For more than 20 years now, surgeons have been exploring minimally invasive techniques to decrease the complications of traditional abdominal hysterectomy.
Although two-thirds of all hysterectomies in the United States still are performed through a large abdominal incision, we know that minimally invasive hysterectomy provides women with a faster recovery, less pain, a quicker return to normal activities, and fewer complications.
Gynecologic surgeons who have embraced laparoscopy for patients who are not candidates for a vaginal hysterectomy have improved their laparoscopic skills notably over the last 10-15 years. The laparoscopic techniques themselves, however, have remained relatively unchanged since laparoscopic hysterectomy became an option.
From my standpoint as a minimally invasive gynecologic surgeon, I view conventional laparoscopic hysterectomy as a wonderful option for women who do not qualify for a vaginal approach. But on the flip side, I see further progress to be made since the surgery still requires several small incisions and ports, each of which increases the potential morbidity from bleeding, nerve injuries, or port-site hernias and hematomas, and each of which diminishes the cosmetic outcome that many women desire.
This next frontier for women needing hysterectomy—the next logical step in the development of minimally invasive surgery—may have recently arrived. It is a new laparoscopic approach, most commonly called single-incision laparoscopy or laparoendoscopic single-site surgery (LESS), that involves a single umbilical incision and the use of one special port through which three to four traditional or slightly modified hand instruments can be passed.
Numerous terms have been used over the years to describe single-incision laparoscopic surgery, from keyhole surgery to transumbilical endoscopic surgery to embryonic natural orifice transluminal endoscopic surgery. Just recently, a multispecialty, industry-sponsored consortium published a white paper/consensus statement saying that the term laparoendoscopic single-site surgery “most accurately conveys the broad philosophical and practical aspects of the field” (Surg. Endosc. 2009 Dec. 9;doi:10.1007/s00464-009-0688-8).
While LESS will likely be the term used most often in print, I still often use the term “single-incision laparoscopic surgery” in my discussions with patients.
Urologists are among the specialists who have reported a significant increase in the use of LESS in the past several years; successes for partial nephrectomy, pyeloplasty, renal biopsy, and numerous other procedures have been described.
In gynecologic surgery, we are building on this experience. We have a unique advantage, though, in that we have access to the uterus through the vagina. Using a uterine manipulator gives us an extra hand, in essence making a single-incision approach much easier for us than it is for other specialists.
My initial experience and that of other gynecologic surgeons suggests that single-incision laparoscopy is feasible and well tolerated and leaves no visible physical scar. Depending on the specific anatomy of each patient's umbilicus, we can often hide the incision completely in its natural creases. And just as—if not more—importantly, we may further reduce the potential morbidity associated with the use of multiple laparoscopic trocars.
History and Instrumentation
Laparoscopic hysterectomy using a single umbilical puncture was first reported by Dr. Marco A. Pelosi and Dr. Marco A. Pelosi III in 1991 (N.J. Med. 1991;88:721-6).hThe instrumentation they used for their laparoscopic-assisted vaginal hysterectomies was primitive, compared with the currently available ports, instruments, and optics, however, and the technique did not catch on. Single-incision total laparoscopic hysterectomy as we know it today really came about in 2007, when Dr. Homero Rivas, a general surgeon who was performing single-incision laparoscopic cholecystectomy at the University of Texas Southwestern Medical Center at Dallas, traveled to Mexico where his brother is a gynecologist. There, with his brother's guidance, Dr. Rivas successfully performed a hysterectomy using single-incision laparoscopy.
Single-incision laparoscopy was really taking off in general surgery and urology at about this time. Many minimally invasive surgeons saw it as a bridge to an experimental approach called natural orifice transluminal endoscopic surgery (NOTES), which uses natural orifices for access to the abdominal viscera and which might, they believed, represent the ultimate approach to minimally invasive surgery.
Single-incision laparoscopy rapidly became more than a bridge to NOTES, however. It came into its own, surpassing NOTES as a technique with lasting and broad acceptance—and one without the limitations or surgical difficulties of NOTES. Nephrectomies, splenectomies, appendectomies, and a host of other procedures were performed using single-incision laparoscopy.
Like Dr. Rivas and other general and gynecologic surgeons who began using the technique several years ago, I began my experience with single-incision total laparoscopic hysterectomy utilizing articulating surgical equipment that had been around for years. (I started using the technique in 2008.) In the past few years, laparoscopic equipment has been modified and refined in ways that have made the technique even easier and achievable by more surgeons. Articulating laparoscopic graspers, endoshears, and graspers all are commercially available.