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The clinical advantages of laparoscopy over laparotomy have been well established over the last several years. As the acceptance and use of laparoscopic approaches have increased among gynecologic surgeons, attention to cosmesis has also evolved.
Laparoscopy has been appealing for its cosmetic benefits as well as reductions in complications and recovery times. Women not only want to resume their normal activities sooner; they also want to take advantage of the smaller incisions that laparoscopy entails, as these incisions do not alter abdominal wall appearance as significantly as do laparotomy incisions.
Still, depending on an individual’s body mass index and wound healing, scars can be disturbing for patients. Some women who have had more than one laparoscopic surgery requiring different port placements have jokingly spoken about "connecting the dots," but such comments reflect concern about aesthetics and should be taken seriously. Although we have improved surgical outcomes with laparoscopy and reduced the size of the surgical scar, we can still create disfigured abdomens.
Last year, the AAGL Fellowship in Minimally Invasive Gynecologic Surgery at Newton-Wellesley (Mass.) Hospital published an article about a survey of women and their preferred abdominal incision choices, based solely on cosmesis (J. Minim. Invasive Gynecol. 2011;18:640-3). The survey participants were shown three photographs of incisions that were commonly performed at their institution and among several Boston-area gynecologic surgeons, and were asked to rank the incisions in order of preference.
The photograph depicting a single incision or single-site laparoscopy showed a vertical 25-mm incision. The robotic laparoscopy photo showed five incisions: umbilical and right midabdomen (paraumbilical) incisions of 12-mm length, and 8-mm incisions in the right lower quadrant, left lower quadrant, and left midabdomen. The incision configuration in the photo of a conventional four-port laparoscopy consisted of a 10-mm incision in the right lower quadrant and 5-mm incisions in the umbilicus, left lower quadrant, and suprapubic area.
The conventional laparoscopy incisions were most preferred by approximately 56% of the 241 women who completed the survey, whereas preference for a single incision was approximately 41% and for robotic surgery was 2.5%.
Granted, there are variable configurations and incision sizes for each of the laparoscopic techniques, and further strides are being made to make the approaches more cosmetically acceptable. Experienced gynecologic surgeons are developing techniques to minimize the number of ports used robotically, for instance, and smaller incision sizes for robotic laparoscopy are anticipated.
In any case, the overarching lesson from this survey is that aesthetics is of value to many women and should be an important consideration for us as treating physicians.
Miniaturization
The use of mini- or microlaparoscopic instrumentation enables us to address aesthetic concerns and take the issue of cosmesis to the next level, as well as to further minimizing trauma. Although conventional laparoscopy involves instruments of 5-mm diameter or larger, the term "minilaparoscopy" usually refers to the use of instruments greater than 2 mm up to less than 5 mm in diameter, and "microlaparoscopy" involves instrumentation of 2 mm or less in diameter.
In gynecology, minilaparoscopy has been utilized diagnostically since the mid-1990s to perform conscious pain mapping with local anesthesia. With a 2.5 mm–diameter scope and 3 mm–diameter trocars, surgeons have used a blunt probe to map trigger sites with the patient’s assistance and response, and to aid in identifying pelvic disease suspected of causing pain (Int. J. Gynaecol. Obstet. 2008;100:94-8).
The diagnostic accuracy of the mini- or microlaparoscope has been reported in various scenarios (including cases of endometriosis and adhesive disease) to be comparable to that of the 10-mm scope that is used in conventional laparoscopy.
In one small study, investigators compared the diagnostic accuracy of 2-mm and 10-mm laparoscopes, with two physicians independently reporting findings to a third person (Fertil. Steril. 1997;67:952-4). Although they had a small sample size, the researchers observed no significant differences between the two laparoscopes or the two physicians. (Scores for endometriosis and adnexal adhesions, for instance, did not differ in any significant way.) This suggested that the diagnostic accuracy achieved with the microlaparoscope was comparable to that of the standard 10-mm laparoscope.
Another study in which 87 consecutive women underwent microlaparoscopic evaluation for chronic pelvic pain similarly found that microlaparoscopy provides comparable efficacy for diagnosing endometriosis and evaluating for the presence of occlusive salpingitis isthmica nodosa. Evaluation through a 2-mm port affords "an excellent minimally invasive view of the pelvis," the investigator wrote (JSLS 2005;9:431-3).
Most of the literature for minilaparoscopy, however, has evolved from the nongynecologic specialties, particularly general surgery. It has been well documented that minilaparoscopy is safe for splenic and liver biopsies, as well as helpful in reducing port sizes and hernias when utilized in cholecystectomies and colorectal resections.
Most recently, the authors of a literature review spanning the last 30 years concluded that minilaparoscopy has been shown in almost all urologic indications to be feasible and safe, with better cosmetic results and reduced postoperative pain (Arch. Esp. Urol. 2012;65:366-83).
Collectively, these studies provide us with a solid body of evidence on the safety, feasibility, and benefits of minilaparoscopy. The findings noted in the surgical literature for minilaparoscopy include operative times, morbidity, and hospital lengths of stay that are comparable to those of conventional laparoscopy; improved cosmesis; a decrease in postoperative pain; and reductions in port-site complications such as bleeding, infection, and herniation.
Surpassing SIL
Single-incision laparoscopy (also known as "scarless" surgery, with the umbilicus viewed as a natural scar) was developed to improve cosmesis. An incision approximately 25 mm in size at the umbilicus allows a scope and two or three instruments to pass into the abdominal cavity.
A main challenge – and a limitation for many surgeons – is the lack of triangulation because of the parallel entry. Instruments are crossed, which is counterintuitive to conventional laparoscopic training, and hands and instruments can clash, which limits the use of instrumentation.
An array of curved and EndoWrist instruments (with flexible joints at the tips) was developed to help ease the technical difficulties of single-port surgery. Many advanced endoscopic surgeons have performed simple to complex single-incision procedures with low complication rates and with operative times and rates of blood loss that are comparable with those of conventional laparoscopy. One advantage to single-incision surgery is that the incision size allows the removal of larger tissue that has been resected from the abdomen.
A recent study in the Netherlands suggests that single-incision surgery may not be all that more difficult to learn (Surg. Endosc. 2012;26:1231-7). The simulation study looked at the performance/learning curves of 20 medical interns (none with laparoscopic experience) who were randomly assigned to perform single-incision or conventional laparoscopy. Each participant practiced each task 11 times. There were no significant differences between the two groups in terms of error or time in performing the tasks, and participants improved significantly in both laparoscopy settings.
There are still many concerns, however, that single-incision laparoscopy is indeed more technically challenging, and that a sizable learning curve for the single-incision approach –in addition to the learning curve of conventional laparoscopy – does exist. Without surgical volume and patience, this technique may be a struggle for many to adapt and teach.
Moreover, as shown in the study at Newton-Wellesley Hospital, the scars remain a concern for many women. The umbilicus is the easiest place to try to "hide" an incision and scar when the incision is made at its base, but a 2-1/2 cm incision can be difficult to hide in a shallow umbilicus; for some women, the larger single scar becomes a focal point of their abdomen and, thus, disfiguring.
Our Experience
With minilaparoscopy, we can maintain triangulation and employ the fundamental principles of conventional laparoscopy with greater technical ease. The approach also has the potential to reduce the risk of incision-site hernias and the incidence of wound complications.
The following drawbacks to minilaparoscopy have been cited:
• A smaller view of the operative field.
• Less tensile strength of the instruments.
• Electrosurgery instruments that are limited to small vessels/pathology.
• Difficulty with large-tissue extraction.
There are solutions to each of these challenges, many of which involve hybrid approaches that incorporate single-incision or conventional laparoscopic ports at the umbilicus to facilitate electrosurgery, tissue extraction, and visualization while maintaining cosmesis. The solutions include the following:
• Better optics. Significant strides have been made in the area of optics, and newer minilaparoscopes (Figure 1) have better resolution and optical clarity than does the previous generation of miniature scopes. We have found that we can zoom the image and reduce light to improve visualization and maximize the operative field.
• Improved instrument strength. As with miniaturized laparoscopes, a wide array of durable instrumentation (Figures 2 and 3) is now available. We employ instruments that are 2.3-3.3 mm in diameter and up to 36 cm in length, ports that are 3.5 mm in diameter and 10-15 cm in length, and scopes that are 2.9-3.3 mm in diameter and up to 25 cm in length.
For skin incisions, a 14-gauge needle is used instead of a scalpel to avoid an incision that is too large and would allow easy slippage of the port. On the 2.3-mm disposable instruments, the tip itself is a 13-gauge needle that is utilized to incise the skin and enter the abdominal cavity. (See Figure 4.) Wounds are not sutured closed, but are merely reapproximated with Steri-Strips at the end of the procedure.
• More versatile electrosurgery instruments. We utilize reusable and disposable bipolar coagulating forceps, as well as reusable instruments with monopolar electrosurgical capability, including dissecting and grasping forceps, scissors, hook, and spatula. For example, when we excise endometriosis, we will utilize a sharp grasping instrument to elevate the lesion away from vital structures, as well as monopolar scissors to excise the disease. Needle holders and knot pushers are sturdy for suturing, and a suction tip is also available in miniaturized form.
In procedures in which the vessel-sealing capacity of a 3-mm energy source is not sufficient, a 5-mm port can be placed at the umbilicus so that a standard 5-mm energy source can be utilized to improve or maintain hemostasis.
• Extraction of large tissues. For tissue extraction requiring an incision larger than 5 mm, a 10- to 12-mm trocar can be placed at the umbilicus for the possible use of an endoscopic specimen bag. We dilate the umbilicus with Hegar dilators to a size 16 to ease the extraction of tissue, if necessary, or for the placement of a laparoscopic morcellator.
Recently, however, we have been able to perform minilaparoscopic hysterectomies with the use of three 3-mm ports, a minilaparoscope, and other miniaturized instrumentation. Specifically, we utilize the 3-mm PKS MoLly forceps by Olympus Gyrus (Figure 5) to coagulate and monopolar scissors to transect the pedicles. A colpotomy is completed with the scissors, and the specimen is delivered through the colpotomy incision. The colpotomy incision is reapproximated with 0-PDS suture on CT-1–sized needles. The suture is backloaded through the miniport and is introduced into the abdomen without difficulty. The incision is sutured; the needle is parked in the upper abdominal wall, and is then cut free. The suture is then pulled through the port for extracorporeal knot tying. The needle is retrieved and pulled through the incision with the removal of the port, and is now ready for loading another suture.
A minilaparoscopic supracervical hysterectomy can be performed in a similar fashion. For tissue extraction, we perform transcervical morcellation. We have found that the morcellators with extra-long shafts (such as the Storz 12-mm extra-long Rotocut or Gynecare Morcellex) work best for transcervical morcellation. Once uterine amputation is completed, the cervical stump is dilated with cervical dilators to allow for the morcellator tip to advance through the cervix and into the pelvic cavity transvaginally. Under direct visualization and with the assistance of a laparoscopic grasper, the specimen is morcellated. Similarly, an endoscopic specimen bag can also be placed transcervically to retrieve specimens that are not to undergo morcellation.
Minilaparoscopy now has multiple applications in our practice. Diagnostically, we employ the use of minilaparoscopic instrumentation in conjunction with hysteroscopic metroplasty, adhesiolysis, or tubal cannulation. Operatively, we have utilized minilaparoscopic instrumentation for excision of endometriosis, ovarian cystectomy, adhesiolysis, enterolysis, tuboplasty, and supracervical and total hysterectomy with or without bilateral salpingo-oophorectomy.
Dr. Cholkeri-Singh is associate director of minimally invasive gynecologic surgery, director of gynecologic surgical education, and codirector of the AAGL/SRS (Society of Reproductive Surgeons) fellowship in minimally invasive gynecologic surgery at Advocate Lutheran General Hospital in Park Ridge, Ill. In addition, she is a board member of the AAGL/SRS fellowship in minimally invasive gynecology and is chair of a postgraduate course at this year’s AAGL Global Congress on Minimally Invasive Gynecology. Dr. Cholkeri-Singh disclosed that she is a speaker for Conceptus Inc., Olympus Gyrus ACMI, and Ethicon Endo Surgery.
The clinical advantages of laparoscopy over laparotomy have been well established over the last several years. As the acceptance and use of laparoscopic approaches have increased among gynecologic surgeons, attention to cosmesis has also evolved.
Laparoscopy has been appealing for its cosmetic benefits as well as reductions in complications and recovery times. Women not only want to resume their normal activities sooner; they also want to take advantage of the smaller incisions that laparoscopy entails, as these incisions do not alter abdominal wall appearance as significantly as do laparotomy incisions.
Still, depending on an individual’s body mass index and wound healing, scars can be disturbing for patients. Some women who have had more than one laparoscopic surgery requiring different port placements have jokingly spoken about "connecting the dots," but such comments reflect concern about aesthetics and should be taken seriously. Although we have improved surgical outcomes with laparoscopy and reduced the size of the surgical scar, we can still create disfigured abdomens.
Last year, the AAGL Fellowship in Minimally Invasive Gynecologic Surgery at Newton-Wellesley (Mass.) Hospital published an article about a survey of women and their preferred abdominal incision choices, based solely on cosmesis (J. Minim. Invasive Gynecol. 2011;18:640-3). The survey participants were shown three photographs of incisions that were commonly performed at their institution and among several Boston-area gynecologic surgeons, and were asked to rank the incisions in order of preference.
The photograph depicting a single incision or single-site laparoscopy showed a vertical 25-mm incision. The robotic laparoscopy photo showed five incisions: umbilical and right midabdomen (paraumbilical) incisions of 12-mm length, and 8-mm incisions in the right lower quadrant, left lower quadrant, and left midabdomen. The incision configuration in the photo of a conventional four-port laparoscopy consisted of a 10-mm incision in the right lower quadrant and 5-mm incisions in the umbilicus, left lower quadrant, and suprapubic area.
The conventional laparoscopy incisions were most preferred by approximately 56% of the 241 women who completed the survey, whereas preference for a single incision was approximately 41% and for robotic surgery was 2.5%.
Granted, there are variable configurations and incision sizes for each of the laparoscopic techniques, and further strides are being made to make the approaches more cosmetically acceptable. Experienced gynecologic surgeons are developing techniques to minimize the number of ports used robotically, for instance, and smaller incision sizes for robotic laparoscopy are anticipated.
In any case, the overarching lesson from this survey is that aesthetics is of value to many women and should be an important consideration for us as treating physicians.
Miniaturization
The use of mini- or microlaparoscopic instrumentation enables us to address aesthetic concerns and take the issue of cosmesis to the next level, as well as to further minimizing trauma. Although conventional laparoscopy involves instruments of 5-mm diameter or larger, the term "minilaparoscopy" usually refers to the use of instruments greater than 2 mm up to less than 5 mm in diameter, and "microlaparoscopy" involves instrumentation of 2 mm or less in diameter.
In gynecology, minilaparoscopy has been utilized diagnostically since the mid-1990s to perform conscious pain mapping with local anesthesia. With a 2.5 mm–diameter scope and 3 mm–diameter trocars, surgeons have used a blunt probe to map trigger sites with the patient’s assistance and response, and to aid in identifying pelvic disease suspected of causing pain (Int. J. Gynaecol. Obstet. 2008;100:94-8).
The diagnostic accuracy of the mini- or microlaparoscope has been reported in various scenarios (including cases of endometriosis and adhesive disease) to be comparable to that of the 10-mm scope that is used in conventional laparoscopy.
In one small study, investigators compared the diagnostic accuracy of 2-mm and 10-mm laparoscopes, with two physicians independently reporting findings to a third person (Fertil. Steril. 1997;67:952-4). Although they had a small sample size, the researchers observed no significant differences between the two laparoscopes or the two physicians. (Scores for endometriosis and adnexal adhesions, for instance, did not differ in any significant way.) This suggested that the diagnostic accuracy achieved with the microlaparoscope was comparable to that of the standard 10-mm laparoscope.
Another study in which 87 consecutive women underwent microlaparoscopic evaluation for chronic pelvic pain similarly found that microlaparoscopy provides comparable efficacy for diagnosing endometriosis and evaluating for the presence of occlusive salpingitis isthmica nodosa. Evaluation through a 2-mm port affords "an excellent minimally invasive view of the pelvis," the investigator wrote (JSLS 2005;9:431-3).
Most of the literature for minilaparoscopy, however, has evolved from the nongynecologic specialties, particularly general surgery. It has been well documented that minilaparoscopy is safe for splenic and liver biopsies, as well as helpful in reducing port sizes and hernias when utilized in cholecystectomies and colorectal resections.
Most recently, the authors of a literature review spanning the last 30 years concluded that minilaparoscopy has been shown in almost all urologic indications to be feasible and safe, with better cosmetic results and reduced postoperative pain (Arch. Esp. Urol. 2012;65:366-83).
Collectively, these studies provide us with a solid body of evidence on the safety, feasibility, and benefits of minilaparoscopy. The findings noted in the surgical literature for minilaparoscopy include operative times, morbidity, and hospital lengths of stay that are comparable to those of conventional laparoscopy; improved cosmesis; a decrease in postoperative pain; and reductions in port-site complications such as bleeding, infection, and herniation.
Surpassing SIL
Single-incision laparoscopy (also known as "scarless" surgery, with the umbilicus viewed as a natural scar) was developed to improve cosmesis. An incision approximately 25 mm in size at the umbilicus allows a scope and two or three instruments to pass into the abdominal cavity.
A main challenge – and a limitation for many surgeons – is the lack of triangulation because of the parallel entry. Instruments are crossed, which is counterintuitive to conventional laparoscopic training, and hands and instruments can clash, which limits the use of instrumentation.
An array of curved and EndoWrist instruments (with flexible joints at the tips) was developed to help ease the technical difficulties of single-port surgery. Many advanced endoscopic surgeons have performed simple to complex single-incision procedures with low complication rates and with operative times and rates of blood loss that are comparable with those of conventional laparoscopy. One advantage to single-incision surgery is that the incision size allows the removal of larger tissue that has been resected from the abdomen.
A recent study in the Netherlands suggests that single-incision surgery may not be all that more difficult to learn (Surg. Endosc. 2012;26:1231-7). The simulation study looked at the performance/learning curves of 20 medical interns (none with laparoscopic experience) who were randomly assigned to perform single-incision or conventional laparoscopy. Each participant practiced each task 11 times. There were no significant differences between the two groups in terms of error or time in performing the tasks, and participants improved significantly in both laparoscopy settings.
There are still many concerns, however, that single-incision laparoscopy is indeed more technically challenging, and that a sizable learning curve for the single-incision approach –in addition to the learning curve of conventional laparoscopy – does exist. Without surgical volume and patience, this technique may be a struggle for many to adapt and teach.
Moreover, as shown in the study at Newton-Wellesley Hospital, the scars remain a concern for many women. The umbilicus is the easiest place to try to "hide" an incision and scar when the incision is made at its base, but a 2-1/2 cm incision can be difficult to hide in a shallow umbilicus; for some women, the larger single scar becomes a focal point of their abdomen and, thus, disfiguring.
Our Experience
With minilaparoscopy, we can maintain triangulation and employ the fundamental principles of conventional laparoscopy with greater technical ease. The approach also has the potential to reduce the risk of incision-site hernias and the incidence of wound complications.
The following drawbacks to minilaparoscopy have been cited:
• A smaller view of the operative field.
• Less tensile strength of the instruments.
• Electrosurgery instruments that are limited to small vessels/pathology.
• Difficulty with large-tissue extraction.
There are solutions to each of these challenges, many of which involve hybrid approaches that incorporate single-incision or conventional laparoscopic ports at the umbilicus to facilitate electrosurgery, tissue extraction, and visualization while maintaining cosmesis. The solutions include the following:
• Better optics. Significant strides have been made in the area of optics, and newer minilaparoscopes (Figure 1) have better resolution and optical clarity than does the previous generation of miniature scopes. We have found that we can zoom the image and reduce light to improve visualization and maximize the operative field.
• Improved instrument strength. As with miniaturized laparoscopes, a wide array of durable instrumentation (Figures 2 and 3) is now available. We employ instruments that are 2.3-3.3 mm in diameter and up to 36 cm in length, ports that are 3.5 mm in diameter and 10-15 cm in length, and scopes that are 2.9-3.3 mm in diameter and up to 25 cm in length.
For skin incisions, a 14-gauge needle is used instead of a scalpel to avoid an incision that is too large and would allow easy slippage of the port. On the 2.3-mm disposable instruments, the tip itself is a 13-gauge needle that is utilized to incise the skin and enter the abdominal cavity. (See Figure 4.) Wounds are not sutured closed, but are merely reapproximated with Steri-Strips at the end of the procedure.
• More versatile electrosurgery instruments. We utilize reusable and disposable bipolar coagulating forceps, as well as reusable instruments with monopolar electrosurgical capability, including dissecting and grasping forceps, scissors, hook, and spatula. For example, when we excise endometriosis, we will utilize a sharp grasping instrument to elevate the lesion away from vital structures, as well as monopolar scissors to excise the disease. Needle holders and knot pushers are sturdy for suturing, and a suction tip is also available in miniaturized form.
In procedures in which the vessel-sealing capacity of a 3-mm energy source is not sufficient, a 5-mm port can be placed at the umbilicus so that a standard 5-mm energy source can be utilized to improve or maintain hemostasis.
• Extraction of large tissues. For tissue extraction requiring an incision larger than 5 mm, a 10- to 12-mm trocar can be placed at the umbilicus for the possible use of an endoscopic specimen bag. We dilate the umbilicus with Hegar dilators to a size 16 to ease the extraction of tissue, if necessary, or for the placement of a laparoscopic morcellator.
Recently, however, we have been able to perform minilaparoscopic hysterectomies with the use of three 3-mm ports, a minilaparoscope, and other miniaturized instrumentation. Specifically, we utilize the 3-mm PKS MoLly forceps by Olympus Gyrus (Figure 5) to coagulate and monopolar scissors to transect the pedicles. A colpotomy is completed with the scissors, and the specimen is delivered through the colpotomy incision. The colpotomy incision is reapproximated with 0-PDS suture on CT-1–sized needles. The suture is backloaded through the miniport and is introduced into the abdomen without difficulty. The incision is sutured; the needle is parked in the upper abdominal wall, and is then cut free. The suture is then pulled through the port for extracorporeal knot tying. The needle is retrieved and pulled through the incision with the removal of the port, and is now ready for loading another suture.
A minilaparoscopic supracervical hysterectomy can be performed in a similar fashion. For tissue extraction, we perform transcervical morcellation. We have found that the morcellators with extra-long shafts (such as the Storz 12-mm extra-long Rotocut or Gynecare Morcellex) work best for transcervical morcellation. Once uterine amputation is completed, the cervical stump is dilated with cervical dilators to allow for the morcellator tip to advance through the cervix and into the pelvic cavity transvaginally. Under direct visualization and with the assistance of a laparoscopic grasper, the specimen is morcellated. Similarly, an endoscopic specimen bag can also be placed transcervically to retrieve specimens that are not to undergo morcellation.
Minilaparoscopy now has multiple applications in our practice. Diagnostically, we employ the use of minilaparoscopic instrumentation in conjunction with hysteroscopic metroplasty, adhesiolysis, or tubal cannulation. Operatively, we have utilized minilaparoscopic instrumentation for excision of endometriosis, ovarian cystectomy, adhesiolysis, enterolysis, tuboplasty, and supracervical and total hysterectomy with or without bilateral salpingo-oophorectomy.
Dr. Cholkeri-Singh is associate director of minimally invasive gynecologic surgery, director of gynecologic surgical education, and codirector of the AAGL/SRS (Society of Reproductive Surgeons) fellowship in minimally invasive gynecologic surgery at Advocate Lutheran General Hospital in Park Ridge, Ill. In addition, she is a board member of the AAGL/SRS fellowship in minimally invasive gynecology and is chair of a postgraduate course at this year’s AAGL Global Congress on Minimally Invasive Gynecology. Dr. Cholkeri-Singh disclosed that she is a speaker for Conceptus Inc., Olympus Gyrus ACMI, and Ethicon Endo Surgery.
The clinical advantages of laparoscopy over laparotomy have been well established over the last several years. As the acceptance and use of laparoscopic approaches have increased among gynecologic surgeons, attention to cosmesis has also evolved.
Laparoscopy has been appealing for its cosmetic benefits as well as reductions in complications and recovery times. Women not only want to resume their normal activities sooner; they also want to take advantage of the smaller incisions that laparoscopy entails, as these incisions do not alter abdominal wall appearance as significantly as do laparotomy incisions.
Still, depending on an individual’s body mass index and wound healing, scars can be disturbing for patients. Some women who have had more than one laparoscopic surgery requiring different port placements have jokingly spoken about "connecting the dots," but such comments reflect concern about aesthetics and should be taken seriously. Although we have improved surgical outcomes with laparoscopy and reduced the size of the surgical scar, we can still create disfigured abdomens.
Last year, the AAGL Fellowship in Minimally Invasive Gynecologic Surgery at Newton-Wellesley (Mass.) Hospital published an article about a survey of women and their preferred abdominal incision choices, based solely on cosmesis (J. Minim. Invasive Gynecol. 2011;18:640-3). The survey participants were shown three photographs of incisions that were commonly performed at their institution and among several Boston-area gynecologic surgeons, and were asked to rank the incisions in order of preference.
The photograph depicting a single incision or single-site laparoscopy showed a vertical 25-mm incision. The robotic laparoscopy photo showed five incisions: umbilical and right midabdomen (paraumbilical) incisions of 12-mm length, and 8-mm incisions in the right lower quadrant, left lower quadrant, and left midabdomen. The incision configuration in the photo of a conventional four-port laparoscopy consisted of a 10-mm incision in the right lower quadrant and 5-mm incisions in the umbilicus, left lower quadrant, and suprapubic area.
The conventional laparoscopy incisions were most preferred by approximately 56% of the 241 women who completed the survey, whereas preference for a single incision was approximately 41% and for robotic surgery was 2.5%.
Granted, there are variable configurations and incision sizes for each of the laparoscopic techniques, and further strides are being made to make the approaches more cosmetically acceptable. Experienced gynecologic surgeons are developing techniques to minimize the number of ports used robotically, for instance, and smaller incision sizes for robotic laparoscopy are anticipated.
In any case, the overarching lesson from this survey is that aesthetics is of value to many women and should be an important consideration for us as treating physicians.
Miniaturization
The use of mini- or microlaparoscopic instrumentation enables us to address aesthetic concerns and take the issue of cosmesis to the next level, as well as to further minimizing trauma. Although conventional laparoscopy involves instruments of 5-mm diameter or larger, the term "minilaparoscopy" usually refers to the use of instruments greater than 2 mm up to less than 5 mm in diameter, and "microlaparoscopy" involves instrumentation of 2 mm or less in diameter.
In gynecology, minilaparoscopy has been utilized diagnostically since the mid-1990s to perform conscious pain mapping with local anesthesia. With a 2.5 mm–diameter scope and 3 mm–diameter trocars, surgeons have used a blunt probe to map trigger sites with the patient’s assistance and response, and to aid in identifying pelvic disease suspected of causing pain (Int. J. Gynaecol. Obstet. 2008;100:94-8).
The diagnostic accuracy of the mini- or microlaparoscope has been reported in various scenarios (including cases of endometriosis and adhesive disease) to be comparable to that of the 10-mm scope that is used in conventional laparoscopy.
In one small study, investigators compared the diagnostic accuracy of 2-mm and 10-mm laparoscopes, with two physicians independently reporting findings to a third person (Fertil. Steril. 1997;67:952-4). Although they had a small sample size, the researchers observed no significant differences between the two laparoscopes or the two physicians. (Scores for endometriosis and adnexal adhesions, for instance, did not differ in any significant way.) This suggested that the diagnostic accuracy achieved with the microlaparoscope was comparable to that of the standard 10-mm laparoscope.
Another study in which 87 consecutive women underwent microlaparoscopic evaluation for chronic pelvic pain similarly found that microlaparoscopy provides comparable efficacy for diagnosing endometriosis and evaluating for the presence of occlusive salpingitis isthmica nodosa. Evaluation through a 2-mm port affords "an excellent minimally invasive view of the pelvis," the investigator wrote (JSLS 2005;9:431-3).
Most of the literature for minilaparoscopy, however, has evolved from the nongynecologic specialties, particularly general surgery. It has been well documented that minilaparoscopy is safe for splenic and liver biopsies, as well as helpful in reducing port sizes and hernias when utilized in cholecystectomies and colorectal resections.
Most recently, the authors of a literature review spanning the last 30 years concluded that minilaparoscopy has been shown in almost all urologic indications to be feasible and safe, with better cosmetic results and reduced postoperative pain (Arch. Esp. Urol. 2012;65:366-83).
Collectively, these studies provide us with a solid body of evidence on the safety, feasibility, and benefits of minilaparoscopy. The findings noted in the surgical literature for minilaparoscopy include operative times, morbidity, and hospital lengths of stay that are comparable to those of conventional laparoscopy; improved cosmesis; a decrease in postoperative pain; and reductions in port-site complications such as bleeding, infection, and herniation.
Surpassing SIL
Single-incision laparoscopy (also known as "scarless" surgery, with the umbilicus viewed as a natural scar) was developed to improve cosmesis. An incision approximately 25 mm in size at the umbilicus allows a scope and two or three instruments to pass into the abdominal cavity.
A main challenge – and a limitation for many surgeons – is the lack of triangulation because of the parallel entry. Instruments are crossed, which is counterintuitive to conventional laparoscopic training, and hands and instruments can clash, which limits the use of instrumentation.
An array of curved and EndoWrist instruments (with flexible joints at the tips) was developed to help ease the technical difficulties of single-port surgery. Many advanced endoscopic surgeons have performed simple to complex single-incision procedures with low complication rates and with operative times and rates of blood loss that are comparable with those of conventional laparoscopy. One advantage to single-incision surgery is that the incision size allows the removal of larger tissue that has been resected from the abdomen.
A recent study in the Netherlands suggests that single-incision surgery may not be all that more difficult to learn (Surg. Endosc. 2012;26:1231-7). The simulation study looked at the performance/learning curves of 20 medical interns (none with laparoscopic experience) who were randomly assigned to perform single-incision or conventional laparoscopy. Each participant practiced each task 11 times. There were no significant differences between the two groups in terms of error or time in performing the tasks, and participants improved significantly in both laparoscopy settings.
There are still many concerns, however, that single-incision laparoscopy is indeed more technically challenging, and that a sizable learning curve for the single-incision approach –in addition to the learning curve of conventional laparoscopy – does exist. Without surgical volume and patience, this technique may be a struggle for many to adapt and teach.
Moreover, as shown in the study at Newton-Wellesley Hospital, the scars remain a concern for many women. The umbilicus is the easiest place to try to "hide" an incision and scar when the incision is made at its base, but a 2-1/2 cm incision can be difficult to hide in a shallow umbilicus; for some women, the larger single scar becomes a focal point of their abdomen and, thus, disfiguring.
Our Experience
With minilaparoscopy, we can maintain triangulation and employ the fundamental principles of conventional laparoscopy with greater technical ease. The approach also has the potential to reduce the risk of incision-site hernias and the incidence of wound complications.
The following drawbacks to minilaparoscopy have been cited:
• A smaller view of the operative field.
• Less tensile strength of the instruments.
• Electrosurgery instruments that are limited to small vessels/pathology.
• Difficulty with large-tissue extraction.
There are solutions to each of these challenges, many of which involve hybrid approaches that incorporate single-incision or conventional laparoscopic ports at the umbilicus to facilitate electrosurgery, tissue extraction, and visualization while maintaining cosmesis. The solutions include the following:
• Better optics. Significant strides have been made in the area of optics, and newer minilaparoscopes (Figure 1) have better resolution and optical clarity than does the previous generation of miniature scopes. We have found that we can zoom the image and reduce light to improve visualization and maximize the operative field.
• Improved instrument strength. As with miniaturized laparoscopes, a wide array of durable instrumentation (Figures 2 and 3) is now available. We employ instruments that are 2.3-3.3 mm in diameter and up to 36 cm in length, ports that are 3.5 mm in diameter and 10-15 cm in length, and scopes that are 2.9-3.3 mm in diameter and up to 25 cm in length.
For skin incisions, a 14-gauge needle is used instead of a scalpel to avoid an incision that is too large and would allow easy slippage of the port. On the 2.3-mm disposable instruments, the tip itself is a 13-gauge needle that is utilized to incise the skin and enter the abdominal cavity. (See Figure 4.) Wounds are not sutured closed, but are merely reapproximated with Steri-Strips at the end of the procedure.
• More versatile electrosurgery instruments. We utilize reusable and disposable bipolar coagulating forceps, as well as reusable instruments with monopolar electrosurgical capability, including dissecting and grasping forceps, scissors, hook, and spatula. For example, when we excise endometriosis, we will utilize a sharp grasping instrument to elevate the lesion away from vital structures, as well as monopolar scissors to excise the disease. Needle holders and knot pushers are sturdy for suturing, and a suction tip is also available in miniaturized form.
In procedures in which the vessel-sealing capacity of a 3-mm energy source is not sufficient, a 5-mm port can be placed at the umbilicus so that a standard 5-mm energy source can be utilized to improve or maintain hemostasis.
• Extraction of large tissues. For tissue extraction requiring an incision larger than 5 mm, a 10- to 12-mm trocar can be placed at the umbilicus for the possible use of an endoscopic specimen bag. We dilate the umbilicus with Hegar dilators to a size 16 to ease the extraction of tissue, if necessary, or for the placement of a laparoscopic morcellator.
Recently, however, we have been able to perform minilaparoscopic hysterectomies with the use of three 3-mm ports, a minilaparoscope, and other miniaturized instrumentation. Specifically, we utilize the 3-mm PKS MoLly forceps by Olympus Gyrus (Figure 5) to coagulate and monopolar scissors to transect the pedicles. A colpotomy is completed with the scissors, and the specimen is delivered through the colpotomy incision. The colpotomy incision is reapproximated with 0-PDS suture on CT-1–sized needles. The suture is backloaded through the miniport and is introduced into the abdomen without difficulty. The incision is sutured; the needle is parked in the upper abdominal wall, and is then cut free. The suture is then pulled through the port for extracorporeal knot tying. The needle is retrieved and pulled through the incision with the removal of the port, and is now ready for loading another suture.
A minilaparoscopic supracervical hysterectomy can be performed in a similar fashion. For tissue extraction, we perform transcervical morcellation. We have found that the morcellators with extra-long shafts (such as the Storz 12-mm extra-long Rotocut or Gynecare Morcellex) work best for transcervical morcellation. Once uterine amputation is completed, the cervical stump is dilated with cervical dilators to allow for the morcellator tip to advance through the cervix and into the pelvic cavity transvaginally. Under direct visualization and with the assistance of a laparoscopic grasper, the specimen is morcellated. Similarly, an endoscopic specimen bag can also be placed transcervically to retrieve specimens that are not to undergo morcellation.
Minilaparoscopy now has multiple applications in our practice. Diagnostically, we employ the use of minilaparoscopic instrumentation in conjunction with hysteroscopic metroplasty, adhesiolysis, or tubal cannulation. Operatively, we have utilized minilaparoscopic instrumentation for excision of endometriosis, ovarian cystectomy, adhesiolysis, enterolysis, tuboplasty, and supracervical and total hysterectomy with or without bilateral salpingo-oophorectomy.
Dr. Cholkeri-Singh is associate director of minimally invasive gynecologic surgery, director of gynecologic surgical education, and codirector of the AAGL/SRS (Society of Reproductive Surgeons) fellowship in minimally invasive gynecologic surgery at Advocate Lutheran General Hospital in Park Ridge, Ill. In addition, she is a board member of the AAGL/SRS fellowship in minimally invasive gynecology and is chair of a postgraduate course at this year’s AAGL Global Congress on Minimally Invasive Gynecology. Dr. Cholkeri-Singh disclosed that she is a speaker for Conceptus Inc., Olympus Gyrus ACMI, and Ethicon Endo Surgery.
