Single port laparoscopic hysterectomy
• Umbilical suturing. We close the umbilicus with one running 3-4-bite suture through the fascia and peritoneum of 0-Vicryl or 0-PDS (polydioxanone). The skin is closed with three to five sutures – one that reattaches the center of the umbilicus to the fascial plate and one or two inverted sutures on either side that reapproximate the lower and upper poles of the umbilicus.
• Postoperative care. Patients are discharged either the evening of the procedure or, if they choose, the following morning. We use 0.25% Marcaine with epinephrine in the umbilicus for preemptive analgesia. Xeroform gauze is placed in the umbilicus. The wound is then covered with an eye patch and Tegaderm for 3 days. The umbilicus has a poor nerve supply, which helps minimize pain, but it also has a poor blood supply, which slows the healing process. We have found that a 1-week course of broad-spectrum antibiotics promotes and speeds healing.
Outcomes/experience
In 2009, at a set point in time, I transitioned to LESS as the primary approach for all laparoscopic hysterectomies. As a result, I have been able to compare the LESS approach to traditional multiport laparoscopic hysterectomy using my own cases as retrospective controls, free of selection bias. Allowing for a short learning curve of about 20 cases, analysis of our data revealed no significant difference in operative times, blood loss, conversion to laparotomy, or complication rates.
Our patients have had significantly lower pain levels with LESS, which is consistent with the literature. The cosmetic advantages of LESS have also been significant. In addition, the lack of accessory ports in LESS eliminates any potential for port-site complications such as hematoma or hernia. Umbilical hernias have been rare in our patients, occurring in only one or two patients.
Interestingly, we found that as uterine weight increased, operating times with the LESS procedure increased at a lower rate than did operating times with traditional laparoscopy. Clearly, large uteri are more easily removed with a single-port technique using extraperitoneal morcellation than with a traditional four-port technique using an automated morcellator through an accessory port. Extracorporeal morcellation with LESS is also safer and less expensive.
Dr. Wagner has been in private practice in East Northport, N.Y., since 1991. He practices at Huntington (N.Y.) Hospital, where he is the codirector of minimally invasive surgery. He was instrumental in developing the gynecologic residency program at the institution. Dr. Wagner reported that he has no financial disclosures relevant to this Master Class.
*Correction 7/30/2013: This article was updated to reflect new information from the author.
