Laparoendoscopic single site surgery for severe pelvic adhesion release and total hysterectomy with bilateral salpingectomy

In worldwide, hysterectomy is one of the most common gynecological procedure ( 1 ). For many years, this procedure was performed via open surgery or vaginally. To achieve a minimally invasive surgery, laparoscopic hysterectomy is developed. The advantages of laparoscopic surgery are smaller surgical wounds, less pain, shorter hospital stay, and fewer complications ( 2 ). The umbilicus is a natural orifice and the scar on it is hided by folds of skin. Laparoendoscopic single-site surgery (LESS) is a new type of laparoscopic surgery, which is performed through a 2–3 cm incision in the umbilicus, and the laparoscope and instruments are inserted to complete the operation ( 3 ). Pelosi et al. in 1991 reported the first LESS hysterectomy ( 4 ). Compared with the traditional surgery, LESS has less trauma, better cosmetic effect and higher patients’ satisfaction. At our hospital, since the introduction of LESS in 2017, LESS hysterectomy gradually became the main management for symptomatic adenomyosis or uterine fibroids. However, gynecologists may convert LESS to multiport laparoscopy or laparotomy for bleeding control or severe pelvic adhesion. This video aims to describe a case for severe pelvic adhesion release and total hysterectomy with bilateral salpingectomy. We present this article in accordance with the SUPER reporting checklist (available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-28/rc ).

To perform the procedure, we utilized a single-port access platform ( Figure 1A ), a uterine manipulator ( Figure 1B ), a 10-mm 30-degree standard-length optical camera, ultrasonic knife, bipolar electrocautery, prototype of laparoscopic instruments. The patient was set in the lithotomy position. All procedures were performed under general anesthesia. We placed the uterine manipulation into the cervix from the vagina and a urinary catheter was inserted. The chief surgeon stood on the left side of the patient and the first assistant stood on the other side, while the second assistant, handling the uterine manipulator, sat between legs. CO 2 was injected into the abdominal cavity, and the pneumoperitoneum pressure was maintained at 
14 mmHg. The instruments used in the operation: (A) the single-port access platform; (B) the uterine manipulation. All procedures performed in this study were in accordance with the Helsinki Declaration (as revised in 2013). This study was approved by the ethics committee on human research at West China Second Hospital, Sichuan University (No. 2023139). The patient provided informed consent for the publication of her clinical and imaging data.

Video 1 demonstrates step-by-step on how to perform LESS for severe pelvic adhesion release and total hysterectomy with bilateral salpingectomy. ❖ Step 1: releasing adhesion between the uterus and sigmoid colon. ❖ Step 2: cauterization of utero-ovarian ligaments and tube pedicles. ❖ Step 3: cauterization and transection of the round ligament. ❖ Step 4: dissection of anterior broad ligament peritoneum. ❖ Step 5: dissection of the bladder. ❖ Step 6: dissection of uterosacral ligaments. ❖ Step 7: dissection and cutting of the uterine vessels. ❖ Step 8: opening of the vaginal walls and removal of the uterus. ❖ Step 9: suture of vaginal walls. ❖ Step 10: controlling bleeding before removal of the laparoscope and the port. A laparoendoscopic single site surgery for severe pelvic adhesion release and total hysterectomy with bilateral salpingectomy.

A 49-year-old female with symptomatic adenomyosis and uterine fibroid was performed LESS hysterectomy with bilateral salpingectomy. The uterus weight was 570 g, surgical duration was 146 minutes and estimated blood loss was 110 mL. After the patient recovered from anesthesia for 6 hours, she started liquid diet. The urinary catheter was removed on the second postoperative day and the patient was discharged on the third day. We followed the patient at 2 weeks and 2 months to visualize the suture of the vaginal walls. There was no morbidity.

Before surgery, gynecologists should fully communicate the patient’s condition and surgical risks with the patient and her family. The patient should be fully informed and understand that the available surgical option is laparotomy, multi-port laparoscopy, or LESS. The CO 2 pneumoperitoneum should be closed to prevent intra-abdominal blood or wash from splashing onto the assistant through the vagina, when we removed the uterus. The most important thing is to protect the ureters during surgery, avoiding direct mechanical injury or thermal radiation damage from energy devices.

There are several advantages of LESS, such as better cosmetic outcomes, less hospital stay ( 5 , 6 ). However, the disadvantage of LESS must be noticed, that is, “chopstick effect”. The “chopstick effect” caused by the interference of instruments, which made delicate operations such as separating intestinal adhesions challenging ( 7 ). Besides, LESS may convert to multiple port laparoscopy or laparotomy due to pelvic adhesions or bleeding ( 8 ). In our work, this surgery was a case of LESS severe pelvic adhesion release and total hysterectomy with bilateral salpingectomy. After the laparoscope was inserted, dense adhesions between the sigmoid colon and the uterus were discovered, necessitating the separation of intestinal adhesions to perform the hysterectomy. The surgeon had mastered the operation of LESS, and this video demonstrated the surgeon’s skilled use of an ultrasonic knife and scissors for the delicate operation of separating intestinal adhesions, minimizing intestinal damage while exposing the surgical field. After the adhesions were separated and the pelvis was fully exposed, the total hysterectomy with bilateral salpingectomy could proceed smoothly. This suggested that after a myomectomy, the use of anti-adhesion materials could be considered to reduce the occurrence of pelvic adhesions. Regarding surgical complications, several studies have found that compared to multi-port laparoscopy, LESS does not increase perioperative complications, postoperative pain, or conversion to open surgery, and it does not extend hospital stay, with only a slight increase in surgical time (13 minutes) ( 5 , 6 ). However, in patients with a history of cesarean section, the risk of urinary system injury is higher ( 9 ). In LESS procedures, injuries to the bladder or ureter may occur due to instrument interference, insufficient visualization, or thermal effects from energy devices, which requires particular attention from the surgeon. In our work, vaginal suturing is performed laparoscopically because this approach allows gynecologists to better expose the anterior and posterior vaginal walls, even by suspending the bladder, resulting in better suturing outcomes. Previous publications also show that for vaginal suture, laparoscopy is a safe and less time-consuming procedure ( 10 , 11 ).

For symptomatic adenomyosis and uterine fibroid, which is ineffective to medicine treatment, hysterectomy with bilateral salpingectomy is the effective therapy. For the requirement of rapid recovery, LESS hysterectomy may be a better choice. However, “chopstick effect” becomes the greatest difficulty of LESS and gynecologists need more practice. These surgical skills may overcome the difficulties and defects of LESS, and could make the operation more convenient. LESS technique is a feasible and safe approach for severe pelvic adhesion release and hysterectomy with bilateral salpingectomy.

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