Two-phase laparoendoscopic single-site cervical ligament-sparing hysterectomy: An initial experience

Abstract

Objective: To report our initial experience with and the short-term outcomes of two-phase laparoendoscopic single-site cervical ligament-sparing hysterectomy (LESS-CLSH).

Materials and methods: A retrospective case study included 40 women who underwent LESS-CLSH from January 2014 to December 2016 at Buddhist Tzu Chi General Hospital. Uterine specimens were extracted through contained manual morcellation with a tissue pouch. The first phase was LESS supracervical hysterectomy and conization of the internal orifice of the cervix. The second phase was transvaginal cervical conization and cylinderization. Women with a uterus diameter of >12 cm, a broad ligament myoma, or severe pelvic adhesion were categorized into a difficult group, and others were categorized into a nondifficult group.

Results: The difficult group required more time and had more blood loss than the nondifficult group. The mean surgical time was 187.2 ± 33.9 and 139.1 ± 20.7 min, and the mean blood loss was 533.3 ± 333.3 and 225.3 ± 168.2 mL in the difficult and nondifficult groups, respectively. The overall visual analog scale (VAS) pain scores at 0-4, 24, and 48 h after surgery were 7.1 ± 1.9, 4.2 ± 1.6, and 2.3 ± 1.5, respectively; no difference in the VAS pain scores, pain relief score, and hospitalization duration was observed between the two groups. Minor surgical complications or adverse events on follow-up were noted. Three months after surgery, the diameter and thickness of the cervix were decreased by approximately 0.5 and 1.0 cm, respectively.

Conclusion: LESS-CLSH is a minimally invasive, safe, and feasible approach, even for difficult laparoscopic hysterectomy. Contained manual morcellation enables more controlled specimen removal than morcellation only.

Keywords: Cervical ligament sparing; Hysterectomy; Laparoendoscopic single site; Single port.

Figure 1

Overall procedure of laparoendoscopic single-site cervical ligament-sparing hysterectomy. (a and b) Schema of the two phases of laparoendoscopic single-site cervical ligament-sparing hysterectomy. Phase 1: Laparoscopic supracervical hysterectomy and conization through the internal orifice of the cervix (1). Phase 2: Transvaginal wide excision of the cervix (2). (c) Laparoendoscopic single-site setting with a wound retractor adapted with a surgical glove. (d) Cervical internal orifice conization using a hook. (e) The uterine specimens were contained in a tissue pouch (P), and the pouch was opened at the umbilical port wound where the uterine body was cut into long strips. (f) The incision line was marked in a vertical spindle shape with coagulation. (g) The cervix was cut to a depth of approximately 1 cm at 70°–80° with respect to the axis of the cervix and circumscribed until the Surgicel (blue star) was visible. (h) The remaining part of the cervix was closed using interrupted sutures with 1-0 vicryl. (i) Resected cervical specimens including the specimen from internal orifice conization (1), external orifice conization (2), and cylinderization (3). (j) Longitudinal section of the squamous–columnar junction (arrow) of the cervical specimen from the wide excision in Phase 2 (H and E, ×25)

Figure 2

Scatter plot of operative time compared with the sequence of surgical procedures performed by the surgeon over the 40 cases of laparoendoscopic single-site cervical ligament-sparing hysterectomy. The smoothed line was generated using a cubic spline routine