Postoperative abdominopelvic adhesion and umbilical wound validation after single-port laparoscopy or two-port laparoscopy for gynecological surgery: A comparison with conventional laparoscopy

Postoperative abdominopelvic adhesion and umbilical wound validation after single-port laparoscopy or two-port laparoscopy for gynecological surgery: A comparison with conventional laparoscopy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Postoperative abdominopelvic adhesion and umbilical wound validation after single-port laparoscopy or two-port laparoscopy for gynecological surgery: A comparison with conventional laparoscopy Sang Wook Yi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3939479/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Jan, 2025 Read the published version in Archives of Gynecology and Obstetrics → Version 1 posted 5 You are reading this latest preprint version Abstract Purpose The emergence of minimally invasive surgery has led to the development of laparoscopic surgery to reduce the number of ports. Although the incision for the umbilical port is sufficiently large, thus reducing the number of ports used during laparoscopic surgery, postoperative complications involving incisions at port sites have been reported. Thus, we analyzed postoperative intraperitoneal outcomes after laparoscopy using operation records and photographs of consecutive surgeries. Methods A total of 134 patients were enrolled in the clinical study to analyze their intraperitoneal outcomes. The patients were divided into groups, which were compared and analyzed based on the number of ports used intraoperatively. The clinical characteristics of the patients were obtained from their medical records, and their operation records, including those of their consecutive operations, were analyzed. Results Patients who underwent single-port laparoscopy were included in Group 1, patients who underwent two-port laparoscopy were included in Group 2, and patients who underwent three-port laparoscopy or four-port laparoscopy were included in Group 3. Correlation analysis of the number of ports used during surgery revealed that the white blood cell count before and after surgery and the intraperitoneal umbilical adhesion score were negatively correlated. The incidence of intraperitoneal umbilical adhesions increased as the number of ports used during laparoscopy decreased. Conclusions Because the incidence of postoperative intraperitoneal umbilical adhesion increases as the size of the umbilical wound increases, such as after single-port laparoscopy, surgical umbilical wounds should be cautiously repaired after single-port laparoscopic surgery. Adnexa Adhesion Complication Operative outcomes Single-site incision laparoscopy Umbilicus Figures Figure 1 Figure 2 Introduction Postoperative adhesions, such as a band of connective tissue that joins two normally separate anatomical structures, occur in 75–93% of patients who undergo gynecological surgeries and are among the most common sequelae of gynecological surgeries. These findings may lead to chronic pain, infertility, or bowel obstruction [ 1 , 2 ]. With this, the development of postoperative adhesions between the pelvis and abdominal cavity is a concern among surgeons. Adhesions are the result of tissue trauma during surgery and postoperative healing. Therefore, adhering to the principles of microsurgery and minimally invasive surgery may help to decrease the incidence of postoperative adhesions [ 3 ]. Laparoscopy is a minimally invasive surgical technique that results in a short recovery time and a quick return to daily life activities. Generally, laparoscopy is a less invasive technique than laparotomy because there is less postoperative scarring, and the recovery time is shorter. Because the abdominal wound scars that develop after laparoscopy are smaller than those that develop after laparotomy, laparoscopy has been proven to have cosmetic advantages. Recently, with the emergence of minimally invasive surgery, laparoscopic surgery has been developed to reduce the number of ports. Due to its ability to reduce tissue trauma and improve cosmetic outcomes, single-port laparoscopic surgery is becoming increasingly common [ 4 ]. Single-port laparoscopic surgery has not yet completely replaced conventional laparoscopic surgery due to the difficulties and limitations of the procedure, and the incidence of postoperative wound hernia is higher because the umbilical wound incision used during single-port laparoscopic surgery is larger than that used for conventional laparoscopic surgery. Although single-port laparoscopy has more cosmetic benefits than conventional laparoscopic surgery due to the single incision made in the umbilicus, umbilical hernias are potentially life-threatening and may require emergency surgery due to bowel obstruction or bowel ischemia [ 5 ]. Because the incision used for single-port laparoscopic surgery is larger than that used for conventional laparoscopic surgery, complications such as umbilical hernia may occur, and it is also estimated that the incidence of complications such as port site adhesions and hemorrhage, which are wound complications, is high. Thus, we analyzed the postoperative intraperitoneal outcomes after laparoscopy using patient operation records and photographs of consecutive surgeries. A comparative study of single-port laparoscopy, two-port laparoscopy, and laparoscopy with three or more ports was also conducted. Materials and Methods From January 1996 to July 2022, 4,510 patients underwent gynecological laparoscopic surgery. Of these, 154 patients underwent laparoscopic surgery or laparotomy after laparoscopic surgery. The intraperitoneal outcomes of twenty patients could not be analyzed because the operation records or operation images were not preserved. A total of 134 patients were enrolled in the clinical study to analyze their intraperitoneal outcomes (Fig. 1 ). The Institutional Review Board reviewed and approved this study. In this retrospective clinical study, the postoperative states of the pelvic and abdominal cavities of patients who underwent consecutive laparotomy or laparoscopic surgery were evaluated for separate reasons after laparoscopic surgery. The patients were divided into groups, which were compared and analyzed based on the number of ports used intraoperatively. The patients were divided into three groups: Group 1 (single-port laparoscopy), Group 2 (two-port laparoscopy), and Group 3 (laparoscopy with three or more ports). Port preparation for single- and two-port laparoscopic adnexal surgery In the single-port laparoscopic surgeries, three trocars (two 12-mm trocars and one 5-mm trocar) were inserted into separate fingers of a surgical glove and secured with rubber bands. The wrist portion of the glove covered the wound retractor, and three Babcock clamps were placed on the edges of the retractor to prevent carbon dioxide leakage. A 10-mm laparoscope and atraumatic forceps were inserted through the umbilical multichannel port. In the two-port laparoscopic surgeries, an ancillary 5-mm trocar was placed low in the left abdomen under laparoscopy. The umbilical trocar was removed, and the skin incision was extended to approximately 1.5 cm, which is sufficiently wide to allow passage of an index finger. The skin incision was extended to the upper and lower margins of the umbilicus to minimize abdominal scarring. An Extrasmall Alexis® wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) was placed in the umbilical incision. Two 12-mm trocars were inserted into separate fingers of a No. 6 surgical glove and secured with rubber bands, and the other three fingers of the glove were tied together. Port preparation for three-port laparoscopic surgery Ancillary 12-mm, 10-mm, or 5-mm trocars were inserted low in the right and left abdomens under laparoscopic observation. In the conventional laparoscopy group, the ancillary port site low in the abdomen was extended to remove surgical specimens if necessary. A wound retractor was not used in the three-port laparoscopic procedure. Outcome measurements Following a review of the medical records and radiological studies, the clinicopathological characteristics of the patients, such as age, parity, previous medical and surgical history, and operative outcomes, such as the operative time, pre- and postoperative white blood cell (WBC) counts, change in the hemoglobin (Hb) level, and postoperative hospitalization duration, were investigated. The operative outcomes of the patients were obtained from their medical records, and the operation records, including those of consecutive operations, were analyzed. The degree of pelvic adhesion and intraperitoneal umbilical adhesion or hernia before and after laparoscopy were recorded using the adhesion score and umbilical outcome scale (Fig. 2 ). Statistical analysis The results were analyzed using IBM SPSS® version 28 statistical software (IBM, Armonk, NY, USA). Continuous variables were compared using Student’s t test. Categorical variables were compared using the chi-square or Kruskal‒Wallis test. All tests were two-sided, and p values ≤ 0.05 were considered significant. Results A total of 134 patients were separated into three groups, and their clinical data were analyzed. Thirteen patients underwent single-port laparoscopic surgery, 53 patients underwent two-port laparoscopic surgery, and 68 patients underwent three-port or four-port laparoscopic surgery. Patients who underwent single-port laparoscopy were included in Group 1 (n = 13), patients who underwent two-port laparoscopy were included in Group 2 (n = 53), and patients who underwent three-port laparoscopy or four-port laparoscopy were included in Group 3 (n = 68). The patients’ age, parity, height, weight, and body mass index (BMI) were not significantly different (Table 1 ). Moreover, there were no significant differences among the study groups in terms of preoperative pelvic adhesion scores, postoperative pelvic adhesion scores, hemoglobin changes, or the occurrence of umbilical hernia. Table 1 Clinical characteristics of the study groups (mean ± SD) Group Age (yrs.) Parity Height (cm) Weight (kg) BMI (kg/m 2 ) 1 30.4 ± 11.0 0.6 ± 1.0 159.7 ± 6.3 60.7 ± 12.0 23.7 ± 4.0 2 32.4 ± 7.4 0.6 ± 0.9 160.6 ± 5.4 59.7 ± 12.8 23.2 ± 5.1 3 33.6 ± 9.3 0.9 ± 1.1 160.1 ± 5.0 58.4 ± 10.0 22.8 ± 3.7 Table 2 Perioperative and Postoperative Outcomes of the Study Groups (Mean ± SD) Group Op time (min) Adhesion score (preop) Adhesion score (postop) Hb change (g/dl)* Preop WBC (/ul) Postop WBC (ul) Postop hospital stay (days) Umbilical adhesion score Umbilical hernia 1 77.5 ± 30.3 1.2 ± 1.2 1.0 ± 1.4 1.7 ± 0.8 6553.8 ± 2269.2 7115.4 ± 2096.0 3.3 ± 0.8 0.5 ± 0.9 none 2 75.2 ± 28.6 1.9 ± 2.2 2.2 ± 2.7 1.8 ± 1.1 9943.4 ± 5114.6 7222.6 ± 2983.8 4.6 ± 1.8 0.2 ± 0.6 1 case 3 83.3 ± 34.6 2.0 ± 2.2 2.4 ± 2.2 1.9 ± 0.8 6575.0 ± 2397.5 6041.8 ± 1965.9 4.2 ± 1.3 0.1 ± 0.3 1 case * Changes in hemoglobin (Hb) levels were calculated as the difference between the preoperative hemoglobin level and the postoperative 2-day hemoglobin level. The differences in the preoperative white blood cell (WBC) count, postoperative white blood cell (WBC) count, need for surgical drainage tube insertion, postoperative hospital stay, operative interval, and intraperitoneal umbilical adhesion score were significantly different among the study groups (Table 3 ). Table 3 Correlation with postoperative umbilical adhesion sores Surgical Factors Pearson’s Correlation Coefficient p Value Port number -0.22 0.01* Adhesion score (AS) difference (Postop. AS – Preop. AS) 0.22 0.10* Umbilical hernia 0.34 0.00* * Statistically significant A comparison of Group 1 and Group 2 revealed that the differences in the preoperative white blood cell count, length of surgical drainage tube insertion, and length of postoperative hospital stay were statistically significant. Among the enrolled patients, single-port laparoscopy was not performed for patients with intraperitoneal inflammatory diseases such as tubo-ovarian abscess. The postoperative hospital stay in Group 2 was longer than that in Group 1 due to antibiotic therapy, and the preoperative white blood cell (WBC) count in Group 2 was greater than that in Group 1 because of inflammatory conditions. A comparison of Group 1 and Group 3 revealed that the differences in postoperative white blood cell count, length of surgical drainage tube insertion, length of postoperative hospital stay, intraperitoneal umbilical adhesion score, and postoperative pelvic adhesion score were statistically significant. Among the enrolled patients, single-port laparoscopy was not performed for patients with intraperitoneal inflammatory diseases such as tubo-ovarian abscess. The postoperative hospital stay of Group 3 was longer than that of Group 1 due to antibiotic therapy, and the postoperative white blood cell count of Group 3 was greater than that of Group 1 because of inflammatory conditions. A comparison of Group 2 and Group 3 revealed that the differences in the preoperative white blood cell count, postoperative white cell count, and reoperation interval were statistically significant. Moreover, there were no significant differences between Group 2 and Group 3 in terms of the preoperative pelvic adhesion score, postoperative pelvic adhesion score, hemoglobin changes, intraperitoneal umbilical adhesion score, or occurrence of umbilical hernia. The correlations between the number of ports used during surgery, the white blood cell (WBC) count before and after surgery, the reoperation interval, and the intraperitoneal umbilical adhesion score were also analyzed (Table 3 ). The postoperative hospital stay, incidence of umbilical hernia, and difference between the preoperative and postoperative pelvic adhesion scores were not correlated with the number of ports used during surgery. The correlations between preoperative and postoperative pelvic adhesion scores and the intraperitoneal umbilical adhesion score, number of ports used during surgery, white blood cell (WBC) count after surgery, and incidence of umbilical hernia were also evaluated (Table 4). Hemoglobin changes, white blood cell (WBC) counts before surgery, postoperative hospital stays, and reoperation intervals were not correlated with the number of ports used during surgery. Because single-port laparoscopic surgery tends not to be performed in patients with inflammatory diseases such as pelvic abscess, correlation analysis revealed that the port number was positively correlated with the WBC count before and after surgery. The incidence of intraperitoneal umbilical adhesions increased as the number of ports used during laparoscopy decreased, and the size of the umbilical incision was greater than that used for conventional laparoscopy. Discussion Due to the increasing interest in minimally invasive surgery, single-port laparoscopic surgery has been used in gynecologic surgeries in many hospitals. Single-port laparoscopic surgery has several limitations in terms of efficacy because surgical instruments must be inserted into the same umbilical port at the same time. Thus, surgeons need time to learn how to adequately perform single-port laparoscopic surgery. In many studies, single-port laparoscopic surgery is suggested to be a safe surgical procedure that yields better cosmetic effects than conventional laparoscopic surgery using multiple ports. Single-port laparoscopic surgery is difficult to perform, and little is known about its learning curve and the factors associated with its operative outcomes during the learning period [ 6 ]. Single-port laparoscopic surgery has become well known as a minimally invasive surgery among both operators and patients because there is only one postoperative wound. In a review, the authors concluded that single-port surgery has many potential benefits, but comparative trials have shown no differences between single-port surgery and conventional laparoscopy in terms of postoperative complications, postoperative pain, hospital stay, or cosmetic results [ 7 ]. However, several studies have reported that single-port laparoscopic surgery is superior to conventional laparoscopic surgery in terms of surgical prognosis. It is considered to have better cosmetic outcomes due to the presence of one postoperative wound, which is hidden within the umbilicus, but there are a few objective studies on this topic. We found that when performing laparoscopic surgery on patients who had previously undergone single-port laparoscopic surgery, there were more empirical findings of intraperitoneal adhesions under the umbilicus than in patients who underwent conventional laparoscopic surgery. Therefore, this study was designed to compare the incidence of intraperitoneal adhesions, including those around the umbilicus, after single-port laparoscopy surgery with that after two-port laparoscopy and conventional laparoscopic surgery. Postoperative adhesions, such as the band of connective tissue that joins two normally separate anatomical structures, occur in 75–93% of patients who undergo gynecological surgeries and are the most common sequelae. These findings may lead to chronic pain, infertility, or bowel obstruction [ 8 , 9 ]. With this, the development of postoperative adhesions between the pelvis and abdominal cavity is a concern among surgeons. Adhesions are the result of surgical tissue trauma and healing. Therefore, adhering to the principles of microsurgery and minimally invasive surgery may help to decrease the incidence of postoperative adhesions [ 10 ]. Several studies have evaluated the occurrence of pelvic adhesions after surgery, and most have used imaging tests. Gerner-Rasmussen et al. reviewed the literature to investigate the usefulness of noninvasive diagnostic methods for detecting intraabdominal adhesions [ 11 ]. This approach has limitations in reflecting the actual condition of the pelvis and abdominal cavity, and visual confirmation through surgery is the most accurate way to determine the degree of adhesion. However, this approach is not feasible in most clinical settings unless patients need to undergo additional laparoscopy for therapeutic purposes. Therefore, we retrospectively evaluated the occurrence of adhesions in patients who underwent laparotomy or laparoscopy following laparoscopy. The tool currently available for evaluating the degree of adhesion is a visual adhesion scoring system. Ichikawa et al. investigated the accuracy and clinical value of the adhesion scoring system using transvaginal ultrasonography for endometriotic adhesion [ 12 ]. The authors concluded that the adhesion scoring system accurately predicts pelvic adhesion status and can predict the occurrence of postoperative adhesions and infertility. With this information, we used the adhesion scoring system to validate the pelvic adhesion status preoperatively and postoperatively. The degree of intraperitoneal adhesion under the umbilical area was graded using the revised scoring system shown in Fig. 2 . Many large-scale meta-analyses on single-port laparoscopic surgery have been conducted and published. Many studies have compared conventional laparoscopic surgery and single-port laparoscopic surgery for cholecystectomy and inguinal herniorrhaphy. In conclusion, most studies show that single-port laparoscopic surgery has no problem in terms of surgical efficacy, and the surgical prognosis is similar to that of conventional laparoscopic surgery. Several systemic reviews and randomized clinical trials of gynecological surgeries have been performed. Bonollo et al. reported a systemic review of randomized clinical trials for laparoendoscopic single-site surgery (LESS) in gynecology [ 13 ]. In their review, they showed that although cosmetic results are intuitively the main advantage of the LESS technique, current evidence does not seem to demonstrate that LESS is clearly superior to conventional multiport laparoscopy for benign gynecological conditions. Gasparri et al. performed a meta-analysis of conventional versus single-port laparoscopy for the surgical treatment of ectopic pregnancy [ 14 ]. They concluded that LESS does not seem to be superior to conventional laparoscopy in terms of the management of ectopic pregnancies. In a report of the long-term application of single-port and multiport total laparoscopic hysterectomy (TLH) in a single center, the authors concluded that some surgical outcomes of single-port TLH have significantly improved after long-term observation as laparoscopic surgical instruments and surgeon skill have improved [ 15 ]. In their study, although the uterine weight of the single-port TLH group was lower than that of the multiport TLH group, single-port TLH was associated with a significantly shorter hospital stay and operative time, a lower Hb change, and a lower complication rate after correction for biases. In another meta-analysis of single-port TLH versus multiport TLH, the authors revealed that single-port TLH is a feasible, safe and effective technique for benign gynecologic conditions, although the operative time may be longer than that of multiport TLH [ 16 , 17 ]. No clinically relevant advantages were identified, and as no data on cost effectiveness are available, there are currently not enough valid arguments to broadly implement LESS for hysterectomy. Regarding the wound complications in 1145 consecutive transumbilical single-incision laparoscopic procedures published by Weiss et al., the authors stated that the incidence of wound complications in transumbilical single-incision surgery is relatively acceptable and that this rate further decreases as surgeons become proficient [ 18 ]. In a study on the incidence of and risk factors for incisional hernia after single-incision endoscopic surgery, Guzmán et al. reported that single-incision laparoscopic cholecystectomy was significantly associated with postoperative incisional hernia [ 19 ]. Casaccia et al. also conducted a comparative study between single-port laparoscopic surgery and conventional laparoscopic surgery for gallbladder removal and reported that single-port laparoscopic surgery is a safe and effective surgical method when performed by an operator who is familiar with the procedure. Single-port laparoscopic surgery is recognized for its cosmetic superiority over conventional laparoscopic surgery, but the operator must pay attention to fascial suturing because of the increased potential for hernia development [ 20 ]. Due to the correlation between wound size and the degree of adhesion, even if there is a small number of wounds, the risk of adhesion and wound complications may increase if the wound size is large. From a cosmetic perspective, having fewer wounds may be an advantage, but minimal wounds are a true advantage of minimally invasive surgery. Our study has several limitations. First, the number of single-port laparoscopic surgery cases was the lowest among the three study groups, which limits the comparative nature of the study. Because single-port laparoscopic surgery has only recently been performed, there is a limitation in that there are only a few cases in which intraperitoneal evaluation was performed through reoperation. Second, because the sizes of the umbilical ports used in single-port laparoscopic surgery and two-port laparoscopic surgery are similar and because the incision size is not accurately measured, there is a limitation in comparing the differences between single-port laparoscopic surgery and two-port laparoscopic surgery. Third, the degree of intrapelvic adhesion and intraperitoneal umbilical adhesion after surgery was evaluated based on the adhesion score obtained during reoperation, which has several limitations because it is difficult to exclude adhesion factors other than surgical variables. There are several strengths of our study. First, an objective evaluation tool, such as the adhesion scoring system, was used to evaluate wound prognosis after single-port or two-port laparoscopic surgery through visual confirmation through reoperation. Second, although the prognosis of laparoscopic surgery was not compared in a prospective study, surgical prognosis after single-port, two-port or conventional laparoscopic surgery was compared retrospectively by setting up appropriate comparison groups. The incidence of postoperative intraperitoneal umbilical adhesion increases as the size of the umbilical wound increases, such as after single-port laparoscopy. Therefore, surgical umbilical wounds after single-port laparoscopic surgery should be repaired with caution. A second laparoscopic surgery should be carefully performed after a previous single-port laparoscopic surgery to avoid causing organ damage due to contact with adhesions when entering the umbilical port. Because the number of study patients who underwent single-port laparoscopic surgery was too small in this study, there was a limit to the analysis of the results, and additional studies with more patients and standardized research methods are needed in the future. Declarations The author has no financial interests to disclose and has not received any financial support for the preparation of this article. Disclosures Prof. Yi has no conflicts of interest to disclose. Author Contribution List each author by surname and describe each of their contributions (select all that apply) to the manuscript using the following terms: Yi SW: Protocol/project development Yi SW: Data collection or management Yi SW: Data analysis Yi SW: Manuscript writing/editing Other (please specify briefly using 1 to 5 words) References Hirschelmann A, Wallwiener CW, Wallwiener M et al (2012) Is patient education about adhesions a requirement in abdominopelvic surgery? Geburtshife Frauenheikd 72:299–304 De Wilde RL, Bakkum EA, Brölmann H et al (2014) Consensus recommendations on adhesions (version 2014) for the ESGE adhesions Research Working Group (European Society for Gynecological Endoscopy): an expert opinion. Arch Gynecol Obstet 290:581–582 Practice Committee of American Society for Reproductive Medicine in collaboration with Society of Reproductive Surgeon (2013) Pathogenesis, consequences, and control of peritoneal adhesions in gynecologic surgery: a committee opinion. Fertil Steril 99:1550–1555 Bunting DM (2010) Port-site hernia following laparoscopic cholecystectomy. J Soc Laparoendosc Surg 14:490–497 Swank HA, Mulder IM, Ia Chapelle CF, Reitsma JB, Lange JF, Bemelman WA (2012) Systemic review of trocar-site hernia. Br J Surg 99:315–323 Fukumoto K, Miyajima A, Hattori S et al (2017) The learning curve of laparoendoscopic single-site adrenalectomy: an analysis of over 100 cases. Surg Endosc 31:170–177 Mencaglia L, Mereu L, Carri G, Arena I, Khalifa H, Tateo S, Angioni S (2013) Single port entry – Are there any advantages? Best Pract Res Clin Obstet Gynecol 27(3):441–455 Hirschelmann A, Wallwiener CW, Wallwiener M et al (2012) Is patient education about adhesions a requirement in abdominopelvic surgery? Geburtshife Frauenheikd 72:299–304 De Wilde RL, Bakkum EA, Brölmann H et al (2014) Consensus recommendations on adhesions(version 2014) for the ESGE adhesions Research Working Group (European Society for Gynecological Endoscopy): an expert opinion. Arch Gynecol Obstet 290:581–582 Practice Committee of American Society for Reproductive Medicine in collaboration with Society of Reproductive Surgeon (2013) Pathogenesis, consequences, and control of peritoneal adhesions in gynecologic surgery: a committee opinion. Fertil Steril 99:1550–1555 Gerner-Rasmussen J, Donatsky AM, Bjerrum F (2019) The role of non-invasive imaging techniques in detecting intra-abdominal adhesion: a systematic review. Langenbecks Arch Surg 404:653–661 Ichikawa M, Akira S, Kaseki H, Watanabe K, Ono S, Takeshita T (2020) Accuracy and clinical value of an adhesion scoring system: A preoperative diagnostic method using transvaginal ultrasonography for endometriotic adhesion. J Obstet Gynaecol Res 46(3):466–478 Bonollo M, Bellaminutti S, Gasparri ML, Papadia A (2022) Is it time to leave multi- for single-port laparoscopy in benign gynecologic surgery? A systemic review of randomized clinical trials. Minerva Obstet Gynecol 74(5):434–443 Gasparri ML, Mueller MD, Taghavi K, Papadia A (2018) Conventional versus single port laparoscopy for the surgical treatment of ectopic pregnancy: A meta-analysis. Gynecol Obstet Invest 83(4):329–337 Lee JH, Lee YS, Hong DG (2022) Long-term experience of single-port and multi-port total laparoscopic hysterectomy in single center. vivo 36:2409–2413 Sandberg EM, la Chapelle CF, van den Tweel MM, Schoones JW, Jansen FW (2017) Laparoendoscopic single-site surgery versus conventional laparoscopy for hysterectomy: a systematic review and meta-analysis. Arch Gynecol Obstet 295:1089–1103 Xie W, Cao D, Yang J, Yu M, Shen K, Zhao L (2016) Single-port vs multi-port laparoscopic hysterectomy: A meta-analysis of randomized controlled trials. J Minim Invasive Gynecol 23(7):1049–1056 Weiss HG, Brunner W, Biebl MO, Schirnhofer J, Pimpl K, Mittermair C, Obrist C, Brunner E, Hell T (2014) Wound complications in 1145 consecutive transumbilical single-incision laparoscopic procedures. Ann Surg 259(1):89–95 De Guzmán CA, Morandeira-Rivas AJ, Herrero-Bogajo ML, Moreno-Sanz C (2020) Incidence and risk factors of incisional hernia after single-incision endoscopic surgery. J Laparoendosc Adv Surg Tech A 30(3):251–255 Casaccia M, Papadia FS, Palombo D, Domenico SD, Sormani MP, Batistotti P, Mascherini M, De Cian F (2019) Single-port versus conventional laparoscopic cholecystectomy: Better cosmesis at the price of an increased incisional hernia rate? J Laparoendosc Adv Surg Tech A 29(9):1163–1167 Cite Share Download PDF Status: Published Journal Publication published 30 Jan, 2025 Read the published version in Archives of Gynecology and Obstetrics → Version 1 posted Reviewers agreed at journal 09 Jun, 2024 Reviewers invited by journal 17 Mar, 2024 Editor invited by journal 14 Feb, 2024 Editor assigned by journal 07 Feb, 2024 First submitted to journal 06 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3939479","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":280480362,"identity":"a3ec70b7-47d1-46fd-867c-d3f713f87468","order_by":0,"name":"Sang Wook Yi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAoUlEQVRIiWNgGAWjYBACAwhpA2QwN5CkJQ3IYCRJC8NhErSYS6Q//nSj4Ly8OXtjA8OPim2EtVjOSEgwzjG4bbiz52ADY8+Z20Q47EbCgWSglgSDG4kNzIxtRGlJbDicY3COJC3JjM05BgdI0GLZ84yZOccg2XDDmYMNB4nyizl7+uPPOX/s5A2ONx988KOCCC0o4ACJ6kfBKBgFo2AU4AIA7TM+HK7dpi0AAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0003-2689-8595","institution":"Gangneung Asan Hospital, University of Ulsan College of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Sang","middleName":"Wook","lastName":"Yi","suffix":""}],"badges":[],"createdAt":"2024-02-08 09:37:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3939479/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3939479/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00404-025-07951-6","type":"published","date":"2025-01-30T15:57:55+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":53179955,"identity":"cfb33cef-66fd-423b-bc4b-a965b804282c","added_by":"auto","created_at":"2024-03-21 15:28:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":375760,"visible":true,"origin":"","legend":"\u003cp\u003eThe flow diagram of this study\u003c/p\u003e","description":"","filename":"Figure01.png","url":"https://assets-eu.researchsquare.com/files/rs-3939479/v1/16aaf0db817326837a7fd5c0.png"},{"id":53179956,"identity":"f713efd3-1cd7-4eb1-a89a-3c61ce3df5fe","added_by":"auto","created_at":"2024-03-21 15:28:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":653875,"visible":true,"origin":"","legend":"\u003cp\u003ePelvic cavity adhesion score and umbilical outcome scale score\u003c/p\u003e","description":"","filename":"Figure02.png","url":"https://assets-eu.researchsquare.com/files/rs-3939479/v1/996f651c3d2bc7d7780dbf7a.png"},{"id":75351344,"identity":"06c0e40c-d0b6-4d18-9dab-78f8bd816030","added_by":"auto","created_at":"2025-02-03 16:09:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1601945,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3939479/v1/4306ca6f-dc94-44d9-a1d3-1e21f0f254d3.pdf"}],"financialInterests":"","formattedTitle":"Postoperative abdominopelvic adhesion and umbilical wound validation after single-port laparoscopy or two-port laparoscopy for gynecological surgery: A comparison with conventional laparoscopy","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePostoperative adhesions, such as a band of connective tissue that joins two normally separate anatomical structures, occur in 75\u0026ndash;93% of patients who undergo gynecological surgeries and are among the most common sequelae of gynecological surgeries. These findings may lead to chronic pain, infertility, or bowel obstruction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. With this, the development of postoperative adhesions between the pelvis and abdominal cavity is a concern among surgeons. Adhesions are the result of tissue trauma during surgery and postoperative healing. Therefore, adhering to the principles of microsurgery and minimally invasive surgery may help to decrease the incidence of postoperative adhesions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLaparoscopy is a minimally invasive surgical technique that results in a short recovery time and a quick return to daily life activities. Generally, laparoscopy is a less invasive technique than laparotomy because there is less postoperative scarring, and the recovery time is shorter. Because the abdominal wound scars that develop after laparoscopy are smaller than those that develop after laparotomy, laparoscopy has been proven to have cosmetic advantages. Recently, with the emergence of minimally invasive surgery, laparoscopic surgery has been developed to reduce the number of ports. Due to its ability to reduce tissue trauma and improve cosmetic outcomes, single-port laparoscopic surgery is becoming increasingly common [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Single-port laparoscopic surgery has not yet completely replaced conventional laparoscopic surgery due to the difficulties and limitations of the procedure, and the incidence of postoperative wound hernia is higher because the umbilical wound incision used during single-port laparoscopic surgery is larger than that used for conventional laparoscopic surgery. Although single-port laparoscopy has more cosmetic benefits than conventional laparoscopic surgery due to the single incision made in the umbilicus, umbilical hernias are potentially life-threatening and may require emergency surgery due to bowel obstruction or bowel ischemia [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Because the incision used for single-port laparoscopic surgery is larger than that used for conventional laparoscopic surgery, complications such as umbilical hernia may occur, and it is also estimated that the incidence of complications such as port site adhesions and hemorrhage, which are wound complications, is high. Thus, we analyzed the postoperative intraperitoneal outcomes after laparoscopy using patient operation records and photographs of consecutive surgeries. A comparative study of single-port laparoscopy, two-port laparoscopy, and laparoscopy with three or more ports was also conducted.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eFrom January 1996 to July 2022, 4,510 patients underwent gynecological laparoscopic surgery. Of these, 154 patients underwent laparoscopic surgery or laparotomy after laparoscopic surgery. The intraperitoneal outcomes of twenty patients could not be analyzed because the operation records or operation images were not preserved. A total of 134 patients were enrolled in the clinical study to analyze their intraperitoneal outcomes (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e The Institutional Review Board reviewed and approved this study. In this retrospective clinical study, the postoperative states of the pelvic and abdominal cavities of patients who underwent consecutive laparotomy or laparoscopic surgery were evaluated for separate reasons after laparoscopic surgery. The patients were divided into groups, which were compared and analyzed based on the number of ports used intraoperatively. The patients were divided into three groups: Group 1 (single-port laparoscopy), Group 2 (two-port laparoscopy), and Group 3 (laparoscopy with three or more ports).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePort preparation for single- and two-port laparoscopic adnexal surgery\u003c/h2\u003e \u003cp\u003eIn the single-port laparoscopic surgeries, three trocars (two 12-mm trocars and one 5-mm trocar) were inserted into separate fingers of a surgical glove and secured with rubber bands. The wrist portion of the glove covered the wound retractor, and three Babcock clamps were placed on the edges of the retractor to prevent carbon dioxide leakage. A 10-mm laparoscope and atraumatic forceps were inserted through the umbilical multichannel port.\u003c/p\u003e \u003cp\u003eIn the two-port laparoscopic surgeries, an ancillary 5-mm trocar was placed low in the left abdomen under laparoscopy. The umbilical trocar was removed, and the skin incision was extended to approximately 1.5 cm, which is sufficiently wide to allow passage of an index finger. The skin incision was extended to the upper and lower margins of the umbilicus to minimize abdominal scarring. An Extrasmall Alexis\u0026reg; wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) was placed in the umbilical incision. Two 12-mm trocars were inserted into separate fingers of a No. 6 surgical glove and secured with rubber bands, and the other three fingers of the glove were tied together.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePort preparation for three-port laparoscopic surgery\u003c/h2\u003e \u003cp\u003eAncillary 12-mm, 10-mm, or 5-mm trocars were inserted low in the right and left abdomens under laparoscopic observation. In the conventional laparoscopy group, the ancillary port site low in the abdomen was extended to remove surgical specimens if necessary. A wound retractor was not used in the three-port laparoscopic procedure.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eOutcome measurements\u003c/h2\u003e \u003cp\u003eFollowing a review of the medical records and radiological studies, the clinicopathological characteristics of the patients, such as age, parity, previous medical and surgical history, and operative outcomes, such as the operative time, pre- and postoperative white blood cell (WBC) counts, change in the hemoglobin (Hb) level, and postoperative hospitalization duration, were investigated.\u003c/p\u003e \u003cp\u003eThe operative outcomes of the patients were obtained from their medical records, and the operation records, including those of consecutive operations, were analyzed. The degree of pelvic adhesion and intraperitoneal umbilical adhesion or hernia before and after laparoscopy were recorded using the adhesion score and umbilical outcome scale (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe results were analyzed using IBM SPSS\u0026reg; version 28 statistical software (IBM, Armonk, NY, USA). Continuous variables were compared using Student\u0026rsquo;s t test. Categorical variables were compared using the chi-square or Kruskal‒Wallis test. All tests were two-sided, and p values\u0026thinsp;\u0026le;\u0026thinsp;0.05 were considered significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 134 patients were separated into three groups, and their clinical data were analyzed. Thirteen patients underwent single-port laparoscopic surgery, 53 patients underwent two-port laparoscopic surgery, and 68 patients underwent three-port or four-port laparoscopic surgery. Patients who underwent single-port laparoscopy were included in Group 1 (n\u0026thinsp;=\u0026thinsp;13), patients who underwent two-port laparoscopy were included in Group 2 (n\u0026thinsp;=\u0026thinsp;53), and patients who underwent three-port laparoscopy or four-port laparoscopy were included in Group 3 (n\u0026thinsp;=\u0026thinsp;68).\u003c/p\u003e \u003cp\u003eThe patients\u0026rsquo; age, parity, height, weight, and body mass index (BMI) were not significantly different (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Moreover, there were no significant differences among the study groups in terms of preoperative pelvic adhesion scores, postoperative pelvic adhesion scores, hemoglobin changes, or the occurrence of umbilical hernia.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical characteristics of the study groups (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge (yrs.)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHeight (cm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e30.4\u0026thinsp;\u0026plusmn;\u0026thinsp;11.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e159.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e60.7\u0026thinsp;\u0026plusmn;\u0026thinsp;12.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e23.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e32.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e160.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e59.7\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e23.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e33.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e160.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e58.4\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e22.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerioperative and Postoperative Outcomes of the Study Groups (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOp time (min)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdhesion score (preop)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdhesion score (postop)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHb change (g/dl)*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePreop WBC\u003c/p\u003e \u003cp\u003e(/ul)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePostop WBC (ul)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePostop hospital stay (days)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUmbilical adhesion score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eUmbilical hernia\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e77.5\u0026thinsp;\u0026plusmn;\u0026thinsp;30.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e6553.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2269.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e7115.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2096.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e3.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e0.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003enone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e75.2\u0026thinsp;\u0026plusmn;\u0026thinsp;28.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e9943.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5114.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e7222.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2983.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e4.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e0.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1 case\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e83.3\u0026thinsp;\u0026plusmn;\u0026thinsp;34.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e2.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e6575.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2397.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e6041.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1965.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e0.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1 case\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003e* Changes in hemoglobin (Hb) levels were calculated as the difference between the preoperative hemoglobin level and the postoperative 2-day hemoglobin level.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe differences in the preoperative white blood cell (WBC) count, postoperative white blood cell (WBC) count, need for surgical drainage tube insertion, postoperative hospital stay, operative interval, and intraperitoneal umbilical adhesion score were significantly different among the study groups (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation with postoperative umbilical adhesion sores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical Factors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePearson\u0026rsquo;s Correlation Coefficient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePort number\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.01*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdhesion score (AS) difference (Postop. AS \u0026ndash; Preop. AS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.10*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUmbilical hernia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.00*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e* Statistically significant\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA comparison of Group 1 and Group 2 revealed that the differences in the preoperative white blood cell count, length of surgical drainage tube insertion, and length of postoperative hospital stay were statistically significant. Among the enrolled patients, single-port laparoscopy was not performed for patients with intraperitoneal inflammatory diseases such as tubo-ovarian abscess. The postoperative hospital stay in Group 2 was longer than that in Group 1 due to antibiotic therapy, and the preoperative white blood cell (WBC) count in Group 2 was greater than that in Group 1 because of inflammatory conditions.\u003c/p\u003e \u003cp\u003eA comparison of Group 1 and Group 3 revealed that the differences in postoperative white blood cell count, length of surgical drainage tube insertion, length of postoperative hospital stay, intraperitoneal umbilical adhesion score, and postoperative pelvic adhesion score were statistically significant. Among the enrolled patients, single-port laparoscopy was not performed for patients with intraperitoneal inflammatory diseases such as tubo-ovarian abscess. The postoperative hospital stay of Group 3 was longer than that of Group 1 due to antibiotic therapy, and the postoperative white blood cell count of Group 3 was greater than that of Group 1 because of inflammatory conditions.\u003c/p\u003e \u003cp\u003eA comparison of Group 2 and Group 3 revealed that the differences in the preoperative white blood cell count, postoperative white cell count, and reoperation interval were statistically significant. Moreover, there were no significant differences between Group 2 and Group 3 in terms of the preoperative pelvic adhesion score, postoperative pelvic adhesion score, hemoglobin changes, intraperitoneal umbilical adhesion score, or occurrence of umbilical hernia.\u003c/p\u003e \u003cp\u003eThe correlations between the number of ports used during surgery, the white blood cell (WBC) count before and after surgery, the reoperation interval, and the intraperitoneal umbilical adhesion score were also analyzed (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The postoperative hospital stay, incidence of umbilical hernia, and difference between the preoperative and postoperative pelvic adhesion scores were not correlated with the number of ports used during surgery.\u003c/p\u003e \u003cp\u003eThe correlations between preoperative and postoperative pelvic adhesion scores and the intraperitoneal umbilical adhesion score, number of ports used during surgery, white blood cell (WBC) count after surgery, and incidence of umbilical hernia were also evaluated (Table\u0026nbsp;4). Hemoglobin changes, white blood cell (WBC) counts before surgery, postoperative hospital stays, and reoperation intervals were not correlated with the number of ports used during surgery.\u003c/p\u003e \u003cp\u003eBecause single-port laparoscopic surgery tends not to be performed in patients with inflammatory diseases such as pelvic abscess, correlation analysis revealed that the port number was positively correlated with the WBC count before and after surgery. The incidence of intraperitoneal umbilical adhesions increased as the number of ports used during laparoscopy decreased, and the size of the umbilical incision was greater than that used for conventional laparoscopy.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDue to the increasing interest in minimally invasive surgery, single-port laparoscopic surgery has been used in gynecologic surgeries in many hospitals. Single-port laparoscopic surgery has several limitations in terms of efficacy because surgical instruments must be inserted into the same umbilical port at the same time. Thus, surgeons need time to learn how to adequately perform single-port laparoscopic surgery. In many studies, single-port laparoscopic surgery is suggested to be a safe surgical procedure that yields better cosmetic effects than conventional laparoscopic surgery using multiple ports. Single-port laparoscopic surgery is difficult to perform, and little is known about its learning curve and the factors associated with its operative outcomes during the learning period [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSingle-port laparoscopic surgery has become well known as a minimally invasive surgery among both operators and patients because there is only one postoperative wound. In a review, the authors concluded that single-port surgery has many potential benefits, but comparative trials have shown no differences between single-port surgery and conventional laparoscopy in terms of postoperative complications, postoperative pain, hospital stay, or cosmetic results [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, several studies have reported that single-port laparoscopic surgery is superior to conventional laparoscopic surgery in terms of surgical prognosis. It is considered to have better cosmetic outcomes due to the presence of one postoperative wound, which is hidden within the umbilicus, but there are a few objective studies on this topic. We found that when performing laparoscopic surgery on patients who had previously undergone single-port laparoscopic surgery, there were more empirical findings of intraperitoneal adhesions under the umbilicus than in patients who underwent conventional laparoscopic surgery. Therefore, this study was designed to compare the incidence of intraperitoneal adhesions, including those around the umbilicus, after single-port laparoscopy surgery with that after two-port laparoscopy and conventional laparoscopic surgery.\u003c/p\u003e \u003cp\u003ePostoperative adhesions, such as the band of connective tissue that joins two normally separate anatomical structures, occur in 75\u0026ndash;93% of patients who undergo gynecological surgeries and are the most common sequelae. These findings may lead to chronic pain, infertility, or bowel obstruction [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. With this, the development of postoperative adhesions between the pelvis and abdominal cavity is a concern among surgeons. Adhesions are the result of surgical tissue trauma and healing. Therefore, adhering to the principles of microsurgery and minimally invasive surgery may help to decrease the incidence of postoperative adhesions [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral studies have evaluated the occurrence of pelvic adhesions after surgery, and most have used imaging tests. Gerner-Rasmussen et al. reviewed the literature to investigate the usefulness of noninvasive diagnostic methods for detecting intraabdominal adhesions [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This approach has limitations in reflecting the actual condition of the pelvis and abdominal cavity, and visual confirmation through surgery is the most accurate way to determine the degree of adhesion. However, this approach is not feasible in most clinical settings unless patients need to undergo additional laparoscopy for therapeutic purposes. Therefore, we retrospectively evaluated the occurrence of adhesions in patients who underwent laparotomy or laparoscopy following laparoscopy.\u003c/p\u003e \u003cp\u003eThe tool currently available for evaluating the degree of adhesion is a visual adhesion scoring system. Ichikawa et al. investigated the accuracy and clinical value of the adhesion scoring system using transvaginal ultrasonography for endometriotic adhesion [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The authors concluded that the adhesion scoring system accurately predicts pelvic adhesion status and can predict the occurrence of postoperative adhesions and infertility. With this information, we used the adhesion scoring system to validate the pelvic adhesion status preoperatively and postoperatively. The degree of intraperitoneal adhesion under the umbilical area was graded using the revised scoring system shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eMany large-scale meta-analyses on single-port laparoscopic surgery have been conducted and published. Many studies have compared conventional laparoscopic surgery and single-port laparoscopic surgery for cholecystectomy and inguinal herniorrhaphy. In conclusion, most studies show that single-port laparoscopic surgery has no problem in terms of surgical efficacy, and the surgical prognosis is similar to that of conventional laparoscopic surgery. Several systemic reviews and randomized clinical trials of gynecological surgeries have been performed. Bonollo et al. reported a systemic review of randomized clinical trials for laparoendoscopic single-site surgery (LESS) in gynecology [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In their review, they showed that although cosmetic results are intuitively the main advantage of the LESS technique, current evidence does not seem to demonstrate that LESS is clearly superior to conventional multiport laparoscopy for benign gynecological conditions. Gasparri et al. performed a meta-analysis of conventional versus single-port laparoscopy for the surgical treatment of ectopic pregnancy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. They concluded that LESS does not seem to be superior to conventional laparoscopy in terms of the management of ectopic pregnancies.\u003c/p\u003e \u003cp\u003eIn a report of the long-term application of single-port and multiport total laparoscopic hysterectomy (TLH) in a single center, the authors concluded that some surgical outcomes of single-port TLH have significantly improved after long-term observation as laparoscopic surgical instruments and surgeon skill have improved [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In their study, although the uterine weight of the single-port TLH group was lower than that of the multiport TLH group, single-port TLH was associated with a significantly shorter hospital stay and operative time, a lower Hb change, and a lower complication rate after correction for biases. In another meta-analysis of single-port TLH versus multiport TLH, the authors revealed that single-port TLH is a feasible, safe and effective technique for benign gynecologic conditions, although the operative time may be longer than that of multiport TLH [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. No clinically relevant advantages were identified, and as no data on cost effectiveness are available, there are currently not enough valid arguments to broadly implement LESS for hysterectomy.\u003c/p\u003e \u003cp\u003eRegarding the wound complications in 1145 consecutive transumbilical single-incision laparoscopic procedures published by Weiss et al., the authors stated that the incidence of wound complications in transumbilical single-incision surgery is relatively acceptable and that this rate further decreases as surgeons become proficient [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn a study on the incidence of and risk factors for incisional hernia after single-incision endoscopic surgery, Guzm\u0026aacute;n et al. reported that single-incision laparoscopic cholecystectomy was significantly associated with postoperative incisional hernia [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Casaccia et al. also conducted a comparative study between single-port laparoscopic surgery and conventional laparoscopic surgery for gallbladder removal and reported that single-port laparoscopic surgery is a safe and effective surgical method when performed by an operator who is familiar with the procedure. Single-port laparoscopic surgery is recognized for its cosmetic superiority over conventional laparoscopic surgery, but the operator must pay attention to fascial suturing because of the increased potential for hernia development [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Due to the correlation between wound size and the degree of adhesion, even if there is a small number of wounds, the risk of adhesion and wound complications may increase if the wound size is large. From a cosmetic perspective, having fewer wounds may be an advantage, but minimal wounds are a true advantage of minimally invasive surgery.\u003c/p\u003e \u003cp\u003eOur study has several limitations. First, the number of single-port laparoscopic surgery cases was the lowest among the three study groups, which limits the comparative nature of the study. Because single-port laparoscopic surgery has only recently been performed, there is a limitation in that there are only a few cases in which intraperitoneal evaluation was performed through reoperation. Second, because the sizes of the umbilical ports used in single-port laparoscopic surgery and two-port laparoscopic surgery are similar and because the incision size is not accurately measured, there is a limitation in comparing the differences between single-port laparoscopic surgery and two-port laparoscopic surgery. Third, the degree of intrapelvic adhesion and intraperitoneal umbilical adhesion after surgery was evaluated based on the adhesion score obtained during reoperation, which has several limitations because it is difficult to exclude adhesion factors other than surgical variables.\u003c/p\u003e \u003cp\u003eThere are several strengths of our study. First, an objective evaluation tool, such as the adhesion scoring system, was used to evaluate wound prognosis after single-port or two-port laparoscopic surgery through visual confirmation through reoperation. Second, although the prognosis of laparoscopic surgery was not compared in a prospective study, surgical prognosis after single-port, two-port or conventional laparoscopic surgery was compared retrospectively by setting up appropriate comparison groups.\u003c/p\u003e \u003cp\u003eThe incidence of postoperative intraperitoneal umbilical adhesion increases as the size of the umbilical wound increases, such as after single-port laparoscopy. Therefore, surgical umbilical wounds after single-port laparoscopic surgery should be repaired with caution. A second laparoscopic surgery should be carefully performed after a previous single-port laparoscopic surgery to avoid causing organ damage due to contact with adhesions when entering the umbilical port. Because the number of study patients who underwent single-port laparoscopic surgery was too small in this study, there was a limit to the analysis of the results, and additional studies with more patients and standardized research methods are needed in the future.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe author has no financial interests to disclose and has not received any financial support for the preparation of this article.\u003c/p\u003e\n\u003ch2\u003eDisclosures\u003c/h2\u003e \u003cp\u003e \u003cem\u003eProf. Yi has no conflicts of interest to disclose.\u003c/em\u003e \u003c/p\u003e \u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eList each author by surname and describe each of their contributions (select all that apply) to the manuscript using the following terms:\u003c/p\u003e\n\u003cp\u003eYi SW: Protocol/project development\u003c/p\u003e\n\u003cp\u003eYi SW: Data collection or management\u003c/p\u003e\n\u003cp\u003eYi SW: Data analysis\u003c/p\u003e\n\u003cp\u003eYi SW: Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eOther (please specify briefly using 1 to 5 words)\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHirschelmann A, Wallwiener CW, Wallwiener M et al (2012) Is patient education about adhesions a requirement in abdominopelvic surgery? Geburtshife Frauenheikd 72:299\u0026ndash;304\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Wilde RL, Bakkum EA, Br\u0026ouml;lmann H et al (2014) Consensus recommendations on adhesions (version 2014) for the ESGE adhesions Research Working Group (European Society for Gynecological Endoscopy): an expert opinion. Arch Gynecol Obstet 290:581\u0026ndash;582\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePractice Committee of American Society for Reproductive Medicine in collaboration with Society of Reproductive Surgeon (2013) Pathogenesis, consequences, and control of peritoneal adhesions in gynecologic surgery: a committee opinion. Fertil Steril 99:1550\u0026ndash;1555\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBunting DM (2010) Port-site hernia following laparoscopic cholecystectomy. J Soc Laparoendosc Surg 14:490\u0026ndash;497\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSwank HA, Mulder IM, Ia Chapelle CF, Reitsma JB, Lange JF, Bemelman WA (2012) Systemic review of trocar-site hernia. Br J Surg 99:315\u0026ndash;323\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFukumoto K, Miyajima A, Hattori S et al (2017) The learning curve of laparoendoscopic single-site adrenalectomy: an analysis of over 100 cases. Surg Endosc 31:170\u0026ndash;177\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMencaglia L, Mereu L, Carri G, Arena I, Khalifa H, Tateo S, Angioni S (2013) Single port entry \u0026ndash; Are there any advantages? Best Pract Res Clin Obstet Gynecol 27(3):441\u0026ndash;455\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHirschelmann A, Wallwiener CW, Wallwiener M et al (2012) Is patient education about adhesions a requirement in abdominopelvic surgery? Geburtshife Frauenheikd 72:299\u0026ndash;304\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Wilde RL, Bakkum EA, Br\u0026ouml;lmann H et al (2014) Consensus recommendations on adhesions(version 2014) for the ESGE adhesions Research Working Group (European Society for Gynecological Endoscopy): an expert opinion. Arch Gynecol Obstet 290:581\u0026ndash;582\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePractice Committee of American Society for Reproductive Medicine in collaboration with Society of Reproductive Surgeon (2013) Pathogenesis, consequences, and control of peritoneal adhesions in gynecologic surgery: a committee opinion. Fertil Steril 99:1550\u0026ndash;1555\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGerner-Rasmussen J, Donatsky AM, Bjerrum F (2019) The role of non-invasive imaging techniques in detecting intra-abdominal adhesion: a systematic review. Langenbecks Arch Surg 404:653\u0026ndash;661\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIchikawa M, Akira S, Kaseki H, Watanabe K, Ono S, Takeshita T (2020) Accuracy and clinical value of an adhesion scoring system: A preoperative diagnostic method using transvaginal ultrasonography for endometriotic adhesion. J Obstet Gynaecol Res 46(3):466\u0026ndash;478\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBonollo M, Bellaminutti S, Gasparri ML, Papadia A (2022) Is it time to leave multi- for single-port laparoscopy in benign gynecologic surgery? A systemic review of randomized clinical trials. Minerva Obstet Gynecol 74(5):434\u0026ndash;443\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGasparri ML, Mueller MD, Taghavi K, Papadia A (2018) Conventional versus single port laparoscopy for the surgical treatment of ectopic pregnancy: A meta-analysis. Gynecol Obstet Invest 83(4):329\u0026ndash;337\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee JH, Lee YS, Hong DG (2022) Long-term experience of single-port and multi-port total laparoscopic hysterectomy in single center. vivo 36:2409\u0026ndash;2413\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSandberg EM, la Chapelle CF, van den Tweel MM, Schoones JW, Jansen FW (2017) Laparoendoscopic single-site surgery versus conventional laparoscopy for hysterectomy: a systematic review and meta-analysis. Arch Gynecol Obstet 295:1089\u0026ndash;1103\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXie W, Cao D, Yang J, Yu M, Shen K, Zhao L (2016) Single-port vs multi-port laparoscopic hysterectomy: A meta-analysis of randomized controlled trials. J Minim Invasive Gynecol 23(7):1049\u0026ndash;1056\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeiss HG, Brunner W, Biebl MO, Schirnhofer J, Pimpl K, Mittermair C, Obrist C, Brunner E, Hell T (2014) Wound complications in 1145 consecutive transumbilical single-incision laparoscopic procedures. Ann Surg 259(1):89\u0026ndash;95\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Guzm\u0026aacute;n CA, Morandeira-Rivas AJ, Herrero-Bogajo ML, Moreno-Sanz C (2020) Incidence and risk factors of incisional hernia after single-incision endoscopic surgery. J Laparoendosc Adv Surg Tech A 30(3):251\u0026ndash;255\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCasaccia M, Papadia FS, Palombo D, Domenico SD, Sormani MP, Batistotti P, Mascherini M, De Cian F (2019) Single-port versus conventional laparoscopic cholecystectomy: Better cosmesis at the price of an increased incisional hernia rate? J Laparoendosc Adv Surg Tech A 29(9):1163\u0026ndash;1167\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Adnexa, Adhesion, Complication, Operative outcomes, Single-site incision laparoscopy, Umbilicus","lastPublishedDoi":"10.21203/rs.3.rs-3939479/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3939479/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThe emergence of minimally invasive surgery has led to the development of laparoscopic surgery to reduce the number of ports. Although the incision for the umbilical port is sufficiently large, thus reducing the number of ports used during laparoscopic surgery, postoperative complications involving incisions at port sites have been reported. Thus, we analyzed postoperative intraperitoneal outcomes after laparoscopy using operation records and photographs of consecutive surgeries.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 134 patients were enrolled in the clinical study to analyze their intraperitoneal outcomes. The patients were divided into groups, which were compared and analyzed based on the number of ports used intraoperatively. The clinical characteristics of the patients were obtained from their medical records, and their operation records, including those of their consecutive operations, were analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePatients who underwent single-port laparoscopy were included in Group 1, patients who underwent two-port laparoscopy were included in Group 2, and patients who underwent three-port laparoscopy or four-port laparoscopy were included in Group 3. Correlation analysis of the number of ports used during surgery revealed that the white blood cell count before and after surgery and the intraperitoneal umbilical adhesion score were negatively correlated. The incidence of intraperitoneal umbilical adhesions increased as the number of ports used during laparoscopy decreased.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eBecause the incidence of postoperative intraperitoneal umbilical adhesion increases as the size of the umbilical wound increases, such as after single-port laparoscopy, surgical umbilical wounds should be cautiously repaired after single-port laparoscopic surgery.\u003c/p\u003e","manuscriptTitle":"Postoperative abdominopelvic adhesion and umbilical wound validation after single-port laparoscopy or two-port laparoscopy for gynecological surgery: A comparison with conventional laparoscopy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-21 15:28:13","doi":"10.21203/rs.3.rs-3939479/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2024-06-09T18:04:15+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-17T09:51:53+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Archives of Gynecology and Obstetrics","date":"2024-02-14T09:31:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-07T15:03:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Gynecology and Obstetrics","date":"2024-02-07T02:06:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"7dd38b87-ade7-453f-aa0c-53a4f642fee6","owner":[],"postedDate":"March 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-03T16:03:15+00:00","versionOfRecord":{"articleIdentity":"rs-3939479","link":"https://doi.org/10.1007/s00404-025-07951-6","journal":{"identity":"archives-of-gynecology-and-obstetrics","isVorOnly":false,"title":"Archives of Gynecology and Obstetrics"},"publishedOn":"2025-01-30 15:57:55","publishedOnDateReadable":"January 30th, 2025"},"versionCreatedAt":"2024-03-21 15:28:13","video":"","vorDoi":"10.1007/s00404-025-07951-6","vorDoiUrl":"https://doi.org/10.1007/s00404-025-07951-6","workflowStages":[]},"version":"v1","identity":"rs-3939479","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3939479","identity":"rs-3939479","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}