No case of single-incision laparoscopic surgery in obese patients who had previously undergone multiple midline vertical laparotomies has been described in the literature to date. Hence we report the first case of single-port laparoscopic salpingo-oophorectomy in an obese patient who was affected by a left adnexal mass and who had previously undergone 3 midline vertical laparotomies

Baffa, A

Boccia, C

Piccione, E

Sesti, F

Sorrenti, G

PubMed

SESTI, FRANCESCO

PICCIONE, EMILIO

English

Single-incision laparoscopic adnexectomy in an obese patient with previous laparotomies

Francesco Sesti

Claudio Boccia

Giuseppe Sorrenti

Alberto Baffa

Emilio Piccione

Crossref

JSLS Journal of the Society of Laparoscopic & Robotic Surgeons

Single-Incision Laparoscopic Adnexectomy in an Obese Patient with Previous Laparotomies

Archivio della Ricerca - Università di Roma Tor vergata

Single-Incision Laparoscopic Adnexectomy in an
Obese Patient with Previous Laparotomies
Francesco Sesti, MD, Claudio Boccia, MD, Giuseppe Sorrenti, MD, Alberto Baffa, MD,
Emilio Piccione, MD
ABSTRACT
Introduction: No case of single-incision laparoscopic
surgery in obese patients who had previously undergone
multiple midline vertical laparotomies has been described
in the literature to date. Hence we report the first case of
single-port laparoscopic salpingo-oophorectomy in an
obese patient who was affected by a left adnexal mass and
who had previously undergone 3 midline vertical laparot-
omies.
Case Description: A postmenopausal 57-year-old woman
with a body mass index of 31.2 kg/m2 and a history of 3
midline vertical cesarean deliveries and a right salpingo-
oophorectomy was diagnosed with a left adnexal mass and
underwent a single-incision laparoscopic salpingo-oopho-
rectomy.
Discussion: The patient was treated successfully. The
operative blood loss was minimal. The postoperative hos-
pital stay lasted 18 hours, and postoperative pain was
short-lasting. No early or long-term postoperative compli-
cations were registered. On histopathologic examination,
a diagnosis of ovarian serous cystadenoma was made.
Even though this unique case is the first to be reported in
the literature, its encouraging results suggest the use of
this new surgical technique in similar clinical situations to
verify whether the feasibility and safety reported in this
article are confirmed.
Key Words: Single-incision laparoscopic surgery, Salpin-
go-oophorectomy, Benign adnexal mass, Midline vertical
laparotomies, Obesity.
INTRODUCTION
Laparoscopic surgery with a single access site, known as
single-incision laparoscopic surgery (SILS), laparoendo-
scopic single-site surgery, or single-port access surgery,
represents a new frontier of minimally invasive surgery. Its
feasibility in gynecologic surgery has been shown by
various authors who performed salpingo-oophorecto-
mies, uterine myomectomies, hysterectomies, and more
recently, radical surgeries with pelvic lymphadenecto-
my.1–3 Interest in this technique is based on its many
benefits over traditional laparoscopy, such as decreased
operative time, reduced incidence of intraoperative com-
plications, improvement of cosmetics results, and shorter
length of hospital stay.2–4
In defining the inclusion and exclusion criteria for SILS in
patients, several authors considered obesity, previous ab-
dominal surgeries, and early-stage gynecologic cancer as
relative contraindications to this surgical approach
whereas patients who had previously undergone 2 mid-
line vertical laparotomies or panniculectomies, who did
not possess a native umbilicus, or who had a diagnosis of
advanced malignancy were judged unsuitable candidates
for SILS.3,5,6
To our knowledge, no case of SILS in obese patients who
had previously undergone multiple midline vertical lapa-
rotomies has been described in the literature. Hence we
report the first case of single-port laparoscopic salpingo-
oophorectomy in an obese patient who was affected by a
left adnexal mass and who had been previously under-
gone 3 midline vertical laparotomies.
CASE REPORT
A postmenopausal 57-year-old woman, gravida III, para
III, with a body mass index of 31.2 kg/m2 presented to our
institution with a diagnosis of left adnexal mass. In 2004
she had undergone a right quadrantectomy for breast
cancer that, at present, was in remission. The patient
reported 3 previous cesarean deliveries performed
through midline vertical umbilical-pubic incisions. During
the last cesarean delivery, she had also undergone right
salpingo-oophorectomy because of a benign ovarian cyst.
Transabdominal and transvaginal ultrasonography showed a
Section of Gynecology and Obstetrics, Department of Biomedicine & Prevention,
Tor Vergata University Hospital, Rome, Italy (all authors).
Address correspondence to: Francesco Sesti, MD, School of Medicine, Department
of Biomedicine & Prevention, Tor Vergata University Hospital, Viale Oxford,
81–00133, Rome, Italy. Telephone: 39 06 20 902 921, Fax: 39 06 20 902 924
E-mail: francesco.sesti@uniroma2.it
DOI: 10.4293/108680812X13517013317158
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
JSLS (2013)17:164–166164
CASE REPORT
34  27  23–mm left ovarian cyst with no peripheral
vascularity, no septa, and no echogenic signs. Ovarian mark-
ers were negative.
RESULTS
The patient received general anesthesia and was placed in
a dorsal lithotomic position. After the uterine manipulator
was inserted, a 2.5-cm intraumbilical vertical incision was
carried out, in part, overlying the old scar. After an open
laparoscopy was performed, a SILS multiple-instrument
access port device was inserted (Covidien, Mansfield, MA)
and pneumoperitoneum was established. We used two
5-mm cannulas for introducing the laparoscopic instru-
ments (Johann forceps [Karl Storz, Tuttlingen, Germany]
and 5-mm LigaSure Advance [Covidien]) and a 12-mm
cannula for insertion of a 5.5-mm-diameter, 30°, 50-cm-
long rigid laparoscope (Storz Hopkins II; Karl Storz). After
the entire abdominal cavity had been observed, which
appeared normal except for a few tenuous peritoneal
adhesions, we visualized the left adnexa that appeared to
be of increased size because of the presence of an ovarian
cyst with a smooth and even wall (Figure 1). We carried
out left salpingo-oophorectomy using a 5-mm LigaSure
Advance device (Figure 2). The whole specimen was
extracted through the umbilicus by use of an Endobag
(Covidien) after partial withdrawal of the port device
(Figure 3). The operative time, from the incision of the
skin to its complete closure, was 30 minutes (Figure 4).
No intraoperative or postoperative complications were
observed, and blood loss was minimal. Postoperative pain
was assessed at 20 minutes and at 2, 4, and 8 hours by a
visual analog scale represented by a line 10 cm long,
ranging from 0 (no pain) to 100 (pain as bad as it could
be). The score ranged between 6 (20 minutes after sur-
gery) and 0 (8 hours after surgery). The postoperative
hospital stay was 18 hours. On histopathologic examina-
tion, a diagnosis of ovarian serous cystadenoma was
made. At 3 months after surgery, the scar healing was opti-
mal and no incisional hernia was observed (Figure 5). We
acquired institutional review board approval from the local
ethics committee and written informed consent from the
patient before reporting this case.
DISCUSSION
SILS is a novel technique that has become progressively
more accepted and applied as data supporting its safety andFigure 1. Left ovarian cyst with smooth and even wall.
Figure 2. Image after salpingo-oophorectomy was performed
with 5-mm LigaSure Advance.
Figure 3. Specimen including left ovarian cyst and tube.
Figure 4. Incision site at end of skin closure.
JSLS (2013)17:164–166 165
enhancements in use have accumulated. A few authors em-
phasize the advantages of this approach over traditional
laparoscopy, such as improved cosmetic results, decreased
operative time, and reduced postoperative pain.7–9 This case
confirms those favorable results. Indeed, postoperative pain
analysis shows that at 8 hours after surgery, the patient
reported no pain. Probably the minor invasiveness of this
approach causes less and rapidly decreasing pain, allowing a
faster recovery time and, consequently, a shorter hospital-
ization. Unlike the conventional laparoscopy, another ad-
vantage is the possibility of extracting the whole adnexal
specimen into a 12-mm Endobag through the unique umbil-
ical incision after partial withdrawal of the port device. This
is of great importance especially in cases of suspected ad-
nexal masses because a whole specimen facilitates the his-
topathologic diagnosis.
However, no case of SILS in an obese patient who had
previously undergone multiple midline vertical laparotomies
has been described in the literature. Fader et al.6 advised
against executing the SILS technique in women with 2
previous midline vertical laparotomies and suggested that
patient selection should initially be geared toward simple
cases because learning these ergonomically challenging
techniques may be less technically demanding in these
cases. Moreover, a body mass index 30 kg/m2 was con-
sidered an absolute contraindication to SILS.8
CONCLUSION
The present case, which was performed by surgeons
who had little experience with this procedure, shows
that this technique was carried out rapidly and without
any intraoperative and postoperative complications in
an obese woman who had previously undergone 2
midline vertical laparotomies. Even though this unique
case is the first to be reported in the literature, its
encouraging results suggest the use of this new surgical
technique in similar clinical situations to verify whether
the feasibility and safety reported in this article are
confirmed.
References:
1. Fader AN, Escobar PF. Laparoendoscopic single-site surgery
(LESS) in gynecologic oncology: technique and initial report.
Gynecol Oncol. 2009;114:157–161.
2. Uppal S, Frumovitz M, Escobar P, Ramirez PT. Laparoendo-
scopic single-site surgery in gynecology: review of literature and
available technology. J Minim Invasive Gynecol. 2011;18:12–23.
3. Fader AN, Rojas-Espaillat L, Ibeanu O, Grumbine FC, Esco-
bar PF. Laparoendoscopic single-site surgery (LESS) in gynecol-
ogy: a multi-institutional evaluation. Am J Obstet Gynecol. 2010;
203:501.e1–501.e6.
4. Fader AN, Cohen S, Escobar PF, Gunderson C. Laparoendo-
scopic single-site surgery in gynecology. Curr Opin Obstet Gy-
necol. 2010;22:331–338.
5. Fagotti A, Fanfani F, Rossitto C, et al. Laparoendoscopic
single-site surgery for the treatment of benign adnexal disease: a
prospective trial. Diagn Ther Endosc. 2010;2010:108258.
6. Fader AN, Levinson KL, Gunderson CC, Winder AD, Escobar
PF. Laparoendoscopic single-site surgery in gynaecology: a new
frontier in minimally invasive surgery. J Minim Access Surg.
2011;7:71–77.
7. Yim GW, Jung YW, Paek J, et al. Transumbilical single-port
access versus conventional total laparoscopic hysterectomy: sur-
gical outcomes. Am J Obstet Gynecol. 2010;203:26.e1–26.e6.
8. Escobar PF, Bedaiwy MA, Fader AN, Falcone T. Laparoen-
doscopic single-site (LESS) surgery in patients with benign ad-
nexal disease. Fertil Steril. 2010;93:2074.e7–2074.e10.
9. Fagotti A, Fanfani F, Marocco F, et al. Laparoendoscopic
single-site surgery for the treatment of benign adnexal diseases:
a pilot study. Surg Endosc. 2011;25:1215–1221.
Figure 5. Incision site at 3 months after surgery.
Single-Incision Laparoscopic Adnexectomy in an Obese Patient with Previous Laparotomies, Sesti F et al.
JSLS (2013)17:164–166166


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Single-incision laparoscopic adnexectomy in an obese patient with previous laparotomies

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