Several years ago, I adopted a single-incision approach to virtually all benign gynecologic laparoscopic procedures as the next logical step in the practice of minimally invasive surgery. In this time, my partner and I have performed more than 450 single-incision hysterectomies using a simple, reproducible technique that differs from other approaches to single-incision laparoscopy, or laparoendoscopic single-site surgery (LESS), as it is most commonly called.
Rather than using articulating instruments, we use a 30-degree 5-mm bariatric-length laparoscope and straight, extra-long instruments. With sequential placement of one instrument at a time and attention to the direction of extra-abdominal hand movements, we create a work space with unimpeded access to the uterus and prevent the clashing of instruments, or "sword fighting," that can come with inserting several instruments through a single port.
Morcellation of the uterine fundus is accomplished extraperitoneally with specimen removal through the umbilicus. Use of a wider port with the LESS technique allows for morcellation by hand under direct vision with a #15 scalpel. This makes morcellation easier, safer, and more efficient than using an automated morcellator placed through a smaller port as in traditional multiport laparoscopic hysterectomy. We have successfully removed multiple uteri in excess of 1,000 grams – including a 3,000-gram uterus – using this technique.
Overall surgical principles/technique
We routinely use either the SILS port (Covidien), which has a predetermined setup of channels as depicted in the illustrations, or the GelPoint (Applied Medical), which allows for various trocar arrangements. Other single-incision ports can be used, though; the key to the procedure lies not in the port used, but in the placement of the instruments. A right-angled light connector also is essential, as it deviates the light cord out of the surgical field.
Regardless of the single-incision port used, the camera and a laparoscopic single-tooth tenaculum are placed in the lateral trocars, in the same horizontal plane. The active, working instrument – either Kleppinger bipolar forceps or a 45-cm Harmonic ACE Shears (Ethicon Endo-Surgery) – is then placed in the middle trocar.
While the use of angled instruments may seem helpful for creating appropriate triangulation in LESS, we have found that such instrumentation is actually counterproductive. Angled instrumentation creates new angles, in essence, which complicates instrument placement and makes it more difficult to achieve enough intra-abdominal working space and avoid sword fighting.
One exception is the laparoscope. We have found that a 30-degree 5-mm bariatric-length laparoscope works best. When exposing the right side of the uterus, the laparoscope is first inserted into the far left trocar and directed toward the right lower quadrant of the abdomen. The camera is then angled to visualize the uterus from a slightly elevated position. In this position, the operator’s external hand – holding the camera – is now deviated inferiorly and to the left side of the patient.
A 5-mm single-tooth tenaculum is then inserted into the other lateral trocar and used to manipulate the uterus anteriorly and to the left. In a simple supracervical hysterectomy, once the uterus is properly positioned, the utero-ovarian ligament and fallopian tube are exposed. In surgeries involving oophorectomy, the ovary rather than the uterus is first grasped and deviated medially and elevated, exposing the infundibulopelvic ligament. In this position, the assistant’s external hand is now deviated slightly inferiorly and to the right side of the patient.
When properly placed, the camera and the tenaculum are crossed intra-abdominally and held in slightly elevated positions. This allows for insertion of the active instrument underneath both the camera and grasper and directly toward the tissue to be incised. The slight elevation and intra-abdominal crossing of the instruments, while at first confusing, serves to create the angles that give the surgeon good external work space as well as excellent internal range of motion. We apply a significant amount of tension on the uterus to create this working space. The greater the deviation of the uterus (and the longer the instruments), the more work space there is.
With correct instrument placement, the active trocar has direct access to the uterus, so insertion of an instrument is simple, ergonomic, and intuitive. With this positioning, the active instrument (bipolar forceps, harmonic scalpel, suction, or probe) also has complete freedom of movement internally and externally. The operator’s hand can move superiorly, inferiorly, or laterally as needed to access the uterus.