{"paper_id":"715513ba-e350-4728-b113-cb7c7c27deb4","body_text":"Submit Manuscript | http://medcraveonline.com\nIntroduction\nPresence of adnexal mass is one of the most common indications \nfor referral to the gynecologist. Adnexal masses can be discovered \naccidently in patients being evaluated for a gynecological complaint \nor even in asymptomatic patient.1\nLaparoscopic surgery is a well-established alternative to open \nsurgery across disciplines due to the benefits of laparoscopy on \npostoperative pain, cosmesis, hospital stay, and convalescence are \nwidely recognized.2,3 Laparoscopy has wide applications in the field \nof reproductive surgery. Firstly, it has been used successfully for the \nassessment of different factors of infertility including the ovarian \nfactor, the tubal factor and the unexplained infertility. Moreover, it \nhas been used for pelvic reconstruction in patients with extensive \nadhesions and those with advanced endometriosis.4\nThe use of laparoscopy in the management of gynecologic \nmalignancies has increased over the last 10 years. 5 The safety of \npelvic and para-aortic lymphadenectomy has been established by \nmany surgeons.6 Patients with early carcinoma of the cervix are now \nundergoing hysterectomy after laparoscopic lymphadenectomy. 7 \nStaging and second – Look procedures are now being performed \nlaparoscopically in selected patients with carcinoma of the ovary.5,8\nLaparo-Endoscopic Single Site Surgery (LESS) was first \ndescribed in the gynecology literature in 1969; tubal ligation being \nthe first procedure routinely performed through a single incision at \nthe umbilicus.9 The first published report in general surgery appeared \nin 1992 with appendectomies. 10 Currently, the debate continues \nof whether LESS has anything more to offer to the patient, to the \nsurgeon, or to the health care industry compared with the conventional \nlaparoscopic approach. 11 Since that time, thousands of (LESS) \nprocedures have been successfully performed in the united states, \nfrom general surgery to urologic, gynecologic and bariatric surgery \napplications.\nWhen compared with traditional multi-port laparoscopic \nObstet Gynecol Int J . 2018;9(5):309‒313. 309\n©2018 Kamel et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which \npermits unrestricted use, distribution, and build upon your work non-commercially.\nLaparo-endoscopic single site (LESS) versus multi-\nport operative laparoscopy for benign adnexal \nmasses\nVolume 9 Issue 5 - 2018\nMostafa M Kamel, Mohammed A Bedaiwy, \nAhmed M Abbas, Safwat A Salman, \nMohammed A Y oussef\nDepartment of Obstetrics & Gynecology, Faculty of Medicine, \nAssiut University, Egypt\nCorrespondence: Ahmed M Abbas MD, Department of \nObstetrics & Gynecology, Faculty of Medicine, Woman’s Health \nHospital, Assiut University, Assiut, Postal code 71111, Egypt, T el \n+2 01003385183, Email bmr90@hotmail.com\nReceived: July 31, 2018 | Published: September 07, 2018\nAbstract\nObjective: The aim of the current study was to compare the use of the single port \nlaparoscopy versus the use of the conventional multiport laparoscopy in the management \nof benign adnexal diseases.\nSetting: Women’s Health Hospital, Assiut University, Egypt.\nPatients and methods: This was a non-randomized comparative study conducted between \nOctober 2014 and October 2016 in Women’s Health Hospital at Assiut University, Egypt. \nThe study included 60 cases: 40 of them by the conventional multiport laparoscopy, 20 of \nthem by the single port laparoscopy with a confidence interval 95% and power 80%.\nStudy outcomes included the mean duration of surgery, the amount of blood loss and need \nfor blood transfusion, the mean total IM analgesia, the mean total numbers of doses of oral \nanalgesics, the recovery duration, the mean time from surgery to unassisted ambulation, the \nmean post-operative hospital stay, the mean time to return to sexual activity and finally the \noverall satisfaction score from the procedure.\nResults: The mean age of the participants in group I was 26.53±5.12 years versus 24.75±3.78 \nyears in group II with no statistically significant difference between the two groups. The \nmean BMI in group I is 26.25±2.33 versus 23.85±2.56 in group II with a statistically higher \ndifference (p=0.001). The mean duration of surgery in group I is 57.90 ± 22.94 minutes \nand in group II is 73.50 ± 17.93 with a statistically significant difference (p=0.006). The \nmean dose of IM analgesic is 41.88±17.35mg in group I versus 76.25±27.48mg in group \nII with a statistically significant difference (p=0.000). The mean dose of oral analgesic \nis 416.25 ± 84.84mg in group I versus 271.25 ± 57.51mg in group II with a statistically \nsignificant difference (p=0.000). The mean recovery duration by minutes is 10.02±1.86 \nin group I versus 9.70±1.26 in group II with no statistically significant difference. The \nmean hospital stay by days is 1.78±0.66 in group I versus 1.20±0.41 in group II with a \nstatistically significant difference (p-0.001). The mean time taken to early ambulation by \nhours is 7.58±1.89 in group I versus 6.85±1.60 in group II with no statistically significant \ndifference. \nConclusion: LESS is better than conventional in post-operative pain in the first week, less in \nhospital stay length, less in time taken to sexual activity and better in the overall satisfaction \nscore. However, LESS takes longer duration of surgery and more pain immediately after \nrecovery in the first few hours post operatively.\nKeywords: laparoscopy, adnexa masses, LESS, ovary\nObstetrics & Gynecology International Journal \nResearch Article\n Open Access\n\n\nLaparo-endoscopic single site (LESS) versus multi-port operative laparoscopy for benign adnexal masses\n310\nCopyright:\n©2018 Kamel et al.\nCitation: Kamel MM, Bedaiwy MA, Abbas AM, et al. Laparo-endoscopic single site (LESS) versus multi-port operative laparoscopy for benign adnexal masses. \nObstet Gynecol Int J. 2018;9(5):309‒313. DOI: 10.15406/ogij.2018.09.00353\ntechniques, benefits of (LESS) techniques include less postoperative \npain, less blood loss, faster recovery time, and better cosmetic results \n“Despite the potential advantages of LESS techniques, there may \nbe complication.12,13 Potential complications include significant post \noperative pain injury to organs, bleeding, infection, incisional hernia, \nintestinal adhesions and scarring.14,15\nA 2016 review found no difference in complication rates comparing \nLESS hysterectomy to conventional hysterectomy for both major and \nminor complications.16 Single incision laparoscopic surgery is a very \nexciting new modality in the field of minimal access surgery which \nworks for further reducing the scars of standard laparoscopy towards \nscarless surgery.17\nIn our study, we compared the use of the single port laparoscopy \nversus the use of the conventional multiport laparoscopy in the \nmanagement of benign adnexal diseases.\nMethods\nThis was a non-randomized comparative study conducted between \nOctober 2014 and October 2016 in Women’s Health Hospital at Assiut \nUniversity, Egypt. All patients signed an informed consent form \nsubmitted for approval from Assiut Medical School Ethical Review \nBoard.\nThe patients were recruited from those visited the outpatient \ngynecological clinic and those admitted inpatient units in Women’s \nHealth Hospital. Patients diagnosed with a variety of benign adnexal \nlesions who are candidates for surgical interventions were included \nin the study. We excluded those with pelvic infection, suspected \nmalignancy, prior laparotomy including CS, morbid obesity (BMI \n>30), medical co-morbidities as DM, hypertension and finally those \nwith large adnexal masses more than 6 cm in diameter.\nThe study included 60 cases: 40 of them by the conventional \nmultiport laparoscopy, 20 of them by the single port laparoscopy with \na confidence interval 95% and power 80%.\nAll patients, after signing the consent, were subjected to the \nfollowing: Full history taking, general examination, local vaginal \nexamination and bimanual examination, weight and height \nmeasurements for calculation of the body mass index (BMI). Ultrasound \nevaluation was done using a SonoAce X8 machine (Medison, Korea) \nwith multifrequency transabdominal and transvaginal probes.\nIn LESS cases, all surgical steps were performed through the \ntransumbilical single port without insertion of addition ports or \nany extraumbilical instruments. 4 Under general anesthesia and \nendotracheal intubation, the patient was placed in the low lithotomy \nposition. Access was gained using a modified open Hasson technique, \nwith a 1,8-cm horizontal umbilical incision. 18 The rectus fascia was \nsharply incised, and a Covidien single access (Coviedien, Mansfield \nMA, USA) multichannel part was inserted in the peritoneal cavity. \nThe port has an insufflation channel that allows carbon dioxide \ninsufflation with the pressure set at 15mm Hg. The conventional 30 \ndegree laparoscope was used. If the flexible scope is to be used, the tip \nof the scope can be adjusted to the center of the surgical field without \nmoving the straight segment to provide adequate triangulation and \navoid clashing with the surgeon’s instruments.19\nLeft pelvic side wall adhesions were be released from the lateral \npelvic wall using flexible or conventional laparoscopic shears \n(Cambridge Endo, Framingham, MA), which help to improve the \nsurgical range of motion to reach extreme angles in the pelvis. 20 \nWe then grasped the tubes and ovaries, brought them through the \nmultichannel port after detaching all the trocars from the abdomen. \nCurved instruments (Pnavel Systems, Morganville, NJ) and \narticulating graspers (Novare Surgical Systems, Cupertion, CA). Was \nhelpful in providing efficient retraction to optimize surgical exposure. \nDeep infiltrating endometriotic implants was carefully dissected of the \nsurrounding structures and excised. In a similar fashion, endometriosis \nof the surface of the urinary bladder was also removed.21\nIn multiport cases,  Patient kept in steep trendelenburg and \nlithotomy position. One assistant stand between the legs of the patient \nto do uterine manipulation whenever required. Position should be in \naccordance with baseball diamond concept. Properly placed uterine \nmanipulator is important to get a good exposure of ovary and tube. It \nis sometimes difficult to mobilize the uterus and the uterine ovarian \nligament can be grasped by one of the traumatic grasper to lift and \nisolate the ovary or the ovary can be wedged against the pelvic \nsidewall using the flattened edges of the opened or closed forceps. 4 \nIt is important to remember that overly aggressive manipulation \ncan cause lacerations in the capsule, follicles, or cysts and result in \nbleeding. Before starting the procedure, we observed the course of the \nureter as it crosses the external iliac artery near the bifurcation of the \ncommon iliac artery at the pelvic brim. The left ureter can be more \ndifficult to find because it is often covered by the base of the sigmoid \nmesocolon.19\nMany time anatomic landmarks are distorted by adhesions \nendometriosis, or prior surgical exploration. In those cases dissection \nstarted from the most normal area and then it should proceed toward the \nmore distorted parts of the operative field. At the end of the procedure, \nthe operative field was inspected and any clots were removed with \na suction-irrigator or grasping forceps. Pedicles are inspected under \nwater and with decreased pneumoperitoneum and any bleeding if \npresent can be controlled with bipolar electrocoagulation.20,21\nAll patients were reevaluated after two weeks. Patients were asked \nabout the time taken for them to resume full domestic function and \nsexual activity. They were also interviewed regarding their level of \nsatisfaction with the appearance of the surgical scar and their overall \nlevel of satisfaction with the procedure. Overall patient satisfaction \nwith the procedure was scored on a numerical 1 to 10 scale, with 1 \nrepresenting lowest level of satisfaction and 10 representing highest \nlevel of satisfaction.22\nStudy outcomes included the mean duration of surgery, the \namount of blood loss and need for blood transfusion, the mean total \nIM analgesia (Pethidine dose), the mean total numbers of doses of \noral analgesics, the recovery duration, the mean time from surgery to \nunassisted ambulation, the mean post-operative hospital stay, the mean \ntime to return to sexual activity and finally the overall satisfaction \nscore from the procedure.\nStatistical analysis\nData were processed using Statistical Package of Social \nSciences version 22.0 (SPSS version 22.0 Inc., Chicago, IL, USA). \nQuantitative data were expressed as means ± standard deviation (SD) \nas appropriate. Qualitative data was expressed as frequency (numbers) \nand percentages. Fisher exact test and T. test were used to compare \nqualitative variables and Mann-Whitney test was used to compare \nquantitative variables between groups. A probability value (p-value) < \n0.05 was considered statistically significant.\n\nLaparo-endoscopic single site (LESS) versus multi-port operative laparoscopy for benign adnexal masses\n311\nCopyright:\n©2018 Kamel et al.\nCitation: Kamel MM, Bedaiwy MA, Abbas AM, et al. Laparo-endoscopic single site (LESS) versus multi-port operative laparoscopy for benign adnexal masses. \nObstet Gynecol Int J. 2018;9(5):309‒313. DOI: 10.15406/ogij.2018.09.00353\nResults\nSixty cases were recruited in our study, 40 cases done by the \nconventional multiport laparoscopy (group I) and 20 cases done by the \nsingle port laparoscopy (group II). The mean age of the participants \nin group I was 26.53±5.12 years versus 24.75±3.78 years in group II \nwith no statistically significant difference between the two groups. \nThe percentage of rural residency is (60%) in group I versus (65%) \nin group II while the percentage of urban residency (40%) in group \nI versus (35%) in group II with no statistically significant difference. \nThe mean BMI in group I is 26.25±2.33 versus 23.85±2.56 in group II \nwith a statistically higher difference (p=0.001) (Table 1). \nT able 1 Demographic data of the study participants \n Group I (n= 40) Group II (n= 20) P-value\nAge: (years)\n0.299Mean ± SD 26.53 ± 5.12 24.75 ± 3.78\nRange 19.0 - 40.0 19.0 - 31.0\nResidency: No. (%)\n0.707Rural 24 (60.0%) 13 (65.0%)\nUrban 16 (40.0%) 7 (35.0%)\nBMI (kg/m2):\n0.001*Mean ± SD 26.25 ± 2.33 23.85 ± 2.56\nRange 20.0 - 29.0 19.0 - 29.0\nPassive smoking: \nNo. (%) 23 (57.5%) 11 (55.0%) 0.854\n*Statistical significant difference\nBMI, body mass index; SD, standard deviation; Group I, conventional \nlaparoscopy group; Group II, single port group\nTable 2 shows that there is no statistically significant difference \nbetween the indications of laparoscopy in both groups. Table \n3 shows the mean duration of surgery in group I is 57.90 ± 22.94 \nminutes and in group II is 73.50 ± 17.93 with a statistically significant \ndifference (p=0.006). There is no statistically significant difference \nbetween group I and group II as the mean amount of blood loss is \n84.00±75.85cc in group I versus 45.00±12.14cc in group II. Similarly, \nno statistically significant difference according the need of blood \ntransfusion between both groups (p=0.291).\nT able 2 The indications of laparoscopy in the study participants \nDiagnosis Group I \n(n= 40)\nGroup II \n(n= 20) P-value\nDermoid cyst 3 (7.5%) 1 (5.0%) 1\nEctopic pregnancy 6 (15.0%) 1 (5.0%) 0.407\nEndometriotic cyst 5 (12.5%) 1 (5.0%) 0.653\nHemorrhagic cyst 2 (5.0%) 2 (10.0%) 0.595\nSimple ovarian cyst 9 (22.5%) 5 (25.0%) 1\nPCO 15 (37.5%) 10 (50.0%) 0.355\nPCO, polycystic ovaries; Group I, conventional laparoscopy group; Group II, \nsingle port group\nThe mean dose of IM analgesic is 41.88±17.35mg in group I versus \n76.25±27.48mg in group II with a statistically significant difference \n(p=0.000). The total dose of oral analgesia which was calculated \nby multiplying the dose by the number of doses by the number of \ndays. The mean dose of oral analgesic is 416.25 ± 84.84mg in group \nI versus 271.25 ± 57.51mg in group II with a statistically significant \ndifference (p=0.000).\nIn Table 4, the postoperative data was presented. The mean recovery \nduration by minutes is 10.02±1.86 in group I versus 9.70±1.26 in \ngroup II with no statistically significant difference. The mean hospital \nstay by days is 1.78±0.66 in group I versus 1.20±0.41 in group II with \na statistically significant difference (p-0.001). The mean time taken to \nearly ambulation by hours is 7.58±1.89 in group I versus 6.85±1.60 \nin group II with no statistically significant difference. The mean time \ntaken to normal sexual activity by days is 15.58±7.18 in group I \nversus 9.95±6.75 in group II with a statistically significant difference \n(p=0.005). The mean of the overall satisfaction score is 5.23±1.48 in \ngroup I of patients versus 7.10±1.12 in group II of patients and the \nrange of the score is from 2.0-8.0 in group I of patients versus 5.0-\n9.0 in group II of patients with a statistically significant difference \nbetween the two groups (p=0.000).\nT able 3 Intra-operative data of the study groups\n Group I (n= 40) Group II (n= 20) P-value\nDuration of surgery: (min)\n0.006*Mean ± SD 57.90 ± 22.94 73.50 ± 17.93\nRange 30.0 - 105.0 50.0 - 100.0\nAmount of blood loss: (cc)\n0.199Mean ± SD 84.00 ± 75.85 45.00 ± 12.14\nRange 20.0 - 350.0 30.0 - 80.0\nBlood transfusion: No. (%)\n0.291Yes 4 (10.0%) 0 (0.0%)\nNo 36 (90.0%) 20 (100.0%)\nSD, standard deviation; Group I, conventional laparoscopy group; Group II, \nsingle port group\nT able 4 Post-operative data of the study groups\n Group I (n= 40) Group II (n= 20) P-value\nRecovery duration: (min)\n0.578Mean ± SD 10.02 ± 1.86 9.70 ± 1.26\nRange 6.0 - 15.0 8.0 - 12.0\nHospital stay: (days)\n0.001*Mean ± SD 1.78 ± 0.66 1.20 ± 0.41\nRange 1.0 - 3.0 1.0 - 2.0\nTime taken to early ambulation: (hours)\n0.149Mean ± SD 7.58 ± 1.89 6.85 ± 1.60\nRange 4.0 - 12.0 4.0 - 10.0\nTime taken to sexual activity: (days)\n0.005*Mean ± SD 15.58 ± 7.18 9.95 ± 6.75\nRange 7.0 - 28.0 1.0 - 28.0\n*Statistical significant difference\nSD, standard deviation; Group I, conventional laparoscopy group; Group II, \nsingle port group\n\nLaparo-endoscopic single site (LESS) versus multi-port operative laparoscopy for benign adnexal masses\n312\nCopyright:\n©2018 Kamel et al.\nCitation: Kamel MM, Bedaiwy MA, Abbas AM, et al. Laparo-endoscopic single site (LESS) versus multi-port operative laparoscopy for benign adnexal masses. \nObstet Gynecol Int J. 2018;9(5):309‒313. DOI: 10.15406/ogij.2018.09.00353\nDiscussion\nAbout 10% of women undergo exploratory surgery for evaluation \nof adnexal masses during their life time. The aim of the current study \nover a period of two years was to compare (LESS) to the conventional \nlaparoscopy in management of adnexal masses. There is only \nstatistically significant difference between the two groups regarding \nBMI explained as it is a new surgical technique, we selected less \nBMI for fear of failure, transport to conventional technique or open \nsurgery, intraoperative or postoperative complications related to the \nincreased BMI and more prolongation to the operative time. Difficulty \nin closure of the port site in obese patients and the possibility of part \nsite hernia post-operative is more suspected with the obese patients. \nThe distance between the umbilicus and the target organ changes \nin obese patients, for these reasons obese patients may not be good \ncandidates for LESS.20\nIn our study, there is increase in the duration of surgery with the \nLESS group, this is agreeing with what we mentioned in the review of \nliterature as with the learning curve with any new surgical techniques, \nit will take a long time in the beginning but by performing more cases, \nthe operation time begins to decrease until it reaches a plateau.7\nAlso, as with most new surgical techniques, the early development \nof LESS surgery was fraught with problems, the main problems \nwith performing LESS surgery are: loss of triangulation, clashing of \ninstruments, telescope and comer ahead and lack of maneuverability. \nThose factors are sharing in the causes of the more prolonged operative \ntime in the (LESS) group.23\nThe use of analgesia either immediately after recovery or during \nthe next post operative week is different between the two groups with \na statistically significant difference. Immediately after recovery, we \nused more concentrations (doses) of analgesia in the group II done \nby LESS, while we used more doses of analgesia in the group I done \nby the conventional multiport laparoscopy in the next post operative \nweek. These results are not coinciding with Meta-analysis study on \npooled data as revealed no significant difference between LESS and \nconventional laparoscopy.24 \nThis is explained by: The increased pain in our study in the first \nfew hours immediately after recovery in the group II may be due to: \nLarger port system in the single port, Decreased the angle of freedom, \nIncisions in the umbilicus cause pain with respiratory movement, \nProlonged operative time and more manipulations causing visceral \npain as it is a new surgical technique and it will have its normal \nlearning curve onwards.\nThe use of more analgesia in the first few days after surgery is \nmore with the conventional laparoscopy. These results agree with \nwhat mentioned in the literature, this is due to: decreased number \nof ports which is associated with fewer painful points after surgery, \nSubsequent fewer potential locations for wound complications \nincluding bleeding and infection.\nThere is a difference between group I and group II according to \nhospital stay, with a statistically significant difference showing that the \n(LESS) is associated with shorter hospital stay than the conventional \nlaparoscopy. These results coincide with what mentioned in the review \nof literature.7,25 These authors declared that faster recovery following \nLESS leads to a reduced time of returning to work and in turn shorter \ntime to regain normal sexual activity.\nThere is no statistically significant difference between group I and \ngroup II according to the time taken to early ambulation by hours \nwhile the time taken to normal sexual activity (few days) is less with \ngroup II which was done by the single port laparoscopy.\nOur results showing also no difference between group I and group \nII according to scar satisfaction, these results coincide with what \nmentioned in the literature. Reduced number of ports causes fewer \nscars. Although LESS port needs a 2 cm incision, it is usually concealed \nin the umbilicus. Therefore, in some cases the minimally invasive \nsurgery may even by virtually scar less. 26 However, other studies \ninvestigated the cosmetic outcomes have not reported a significant \ndifference between LESS and CLS in abdominal procedures.7,25\nIn our study, there is a statistically significant difference between \ngroup I and group II, showing that there is more overall satisfaction \nscore in group II than that in group I. these results coincide and agree \nwith what reported in the review of literature. However, standardized \nmethods of measuring patient’s satisfaction should be used in \nlarge sample size randomized controlled trials (RCTs) to compare \nsatisfaction between single port laparoscopy groups and conventional \nlaparoscopy groups.\nConclusion \nThe present study demonstrated that the LESS approach is a \npromising method of laparoscopy and we compared between it and \nthe conventional multiport operative laparoscopy. LESS is better \nthan conventional in post-operative pain in the first week, less in \nhospital stay length, less in time taken to sexual activity and better in \nthe overall satisfaction score. However, LESS takes longer duration \nof surgery and more pain immediately after recovery in the first few \nhours post operatively.\nThe present study represents a small size population, which was one \nof our limitations, so large population size studies are recommended, \nwith more inclusion criteria to reach more informative results and put \nclear values for different variables and more diagnostic models than \nthat used in this study. Our recommendations, regarding LESS are \nmore training, more cases to increase the learning curve especially the \nresidents in the tertiary hospitals to overcome the increased operative \ntime and in turn the pain immediately after recovery. Uniforming one \ndiagnosis will help more training, more experience and judgment in \nLESS surgery, as ectopic pregnancy either undisturbed, disturbed \nand chronic ectopic pregnancy. Encouraging all highly experience \nsurgeons in the conventional laparoscopy to use the LESS and train \nthe residents as LESS is considered a growing minimally invasive \nfuture laparoscopic surgery.\nAcknowledgments\nNone. \nConflicts of interest\nThe author declares that they have no conflict of interest.\nReferences\n1. Gaughan E, Javaid T, Cooley S. Study of ovarian cancer management. \nIrish medical journal. 2006;99(9):279−280.\n2. Ali MK, Abdelbadee AY , Abbas AM, et al. Laparoendoscopic single-\nsite surgery in gynaecologic oncology. World J Laparosc Surg . \n2012;5(3):121–127.\n\nLaparo-endoscopic single site (LESS) versus multi-port operative laparoscopy for benign adnexal masses\n313\nCopyright:\n©2018 Kamel et al.\nCitation: Kamel MM, Bedaiwy MA, Abbas AM, et al. Laparo-endoscopic single site (LESS) versus multi-port operative laparoscopy for benign adnexal masses. \nObstet Gynecol Int J. 2018;9(5):309‒313. DOI: 10.15406/ogij.2018.09.00353\n3. Boruta DM. Laparoendoscopic single-site surgery in gynecologic \noncology: an update. Gynecol Oncol. 2016;141(3):616−623.\n4. Ahmed K, Wang TT, Patel VM, et al. The role of single-incision \nlaparoscopic surgery in abdominal and pelvic surgery: a systematic \nreview. Surg Endosc. 2011;25(2):378−396.\n5. Zullo F, Falbo A, Palomba S. Safety of laparoscopy vs laparotomy in \nthe surgical staging of endometrial cancer: a systematic review and \nmetaanalysis of randomized controlled trials. Am J Obstet Gynecol . \n2012;207(2):94−100.\n6. Azziz M, Frumovitz M, Greer M, et al. Trends in laparoscopic and robotic \nsurgery among gynecologic oncologists: a survey update. Gynecol Oncol. \n2004;112(3):501−505.\n7. Fader AN, Escobar PF. Laparoendoscopic single-site surgery (LESS) \nin gynecologic oncology: Technique and initial report. Gynecol Oncol. \n2009;114:157–161. \n8. Ali MK, Abdelbadee AY , Shazly SA, et al. Robotic gynecological surgery: \na clinical approach. World J Laparoscop Surg. 2013;6(3):156–162.\n9. Scott F, Cromi A, Fasola M, et al. One trocar salpingectomy for the \ntreatment of tubal pregnancy: a ‘marionette-like’technique. BJOG. \n2007;112(10):1417−1419.\n10. Koh AR, Lee JH, Choi JS, et al. Singleport laparoscopic appendectomy \nduring pregnancy. Surg Laparosc Endosc Percutan Tech. 2012;22(2):e83−\ne86. \n11. Kommu SS, Kaouk JH, Ran é A. Laparo-endoscopic single-site \nsurgery: preliminary advances in renal surgery. BJU international . \n2009;103(8):1034−1037.\n12. Hall TC, Dennison AR, Bilku DK, et al. Single-incision laparoscopic \ncholecystectomy: a systematic review. Arch Surg. 2012;147(7):657−666.\n13. Aarts JW, Nieboer TE, Johnson N, et al. Surgical approach to \nhysterectomy for benign gynaecological disease. The Cochrane Library. \n2015;(8):Cd003677.\n14. Song T, Kim ML, Jung YW, et al. Laparoendoscopic single-site versus \nconventional laparoscopic gynecologic surgery: a metaanalysis of \nrandomized controlled trials. Am J Obstet Gynecol. 2013;209(4):317.\n15. Mittermair C, Schirnhofer J, Brunner E, et al. Single port laparoscopy \nin gastroenterology and hepatology: a fine step forward. World J \nGastroenterol. 2014;20(42):15599−15607.\n16. Sandberg EM, la Chapelle CF, van den Tweel MM, et al. \nLaparoendoscopic single-site surgery versus conventional laparoscopy \nfor hysterectomy: a systematic review and meta-analysis. Arch Gynecol \nObstet. 2017;295(5):1089−1103.\n17. Sajid MS, Ladwa N, Kalra L, et al. Single-incision laparoscopic \ncholecystectomy versus conventional laparoscopic cholecystectomy: \nmetaanalysis and systematic review of randomized controlled trials. \nWorld J Surg. 2012;36(11):2644−2653.\n18. Escobar PF, Bedaiwy MA, Fader AN, et al. Laparoendoscopic single-\nsite (LESS) surgery in patients with benign adnexal disease. Fertil Steril. \n2010;93(6):2074.\n19. Pontis A, Sedda F, Mereu L, et al. Review and meta-analysis of prospective \nrandomized controlled trials (RCTs) comparing laparo-endoscopic single \nsite and multiport laparoscopy in gynecologic operative procedures. Arch \nGynecol Obstet. 2016;294(3):567−577.\n20. Murji A, Patel VI, Leyland N, et al. Single-incision laparoscopy in \ngynecologic surgery: a systematic review and meta-analysis. Obstet \nGynecol. 2013;121(4):819−828.\n21. Malik M, McCormack K, Krukowski ZH, et al. Single port/incision \nlaparoscopic surgery compared with standard three-port laparoscopic \nsurgery for appendicectomy-a randomised controlled trial. Trials. \n2012;13(1):201.\n22. Abdellah MS, Abbas AM, Hegazy AM, et al. Vaginal misoprostol prior \nto intrauterine device insertion in women delivered only by elective \ncesarean section: a randomized double-blind clinical trial. Contraception. \n2017;95(6):538−543.\n23. Tacchino RM, Greco F, Matera D, et al. Single incision laparoscopic \ngastric bypass for morbid obesity. Obes Surg. 2010;20(8):1154−1160.\n24. Garg P, Thakur JD, Garg M, et al. Single-incision laparoscopic \ncholecystectomy vs. conventional laparoscopic cholecystectomy: a \nmeta-analysis of randomized controlled trials. J Gastrointest Surg . \n2012;16(8):1618−1628.\n25. Podolsky ER, Rottman SJ, Curcillo PG. Single port access (SPA) \ncholecystectomy: Two year follow-up. JSLS. 2009;13(4):528–535. \n26. Leroy J, Cahill RA, Asakuma M, et al. Single-access laparoscopic \nsigmoidectomy as definitive surgical management of prior diverticulitis \nin a human patient. Arch Surg. 2009;144:173–179.","source_license":"CC0","license_restricted":false}