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Laparo Endoscopic Single Site LESS surgery for ovarian cyst

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           Laparo-Endoscopic Single-Site (LESS ) surgery
           for ovarian cyst enucleation: A case report
           Fagotti	A,	Fanfani	F,	Rossitto	C,	Gallotta	V,	Marocco	F,	Scambia	G.
           Division	of	Gynaecologic	Oncology,	Catholic	University	of	the	Sacred	Heart,	Rome,	Italy




           Introduction                                          Under	general	anaesthesia,	the	patient	was	           Afterwards	the	incision	in	the	ovarian	cor­
           Today,	LESS	surgery	has	emerged	as	one	               positioned	in	the	dorsal	lithotomy	position.	         tex	 was	 extended	 to	 allow	 removal	 of	 the	
           of	 the	 most	 promising	 technical	 advances	        A	 multi­channel	 port	 (TriPort,	 Olympus)	          intact	cyst.	Repeated	irrigation	with	saline	
           in	 minimally	 invasive	 surgery	 (MIS).	 In	         that	 enabled	 the	 surgeon	 to	 introduce	           was	 used	 for	 full	 peritoneal	 toilet.	 After	
           LESS	surgery,	complex	surgeries	are	per­              three	 instruments	 simultaneously	 was	 in­          cyst	enucleation	and	inspection	for	poten­
           formed	 through	 only	 one	 small	 incision,	         serted	transumbilically	(incision	size	2	cm).         tial	 bleeding,	 an	 endo­bag	 was	 inserted	
           thus	 leaving	 excellent,	 virtually	 scarfree	                                                             through	 the	 12­mm	 valve	 of	 the	 TriPort	
           cosmetic	results.	By	minimising	the	access	           After	 pneumoperitoneum	 (12	 mmHg),		                and	 the	 specimen	 removed	 successfully
           trauma,	 LESS	 surgery	 may	 offer	 further	          intra­abdominal	 visualisation	 was	 obtained	        through	the	port.
           potential	 benefits	 like	 reduced	 wound	            with	 the	 endoeYe	 LS	 video	 laparoscope	           At	discharge,	a	serial	visual	analogue	scale	
           complications,	 minimised	 postoperative	             (Olympus).	Its	bendable	handgrip	enabled	             (VAS)	 was	 used	 to	 assess	 postoperative	
           pain	and	faster	recovery	times.                       the	assistant	to	move	the	handpiece	out	of	           pain	 and	 cosmetic	 outcome	 ratings,	 by	
           In	 the	 past	 two	 years,	 LESS	 surgery	 has	       the	 workspace	 of	 the	 hand	 instruments		          both	patient	and	surgeon.
           made	 considerable	 progress,	 owing	 espe­           employed	 by	 the	 surgeon.	 The	 surgeon	
           cially	to	innovative	and	optimised	technical	         used	one	straight	(36	cm)	and	one	curved	
           equipment	facilitating	the	procedure.                 HiQ	LS	hand	instrument,	choosing	among	
           At	the	beginning,	in	europe,	LESS	surgery	            graspers,	cold	scissors,	suction/irrigation	
           was mainly applied in the fields of urology           and	 bipolar	 coagulator.	 Combining	 a	
           and	general	surgery,	but	shortly	thereafter	          straight	with	a	curved	instrument	helped	to	
           also	 has	 successfully	 found	 its	 place	 in	       prevent	 excessive	 contact	 between	 the	
           gynaecology.	The	number	of	cases	is	rising		          surgeon’s	hands	outside	of	the	abdominal	
           rapidly,	 the	 range	 of	 application	 is	 ex­        cavity,	 facilitated	 stripping	 and	 traction	
           panding	 as	 well	 as	 the	 number	 of	 publi­        manoeuvres	 and	 increased	 jaw	 visibility	
           cations.	The	following	case	report	aims	to	           during	the	surgical	procedures.
           demonstrate	 the	 feasibility	 and	 safety	 of	       After	pelvic	and	abdominal	exploration	and	
           LESS	surgery	and	shows	that	former	ergo­              washing,	 the	 adnexa	 were	 mobilised	 to	
           nomic	obstacles	resulting	from	the	limited	           perform	 stripping	 for	 excising	 the	 cyst.	
           workspace	can	be	overcome	using	the	right	            Once	the	ovary	was	mobilised	and	released	
           instrumentation.                                      from	 the	 posterior	 leaf	 of	 the	 broad		
                                                                 ligament,	 the	 utero­ovarian	 ligament	 was		        Fig. 1 Application	of	new	instruments	during		
                                                                 grasped	to	elevate	and	rotate	the	ovary.	A	           LESS	surgery:	the	transumbilically	inserted	TriPort,	
           Case Report                                           small	 longitudinal	 incision	 was	 made	             the	HiQ	LS	curved	hand	instrument	(left)	and	the		
           A	 39­year­old	 nullipara	 woman	 (height	            contralateral	to	the	ovarian	hilum,	reaching	         endoeYe	LS	video	laparoscope	(right).
           163	 cm,	 weight	 57	 kg)	 with	 no	 relevant		       to	 the	 wall	 of	 the	 cyst.	 Once	 the	 cleavage	
           co­morbidities	 and	 no	 history	 of	 previous	       plane	 between	 the	 capsule	 and	 ovary	 was	
           abdominal	surgeries	was	diagnosed	with	a	             identified, the cyst capsule was detached             Results
           72	x	35	mm	bilocular	benign	right	ovarian	            from	 the	 ovarian	 parenchyma	 using	 a		            The	TriPort	placement	was	successful,	un­
           cyst	 in	 the	 presence	 of	 negative	 Ca125	         blunt­tip	 instrument.	 Haemostasis	 of	 the	         problematic,	safe	(no	vascular	or	gastroin­
           serum	levels.                                         ovarian	 bed	 was	 obtained	 with	 a	 bipolar	        testinal	injuries,	or	bleedings)	and	required	
           A	LESS	cyst	enucleation	was	performed:1	              coagulation	electrode.	                               only	 1.35	 minutes	 until	 complete	 pneu­



           	 The	patient	signed	a	written	informed	consent	which	was	mandatory	to	perform	this LESS	procedure.
           1




LEW_017_SecPub_GynSur.indd 1                                                                                                                                        07.08.2009 11:12:51 Uhr
     ADVeRTISeMenT




           moperitoneum.	 The	 ovarian	 cyst	 was	 re­ separately,	were	8	and	7	respectively,	with	           times.	 Whereas	 in	 the	 beginning	 of	 the	
           moved	successfully,	sparing	the	ovary	and	 an	 improvement	 after	 thirty	 days.	 The		            LESS	technique,	the	new	way	of	access	and	
           without	 rupture	 or	 spillage	 of	 the	 cyst.	 patient	was	discharged	home	on	day	1	after	        resulting	ergonomic	restraints	impeded	the	
           Operative	 time	 from	 skin	 incision	 to	 skin	 surgery	with	only	optional	analgesic	therapy.	    surgical	procedure,	now	new	technological	
           closure	 was	 38	 minutes.	 estimated	 blood	 Final	pathological	analysis	showed	a	benign	         developments	like	the	TriPort,	the	HiQ	LS	
           loss	 was	 15	 ml.	 After	 surgery,	 there	 were	 serous	cyst.                                     hand	 instruments	 and	 the	 endoeYe	 LS	
           no	 wound	 haematomas,	 wound	 infections	                                                         used	 in	 this	 case	 report	 facilitate	 the	
           or	 delayed	bleedings.	The	patient	did	not	                                                        surgeon’s	 work.	 Thus,	 LESS	 surgery	 is	 a	
           require	 analgesic	 therapy	 after	 surgery.	 Conclusion                                           promising	 advanced	 surgical	 approach,	
           The	postoperative	VAS	score	on	pain	was	 This	case	report	is	one	of	many	ovarian	cyst	             that,	 as	 stated	 by	 Professor	 Scambia,	 “of­
           very	 low	 (3	 at	 rest,	 4	 post	 Valsava’s	 ma­ enucleations	 proving	 LESS	 surgery	 is	        fers	 the	 patient	 many	 advantages	 without	
           noeuvre)	and	progressively	decreased	over	 feasible,	 safe	 and	 effective.	 LESS	 surgery	        increasing	the	risk	of	complications”.	If	es­
           the	subsequent	eight	hours.	Results	(VAS)	 offers	 patients	 enhanced	 cosmetic	 results	          tablished	 responsibly,	 LESS	 surgery	 has	 a	
           on	the	cosmetic	outcome	due	to	the	umbil­ and,	 as	 this	 data	 suggests,	 also	 reduced	          promising	future	in	gynaecology	for	various	
           ical	 scar,	 rated	 by	 patient	 and	 surgeon		 postoperative	 pain	 and	 faster	 recovery	        benign	and	even	oncological	applications.




                                   Interview with Professor Giovanni Scambia
                                   Catholic		University		of		the		Sacred		Heart,		Rome,		Italy


                                 Which surgical pro-           diseases	like	ovarian	cysts	and	tubal	dis­	   Is LESS surgery associated with an
                                 cedures have you per-         eases.	But,	as	gynaecologists	gain	expe­      increased risk of complications or
                                 formed with LESS              rience	 and	 implement	 the	 new	 instru­	    side effects?
                                 surgery so far?               ments,	the	application	range	will	increase	   no.	So	far,	the	data	generated	from	our	
                                 We	 have	 performed	          and	we	will	probably	be	able	to	use	LESS	     30	LESS	cases	has	not	indicated	any	in­
                                 about	 30	 LESS	 surger­      surgery	in	oncological	diseases	as	well.      creased	risk	compared	to	conventional	
               ies	so	far	including	 ovarian	 cyst	 enucle­                                                  laparoscopy.
               ations,	 adnexectomies	 and	 diagnostic	        What are the benefits of LESS surgery
               laparoscopies	 for	 sterilisations.	 We		       for the patient?                              Which application do you recom-
               recently	 performed	 our	 first	 LESS		         There are several potential benefits as­      mend interested surgeons start LESS
               hysterectomy	 –	 an	 application	 that	         sociated	with	LESS	surgery.	Right	now	        surgery with?
               seems	very	suitable	for	LESS	surgery.           we	are	conducting	a	study	in	our	clinic	      Monolateral	and	bilateral	adnexectomy	
                                                               that	is	aimed	at	demonstrating	these	ad­      is	 a	 good	 procedure	 to	 start	 LESS		
               In which applications do you expect             vantages.	 I	 think	 less	 postoperative	     surgery with. The level of difficulty is
               LESS surgery to become most suc-                pain	probably	is	one	of	the	most	impor­       relatively	 low,	 so	 that	 experienced	
               cessful in gynaecology?                         tant benefits, but also the virtually         laparoscopists	can	easily	apply	the	LESS	
               In	 the	 early	 stages,	 LESS	 surgery	 will	   scarfree	 cosmetic	 result	 achieved	 by	     technique.
               mainly	 be	 applied	 for	 benign	 ovarian	      the	transumbilical	access	is	essential.




           For	more	information,	visit	www.less-surgery.eu	or	the	Olympus	symposium:
           LESS Surgery – An Evolution in Laparoscopy?
           Location:	 	18th	Annual	Congress	of	the	european	Society	for	Gynaecological	endoscopy,	Florence,	Palazzo	dei	Congressi
           Room:		 Sala	Verde
           Date: 	     Thursday,	October	29th	2009
           Time: 	 14:00	–	15:30	h




LEW_017_SecPub_GynSur.indd 2                                                                                                                         07.08.2009 11:12:51 Uhr

								
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