{"paper_id":"70ab2428-8f04-4c7b-89ff-c655b9d20ee3","body_text":"Journal of Investigative Surgery\nISSN: 0894-1939 (Print) 1521-0553 (Online) Journal homepage: www.tandfonline.com/journals/iivs20\nComparative Study of Complications and Incision\nEsthetic Satisfaction Between Single-Port\nLaparoscopy and Traditional Laparoscopy in\nBenign Gynecological Surgery\nJian Chen, Mengying Li, Yujiao Lai & Ping Xu\nTo cite this article: Jian Chen, Mengying Li, Yujiao Lai & Ping Xu (2024) Comparative Study\nof Complications and Incision Esthetic Satisfaction Between Single-Port Laparoscopy and\nTraditional Laparoscopy in Benign Gynecological Surgery, Journal of Investigative Surgery, 37:1,\n2419139, DOI: 10.1080/08941939.2024.2419139\nTo link to this article:  https://doi.org/10.1080/08941939.2024.2419139\n© 2024 The Author(s). Published with\nlicense by Taylor & Francis Group, LLC\nView supplementary material \nPublished online: 03 Nov 2024.\n Submit your article to this journal \nArticle views: 1109\n View related articles \nView Crossmark data\n Citing articles: 1 View citing articles \nFull Terms & Conditions of access and use can be found at\nhttps://www.tandfonline.com/action/journalInformation?journalCode=iivs20\n\nOriginal research\nJournal of InvestIgatIve surgery\n2024, vol. 37, no . 1, 2419139\nComparative Study of Complications and Incision Esthetic Satisfaction \nBetween Single-Port Laparoscopy and Traditional Laparoscopy in Benign \nGynecological Surgery\nJian chen, Mengying li, Yujiao lai and Ping Xu\ngynecological o ncology, Zhejiang Jinhua tumor Hospital, Jinhua, Zhejiang, China\nABSTRACT\nObjective: single-port laparoscopic surgery (sPls) is an effective, minimally invasive, feasible, and \npromising surgical technique for the treatment of various benign and malignant gynecological \ndiseases. This study aimed to evaluate the differences in surgical conditions, complications, and \nesthetic incisions between sPls and traditional laparoscopic surgery (Tls) in benign gynecological \nsurgeries.\nMethods: Fifty-one eligible patients were included, and their general information (age, surgical \napproach), surgical conditions (surgical time, blood loss, postoperative first flatus), postoperative \npain, and incision healing were collected.\nResults: There was a significant difference in the results of hysterectomy between the two groups. \nThe surgical time in the sPls group was significantly shorter than that in the Tls group ( p = 0.026). \nFurthermore, the sPls group had less blood loss ( p < 0.05) and earlier postoperative first flatus \n(p < 0.05) than the control group. There was no significant difference in postoperative conditions \nbetween the two groups. During the follow-up, it was found that the Vancouver s car s cale score \nwas 8.37 ± 2.30 in the control group and 6.81 ± 2.14 in the study group. The cosmetic effect and \nsatisfaction were better in the sPls group ( p = 0.018). subgroup analysis showed that in other \nbenign gynecological diseases without uterine lesions, sPls significantly improved surgical time, \nintraoperative blood loss, and postoperative first flatus ( p < 0.05).\nConclusion:  sPls demonstrated good clinical efficacy in benign gynecological surgery, with shorter \nsurgical time, less blood loss, earlier postoperative first flatus, fewer complications, and better \ncosmetic effects of scars.\nIntroduction\nGynecological diseases refer to reproductive system diseases \nin women, including endocrine disorders, infections, and \nvarious benign and malignant tumors. 1 Common benign \ngynecological diseases such as endometriosis, hysteromyoma, \nand adenomyosis can cause uterine bleeding, pelvic pain, \nreduced fertility, psychological disorders, and comorbidi -\nties,2–4 severely affecting women’s quality of life and mental \nhealth. The burden of benign gynecological diseases is high, \nespecially in low- and middle-income countries, where 7.75% \nof women of reproductive age are affected by benign gyne -\ncological diseases. 5 Surgery is the main treatment method \nfor most gynecological diseases, 6 especially minimally inva -\nsive surgery, which plays an important role in the treatment \nof benign or malignant gynecological diseases. 7,8 Minimally \ninvasive surgery has advantages such as smaller incisions, \nfaster recovery, shorter hospital stays, better cosmetic effects, \nand higher quality of life than traditional open surgery, 9,10 \nand it is increasingly favored by medical professionals, \npatients, and their families.\nLaparoscopic surgery is a commonly used minimally \ninvasive surgery in gynecology in recent years, which can be \nused to remove uterine and ovarian lesions, and even clean \nlymph nodes of malignant tumors. 11,12 Compared with tradi -\ntional surgery, it has the advantages of less damage, faster \nrecovery, and less postoperative discomfort. It has gradually \nreplaced laparotomy and is widely used in gynecology. 13,14 In \nrecent years, with the increasing demand for minimally \ninvasive surgery and the advancement of surgical instru -\nments and techniques, single-port laparoscopic surgery \n(SPLS) has been introduced into gynecological surgery. As a \nsurgical technique, SPLS usually consists of a single incision \nthrough the umbilicus, which is different from traditional \nlaparoscopic surgery (TLS), which requires at least two to \nthree incisions. 15 In the treatment of benign gynecological \ndiseases such as ovarian cysts, hysteromyoma, and ectopic \npregnancy, SPLS and TLS have become the gold standard for \n© 2024 t he a uthor(s). Published with license by taylor & f rancis group, ll C\nCONTACT Ping Xu  pingxu477@163.com   gynecological o ncology, Zhejiang Jinhua tumor Hospital, 1296 north r ing r oad, Jinhua, Zhejiang, 321000, China.\n supplemental data for this article can be accessed online at https://doi.org/10.1080/08941939.2024.2419139.\nhttps://doi.org/10.1080/08941939.2024.2419139\nt his is an o pen a ccess article distributed under the terms of the Creative Commons a ttribution-nonCommercial license ( http://creativecommons.org/licenses/by-nc/4.0/), which permits \nunrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. t he terms on which this article has been published allow \nthe posting of the a ccepted Manuscript in a repository by the author(s) or with their consent.\nARTICLE HISTORY\nr eceived 16 July 2024\na ccepted 15 o ctober 2024\nKEYWORDS\nsingle-port laparoscopic surgery; \ntraditional laparoscopic surgery; \ngynecology; complications; \nesthetic incision\n\n2 J. chen e T al.\ndisease treatment. 16,17 There could still be some variations of \nexperimental findings between the two in some illnesses, \nthough. A study on benign ovarian cysts showed that com -\npared to TLS, SPLS had no significant difference in hospi -\ntalization costs, but SPLS was associated with shorter \noperative times, less postoperative pain, and a significantly \nlower cyst rupture rate (3.0% vs. 22.2%). 18 However, an \nopposing result was observed in another study. 19 Similar \nissues have been found in other benign gynecological dis -\neases.15,17,20,21 In addition, due to the independence of the \nstudy, fewer studies have compared the results of SPLS and \nTLS in the comprehensive treatment of various benign gyne -\ncological diseases in clinical practice.\nTherefore, to determine the effectiveness of SPLS in \nbenign gynecological diseases, this study aimed to compare \nthe advantages and disadvantages of SPLS and TLS in terms \nof surgical time, postoperative pain, postoperative follow-up, \nand patient satisfaction in benign gynecological diseases, to \nassess the feasibility and safety of SPLS in benign gynecolog -\nical diseases and provide a new clinical basis for the appli -\ncation of SPLS in gynecological diseases.\nMethods\nEthical statement\nThe study was conducted under the principles of the \nDeclaration of Helsinki and obtained ethical approval from \nthe Institutional Review Board and Ethics Committee of our \nhospital. All participants in this study were fully informed \nand signed informed consent forms.\nSample size calculation\nThis study is designed as a single-center randomized con -\ntrolled trial, with the primary outcome being the amount of \nbleeding.18,22 The significance level is set at α = 0.05, and the \nstatistical power is 1 – β = 0.80. Utilizing an online sample \nsize calculation tool ( https://www.trialstats.com/statbox/\nindex.htm/samplesize/estimation?sid=4), we determined that \na total sample size of 34 to 124 participants is required. \nTaking into account a 20% dropout rate and the specific cir -\ncumstances of our hospital, we have established the target \nsample size at 80 patients, with 40 participants in each group.\nStudy design and population\nA total of 80 patients who underwent uterine lesion resec -\ntion surgery for uterine lesions and those who underwent \nlaparoscopic surgery for adnexal lesions (such as ovarian \ncysts, ovarian tumors, and ectopic pregnancy) at our hospital \nfrom July/2022 to November/2023 were collected. All patients \nwho agreed to participate were randomly assigned to either \nthe SPLS group ( n = 40) or the TLS group ( n = 40) using a \ncomputer-generated random number table after signing \ninformed consent forms. Both groups underwent surgery by \nthe same experienced surgical team, ensuring minimal tech -\nnical variation between the different approaches. Ultimately, \ndue to factors such as prolonged surgical time or significant \nbleeding caused by severe adhesions, loss to follow-up for \npatients from other regions, and noncompliance issues, 21 \npatients in the SPLS group and 30 patients in the TLS con -\ntrol group completed the study.\nWe collected general information on eligible patients, \nincluding age, body mass index, and underlying diseases. \nThe inclusion criteria for patients were as follows: (1) gen -\neral good condition; (2) no obvious pelvic adhesions; (3) \novarian cysts <8 cm, normal carbohydrate antigen 125 \n(CA-125) levels; (4) uterus <90 days of pregnancy, good \nactivity; (5) hysteromyoma smaller than 5 cm and solitary; \n(6) body mass index <35 kg/m2; (7) signed informed consent \nform; (8) good compliance and able to follow up regularly.\nThe following patients were excluded: (1) umbilical hole \ndysplasia or infection; (2) history of complex gynecological \nsurgery considered severe pelvic adhesions; (3) submucosal \nhysteromyoma; (4) cervical myoma; (5) gynecological malig -\nnant tumors. The detailed selection process of subjects for \nthis study is shown in Figure 1 .\nTreatment\n(1) Group\nSPLS group: General intravenous anesthesia with tracheal \nintubation was administered. Married patients were posi -\ntioned in a modified lithotomy position with a minimally \ninvasive uterine manipulator placed via the vagina, while \nunmarried patients were positioned in a “V” shape without \nthe use of a uterine manipulator, and a urinary catheter was \ninserted preoperatively.\nTo establish the surgical access, a 20 mm vertical incision \nwas made at the umbilicus, followed by the insertion of a \npneumoperitoneum needle and insufflation of CO 2 to a \npressure of 10–12 mmHg. A 10 mm trocar was placed at \nthe upper edge of the umbilicus for the laparoscope. Below \nthe umbilical trocar, one or two 5 mm trocars were inserted \non both sides for surgical instruments, arranged in a pattern \nresembling the Chinese character “pin” ( 品).\nTLS group: The anesthesia method and position were the \nsame as the SPLS group. A 10 mm vertical incision was made \nat the umbilicus, and after successfully establishing pneumoperi-\ntoneum, a 10 mm laparoscope was inserted. At McBurney’s \npoints on both sides and 1–2 cm above the pubic symphysis, \ntrocars and graspers were inserted through 5 mm incisions. For \nmyomectomy cases, the left McBurney’s incision was extended \nto 15–20 mm to allow the insertion of a uterine morcellator. \nThe surgical steps were essentially the same as those in SPLS.\n(2) Surgical procedure\nBoth groups underwent four types of surgeries: hysterec -\ntomy, adnexectomy, ovarian cystectomy, and myomectomy. \nThe techniques for these procedures were based on estab -\nlished methods from previous literature. For ovarian cystec -\ntomy, we followed the approach described by Zuo et  al., 23 \nwhich involved flipping and securing the affected ovary to \nthe abdominal wall. After electrocauterization to incise the \ncyst, it was carefully dissected from the ovarian cortex and \n\nJOurnal OF  inVesTiga TiVe surger Y 3\ncompletely excised, followed by hemostasis. Similarly, adnex -\nectomy was performed in accordance with previous stud -\nies,24,25 while myomectomy followed the method outlined by \nNiu et  al. 26 Hysterectomy was conducted according to the \ntechnique described by Xu et  al. 27\n(3) Postoperative management\nBoth groups of patients received postoperative care accord -\ning to standard protocols, including routine wound dressing \nchanges for the abdominal incision and other nursing \nmeasures.\nData collection\nMain observation indicators ( Online Appendix 1 , supple -\nmentary material):\n1. Surgical time (minutes, min): The time was counted \nfrom the start of the skin incision to the completion \nof skin closure.\n2. Intraoperative blood loss (milliliters, ml): The total \nvolume of liquid in the negative pressure suction bot -\ntle was subtracted from the total volume of irrigation \nfluid, and the blood loss was estimated using the area \nmethod. For example, the absorption of a 15 cm × \n20 cm gauze was 10 ml, and the absorption of four \nlayers of a 15 cm × 30 cm gauze pad was 60 ml. Total \nblood loss = Suction volume + Gauze absorption – \nVarious irrigation water volume during surgery.\n3. Postoperative first flatus of anus (hours, h): The clin -\nical efficacy of patients in the two groups was com -\npared. Criteria for efficacy assessment: ① Apparent \neffectiveness: Patients had no obvious infection after \nsurgery and had satisfactory recovery; ② Effectiveness: \nPatients had mild infection after surgery but had \ngood recovery; ③ Ineffectiveness: Patients had obvi -\nous infection after surgery and had unsatisfactory \nrecovery. Overall efficiency = (apparent effective -\nness + effectiveness)/total number × 100%.\nSecondary observation indicators:\n1. Pain scoring at 24 and 48 h after surgery. Changhai \nPain Scale ( Figure 2): a combination of the Numerical \nRating Scale (NRS) and Visual Analog Scale (V AS).\n2. Pain survey questionnaire scoring at 1 month after \nsurgery, also known as Brief Pain Inventory (BP) \n(Online Appendix 2 ).\nFigure 1.  f low chart of selecting study cohort.\nFigure 2.  Changhai pain scale.\n\n4 J. chen e T al.\n3. Esthetic satisfaction score: The Vancouver Scar Scale \n(Online Appendix 3 ) was used to evaluate scar \nappearance at 3 months postoperatively.\nStatistical analysis\nAll statistical analyses were performed using SPSS 26.0 \nsoftware. Normally distributed continuous variables were \npresented as mean ± standard deviation and compared \nusing independent samples t-test. Non-normally distrib -\nuted data were presented as median [interquartile range] \nand compared using the Mann-Whitney U test. Categorical \nvariables were presented as counts (percentages) and com -\npared using the chi-square test or Fisher’s exact test. A \ntwo-sided P value < 0.05 was considered statistically \nsignificant.\nResults\nGeneral information\nThis study included 51 patients with respectable benign \ngynecological tumors and divided them into two groups. \nThere were 30 cases in TLS group, with an average age of \n51.77 ± 9.03 years, and 21 cases in SPLS group, with an aver -\nage age of 49.19 ± 12.56 years. There was no significant dif -\nference in age between the two groups ( p > 0.05) (Table 1 ). \nThere were four surgical methods, including hysterectomy, \nadnexectomy, oophorocystectomy, and myomectomy. TLS \nwas most used for hysterectomy ( p = 0.011), as shown in \nTable 1.\nComparison of basic surgical conditions\nThe perioperative surgical outcomes are shown in Table 2 . \nCompared with TLS group, SPLS group had shorter surgical \ntime (98.95 ± 48.49 min, p = 0.026), less blood loss \n(16.76 ± 13.24 mL, p = 0.010), and earlier postoperative first \nflatus (31.29 ± 5.99 h, p < 0.001). These results indicated a sig -\nnificant advantage in SPLS.\nComparison of pain after surgery\nThe results in Table 3  showed that there were no signifi -\ncant differences in pain scores between the two groups, \nwhether it was in the short-term postoperative period (24, \n48 h) or in the long-term postoperative period (1 month) \n(p > 0.05).\nComparison of incision healing\nThe scar scores were 8.37 ± 2.30 in TLS group and 6.81 ± 2.14 \nin SPLS group. The wound healing of SPLS was significantly \nbetter than TLS ( p = 0.018). SPLS group patients had better \ncosmetic effects and higher satisfaction with the outcomes \nthan TLS group.\nSubgroup analysis\nComparison of indicators between the two groups in patients \nundergoing hysterectomy with adnexectomy showed no sig -\nnificant differences in any parameter ( p > 0.05, Online \nAppendix 4 ). In other benign gynecological surgeries, the \nuse of SPLS significantly improved surgical time, intraoper -\native blood loss, and postoperative first flatus time ( p < 0.05, \nTable 4).\nDiscussion\nIn recent years, with the growing focus of gynecological sur -\ngeons on minimally invasive techniques, laparoscopic \nTable 1. g eneral information of patients in the two groups.\nParameters\ntls group \n(n = 30)\nsPls group \n(n = 21) t value P value\nage 51.77 ± 9.03 49.19 ± 12.56 0.853 0.398\nsurgical methods\n Hysterectomy 20(66.7) 6(28.6) 7.714 0.011\n a dnexectomy 24(80.0) 15(71.4) – 0.518\n o ophorocystectomy 11(36.7) 6(28.6) 0.364 0.763\n Myomectomy 8(26.7) 1(4.8) – 0.064\nnote: Bold is the P value < 0.05, indicating a significant difference.\nTable 2. Comparison of surgery conditions between the two groups.\ngroup Case\nsurgical time \n(min) Blood loss (ml)\nPostoperative \nfirst flatus time \n(h)\ntls group 30 126.47 ± 37.10 32.17 ± 27.03 38.73 ± 5.83\nsPls group 21 98.95 ± 48.49 16.76 ± 13.24 31.29 ± 5.99\nt value – 2.296 2.412 4.441\nP value – 0.026 0.010 <0.001\nnote: Bold is the P value < 0.05, indicating a significant difference.\nTable 3. Comparison of postoperative pain between the two groups.\ngroup Case\nPain score at \n24 h after \nsurgery\nPain score at \n48 h after \nsurgery\nPain score at 1 \nmonth after \nsurgery\ntls group 30 4.07 ± 1.14 2.30 ± 0.54 0.67 ± 0.61\nsPls group 21 3.67 ± 0.91 2.33 ± 0.58 0.76 ± 0.70\nt value – 1.333 −0.212 −0.518\nP value – 0.189 0.833 0.607\nTable 4. Comparison o f tls and sPls in other benign gynecological diseases.\nIndicators\ntls group \n(n = 11)\nsPls group \n(n = 14) t value P value\nage 49.82 ± 10.22 46.50 ± 14.26 0.651 0.522\nsurgical time \n(min)\n106.82 ± 26.28 77.21 ± 32.71 2.443 0.023\nBlood loss (ml) 34.55 ± 26.16 11.21 ± 6.32 −3.325 0.001\nPostoperative \nfirst flatus \ntime (h)\n40.55 ± 5.80 29.14 ± 4.59 5.493 <0.001\nPain score at \n24 h after \nsurgery\n4.09 ± 1.38 3.36 ± 0.93 1.591 0.125\nPain score at \n48 h after \nsurgery\n2.27 ± 0.65 2.29 ± 0.47 −0.058 0.954\nPain score at 1 \nmonth after \nsurgery\n0.00[0.00,1.00] 1.00[0.00,1.00] −0.791 0.437\nscar scores 8.00 ± 2.05 6.93 ± 2.50 1.150 0.262\nnote: Bold is the P value < 0.05, indicating a significant difference.\n\nJOurnal OF  inVesTiga TiVe surger Y 5\nsurgery has become widely used in the treatment of benign \ngynecological diseases. 28 Among these, SPLS has gradually \nemerged as an alternative to TLS due to its association with \nless tissue damage, superior cosmetic outcomes, reduced \npostoperative pain, and shorter recovery periods. 20,29 Of \nthese advantages, the most notable is the cosmetic outcome, \nas SPLS utilizes an umbilical incision, rendering the scar vir -\ntually invisible, which is particularly appealing to younger \nfemale patients. 30 This esthetic benefit has significantly con -\ntributed to the growing demand for SPLS.\nThe results of this study indicate that compared to TLS, \nSPLS offers several advantages during the treatment of \nbenign gynecological diseases, including shorter surgical \ntime, reduced blood loss, earlier postoperative first flatus, \nand better cosmetic outcomes after scar healing. These find -\nings are consistent with those of Jiang et  al., 15 who reported \nthat in the SPLS group, specimen extraction time, postoper -\native ambulation time, postoperative first flatus time, and \nhospital stay were all significantly shorter, and the satisfac -\ntion with abdominal wall scarring was higher. However, the \nsurgical duration for SPLS was notably longer than for TLS. \nThis extended duration may be attributed to factors such as \nthe smaller sample size, the complexity of the procedures, \nand the experience of the surgeons. Specifically, the limited \noperating space within a single port can complicate and pro -\nlong the surgical steps. 31 Additionally, the size of the uterus \naffects the duration of hysterectomy, with larger uterine \nweights associated with longer operative times and greater \nestimated blood loss. 32 Moreover, reports suggest that fewer \ntrocar cannulas in laparoscopic approaches are associated \nwith smaller intraoperative spaces, potentially increasing the \ntime required for the procedure. 33 Therefore, the experience \nand technical skill of the surgeon are crucial for the success -\nful implementation of SPLS. Research on surgical scars and \npatient satisfaction also supports the cosmetic benefits of \nSPLS. A meta-analysis of patients undergoing myomectomy \nshowed that the SPLS group had significantly higher \nfollow-up satisfaction scores regarding abdominal scarring \ncompared to the TLS group, 17 indicating that SPLS, by \nreducing the number of incisions, achieved a more estheti -\ncally pleasing postoperative appearance, meeting patients’ \ndemand for a “scarless” surgery.\nPostoperative pain is a critical factor affecting patient \nrecovery, as it influences both the time to ambulation and \nimposes a significant psychological burden on patients. In \nour study, there were no significant differences in either \nearly or late postoperative pain scores between the SPLS and \nTLS groups. This finding suggests that, despite the relatively \nlarger umbilical incision in SPLS, it does not contribute to \nincreased postoperative pain. This observation contrasts with \nthe widely held belief that SPLS generally reduces postoper -\native pain. Theoretically, SPLS should reduce pain due to \nfewer incisions and less tissue damage. However, some stud -\nies have reported contrary findings, indicating that SPLS \nmay not significantly alleviate postoperative pain and could \neven increase pain due to specific factors. 34,35 We hypothe -\nsize that differences in postoperative pain may be attributed \nto variations in tissue handling during surgery, particularly \ninflammatory responses in surrounding tissues and potential \npostoperative complications such as hernias. Meta-analyses \nhave shown that the incidence of postoperative incisional \nhernias in SPLS is significantly higher than in TLS, approx -\nimately three times more frequent. 36,37 This increased inci -\ndence may contribute to higher postoperative pain in some \npatients. Therefore, despite the evident cosmetic advantages \nof SPLS, surgeons should inform patients about potential \ncomplications, particularly the risk of incisional hernia, \nbefore the procedure. Additionally, the number of trocars \nused during surgery may also affect postoperative pain. 38 \nTherefore, reducing the number of trocars or improving sur -\ngical techniques may help further minimize postopera -\ntive pain.\nIn this study, we also conducted a subgroup analysis to \ninvestigate the differences in outcomes between SPLS and \nTLS for hysterectomy with adnexectomy and other benign \ngynecological procedures. The results indicated that, except \nfor hysterectomy with adnexectomy, SPLS offered advantages \nsuch as reduced operative time, lower postoperative bleed -\ning, and earlier postoperative first flatus in other benign \ngynecological conditions, suggesting that SPLS has certain \nbenefits in these cases. These advantages may be diminished \nby the complexity of hysterectomy and adnexectomy and the \nrelatively small sample size. The anatomical complexity of \nthe uterus and adnexa could increase surgical difficulty, \nthereby reducing the potential advantages of SPLS compared \nto TLS. Moreover, the limited operating space within a sin -\ngle incision may contribute to increased surgical time and \ncomplexity. For larger ovarian cysts and uterine fibroids, the \nrestricted maneuverability of instruments in SPLS may lead \nto greater difficulty due to interference between instruments. \nAdditionally, patient factors such as obesity and tall stature \ncan complicate the procedure. Practical experience suggests \nthat combining SPLS with suspension techniques and effec -\ntive dissection can somewhat expand the surgical field and \nreduce operational difficulty. 39 Furthermore, robotic-assisted \nsurgery presents a viable solution, utilizing the precision of \nrobotic technology to mitigate the ergonomic limitations of \nSPLS.40–42 Future research should consider increasing sample \nsizes and exploring additional optimization strategies to val -\nidate the advantages and potential applications of SPLS in \nvarious clinical scenarios.\nWhile this study has provided valuable insights into the \ncomparison between SPLS and TLS for benign gynecological \nprocedures, it is not without limitations that may affect the \ngeneralizability and robustness of the results. Firstly, the \nstudy’s sample size is limited, particularly in the subgroup \nanalysis of hysterectomy with adnexectomy, where the num -\nber of patients is insufficient to achieve adequate statistical \npower. This small sample size may lead to result instability \nand limits a comprehensive assessment of the potential dif -\nferences between the surgical methods. Secondly, SPLS is \ntechnically challenging, especially when dealing with larger \nlesions. Variations in surgeon experience and skill levels \ncould significantly impact surgical outcomes. Although most \nsurgeries in this study were performed by the same surgical \nteam, the learning curve of the surgeons might still affect \nthe operation time and complication rates. Thirdly, the \nfollow-up period of this study was relatively short, focusing \n\n6 J. chen e T al.\nprimarily on the short-term postoperative recovery phase \nand not adequately assessing long-term outcomes such as \ndelayed complications (e.g., incisional hernias) or quality of \nlife improvements. Thus, differences in long-term prognosis \nbetween SPLS and TLS need further validation through \nextended follow-up data. Lastly, some postoperative metrics, \nsuch as pain scores and scar satisfaction, are based on sub -\njective patient assessments, which may be influenced by \nindividual differences, psychological state, and pain toler -\nance, potentially introducing bias in the scoring results. This \ncould somewhat obscure the actual differences in postoper -\native recovery between SPLS and TLS. Future research \nshould address these limitations by increasing the sample \nsize, conducting multi-center studies, and extending \nfollow-up periods to more thoroughly evaluate the advan -\ntages and disadvantages of SPLS versus TLS. Additionally, \ncontrolling for surgeon experience and using objective \nassessment criteria can provide a more comprehensive eval -\nuation of the clinical effects of these surgical approaches.\nAuthor contribution\nJian Chen: Conceptualization, Data curation, Writing – Original draft  \npreparation.\nMengying Li: Data curation, Visualization, Investigation, Writing – \nOriginal draft preparation.\nYujiao Lai: Validation, Investigation, Writing – Reviewing and \nEditing.\nPing Xu: Supervision, Software, Writing – Reviewing and Editing.\nDisclosure statement\nNo potential competing interest was reported by the authors.\nEthics approval and consent to participate\nThis study was approved by Zhejiang Jinhua Tumor Hospital Ethics \nCommittee (2022-006-01). Informed consent was waived by the com -\nmittee because of the retrospective nature of the study.\nData availability statement\nThe datasets generated and analyzed during the current study are not \npublicly available but are available from the corresponding author on \nreasonable request.\nReferences\n 1. Ciebiera M, Esfandyari S, Siblini H, et  al. Nutrition in gynecolog -\nical diseases: current perspectives. Nutrients. 2021;13(4):1178. \ndoi:10.3390/nu13041178.\n 2. Zondervan KT, Becker CM, Koga K, Missmer SA, Taylor RN, \nViganò P . Endometriosis. Nat Rev Dis Primers . 2018;4(1):9. \ndoi:10.1038/s41572-018-0008-5.\n 3. Vannuccini S, Petraglia F . Recent advances in understanding and \nmanaging adenomyosis. F1000Res. 2019;8:283. doi: 10.12688/\nf1000research.17242.1.\n 4. Shi X, Chen S, Y ang Y , Liu L, Huang L. Laparoscopic surgeries \nfor uterine fibroids and ovarian cysts reduce ovarian reserve via \nage- and surgical type-manner. 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