Single-Port Vs Four-Port Total Laparoscopic Hysterectomy
Video of Total Laparoscopic Hysterectomy by Four Ports
Laparoscopic surgery performed with a single access site is known as single-incision laparoscopic surgery (SILS), laparoendoscopic single-site surgery, single port laparoscopic surgery (SPLS) or single-port access surgery. Single-incision laparoscopic surgery can also referred to as embryonic natural orifice transumbilical endoscopic surgery.
It represents a new aspect of minimally invasive surgery. Various research studies show Its feasibility in gynaecologic surgery including ovarian cystectomy, salpingo-oophorectomies, uterine myomectomies, bilateral tubal ligation, surgical treatment of ectopic pregnancy, both total and partial hysterectomy and even radical surgeries with pelvic lymphadenectomy.
Obesity, past abdominal surgeries, and early-stage gynaecologic cancer are considered by many surgeons as relative contraindications for single-incision laparoscopic surgery. Patients who had previously undergone >2 midline vertical laparotomies or panniculectomies or who did not possess an umbilicus or with a diagnosis of advanced malignancy are contraindicated for SILS.
In Standard laparoscopic hysterectomy procedures the surgeons use two 10 mm major manipulating trocars along with two 5 mm ancillary trocars. It is widely known that the use of fewer and smaller ports decreases incisional morbidity and improves cosmetic outcomes in laparoscopic surgical procedures.
Single port laparoscopic surgery (SPLS) is the latest advancement in the world of laparoscopy. Using flexible endoscopes and articulating instruments, the surgeon can perform complex procedures through a single 2-cm incision.
Few surgeons have also invented a technique of performing SPLS using standard instrumentation by fitting a self-retaining ring retractor with surgical glove in which 3 fingers have been removed and replaced with trocars. Suturing which is very commonly performed in gynaecological surgeries, is difficult to perform through a single port. However it is possible to do standard suturing with both intracorporeal & extracorporeal methods when endoscopic suturing is necessary.
The modern instruments are especially designed to dissect, cauterize and cut, such that it decreases the number of instrument exchanges that are required. Concurrent manipulations are vital to operate efficiently and to prevent the apparatus from suddenly disappearing from view. The surgeon needs to be experienced with laparoscopic operations to overcome these problems though these can be addressed to some extent by the usage of advanced instruments. However these instruments are very expensive and unaffordable to surgeons in developing countries.
Recent reports suggest that laparoendoscopic single-site surgery (LESS), also known as single-port surgery, is technically capable in treating a variety of disease processes
Single-access laparoscopy using a transumbilical port has maximum cosmetic benefits as the surgical incision is hidden in the umbilicus. Since the port incisions are limited to one site, the umbilicus, the surgical scar can be hidden within the umbilicus, thus making the surgery virtually “scarless.” Other advantages of SPLS include less bleeding, lower rates of infection and hernia formation and better cosmetic results along with less postoperative pain. Lower morbidity is too observed. The minor invasiveness of this approach causes less and rapidly vanishing pain which allows for a faster recovery time and thus leads to a shorter hospitalization stay.
The disadvantages and limitations include longer operation time, steep learning curve and the need for sophisticated instruments. New instrumentation and approaches have alleviated some of the challenges of performing laparoscopy through a single abdominal incision for a range of gynecological procedures. With increase in surgical experience and advancement in development of new modern instruments the time required for operation of transumbilical single-port laparoscopic hysterectomy (TSPLH) is likely to become as short as that for traditional four-port total laparoscopic hysterectomy (TLH).
Careful case selection and a low threshold of conversion to conventional laparoscopic surgery are essential. There is a need for large-scale, prospective randomized studies with long-term follow-up to confirm these initial findings.
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