- Academic Editor
†These authors contributed equally.
Background: The operative field in gasless surgery is limited, and it
is difficult to adequately expose the operative field when compared to the use of
gas surgery. Gasless laparoscopic single-site (GLESS) is difficult to apply to
endometrial cancer surgery. The aim of this study is to investigate the
improvement in GLESS lifting style for use in
surgery for endometrial cancer as well as to compare the outcome of different
surgical approaches in endometrial cancer. Methods: A tissue retractor
is added to the routine step of GLESS to lift the abdominal wall. The lateral
umbilical ligament is exposed, a 2-0 buckwheat thread is passed through the
lateral umbilical ligament and abdominal wall in order to lift the umbilical
ligament. We measured the changes of space length or height in different
dimensions of the improved GLESS approach. Also, we measured the vertical height
from the upper edge of the umbilical site to the abdominal cavity, the length
from the lower edge of the umbilical site to the right Michaelis point, the
height from the bottom of the uterus to the peritoneal cavity of the anterior
abdominal wall, and the length from the lateral umbilical ligament to the
ipsilateral psoas major muscle. We analyzed the differences in procedures in 177
cases of endometrial carcinoma. We collected data on operative time, hemoglobin
change, number of lymph nodes removed, postoperative recovery time and
postoperative complications for open surgery, multi site laparoscopic surgery,
single site laparoscopic surgery and gasless laparoscopic single-site surgery.
Results: The vertical height from the upper edge of the umbilical
foramen to the abdominal cavity (4.395
Laparoscopic surgery is a minimally invasive procedure used in both benign and
malignant gynecologic surgery. However, laparoscopic surgery requires the abdomen
to be filled with CO
A retrospective study was carried out on women with endometrial cancer who
underwent primary surgical treatment at Department of Obstetrics and Gynecology,
Guangxi Medical University Cancer Hospital, from March 2018 through March 2022.
We selected 177 patients (Table 1) with endometrial cancer which included 22
cases in the gasless laparoscopic single site (GLESS) group, 62 cases in the
laparotomy group (LT), 62 cases in the multi hole laparoscopic surgery group
(LS), and 31 cases in the laparoscopic single site surgery group (LESS). The
inclusion criteria in the study were as follows: patients undergoing primary
surgical treatment for endometrial cancer at our hospital after having been
diagnosed by preoperative endometrial sampling; patient age
Variables | Group | p value | ||||
GLESS (n = 22) | LT (n = 62) | LS (n = 62) | LESS (n = 31) | |||
Age, years, mean (SD) | 52.41 |
52.91 |
54.18 |
50.94 |
0.340 | |
BMI, kg/m |
23.675 |
23.342 |
24.512 |
23.870 |
0.577 | |
FIGO Stage | ||||||
IA | 16 | 40 | 54 | 24 | 0.034* | |
IB | 6 | 22 | 8 | 7 | ||
Pathological grade | ||||||
G1-G2 | 22 | 45 | 54 | 29 | 0.004** | |
G3 | 0 | 17 | 8 | 2 |
SD, standard deviation; BMI, body mass index; GLESS, gasless laparoscopic single-site; LT, laparotomy; LS, laparoscopic surgery group; LESS, laparoendoscopic single-site surgery; FIGO, International Federation of Gynecology and Obstetrics.
* Comparison between FIGO stage IA and IB.
** Comparison between Pathological grade of G1-2 and G3.
The data were extracted from the medical records, including age, histologic type and tumor grade, FIGO stage I, operative time, hemoglobin change, number of lymph nodes removed, postoperative recovery time and postoperative complications. We analyzed the differences in operative time, hemoglobin change, number of lymph nodes removed, postoperative recovery time and postoperative complications for the different groups. Postoperative complications included intestinal obstruction, intestinal fistula, double-J tube insertion, poor healing of the abdominal wound, lymphatic fistula, urinary fistula, urinary tract infection, incisional hernia, reoperation for postoperative bleeding, injury of blood vessels, thrombosis, and injury of bladder or bowel. Table 1 demonstrates that there are statistical differences in clinical stage and pathological grade of the cases reviewed.
Routine suspension of GLESS requires making a longitudinal incision in the middle of the umbilicus, 3–4 cm long, and placing a protective sleeve on the incision. A Kirschner wire is used to penetrate subcutaneously along the abdominal white line. The suspension rod of the gasless suspension equipment is fixed on the right side of the patient and the steel needle is fixed on the steel needle grip. The lifting rod is crossed across the white line, the steel needle grab chain is hung on the cross bar of the suspension rod, and the suspension height of the abdominal wall is adjusted by the chain. Improved suspension of GLESS requires adding a tissue retractor to the step of routine suspension and pulling the abdominal wall upward (Fig. 1B). This is followed by opening the lateral peritoneum with an ultrasonic scalpel, exposing the right umbilical ligament, passing a 2-0 buckwheat thread through the umbilical ligament, passing it through the abdominal wall, and lifting the umbilical ligament to the left.
Use the Kirschner wire to penetrate subcutaneously along the abdominal white line, fix the suspension rod of the gasless suspension equipment on the right side of the patient, and fix the steel needle on the steel needle grip. (A) Cross the lifting rod across the white line, hang the steel needle grab chain on the cross bar of the suspension rod, with the suspension height of the abdominal wall being adjusted by the chain. (B) Improved suspension of GLESS: add a tissue retractor to the step of routine suspension of GLESS and pull the abdominal wall upward.
We measured the vertical height from the upper edge of the umbilical foramen to the abdominal cavity, the length from the lower edge of the umbilical foramen to the right Michaelis point, the height from the bottom of the uterus to the peritoneal cavity of the anterior abdominal wall, and the length from the lateral umbilical ligament to the ipsilateral psoas major muscle and iliac vessels. The LT group, LS group, and LESS group were performed in the conventional way.
SPSS 26 (IBM Corp., Armonk, NY, USA) was used to analyze the data. Prior to
statistical analysis, measurement data were tested for normal distribution and
variance homogeneity. Rand sum test and ANOVA analysis of variance (F-test) were
evaluated for significant differences between clinicopathologic data. Chi-square
test and t-test analyses were used to evaluate the improvement of
gasless laparoscopic single-site lifting and the effects of different surgical
methods. p
Routine suspension of GLESS is showed in Fig. 1A and Fig. 2. Improved suspension of GLESS is showed in Fig. 1B.
Surgical incision protective sleeve. This is an elastic device with the shape being easy to match with surgical incision.
Different surgical fields are presented in routine suspension of GLESS and improved suspension of GLESS. It can be seen that after the change, the operative space is significantly increased (Fig. 3).
Surgical fields after improved suspension of GLESS. Expose the right umbilical ligament, pass 2-0 buckwheat thread through the umbilical ligament, pass it through the abdominal wall, and lift the umbilical ligament to the left.
The vertical height from the upper edge of the umbilical foramen to the abdominal cavity, the length from the lower edge of the umbilical foramen to the right Michaelis point, the height from the bottom of the uterus to the peritoneal cavity of the anterior abdominal wall, and the length from the lateral umbilical ligament to the ipsilateral psoas major muscle and iliac vessels were measured (Table 2).
Measuring method | Group | p | |
Routine-GLESS (n = 22) | Improved-GLESS (n = 22) | ||
The vertical height from the upper edge of the umbilical foramen to the abdominal cavity (cm) | 4.395 |
7.418 |
|
The length from the lower edge of the umbilical foramen to the right Michaelis point (cm) | 9.850 |
12.795 |
|
The height from the bottom of the uterus to the peritoneal cavity of the anterior abdominal wall (cm) | 6.900 |
9.827 |
|
The length from the lateral umbilical ligament to the ipsilateral psoas major muscle and iliac vessels were measured (cm) | 2.345 |
4.318 |
There were no differences in the 177 cases of endometrial carcinoma in operative time, hemoglobin change, number of lymph nodes removed, postoperative recovery time and postoperative complications (Table 3).
Classification | Groups | p value | |||
GLESS (n = 22) | LT (n = 62) | LS (n = 62) | LESS (n = 30) | ||
Operative time | 201.41 |
219.44 |
204.40 |
210.16 |
0.670 |
Hemoglobin change | 14.41 |
16.13 |
15.53 |
12.65 |
0.065 |
Number of lymph nodes removed | 12.68 |
15.87 |
14.05 |
13.84 |
0.179 |
Postoperative recovery time | 2.05 |
2.18 |
2.05 |
2.10 |
0.331 |
Postoperative complications | 1/22 | 10/62 | 7/62 | 3/31 | 0.442 |
Gynecologic minimally invasive surgery has the benefits of less trauma and rapid
recovery. Studies have demonstrated that the application of LESS in endometrial
cancer is safe and feasible, but previous reports are single site laparoscopic
surgery with pneumoperitoneum [9, 10]. The use of CO
The exposure of laparoscopic operative field and space in gynecologic malignant tumor surgery includes several important dimensions, including the vertical height between the anterior abdominal wall and abdominal organs (intestinal tube surface, etc.), the length from the single hole puncture site to the lateral abdominal wall, and the vertical height from the anterior abdominal wall peritoneum to the bottom of the uterus. During lymph node dissection, it is necessary to expose and measure the gap between the umbilical ligament, psoas major muscle and external iliac vessels as well as expanding the operative space to avoid damage to the intestines and blood vessels.
The traditional gasless abdominal suspension equipment utilized has limitations
in exposing the spatial visual field (Fig. 1A). It may lead to prolonged
operative time, increased surgical bleeding, increased postoperative
complications and other adverse factors, which limits the development of
pneumoperitoneum free surgery. We have improved the procedure as shown in Fig. 1B. The results of this study demonstrate that the space of gasless laparoscopic
single site surgery is improved by improving the suspension mode. This allows
progress in the following aspects of the procedure: Adding a thyroid retractor at
the single puncture site on the abdominal wall can lift the abdominal wall upward
(4.395
After the improvement, we compared the influence of different surgical methods on the operation of early endometrial cancer, and found that there was little difference in the operative time of several surgical methods, minimal change in hemoglobin before and after surgery, and no difference in postoperative complications, indicating that non-pneumoperitoneal laparoscopic surgery is safe and feasible in endometrial cancer.
However, this study has certain limitations. The technique of the operation is different, which may lead to the differences in operative time and blood loss. There is the possibility of data bias in a retrospective analysis. The small sample size may lead to errors in the results [18]. This study may not reflect its advantages due to the small number of cases.
GLESS appears to offer several advantages over conventional laparoscopy, such as
elimination of the adverse effects and potential risks associated with CO
The improvement of GLESS can increase surgical exposure. This method of suspending the umbilical ligament through abdominal silk thread can increase exposure of the anatomical structure of the obturator position. The application of GLESS in the operation for endometrial cancer is safe and feasible.
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
JZ and LL designed the research study; XL, XG and BZ analyzed the data and performed research; JZ and BZ were involved in formal analysis; JZ and ZY conducted quality control over the surgical process. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.
All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Guangxi Medical University Cancer Hospital (approval number: KYB2023134).
Thanks to the medical staff of Guangxi Medical University Cancer Hospital for the surgery and nursing. Thanks to the teachers who helped in the process of writing the paper. Thanks to all the peer reviewers for their opinions and suggestions.
Guangxi Medical and Health Appropriate Technology and Popularization and Application Project (S2020094).
The authors declare no conflict of interest.
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