Single Incision Total Laparoscopic Hysterectomy at a private hospital, Kampala, Uganda; a case series

Single Incision Total Laparoscopic Hysterectomy at a private hospital, Kampala, Uganda; a case series | 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 Case Report Single Incision Total Laparoscopic Hysterectomy at a private hospital, Kampala, Uganda; a case series Leonard Ssebwami This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7274436/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Single Incision Total Laparoscopic Hysterectomy (SITLH) is a modified version of the Conventional Total Laparoscopic Hysterectomy (CTLH). The newer technique requires advanced skills with special trocars. This may partly explain the rareness of the technique in low-income countries where the special trocars may be lacking due to them being expensive. There is no documented hysterectomy performed using the SITLH technique in Africa. We present two cases of hysterectomies successfully performed using this advanced technique, by a single surgical team led by Dr John Bosco Spire Kiggundu, at Henrob laparoscopy hospital, Kampala, Uganda, using improvised conventional laparoscopic trocars. Case series We present two cases of a 48-year old, Para 2+0, black African with symptomatic uterine fibroids and a 47-year-old para 4+0, black African with endometriosis; Enzian classification P-0 O-0/0 T-2/2 A-1 B-2/0 C-0 FA . These were successfully managed using the SITLH technique by a single surgical team led by Dr John Bosco Spire Kiggundu, at Henrob Laparoscopy Hospital, using improvised conventional laparoscopic trocars. Conclusion Though the single incision total laparoscopic hysterectomy technique requires special trocars, it is still possible to be performed using improvised conventional laparoscopic trocars in low-resource setting. These two cases demonstrate the ability and innovativeness of the surgical team, to use the limited available resources and successfully perform a task that would actually demand advanced special equipment. Obstetrics & Gynecology Azimuth angle Ergonomics Single Incision Total Laparoscopic Hysterectomy manipulation angle Triangulation Figures Figure 1 Figure 2 Background The practice of minimal access surgery started way back in the 1940 by Raoul Palmer, and over time, it has gained popularity throughout the world(1). The first laparoscopic hysterectomy was performed by Dr Harry Reich in 1988 and since then, the technique has been modified to achieve a less invasive, more cosmetically appealing and enhanced patients’ satisfaction(2)(3). The index laparoscopic hysterectomy involved accessing the peritoneal cavity through four ports (one optical and three accessory ports). To reduce on the number of skin incisions, associated pain and improving patient’s satisfaction, the SITLH technique was developed as a modified version of the former(4)(5). The SITLH involves creating a single skin incision through the umbilicus, that gives access to the peritoneal cavity to perform the steps of hysterectomy(6). The SITLH technique is now widely used to operate on a wide range of benign gynecological conditions. Recent literature has documented the application of the SITLH technique as a treatment modality for early-stage malignancy(7). Despite the documented merits of the SITLH compared to the conventional multi-port conventional total laparoscopic hysterectomy, the former requires advanced skills and training, more agronomics adjustments, thus rarely performed. There are few hysterectomies that are performed laparoscopically and no documented cases of SITLH in sub-Saharan Africa(8)(9). Henrob hospital Laparoscopy and Endometriosis Centre located 6km south of Kampala city; is one of the leading laparoscopic center in Uganda with over 1300 cases performed laparoscopically in the last five years. There were 18 cases of Single Incision laparoscopic surgeries performed and we present two cases of Single Incision total Laparoscopic hysterectomies at Henrob Laparoscopy Hospital. Case series We present two cases of total laparoscopic hysterectomy performed successfully at Henrob hospital, using the SITLH technique, a rare surgical procedure in our setting. Case 1 A 48-year old Para 2+0, who presented with symptomatic uterine fibroids. She reported a long-standing history of menorrhagia with severe dysmenorrhea associated with dysuria and frequency. She had used a number of analgesics but with no improvement. Past obstetric history: had two spontaneous vertex deliveries. Past medical history: known patient of peptic ulcer disease, denies any other chronic medical illness, no known food or drug allergy reported Physical examination revealed fair general condition, afebrile, moderate, pallor, not jaundiced, fully conscious and well oriented, blood pressure-142/82mmHg. Respiratory examination revealed a normal respiratory of 20 breaths/minute, and normal breath sounds. Cardiovascular exam: Heart sound 1 and Heart sound 2 heard, no added sounds appreciated. Abdominal exam revealed normal fullness abdomen, soft, moving on respiration. Bulky uterus palpable at 14cm, with firm tender masses. Speculum exam showed a grossly normal cervix. Pre-operative haemoglobin was 7.8g/dl, renal function tests, liver function tests were normal Procedure Informed consent was obtained and general anaesthesia was used. Patient in a semi-lithotomy position, insufflation of peritoneal cavity with Carbon dioxide through a veress needle. Patient put in Trendelenburg position and made a six centimetre umbilical skin incision, through which three ports were inserted into the abdomen as shown in figure 1. These ports included a 10mm optical and two 5mm ports. Upon peritoneal entry, we found a bulky uterus at 14 weeks with two anterior intramural fibroids. We developed the urinary bladder peritoneum to release the bladder, all pedicles were released and haemostasis achieved. Bilateral salpingectomy was done and ovaries left in situ. The specimens were retrieved via the vault after bisecting the uterus with a scissor. The vaginal vault was repaired in layers using vinyl number one. All pedicles were inspected and both ureters were safely dissected and the port was closed. Intraoperative time was 90 minutes. The postoperative period was non-eventful and the patient was discharged after 24 hours. Postoperative follow-up on day seven and week six was normal. Case 2 A 47-year-old para 4+0, black African presented with a long standing history of chronic pelvic pain. She was diagnosed with abnormal uterine bleeding due to endometriosis with Enzian classification: P-0 O-0/0 T-2/2 A-1 B-2/0 C-0 FA . Past Obstetric history: she had two spontaneous vertex deliveries and two previous caesarian sections. Past surgical history: reported history of epigastric herniorraphy and open reduction and internal fixation of the left femur. Past medical history: known asthmatic patient, no known drug and food allergy. On physical examination, she was in fair general condition, afebrile, not pale, no oedema. She was normotensive with a blood pressure of 113/63mmHg, Uterus was palpable around 16 weeks. Trans-vaginal ultrasound scan showed posterior deep endometriosis involving the left uteral sacral ligament and posterior vaginal fornix. Pelvic adhesions and obliteration of the pouch of Douglas. Procedure Informed consent was obtained and general anaesthesia was used. Patient in a semi-lithotomy position Insufflation was achieved through a veress needle inserted in the umbilicus until loss of liver dullness and attainment of uniform abdominal distension. A six centimeter single umbilical incision was made on skin and fascia; a 10mm and two 5mm ports were inserted through this single incision as shown in figure 1. We found a bulky uterus with posterior compartment endometriosis involving both USL, both ureter were not involved, both ovaries grossly appeared normal and were spared. We released the bladder, posterior peritoneum and dissected ureter. We secured all vascular pedicles, did colpotomy and bilateral salpingectomy. We delivered the uterus via the colpos and repaired the vault. Excision of endometriosis lesion was done inspected all pedicles. Operation lasted 90 minutes. This patient was discharged on the first postoperative day and had no complications. Postoperative follow up at seven days and six weeks was un-eventful. Discussion Our team successfully performed the SITL hysterectomies, using improvised basic conventional laparoscopic equipment through a six centimeter umbilical incision. Previous literature in India, documented a similar improvising of conventional laparoscopic equipment to perform the same technique( 10 ). However in High income countries, where the special SITLH equipment are available for this procedure, such a hurdle of improvising hardly occurs. For both our patients, peritoneal cavity was accessed through a six centimeter trans-umbilical incision, which was used to transmit three ports (one optical and two accessory). This access incision is quite longer than the standard two centimeter umbilical incision given when you have the special trocars for performing the SITLH technique( 6 ). For both our patients, we achieved a pneumoperitoneum using a veress needle through the umbilicus and insufflating carbon dioxide. However in some cases of SILS, a veress needle may be inserted through a palmer’s point (a point 3cm below the left costal margin in the mid-clavicular line)( 11 ). The Average intraoperative time was 90 minutes, which is similar to earlier reported cases of SITLH performed in Asia and Europe using standard SITLH equipment( 10 ). Compared to the CTLH, the task analysis and performance of the SITLH technique is more ergonomically demanding in terms of surgical skills competency of the team especially in terms of suturing and triangulation. This is because of the limited working space offered by a single incision through which the scope and hand instruments are manipulated. This leads to instrument crowding, with the resulting shortened manipulation and Azimuth angles making suturing of the vault more difficult. In high income countries, self-locking barbed sutures are available that make the suturing of the vault more friendly to the surgical team( 12 ). For both our patients, the vault was closed using vinyl number one. Previous literature has recommended frequent practice on an endotrainer in order to improve on the suturing skill competency to suit the SITLH technique( 10 ). Conclusion Though the single incision total laparoscopic hysterectomy technique requires special trocars, it is still possible to be performed using improvised conventional laparoscopic trocars in low-resource setting. These two cases demonstrate the ability and the innovativeness of the surgical team, to use the limited available resources to perform a task that would actually require advanced special equipment. Abbreviations CTLH Conventional total laparoscopic hysterectomy SITLH Single incision total laparoscopic hysterectomy SILS Single Incision Laparoscopic Surgery Declarations Acknowledgement We acknowledge and thank our patients who consented to have this work published, and also to the hospital staffs who participated either directly or indirectly in the management of these patients. Consent for publication and Ethics approval An informed written consent to publish this work was obtained from the two patients. Availability of data and materials Not applicable Conflict of interest The authors report no conflict of interest in this work. Funding No funding to report Author contributions JBSK, JW and LS participated in the conceptualization and literature search. CK, MK, GN, JCL contributed to the discussion. All authors participated in the proof reading and approval of the final manuscript. References Nisolle M. Perspectives on laparoscopic hysterectomy. Gynecol Surg. 2010;7(2):105–7. Koffi KA, Aka KE, Fomba M, Seni K, Horo A, Kone M. African experiences of laparoscopic hysterectomy about a continuous series of 52 cases by the same practitioner: indications, surgical procedures and complications. Int J Reprod Contraception, Obstet Gynecol. 2018;7(3):789. Soo S, Lee S, Ang CW. Case Series of Single Incision Laparoscopic Hysterectomy - An Australian Experience. J Minim Invasive Gynecol [Internet]. 2010;18(6):S96. Available from: http://dx.doi.org/10.1016/j.jmig.2011.08.338 Sendag F, Turan V, Zeybek B, Bilgin O. Transumbilical single-incision total laparoscopic hysterectomy: Technique and initial experience in Turkey. Ginekol Pol [Internet]. 2012;83(8):581–5. Available from: http://dx.doi.org/10.1016/j.jmig.2010.08.382 Huang KJ, Lin KT, Wu CJ, Li YX, Chang WC, Sheu BC. Single incision laparoscopic surgery using conventional laparoscopic instruments versus two-port laparoscopic surgery for adnexal lesions. Sci Rep [Internet]. 2021;11(1):1–6. Available from: https://doi.org/10.1038/s41598-021-82204-5 Sinha R, Sundaram M, Mahajan C, Raje S, Kadam P, Rao G, et al. Single-incision total laparoscopic hysterectomy. J Minim Access Surg. 2011 Jan;7(1):78–82. Rezai S, Zeng C, Alexander C, Bergdahl H, Cassandra E, Guan X, et al. Single-incision laparoscopic surgery ( SILS ), radical hysterectomy for early stage cervical cancer , a case report and review of literature. 2018;9(5):371–6. Rudnicki M, Shayo BC, Mchome B. Is abdominal hysterectomy still the surgery of choice in sub-Saharan Africa? Acta Obstet Gynecol Scand. 2021;100(4):715–7. Chrysostomou A, Djokovic D. Preferred and actual methods of hysterectomy: A survey of current practices among members of the South African society of obstetricians and gynaecologists. S Afr J Obstet Gynaecol. 2020;26(1):1–6. Reynders A, Baekelandt J. Low-cost total laparoscopic hysterectomy by single-incision laparoscopic surgery using only reusable standard laparoscopic instruments. Gynecol Surg [Internet]. 2015;12(2):101–5. Available from: https://doi.org/10.1007/s10397-015-0886-4 Shukr G, Gonte MR, Webber VE, Zwain O, Eisenstein D. E-Z point: A new safe and reproducible laparoscopic entry in the left upper quadrant using a Veress needle. J Hum Reprod Sci. 2022;15(3):300–6. Förster CE, Calabretti I, Gubser L, Schötzau A, Fellmann-Fischer B, Heinzelmann-Schwarz V, et al. Comparison of different suture techniques for laparoscopic vaginal cuff closure. Sci Rep [Internet]. 2024;14(1):1–9. Available from: https://doi.org/10.1038/s41598-024-55586-5 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted 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. 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The first laparoscopic hysterectomy was performed by Dr Harry Reich in 1988 and since then, the technique has been modified to achieve a less invasive, more cosmetically appealing and enhanced patients’ satisfaction(2)(3). The index laparoscopic hysterectomy involved accessing the peritoneal cavity through four ports (one optical and three accessory ports). To reduce on the number of skin incisions, associated pain and improving patient’s satisfaction, the SITLH technique was developed as a modified version of the former(4)(5). The SITLH involves creating a single skin incision through the umbilicus, that gives access to the peritoneal cavity to perform the steps of hysterectomy(6). The SITLH technique is now widely used to operate on a wide range of benign gynecological conditions. Recent literature has documented the application of the SITLH technique as a treatment modality for early-stage malignancy(7).\u003c/p\u003e\n\u003cp\u003eDespite the documented merits of the SITLH compared to the conventional multi-port conventional total laparoscopic hysterectomy, the former requires advanced skills and training, more agronomics adjustments, thus rarely performed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere are few hysterectomies that are performed laparoscopically and no documented cases of SITLH in sub-Saharan Africa(8)(9).\u003c/p\u003e\n\u003cp\u003eHenrob hospital Laparoscopy and Endometriosis Centre located 6km south of Kampala city; is one of the leading laparoscopic center in Uganda with over 1300 cases performed laparoscopically in the last five years. There were 18 cases of Single Incision laparoscopic surgeries performed and we present two cases of Single Incision total Laparoscopic hysterectomies at Henrob Laparoscopy Hospital.\u003c/p\u003e"},{"header":"Case series ","content":"\u003cp\u003eWe present two cases of total laparoscopic hysterectomy performed successfully at Henrob hospital, using the SITLH technique, a rare surgical procedure in our setting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 48-year old Para 2+0, who presented with symptomatic uterine fibroids. She reported a long-standing history of menorrhagia with severe dysmenorrhea associated with dysuria and frequency. She had used a number of analgesics but with no improvement. Past obstetric history: \u0026nbsp;had two spontaneous vertex deliveries.\u003c/p\u003e\n\u003cp\u003ePast medical history: known patient of peptic ulcer disease, denies any other chronic medical illness, no known food or drug allergy reported\u003cbr\u003e\u0026nbsp;Physical examination revealed \u0026nbsp;fair general condition, afebrile, moderate, pallor, not jaundiced, fully conscious and well oriented, blood pressure-142/82mmHg.\u003c/p\u003e\n\u003cp\u003eRespiratory examination revealed a normal respiratory of 20 breaths/minute, and normal breath sounds.\u003cbr\u003e\u0026nbsp;Cardiovascular exam: Heart sound 1 and Heart sound 2 heard, no added sounds appreciated.\u003cbr\u003e\u0026nbsp;Abdominal exam revealed normal fullness abdomen, soft, moving on respiration. Bulky uterus palpable at 14cm, with firm tender masses.\u0026nbsp;\u003cbr\u003e\u0026nbsp;Speculum exam showed a grossly normal cervix.\u003cbr\u003e\u0026nbsp;Pre-operative haemoglobin was 7.8g/dl, renal function tests, liver function tests were normal\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained and general anaesthesia was used. Patient in a semi-lithotomy position, insufflation of peritoneal cavity with Carbon dioxide through a veress needle.\u003c/p\u003e\n\u003cp\u003ePatient put in Trendelenburg position and made a six centimetre umbilical skin incision, through which three ports were inserted into the abdomen as shown in figure 1. These ports included a 10mm optical and two 5mm ports. Upon peritoneal entry, we found a bulky uterus at 14 weeks with two anterior intramural fibroids.\u003c/p\u003e\n\u003cp\u003eWe developed the urinary bladder peritoneum to release the bladder, all pedicles were released and haemostasis achieved. Bilateral salpingectomy was done and ovaries left in situ. The specimens were retrieved via the vault after bisecting the uterus with a scissor.\u003c/p\u003e\n\u003cp\u003eThe vaginal vault was repaired in layers using vinyl number one.\u003c/p\u003e\n\u003cp\u003eAll pedicles were inspected and both ureters were safely dissected and the port was closed.\u003c/p\u003e\n\u003cp\u003eIntraoperative time was 90 minutes.\u003c/p\u003e\n\u003cp\u003eThe postoperative period was non-eventful and the patient was discharged after 24 hours.\u003c/p\u003e\n\u003cp\u003ePostoperative follow-up on day seven and week six was normal.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eCase 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 47-year-old para 4+0, black African presented with a long standing history of chronic pelvic pain. She was diagnosed with abnormal uterine bleeding due to endometriosis with Enzian classification:\u003cstrong\u003eP-0 O-0/0 T-2/2 A-1 B-2/0 C-0 FA\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003ePast Obstetric history: she had two spontaneous vertex deliveries and two previous caesarian sections.\u003c/p\u003e\n\u003cp\u003ePast surgical history: reported history of epigastric herniorraphy and open reduction and internal fixation of the left femur.\u003c/p\u003e\n\u003cp\u003ePast medical history: known asthmatic patient, no known drug and food allergy.\u003c/p\u003e\n\u003cp\u003eOn physical examination, she was in fair general condition, afebrile, not pale, no oedema.\u003c/p\u003e\n\u003cp\u003eShe was normotensive with a blood pressure of 113/63mmHg,\u003c/p\u003e\n\u003cp\u003eUterus was palpable around 16 weeks.\u003c/p\u003e\n\u003cp\u003eTrans-vaginal ultrasound scan showed posterior deep endometriosis involving the left uteral sacral ligament and posterior vaginal fornix. Pelvic adhesions and obliteration of the pouch of Douglas.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Procedure\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained and general anaesthesia was used. Patient in a semi-lithotomy position\u003c/p\u003e\n\u003cp\u003eInsufflation was achieved through a veress needle inserted in the umbilicus until loss of liver dullness and attainment of uniform abdominal distension.\u003c/p\u003e\n\u003cp\u003eA six centimeter single umbilical incision was made on skin and fascia; a 10mm and two 5mm ports were inserted through this single incision as shown in figure 1. We found a bulky uterus with posterior compartment endometriosis involving both USL, both ureter were not involved, both ovaries grossly appeared normal and were spared. We released the bladder, posterior peritoneum and dissected ureter. We secured all vascular pedicles, did colpotomy and bilateral salpingectomy. We delivered the uterus via the colpos and repaired the vault. Excision of endometriosis lesion was done inspected all pedicles. Operation lasted 90 minutes. This patient was discharged on the first postoperative day and had no complications. Postoperative follow up at seven days and six weeks was un-eventful.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur team successfully performed the SITL hysterectomies, using improvised basic conventional laparoscopic equipment through a six centimeter umbilical incision. Previous literature in India, documented a similar improvising of conventional laparoscopic equipment to perform the same technique(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). However in High income countries, where the special SITLH equipment are available for this procedure, such a hurdle of improvising hardly occurs.\u003c/p\u003e\u003cp\u003eFor both our patients, peritoneal cavity was accessed through a six centimeter trans-umbilical incision, which was used to transmit three ports (one optical and two accessory). This access incision is quite longer than the standard two centimeter umbilical incision given when you have the special trocars for performing the SITLH technique(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFor both our patients, we achieved a pneumoperitoneum using a veress needle through the umbilicus and insufflating carbon dioxide. However in some cases of SILS, a veress needle may be inserted through a palmer\u0026rsquo;s point (a point 3cm below the left costal margin in the mid-clavicular line)(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe Average intraoperative time was 90 minutes, which is similar to earlier reported cases of SITLH performed in Asia and Europe using standard SITLH equipment(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCompared to the CTLH, the task analysis and performance of the SITLH technique is more ergonomically demanding in terms of surgical skills competency of the team especially in terms of suturing and triangulation. This is because of the limited working space offered by a single incision through which the scope and hand instruments are manipulated. This leads to instrument crowding, with the resulting shortened manipulation and Azimuth angles making suturing of the vault more difficult. In high income countries, self-locking barbed sutures are available that make the suturing of the vault more friendly to the surgical team(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFor both our patients, the vault was closed using vinyl number one. Previous literature has recommended frequent practice on an endotrainer in order to improve on the suturing skill competency to suit the SITLH technique(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThough the single incision total laparoscopic hysterectomy technique requires special trocars, it is still possible to be performed using improvised conventional laparoscopic trocars in low-resource setting.\u003c/p\u003e\u003cp\u003eThese two cases demonstrate the ability and the innovativeness of the surgical team, to use the limited available resources to perform a task that would actually require advanced special equipment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCTLH\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConventional total laparoscopic hysterectomy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSITLH\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSingle incision total laparoscopic hysterectomy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSILS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSingle Incision Laparoscopic Surgery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge and thank our patients who consented to have this work published, and also to the hospital staffs who participated either directly or indirectly in the management of these patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication and Ethics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn informed written consent to publish this work was obtained from the two patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no conflict of interest in this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding to report\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJBSK, JW and LS participated in the conceptualization and literature search. CK, MK, GN, JCL contributed to the discussion. All authors participated in the proof reading and approval of the final manuscript.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eNisolle M. Perspectives on laparoscopic hysterectomy. Gynecol Surg. 2010;7(2):105\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eKoffi KA, Aka KE, Fomba M, Seni K, Horo A, Kone M. African experiences of laparoscopic hysterectomy about a continuous series of 52 cases by the same practitioner: indications, surgical procedures and complications. Int J Reprod Contraception, Obstet Gynecol. 2018;7(3):789.\u003c/li\u003e\n \u003cli\u003eSoo S, Lee S, Ang CW. Case Series of Single Incision Laparoscopic Hysterectomy - An Australian Experience. J Minim Invasive Gynecol [Internet]. 2010;18(6):S96. Available from: http://dx.doi.org/10.1016/j.jmig.2011.08.338\u003c/li\u003e\n \u003cli\u003eSendag F, Turan V, Zeybek B, Bilgin O. Transumbilical single-incision total laparoscopic hysterectomy: Technique and initial experience in Turkey. Ginekol Pol [Internet]. 2012;83(8):581\u0026ndash;5. Available from: http://dx.doi.org/10.1016/j.jmig.2010.08.382\u003c/li\u003e\n \u003cli\u003eHuang KJ, Lin KT, Wu CJ, Li YX, Chang WC, Sheu BC. Single incision laparoscopic surgery using conventional laparoscopic instruments versus two-port laparoscopic surgery for adnexal lesions. Sci Rep [Internet]. 2021;11(1):1\u0026ndash;6. Available from: https://doi.org/10.1038/s41598-021-82204-5\u003c/li\u003e\n \u003cli\u003eSinha R, Sundaram M, Mahajan C, Raje S, Kadam P, Rao G, et al. Single-incision total laparoscopic hysterectomy. J Minim Access Surg. 2011 Jan;7(1):78\u0026ndash;82.\u003c/li\u003e\n \u003cli\u003eRezai S, Zeng C, Alexander C, Bergdahl H, Cassandra E, Guan X, et al. Single-incision laparoscopic surgery ( SILS ), radical hysterectomy for early stage cervical cancer , a case report and review of literature. 2018;9(5):371\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003eRudnicki M, Shayo BC, Mchome B. Is abdominal hysterectomy still the surgery of choice in sub-Saharan Africa? Acta Obstet Gynecol Scand. 2021;100(4):715\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eChrysostomou A, Djokovic D. Preferred and actual methods of hysterectomy: A survey of current practices among members of the South African society of obstetricians and gynaecologists. S Afr J Obstet Gynaecol. 2020;26(1):1\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003eReynders A, Baekelandt J. Low-cost total laparoscopic hysterectomy by single-incision laparoscopic surgery using only reusable standard laparoscopic instruments. Gynecol Surg [Internet]. 2015;12(2):101\u0026ndash;5. Available from: https://doi.org/10.1007/s10397-015-0886-4\u003c/li\u003e\n \u003cli\u003eShukr G, Gonte MR, Webber VE, Zwain O, Eisenstein D. E-Z point: A new safe and reproducible laparoscopic entry in the left upper quadrant using a Veress needle. J Hum Reprod Sci. 2022;15(3):300\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003eF\u0026ouml;rster CE, Calabretti I, Gubser L, Sch\u0026ouml;tzau A, Fellmann-Fischer B, Heinzelmann-Schwarz V, et al. Comparison of different suture techniques for laparoscopic vaginal cuff closure. Sci Rep [Internet]. 2024;14(1):1\u0026ndash;9. Available from: https://doi.org/10.1038/s41598-024-55586-5\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Azimuth angle, Ergonomics, Single Incision Total Laparoscopic Hysterectomy, manipulation angle, Triangulation","lastPublishedDoi":"10.21203/rs.3.rs-7274436/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7274436/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSingle Incision Total Laparoscopic Hysterectomy (SITLH) is a modified version of the Conventional Total Laparoscopic Hysterectomy (CTLH). The newer technique requires advanced skills with special trocars. This may partly explain the rareness of the technique in low-income countries where the special trocars may be lacking due to them being expensive. There is no documented hysterectomy performed using the SITLH technique in Africa. We present two cases of hysterectomies successfully performed using this advanced technique, by a single surgical team led by Dr John Bosco Spire Kiggundu, at Henrob laparoscopy hospital, Kampala, Uganda, using improvised conventional laparoscopic trocars.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase series\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe present two cases of a 48-year old, Para 2+0, black African with symptomatic uterine fibroids and a 47-year-old para 4+0, black African with endometriosis; Enzian classification \u003cstrong\u003eP-0 O-0/0 T-2/2 A-1 B-2/0 C-0 FA\u003c/strong\u003e. These were successfully managed using the SITLH technique by a single surgical team led by Dr John Bosco Spire Kiggundu, at Henrob Laparoscopy Hospital, using improvised conventional laparoscopic trocars.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThough the single incision total laparoscopic hysterectomy technique requires special trocars, it is still possible to be performed using improvised conventional laparoscopic trocars in low-resource setting.\u003c/p\u003e\n\u003cp\u003eThese two cases demonstrate the ability and innovativeness of the surgical team, to use the limited available resources and successfully perform a task that would actually demand advanced special equipment.\u003c/p\u003e","manuscriptTitle":"Single Incision Total Laparoscopic Hysterectomy at a private hospital, Kampala, Uganda; a case series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-05 14:00:53","doi":"10.21203/rs.3.rs-7274436/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"11c8cf91-ff68-4f33-9f18-e9b091bc92a3","owner":[],"postedDate":"August 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":52523014,"name":"Obstetrics \u0026 Gynecology"}],"tags":[],"updatedAt":"2025-08-05T14:00:53+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-05 14:00:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7274436","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7274436","identity":"rs-7274436","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}