Commentary

A few tools and techniques can simplify single-port laparoscopic surgery...and more


 

References


APPLYING SINGLE-INCISION LAPAROSCOPIC SURGERY TO GYN PRACTICE: WHAT’S INVOLVED
RUSSELL P. ATKIN, MD; MICHAEL l. NIMAROFF, MD; AND VRUNDA BHAVSAR, MD (SURGICAL TECHNIQUES, APRIL 2011)

A few tools and techniques can simplify single-incision
laparoscopic surgery

I commend Drs. Atkin, Nimaroff and Bhavsar for their excellent article! I’d like to raise several additional important matters about single-incision laparoscopic surgery.

A good uterine manipulator is critical to get good exposure. I have had great success with the VCare (ConMed Endosurgery) uterine manipulator. While an assistant holds the camera, I usually have a LigaSure (Covidien) in my right hand and my left hand on the manipulator. This positioning allows me to push either side of the uterus up into the vessel-sealing device. It also limits the number of instruments that need to be placed through the umbilical port, reducing the problem of having too many instruments crowded together.

In the absence of a flexible laparoscope, consider using a 5-mm 30° or 45° bariatric laparoscope. This moves the camera head back out of the area where the surgeon’s hands must operate. A little judicious practice with this scope allows one to easily see around corners and up the posterior aspect of the uterus. This maneuver is similar to using a 30° hysteroscope to easily visualize the tubal ostia.

For supracervical hysterectomy, consider placing a 5-mm port in the midline at the pubic hairline. Although some surgeons claim that this technique is “cheating,” the cosmetic impact is minimal. Moreover, as with most midline incisions, there is less innervation here and, therefore, minimal discomfort. This access allows for easy placement of a LiNA Loop (LiNA Medical) or similar device to excise the fundus from the cervix.

Other observations from my experience:

  • After the 12-mm morcellator is placed through the umbilical port, I can observe the morcellation process using a 5-mm scope in the suprapubic port. This affords a considerable safety margin.
  • Almost all single-incision procedures are performed using standard, straight laparoscopic instruments. Articulating graspers, scissors, and cautery devices are an expensive and usually unnecessary complication.
  • In total laparoscopic hysterectomy cases, we close the vagina from below, using standard surgical techniques.

Most of my single-incision hysterectomy patients go home within 4 hours after surgery. The gyn nurses maintain telephone contact with them for several days. Patients are reassured that, even though they are leaving the hospital, the hospital does not leave them! This arrangement also saves the surgeons from having to handle many routine late-night calls.

Jeffrey M. Schulman, MD
Inova Fairfax Hospital
Falls Church, Va
Dr. Schulman reports no financial relationships relevant to his letter.

UPDATE ON CERVICAL DISEASE
J. THOMAS COX, MD (MARCH 2011)

How should we manage pregnant teenagers who have
abnormal Pap tests?

Cervical cytology screening guidelines from ACOG recommend that Pap screening be initiated at 21 years of age. It also is widespread practice to obtain a Pap test at the first prenatal visit. I’ve had several pregnant teenagers who have had abnormal Pap test results. The group practice to which I belong reached consensus that we would perform colposcopy in a pregnant teenage patient only if Pap test results are designated as high-grade squamous intraepithelial lesions (HGSIL); we also defer most biopsies until the postpartum period. Nevertheless, it is difficult to counsel a teenage patient who has an abnormal Pap test during pregnancy about her options.

Do you have any recommendations on how to advise this type of patient?

Deni Malave-Huertas, MD
Vero Beach, Florida

Dr. Cox responds: Don’t screen adolescents—pregnant or not

The ACOG guidelines call for screening to begin at 21 years. There is no exception for pregnant adolescents, nor was there any exception given for pregnant women under the age of screening in either the American Cancer Society guidelines of 2002 or the US Preventive Services Task Force guidelines of 2003. Although it June be accepted practice to screen pregnant adolescents in Dr. Malave-Huertas’s locale, it is more appropriate to stop screening patients under the age of 21, whether they are pregnant or not.

WHERE HAVE ALL THE YOUNG MEN GONE? NOT TO OBSTETRICS AND GYNECOLOGY”
lOUIS WEINSTEIN, MD (COMMENTARY, JANUARY 2011)

Complete reversal of discrimination is not a problem for some

I’m not surprised that Dr. Weinstein’s commentary on the dwindling number of young men entering the specialty of obstetrics and gynecology generated a number of letters [see the April 2011 issue of OBG Management]. Both the commentary and the letters were more balanced than the conversation I was recently a party to, which involved a young female resident in our program. This resident argued that any patient who specifically requests a male provider is “sick, twisted, obviously damaged, seeking secondary gain” or “sexually motivated.” When the logical argument was then made that any patient specifically requesting a female provider could have the same motivations, I was met with incredulity at my gall. Quite obviously, to the resident in question, a patient requesting a female provider has made the sane and natural choice.

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