access over conventional laparoscopic procedures. Some investigators believe further studies are required to establish the superiority of this approach over traditional multiport laparoscopy. Cosmesis is definitely a benefit if the reconstruction of the umbilicus is carefully performed. Care must be taken to preserve the integrity of the umbilicus stalk. If the umbilicus stalk has been cut, it should be reattached to its fascial attachment. For the best cosmetic results, the scar should not extend outside the perimeter of the umbilical crater and should not disfigure the natural configuration of the umbilicus. In a randomized controlled trial, Song et al [21] compared cosmetic satisfaction with laparoendoscopic single-site surgery compared with multiport surgery; the 2 surgery groups did not differ in clinical demographic data. Compared with the multiport group, the laparoendoscopic single-site surgery group reported significantly higher cosmetic satisfaction at 1, 4, and 24 weeks after surgery. In our study, we used validated questionnaires to determine that perceived body image and cosmetic satisfaction were higher by a statistically significant amount in the SPAL group in comparison with the MPAL group and that these results were maintained at the 24-week follow-up. SH is a minimally invasive surgical option that we can propose to patients with symptomatic adenomyosis or dysfunctional uterine bleeding not responsive to medical treatment. Once surgery is decided on, the presurgical evaluation should exclude any suspicion of malignant disease to minimize the possible risk related to morcellation as recently recommended by many scientific societies [22]. In these patients it is mandatory to perform an office hysteroscopy and an endometrial biopsy to rule out endometrial carcinoma [23]. Moreover, we believe that patients with deep endometriosis are not suitable for SPAL surgery because pelvic adhesions increase surgical difficulties and time. Consequently, we excluded these patients in our study in the presurgical evaluation as previously described [24]. Conclusion Our case-control study has shown that a SH can be performed successfully through a single umbilical incision and can provide some benefits to the patient. We believe the SPAL-SH can be performed in patients with symptomatic benign uterine pathology. In the hands of a surgeon
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accomplished in the skills and techniques of singleincision surgery, it can reduce patient morbidity and may become a preferred technique. Still, additional randomized control studies are needed to prove this. If both multiport and single-port approaches are feasible for a particular patient, in the hands of a skilled surgeon, patient preference may become a deciding factor in the future. Nevertheless, the recent debate about uterus morcellation and the risk of dissemination and subsequent implant of a preoperatively unexpected malignant condition should limit the indications of SH to low-risk cases in accordance with national guidelines, and the development of devices dedicated to intracavitary morcellation in a closed system should be encouraged to minimize the risk of tissue dispersion [22]. References 1. Angioni S, Pontis A, Dessole M, et al. Pain control and quality of life after laparoscopic en-block resection of deep infiltrating endometriosis (DIE) vs. incomplete surgical treatment with or without GnRHa administration after surgery. Arch Gynecol Obstet. 2015;291:363–370. 2. Tinelli R, Litta P, Meir Y, et al. Advantages of laparoscopy versus laparotomy in extremely obese women (BMI.35) with early stage endometrial cancer: a multicenter study. Anticancer Res. 2014;34:2497–2502. 3. Mereu L, Angioni S, Melis GB, Mencaglia L. Single access laparoscopy for adnexal pathologies using a novel reusable port and curved instruments. Int J Gynaecol Obstet. 2010;109:78–80. 4. Angioni S, Mais V, Pontis A, Peiretti M, Nappi L. First case of prophylactic salpingectomy with single port access laparoscopy and a new diode laser in a woman with BRCA mutation. Gynecol Oncol Case Rep. 2014;9:21–23. 5. Mereu L, Angioni S, Pontis A, Carri G, Mencaglia L. Single port access laparoscopic myomectomy with X-Cone. Gynecol Surg. 2011;8:337–340. 6. Angioni S, Pontis A, Sorrentino F, Nappi L. Bilateral salpingooophorectomy and adhesiolysis with single port access laparoscopy and use of diode laser in a BRCA carrier. Eur J Gynaecol Oncol. (in press). 7. Angioni S, Mereu L, Maricosu G, Mencaglia L, Melis GB. Single port access laparoscopy (SPAL) for endometrioma excision. J Endometriosis. 2010;2:95–96. 8. Angioni S, Pontis A, Cela V, Nappi L, Mereu L, Litta P. Single-port access laparoscopic hysterectomy: a literature review. J Gynecol Surg. 2014;30:329–337. 9. Angioni S, Maricosu G, Mereu L, Mencaglia L, Melis GB. Single-port access laparoscopic assisted vaginal hysterectomy in a case of uterine ventrofixation using a new reusable device. J Obstet Gynaecol Res. 2011;37:993–996. 10. Wenger JM, Dubuisson JB, Dallenbach P. Laparoendoscopic single-site supracervical hysterectomy with endocervical resection. J Minim Invas Gynecol. 2012;19:217–219. 11. Pelosi MA, Pelosi MA 3rd. Laparoscopic supracervical hysterectomy using a single-umbilical puncture (mini-laparoscopy). J Reprod Med. 1992;37:777–784. 12. Dunker MS, Stiggelbout AM, van Hogezand RA, Ringers J, Griffioen G, Bemelman WA. Cosmesis and body image after laparoscopic-assisted and open colic ileocolic resection for Chrohn disease. Surg Endosc. 1998;12:1334–1340. 13. Rizzo A, Spedicato M, Mutinati M, et al. Peritoneal adhesions in human and veterinary medicine: from pathogenesis to therapy. A review. Immunopharmacol Immunotoxicol. 2010;32:481–494. 14. Pluchino N, Litta P, Freschi L, et al. Comparison of the initial surgical experience with robotic and laparoscopic myomectomy. Int J Med Robot. 2014;10:208–212. 15. Mencaglia L, Mereu L, Carri G, et al. Single port entry-are there any advantages? Best Pract Res Clin Obstet Gynaecol. 2013;27:441–455.
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16. Chen YJ, Wang PH, Ocampo EJ, Twu NF, Yen MS, Chao KC. Single-port compared with conventional laparoscopic-assisted vaginal hysterectomy: a randomized controlled trial. Obstet Gynecol. 2011;117:906–912. 17. Yim GW, Jung YW, Paek J, et al. Transumbilical single port versus conventional total laparoscopic hysterectomy: surgical outcomes. Am J Obstet Gynecol. 2010;203:26.e1–26.e6. 18. Jung YW, Lee M, Yam GW, et al. A randomized prospective study of single-port and four-port approaches for hysterectomy in terms of postoperative pain. Surg Endosc. 2011;25:2462–2463. 19. Kim SM, Park EK, Jeung IC, Kim CJ, Lee YS. Abdominal, multi-port and single-port total laparoscopic hysterectomy: eleven-year trends comparison of surgical outcomes complications of 936 cases. Arch Gynecol Obstet. 2014. 20. Yoon G, Kim TJ, Lee YY, et al. Single-port access subtotal hysterectomy with transcervical morcellation: a pilot study. J Minim Invas Gynecol. 2010;17:78–81.
21. Song T, Cho J, Kim TJ, et al. Cosmetic outcomes of laparoendoscopic single-site hysterectomy compared with multi-port surgery: randomized controlled trial. J Minim Invas Gynecol. 2013;20:460–467. 22. Angioni S, Malzoni M, Schettini S. Recommendations for laparoscopic morcellation of uterus and leiomyomas. Position paper of the SEGi (Societa Italiana di Endoscopia Ginecologica). Giorn It Gin Ost. (in press). 23. Angioni S, Loddo A, Milano F, Piras B, Minerba L, Melis GB. Detection of benign intracavitary lesions in postmenopausal women with abnormal uterine bleeding: a prospective comparative study on outpatient hysteroscopy and blind biopsy. J Minim Invas Gynecol. 2008;15: 87–91. 24. Angioni S, Pontis A, Cela V, Sedda F, Genazzani AD, Nappi L. Surgical technique of endometrioma excision impacts on the ovarian reserve. Single-port access laparoscopy versus multiport access laparoscopy: a case control study. Gynecol Endocrinol. (in press).
