Transumbilical laparoendoscopic single-site surgery (TU-LESS) for gynecological diseases during pregnancy: a retrospective study from a single center.

In total, 75 patients underwent TU-LESS during pregnancy. The mean age of these patients was 29.2 ± 3.4 years (range, 20–38 years), with a mean BMI of 22.0 ± 3.1 kg/m 2 (range, 16.9–31.2 kg/m 2 ). Among them, seventeen patients underwent abdominal surgery previously: thirteen patients underwent laparotomy (nine Cesarean sections and four appendectomies) and six patients underwent laparoscopy. Two patients had both laparoscopy and laparotomy. Nineteen patients had previously given birth, and the remaining 56 were nulliparous. For this pregnancy, 70 patients conceived spontaneously, and the remaining five patients underwent in vitro fertilization. There were only two twins and 73 singletons. Among them, two patients underwent Level III Obstetric Ultrasound before surgery to check for fetal growth and development, whereas the other 73 patients did not. Fifty-six patients underwent surgery for an adnexal mass, fifteen for adnexal torsion, two for suspected rupture of the adnexal mass, and two for intrauterine pregnancy combined with a fallopian pregnancy. At the time of TU-LESS, 23 patients were in their first trimester at 14 weeks of gestation (6 +1 –13 +6  weeks), 52 patients were in their second trimester beyond 14 weeks of gestation (14 +0 – 30 +2  weeks), and the median gestational age was 15 + 2  weeks. The patient characteristics and medical histories are listed in Table  1 . Table 1 Patients’ characteristics and histories of reproduction and surgeries Patient characteristics ( n  = 75) Values/No. of patients Percentage (%, 95% CI) Mean age (y) 29.2 ± 3.4 / Mean body mass index (kg/m 2 ) 22.0 ± 3.1 / History of abdominal surgery  None 58 77.3 (67.9–86.8)  Yes 17 22.7 (13.2–32.1)  laparoscopy 6 8.0 (1.9–14.1)  laparotomy 13 17.3 (8.8–25.9) Reproductive history  Multipara 19 25.3 (15.5–35.2)  Nullipara 56 74.7 (64.8–84.5) Mode of conception  Spontaneous conception 70 93.3 (87.7–99.0)  In vitro fertilization (IVF) 5 6.7 (1.0–12.3) Twins 2 2.7 (0.0–6.3) Singletons 73 97.3 (93.7–100.0) Gestational weeks  < 14 gestational weeks 23 30.1 (20.2–41.1)  ≥ 14 gestational weeks 52 69.3 (58.9–79.8) Level III Obstetric Ultrasound  Yes 2 2.7 (0.0–6.3)  None 73 97.3 (93.7–100.0) Indication for surgery  Adnexal mass 56 74.7 (64.8–84.5)  Adnexal torsion 15 20.0 (10.9–29.1)  Rupture of adnexal mass 2 2.7 (0.0–6.3)  Intrauterine pregnancy combined with ectopic pregnancy 2 2.7 (0.0–6.3) CI Confidence Interval Patients’ characteristics and histories of reproduction and surgeries CI Confidence Interval The details of the patients’ perioperative outcomes are shown in Table  2 . Perioperative outcomes in women with gestational weeks less than 14 and beyond 14 weeks were also compared. There was no significant difference of mean BMI ( P  = 0.135) and age ( P  = 0.283) between the two groups. Eleven emergent and 61 elective surgeries were performed. More elective surgeries were performed for the patients in the second trimester, and more emergent surgeries were performed for the patients in the first trimester ( p  = 0.008). The main procedure, oophorocystectomy were performed in 66 patients, salpingo-oophorectomy in 3 patients had salpingectomy, salpingo-oophoroplasty/suture in 4 patients, and the other two patients had salpingectomy. Totally, mean operative time was 101.2 ± 39.3 min, the mean estimated blood loss was 23.9 ± 28.7 mL and the mean transfusion volume was 1243.3 ± 411.0 mL. There were no significant difference of the mean operative time (100.7 ± 48.4 min versus 101.4 ± 35.1 min, p  = 0.421) and mean transfusion volume (1260.9 ± 540.8 mL versus 1235.6 ± 344.6 mL, p  = 0.799) between the patients in the first trimester and patients in the second trimester. Though the mean estimated blood loss of patients in the first trimester was less than that of patients in the second trimester (17.1 ± 10.5 mL versus 26.8 ± 33.3 mL), there was no statistic difference beween them according to the p value at 0.641. Table 2 A summary of the patients’ perioperative outcomes Perioperative outcomes Values/No. of patients Total < 14 gestational weeks ≥ 14 gestational weeks P value Mean gestational weeks 15 + 2 12 + 0 16 +5 Mean body mass index (kg/m 2 ) 22.0 ± 3.1 21.1 ± 3.2 22.5 ± 3.0 0.135 Mean age (y) 29.2 ± 3.4 29.9 ± 4.0 28.8 ± 3.0 0.283 Emergent surgery 14 9 5 0.008* Elective surgery 61 14 47 Main procedures  Oophorocystectomy 66 18 48  Salpingo-oophoroplasty 3 0 3  Salpingo-oophorectomy 4 3 1  Salpingectomy 2 2 0 Mean operative time (min) 101.2 ± 39.3 100.7 ± 48.4 101.4 ± 35.1 0.421 Mean estimated blood loss (mL) 23.9 ± 28.7 17.1 ± 10.5 26.8 ± 33.3 0.641 Transfusion volume 1243.3 ± 411.0 1260.9 ± 540.8 1235.6 ± 344.6 0.799 Postoperative Activities of Daily Living  Day 0 41.5 ± 10.6 40.7 ± 10.5 41.9 ± 10.7 0.372  Day 1 61.9 ± 12.4 62.0 ± 11.6 61.9 ± 12.9 0.329  Day 2 79.6 ± 13.8 80.2 ± 14.6 79.3 ± 13.5 0.620 Numerical Rating Scale of pain  Day 0 2.6 ± 0.5 2.6 ± 0.6 2.6 ± 0.5 0.804  Day 1 1.9 ± 0.6 1.9 ± 0.7 1.9 ± 0.6 0.489  Day 2 1.3 ± 0.7 1.4 ± 0.5 1.3 ± 0.7 0.533 Use of analgesic  Oral 2 1 1  Intramuscular 3 1 2 Postoperative hospital stay 3.4 ± 1.2 3.1 ± 1.3 3.5 ± 1.2 0.184 Total hospital stay 4.7 ± 1.5 4.2 ± 1.6 4.9 ± 1.4 0.079 * P  < 0.05 A summary of the patients’ perioperative outcomes * P  < 0.05 The Barthel scale was used to evaluate basic Activities of Daily Living on the day of surgery (Day 0), the first day after surgery (Day 1), and the second day after surgery (Day 2) [ 24 ]. The assessment results are listed in Table  2 . Mean score of Activities of Daily Living was 41.5 ± 10.6 at Day 0, 61.9 ± 12.4 at Day 1, and 79.6 ± 13.8 at Day 2, suggesting patients regained their physical function on the first day after surgery. At the same time, the numerical rating scale (range, 0–10 score) was used to measure pain intensity [ 25 ]. Patients felt mild pain at Day 1 (mean score, 1.91 ± 0.63) and Day 2 (mean score, 1.3 ± 0.7). Three patients required intramuscular injection and other two patients required oral analgesics. The assessment of Activities of Daily Living and pain intensity was not significantly different between the first- and second-trimester patients at different time points. However, the postoperative hospital staying and total hospital staying was longer for the patients in the second trimester than those in the first trimester [(3.5 ± 1.2 versus 3.1 ± 1.3, p  = 0.184), (4.9 ± 1.4 versus 4.2 ± 1.6, p  = 0.079)], while no statistic difference between these two groups. Perioperative and long-term complications associated with TU-LESS are shown in Table  3 . All patients had benign disease based on intraoperative observation or pathological diagnosis. There were no cases of reoperation within 48 h, unplanned ICU admission, or blood transfusion. There were no reports of postoperative fever, urinary retention, or thrombotic diseases. For 74 patients, the incision wound got healed well without records about the discharge, infection, dehiscence or cellulitis in a short term postoperation. One patient experienced incisional dehiscence after discharge and was sutured under local anesthesia 14 days after surgery. Table 3 A summary of the patients’ postoperative outcomes Postoperative outcomes Values/No. of patients Percentage (%, 95%CI) Benign diseases 75 Perioperative complications 75  Perioperative complications 0 /  Re-operation within in < 48 h 0 /  Unplanned ICU admission 0 /  Postoperative blood transfusion 0 /  Postoperative fever 0 /  Urinary retention 0 /  Deep Venous Thrombosis within 30 days of surgery 0 /  Urinary tract infection 0 /  Pulmonary embolism within 30 days of surgery 0 / Short-term complications of incision 75  Discharge 0 /  Infection 0 /  Dehiscence 1 1.3 (0.0–3.9)  Cellulitis 0 / Long-term complications of incision 59  Mild hypertrophic scar 9 15.3 (6.0–24.5)  Incisional hernia 0 / Cosmetic satisfaction score for incision 8.0 ± 1.6 / CI Confidence Interval A summary of the patients’ postoperative outcomes CI Confidence Interval A total of 59 patients completed our follow-up after delivery. For the 16 patients who were lost to follow-up, 13 patients could not be contacted and the other 3 patients refused to follow-up with no given reasons. During long-term observation of the incision wound, no incisional hernia was reported; however, 9/59 patients (15.3%, 95%CI 6.0–24.5) complained of mild hypertrophic scar. A satisfaction survey of the incision was conducted three months after giving birth. A numerical rating scale (range, 0–10) was used to evaluate the cosmetic satisfaction made by the patients themselves. The mean score was found to be 8.0 ± 1.6, ranging from 2 to 10. The patient’s umbilical incision (42 days after childbirth) were shown in Fig.  1 . Fig. 1 The patient’s incision of transumbilical laparoendoscopic single-site surgery (TU-LESS) during pregnancy on 42 days postpartum. The patient had TU-LESS at 16 +5 gestational weeks for ovarian terotoma and then had vaginal delivery at 40 +2 gestational weeks The patient’s incision of transumbilical laparoendoscopic single-site surgery (TU-LESS) during pregnancy on 42 days postpartum. The patient had TU-LESS at 16 +5 gestational weeks for ovarian terotoma and then had vaginal delivery at 40 +2 gestational weeks Postoperative obstetric outcomes were collected from 59 patients. For obstetric complications, one patient had gestational hypertension, seven had gestational diabetes mellitus, three had hypothyroidism, and two had an autoimmune disease. Three patients experienced fetal loss: one patient had miscarriage two month after the operation because of premature rupture of the fetal membranes; one patient had stillbirth two month after the operation without definite cause; one patient had miscarriage due to uncontrolled urterine contraction. The fetal loss rate was not higher than the average rate in China, which was reported to be 13.88% [ 26 ]. A total of 56 patients had live births, 47 cases were full-term deliveries, and 9 were pre-term deliveries. The interval from TU-LESS to childbirth was 23.3 ± 4.4 weeks. Among the 56 cases of live births, 27 had a vaginal delivery and 29 were delivered by Cesarean section. The Cesarean section rate was 51.78% (95%CI 38.7–64.9) of all the live birth, which was similar to that (51.56%) in the general obstetric populations in Sichuan Province which was reported by National Center for Healthcare Quality Management In Obstetrics in 2022. For vaginal delivery, 21 of 27 patients had a second stage of labor duration within 60 min. One patient experienced the second stage of labor duration for 150 min and no dehiscence of umbilical incision or umbilical hernia occurred after childbirth. Mean neonatal weight was 3047.8 ± 512.2 g including two twins. Three preterm neonatals needed neonatal intensive care units after birth, and no neonatal deaths were reported. Postoperative obstetric outcomes are listed in Table  4 . Table 4 Obstetric outcomes of patients after transumbilical laparoendoscopic single-site surgery (TU-LESS) Obstetric outcomes ( n  = 59) Values/No. of patients Percentage (%, 95% CI) Obstetric complications  Gestational hypertension 1 1.7 (0.0—5.0)  Gestational diabetes mellitus 7 11.9 (3.6—20.1)  Hypothyroidism 3 5.1 (0.0—10.7)  Autoimmune disease 2 3.4 (0.0—8.0) Fetal loss 3 5.1 (0.0—10.7) Live birth 56 94.92 (89.3—100.0)  Preterm delivery (≥ 26 weeks, < 37 weeks) 9 15.3 (6.1—24.4)  Full-term delivery 47 79.7 (69.4—89.9) Delivery mode  Vaginal delivery 27 48.2 (35.1—61.3)  Cesarean section 29 51.8 (38.7—64.9) The interval from surgery to childbirth(weeks) 23.3 ± 4.4 / Second stage of labor duration (min)  0—30 11 40.7 (22.2—59.3)  31—60 10 37.0 (18.8—55.2)  61—90 3 11.1 (0.0—23.0)  91–120 2 7.4 (0.0—17.3)  121—150 1 3.7 (0.0—10.8) Neonatal weight (g) (living newborn) 3047.8 ± 512.2 / Number of low birth weight (< 2500 g) 8 14.3 (5.1—23.5) Requiring neonatal intensive care units 3 5.4 (0.0—11.3) Neonatal death 0 / CI Confidence Interval Obstetric outcomes of patients after transumbilical laparoendoscopic single-site surgery (TU-LESS) CI Confidence Interval

This retrospective observational study was conducted between 2019 and 2024 at West China Second University Hospital, Sichuan University. A total of 75 eligible patients who required gynecological surgery during pregnancy were included in this study. The patients were extensively evaluated by surgeons, anesthetists, and nurses upon admission. The features of conventional laparoscopy and TU-LESS were both discussed between surgeons and patients before the surgery took place. Written informed consent was obtained from each patient after extensive evaluation prior to surgery. Level III Obstetric Ultrasound was performed to evaluate the fetal structure of patients with a gestational age of > 22 weeks. All patients were included by strictly following the inclusion criteria: 1) TU-LESS for gynecological diseases during pregnancy, 2) live fetus during surgery, 3) willingness to continue the pregnancy, and 4) patients’ disease and health status were fit for pregnancy. All surgical procedures were performed by experienced minimally invasive surgeons at the Department of Gynecology of West China Second University Hospita. The details of the surgical procedures varied according to the patients’ diseases; however, the anesthesia approach, procedure of cutting and opening, and intraoperative devices remained consistent. The patients were placed in the left lateral tilt position during surgery. A 2–2.5 cm longitudinal incision was made in the umbilical site, and a disposable single Port Trocar (Kangji Medical Instrument Ltd., Hangzhou, China) was placed. A pneumoperitoneum was created with carbon dioxide and the intra-abdominal pressure was set at 13 mmHg. During the surgery, a 10 mm HD laparoscope (Olympus, Hamburg, Germany) was used as the optical system. An ultrasonic blade (HARMONIC ACE + Shears, Ethicon,) was used for cutting and a BiClamp (Erbe Elektromedizin GmbH, Tübingen, Germany) was used for coagulation. The use of a unipolar device was strictly prohibited throughout the procedure in order to minimize fetal injury. All resected tissues were placed in an Endo Catch bag (LANP, Wuhan, China) through the umbilical incision site. Zheng’s anchor suturing technique was used for incision closure to improve the restoration of umbilical contours [ 21 ]. The peritoneum and fascial layers were repaired with running sutures using a 2–0 unabsorbable silk suture (SA845G, Ethicon, Bridgewater, New Jersey, USA). The fat layer was closed with simple interrupted suture using 2–0 absorbable suture. Finally, the skin was closed using intradermic running suture with 4–0 absorbable suture (VCP1422; Ethicon, Bridgewater, New Jersey, USA). The fetal heart rate was documented before and after surgery in order to evaluate fetal status. The patients were encouraged to get off the bed in order to regain their activity 4 h postoperatively. The fetal heart rate was monitored three times a day. For patients with a gestational age over 12 weeks, magnesium sulfate was administered by intravenous infusion at 1.0 g/h for 48 h to inhibit uterine contraction. While for patients with a gestational age less than 12 weeks, oral dydrogesterone was administered at 10 mg per 8 h to prevent fetal loss. Most patients were discharged on the third postoperative day, and an obstetrical ultrasound examination was performed before discharge to check fetal status. The patients were followed-up at one week after discharge by telephone and then underwent regular prenatal checkups and postpartum visits at clinic. Patient characteristics (age, body mass index, gestational weeks, reproductive history, previous abdominal surgeries, indications for surgery, comorbidities, and physical status classification according to the American Society of Anesthesiologists physical status classification system [ASA]) were carefully recorded. Perioperative parameters (procedures, operative duration, estimated total blood loss, complications, Activities of Daily Living, and pain scores) were also recorded. Obstetric outcomes (obstetric complications, delivery mode, the interval from surgery to childbirth, second stage of labor duration and infant health status), long-term postoperative complications, and cosmetic satisfaction score with the incision were assessed via telephone. Cosmetic satisfaction was assessed with a numerical rating scale ranging from 0 to 10, the higher numbers indicating greater satisfaction [ 22 , 23 ]. The chi-square test or Mann–Whitney U test was used to analyze the perioperative outcomes in women with gestational weeks less than 14 and beyond 14 weeks.

Nonobstetric surgery during pregnancy is rare; however, gastrointestinal procedures, such as cholecystectomy and appendectomy, are the most common, followed by nonobstetric gynecological surgeries [ 5 , 27 , 28 ]. Non-obstetric surgery during pregnancy is generally known to be safe, with an overall low risk of adverse birth outcomes such as stillbirth, preterm delivery, additional low-birth-weight babies, and Cesarean section [ 29 ]. Most studies and guidelines suggest that elective surgery should be postponed as late as 6 weeks postpartum. However, pregnant women should not be denied medically necessary gynecological surgery in the following situations, regardless of the trimester: 1) suspicion of malignancy, 2) ovarian torsion, and 3) a large mass with a potential for dystocia. At our center, pregnant women with asymptomatic adnexal cysts > 6–8 cm, highly suspected malignancies with a solid component, or gradually enlarging cysts were considered for semi-elective surgery. Generally, once an adnexal cyst is detected on routine ultrasonography, the patient is referred to an experienced gynecologist for further evaluation. Magnetic resonance imaging (MRI) was required in certain cases. If semi-elective surgery was indicated, the patient was taken over by a multidisciplinary team, including a gynecologist, obstetrician, anesthetist, and even a nurse, to make a surgery plan. Regarding the acute gynecological conditions, such as torsion or rupture of adnexal cysts, emergency surgery was performed immediately to save their life. However, the anesthetist should be involved in the patient evaluation before surgery. Surgery during the first trimester increases the risk of abortion, while it poses the highest risk of preterm labor during the third trimester [ 30 , 31 ]. Thus, the second trimester is the most suitable for surgery. In our study, most elective surgeries (47/61) were performed in the second trimester with a gestational age of more than 14 weeks. Most of the emergent surgeries (9/14) occurred in the first trimester: seven in adnexal torsion, one in rupture of the adnexal mass, and one in intrauterine pregnancy combined with fallopian pregnancy. The other five emergent surgeries (5/14) were performed in the second trimester due to adnexal torsion. To compare the potential differences in perioperative outcomes at different pregnancy stages, we analyzed the parameters of patients in the first and second trimesters. The mean body mass index and age were similar in the two groups. No significant differences in estimated blood loss, operative time, transfusion volume, Activities of Daily Living, or pain intensity were observed between the first and second trimesters. With the long-term use of laparoscopy during pregnancy, there is an overall consensus that it is a safe alternative to performing open surgery [ 1 , 8 , 32 ]. The laparoscopic approach in pregnancy offers some advantages, which are similar to those of laparoscopy in the nonpregnant state, such as early ambulation, short hospital stay, low rate of wound infection, and less pain, less surgical bleeding and less delayed wound healing [ 33 ]. The laparoscopic appendectomy and cholecystectomy were first offered to pregnant women in 1991 and then the laparoscopy was expanding to adnexal surgery with those benefits [ 34 ]. Obstetric outcomes such as miscarriage or preterm labor were not increased in laparoscopy patients compared to the open surgery patients for adnexal disorders [ 35 , 36 ]. Another advantage of laparoscopy was that it could be performed in any trimesters during pregnancy [ 37 ]. It affords better visualization and obtained optimum exposure of the surgical field in less manipulation of the gravid uterus. Moreover, early ambulation could reduce the frequency of maternal thrombosis and embolic events, which could also favor its use in pregnant women. While there exists concern regarding the application of laparoscopy during pregnancy is injury to blood vessels and the gravid uterus caused by the trocar. The overall trocar injury was low from 0.14% in Finland to 0.57% in the Netherlands [ 38 ]. More than half of the injuries occur in blood vessels, and a defect in the instrument or errors in usage could be responsible for this complication [ 39 ]. Organ injury was the second most common complication, especially in patients with postoperative adhesions resulting from a previous abdominal surgery. The open (Hasson) troca technique can eliminate vessel injury from 0.44% in closed laparoscopy to 0% and bowel injury from 0.7% in closed laparoscopy to 0.5% [ 38 ]. TU-LESS uses the Hasson technique to enter the abdomen, which is expected to avoid injury to the blood vessels and gravid uterus. Unlike in conventional laparoscopy, there are two or more port sites on the lateral abdominal wall close to the gravid uterus. Another advantage of TU-LESS for pregnant women is that all instruments are placed in the umbilical single site, which is higher than the uterus, avoiding any unexpected stabbing of the uterus during surgery. In our study, all surgeries were performed with TU-LESS and no organ or vessel injuriy occurred. Moreover, no one was transferred to conventional multiport laparoscopy or open surgery intraoperatively. No intraoperative complications occurred in any of the five patients who had previously undergone abdominal surgeries. Additionally, seven patients underwent enterolysis at the same time, and no organ or vessel injuries occurred. These results suggest that TU-LESS is safe procedure during pregnancy. Another advantage of TU-LESS over conventional laparoscopy is the convenience of specimen retrieval from the abdomen, which also contributes to the short operative time [ 40 , 41 ]. The incision of TU-LESS is relatively large, which is conducive to the retrieval of intraperitoneal resection specimens, especially for the removal of solid tissue specimens. In our study, 34 patients were diagnosied with ovarian teratoma and one patients had ovarian fibroids. Both of the ovarian tumors have a large solid component, which are more suitable for retrival via TU-LESS incision. In general, based on the above advantages, TU-LESS is suitable for pregnant women. The incision length of TU-LESS is 2.5 cm, and that of a conventional laparoscopy is 1.0 cm. With the larger incision size in TU-LESS than in conventional laparoscopy, there is a rising concern about the occurrence of hernia within the bulging abdomen in pregnant women. However, according to several studies on the use of TU-LESS during pregnancy, neither vessel or organ injury nor incisional hernia associated with a single incision have been reported [ 11 , 13 , 42 , 43 ]. In our study, we adopted Zheng’s anchor suturing technique, which effectively minimized incisional complications and met the patient’s cosmetic expectations. Those were concluded from a study including 5489 patients who underwent “Zheng’s anchor suturing technique” after TU-LESS procedures [ 21 ]. However, there was still one case of incisional dehiscence, and the patient underwent a secondary suture two weeks after surgery. Her main procedure was oophorocystectomy, and two large (30 cm × 19 cm × 19 cm in the right ovary and 28 cm × 19 cm × 15 cm) ovarian serous cystadenomas were excised. The operative time was 180 min, nearly double the mean operative time (97.3 min), and the patient was overweight before pregnancy with a BMI of 24.2 kg/m 2 . The subcutaneous tissue beneath the upper end of the incision is not completely closed. These combined factors may have led to the dehiscence. However, the incision healed well soon after the secondary suturing. There is another concern that whether the TU-LESS incision could withstand the huge abdominal pressure during labor, which could exceed 100mmHg during contraction. We adopted a different suturing strategy for pregnant women. Normally, 2–0 VICRYL suture made of polyglycolic acid is used to close the peritoneum and fascial layers, which is absorbable within 56–70 days [ 44 ]. For pregnant women, especially for those who were in the second trimester, we use unabsorbable silk suture to prevent wound dehiscence which may result from increasing abdominal tension. In our follow-up, 27 patients who underwent vaginal delivery had good incision healing without dehiscence or hernia after birth. This suggests the incision sutured with Zheng’s anchor suturing technique can withstand the tension of a growing abdomen and the pressure of uterine contractions during labor. For the long-term observation, no hernia were reported and the mean cosmetic satisfaction score reached 8.0 ± 1.6 among the 59 patients. Postoperative care is also crucial because poorly controlled pain can induce labor. There has been some debate regarding postoperative pain in the TU-LESS and conventional laparoscopy groups. However, some past studies have suggested that postoperative pain scores are lower in the LESS group than in the conventional laparoscopy group [ 45 ]. However, Jung et al. reported higher total requests for analgesics in patients who underwent TU-LESS after hysterectomy than in those who underwent conventional laparoscopy [ 46 ]. Another meta-analysis studies including also found no significant difference in postoperative pain between 1985 and 2466 women in the LESS and conventional laparoscopy groups, respectively, by analyzing data from 23 articles [ 47 ]. Low doses of Nonsteroidal Anti-inflammatory Drugs are safe for pregnancy in the in the second trimester and could be a choice to control the postoperative pain [ 48 ]. At our center, acetaminophen is frequently administered to patients in their second trimester. Intramuscular injection of 100 mg pethidine and 25 mg phenergan is an alternative treatment for acute to moderate pain. In this study, patients received a local incisional injection of ropivacaine after incision suturing to ease pain. Only two patient required oral acetaminophen and three other patients required an intramuscular injection of analgesics on Day 0. The pain was mild on Day1 and Day2, and the patients could get off the bed for some small walks in the ward. Moreover, we analyzed the different postoperative pain scores in the first- and second-trimester groups. We found no significant differences in pain scores between the two groups at any time point. Pregnant women are at high risk for venous thromboembolism, and appropriate perioperative thromboprophylaxis has been suggested [ 8 ]. The basic thromboprophylaxis for the prevention of venous thromboembolism was pneumatic compression of the lower limbs, which was performed twice daily for each patient. Ankle pump exercises were encouraged and completed under the guidance of the nurses. In addition, each patient was screened for the risk of venous thromboembolism using the Caprini scoring system, and low-molecular-weight heparin was administered if the patient was at a high risk of thromboembolism. To date, no guidelines discuss the prophylactic use of drugs to suppress uterine contractions. At our center, magnesium sulfate is routinely administered to patients with gestational weeks over 12 weeks, and dydrogesterone is used for patients under 12 weeks. No signs of irritation were observed in the gravid uteri. Due to the use of magnesium sulfate, patients in the second trimester had a longer hospital stay than the patients in the first trimester (3.50 ± 1.21 days verus 3.13 ± 1.29 days). However, the difference of postoperative hospital stay between these two groups was no significant. More elective surgery were performed in the second trimester which needs more time to prepare the surgery, thus the total hospital stay was also longer in this group. Three cases of fetal loss happened among the 59 patients with complete obstetric information. One patient had miscarriage 8 weeks after the operation at 23 +1 gestational weeks and this patient had no signs of uterine contraction until two days before PROM; one patient started uterine contraction and then had miscarriage 11 weeks after the operation at 24 +2 gestational weeks. The other patient had stillbirth 9 weeks after the operation at 19 +5 gestational weeks. The fetal loss rate was to be 5.08% (3/59) in this study, not higher than the average rate in China, which was reported to be 13.88%, indicating the patients after TU-LESS would not increase the fetal loss rate compared to the general obstetric population [ 26 ]. However, those were observations from this retrospective study. The real relationships between TU-LESS and obstetric outcomes should be evaluated in larger controlled studies in the future. In conclusion, we studied the perioperative and postoperative outcomes of the 75 pregnant patients who underwent TU-LESS for gynecological diseases. All the surgeries were performed under TU-LESS and no surgery-related complications occurred during hospitalization. Most elective studies were performed in the second trimester, while most emergent studies were performed in the first trimester. TU-LESS is feasible for both trimesters, with no significant difference of perioperative outcomes such as operative time, estimated blood loss, postoperative pain and Activities of Daily Living between the two groups. No incisonal dehiscence or hernia occurred in patients who underwent vaginal delivery. TU-LESS incision after Zheng’s anchor suturing technique can withstand the tension of a growing abdomen and the pressure of uterine contractions during labor. However, this study had several limitations: First, it was a small retrospective cohort study conducted in a single center, and there was no comparison group. Secondly, selection bias and the lost follow-up rate could weaken the validity of data, especially for the obstetric outcomes. A multicenter study with more variable patients may provide further evidence to favor the idea that TU-LESS is a feasible and safe option for gynecological surgery during pregnancy.

Nonobstetric abdominal surgery was required in approximately 1 in 500 pregnant women. Acute digestive tract diseases, such as acute appendicitis and cholecystitis, are the most common causes [ 1 ]. An adnexal mass is also a common indication. With the extensive adoption of prenatal ultrasonography, an increasing number of maternal adnexal masses have been detected [ 2 ]. Surgical intervention is indicated if the adnexal mass is highly suspicious for malignancy, has a risk of torsion, and presents with symptoms such as pain, distension, or constipation [ 3 , 4 ]. In Denmark, during 1996–2015, the overall prevalence of gynecological surgery during pregnancy varied between 0.5% and 0.8%, and it was more common in multiple pregnancies than in singleton pregnancies (0.9% vs. 0.7%) [ 5 ]. The effects of the operations and anesthetic drugs on the safety of the mother and fetus are of utmost importance during non-obstetrical abdominal surgery. Fortunately, the overall maternal postoperative complication rate following non-obstetric antenatal surgery is low (5.8%) [ 6 ]. Surgery may increase the risk of adverse pregnant outcomes such as small-for-gestational-age, preterm birth and miscarriage [ 7 ]. The American College of Obstetricians and Gynecologists’ Committee recommends that pregnant women undergo medically necessary surgery; there is no evidence that in utero human exposure to anesthetic or sedative drugs has any effect on the developing fetal brain [ 8 ]. Most non-obstetric abdominal surgeries are performed laparoscopically, and their proportion has increased [ 6 ]. Patients who underwent laparoscopy had a shorter hospital stay and lower pain scores than those who underwent open surgery, and there were no differences in postoperative complications between the two groups [ 9 , 10 ]. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGE) demonstrated the safety of laparoscopic surgery during any trimester without increasing the risk to the mother or fetus [ 1 ]. For the adnexal masses, relevant reports supported the performance of laparoscopy in the management of adnexal masses through the whole pregnancy period [ 1 , 11 – 14 ]. Laparoscopy is the preferred diagnostic method for emerging gynecological problems such as adnexal torsion, rupture, and hemorrhage [ 1 , 14 , 15 ]. Laparoendoscopic single-site surgery (LESS) is a less invasive alternative to conventional laparoscopy that allows operations via a single incision, most commonly through the umbilicus, and is also called transumbilical laparoendoscopic single-site surgery (TU-LESS) [ 16 , 17 ]. With the benefits of cosmesis, a decreased risk of perioperative complications related to trocar placement, and the convenience of tissue retrieval, LESS has been widely used in multiple gynecological fields, including benign diseases and malignant tumors [ 18 – 20 ]. In pregnant women with uterine enlargement, TU-LESS may be a more feasible and safe approach for entry into the abdominal cavity using an open procedure. However, reports regarding the use of LESS during pregnancy are limited. However, the safety and efficacy of TU-LESS during pregnancy remain unclear. Herein, we report 75 cases of TU-LESS during pregnancy and share our 5-year experience. We described the perioperative data and followed-up the obstetric outcomes of this group.