LESS hysterectomy through a bluntly created 11 mm incision

In the field of minimally invasive surgery, there is a constant drive to devise and execute the most minimally invasive surgeries possible. By the very nature of laparoscopy and robotic surgery, what one can accomplish with several ports of a given size will invariably be studied and attempted with fewer ports and with ports of smaller sizes. After researching the literature, we were not able to find any single port hysterectomies performed through a port size of smaller than 15 mm. We were able to perform, described here, a technique for performing laparoscopic hysterectomy through a single port of only 11 mm in diameter. We illustrate the technique in the accompanying video and believe the technique to be safe and reproducible.


Introduction
Unlike other specialties which are defined by the general field of medicine they pertain to, "minimally invasive surgery" itself can be understood as a challenge to its practitioners, its very name encouraging them to pursue a more minimally invasive approach. The specific issue we sought to address here was attempting the most minimally invasive, singleport hysterectomy ever performed, while still performing meaningful laparoscopic visualization of the abdomen and with the expectation to be able to realistically operate in the abdomen from a laparoscopic approach. This meant that we specifically did not wish to perform a procedure that one could consider to be a laparoscopy then followed by vaginal hysterectomy, and desired meaningful laparoscopic access to deal with issues such as adhesions, mobilization of the bladder flap, or performing a bilateral salpingooophorectomy without significant vaginal assistance. After researching the literature, we were not able to find any single port hysterectomies performed through a port size of smaller than 15 mm (1 Multiple authors have documented the feasibility of single incision laparoscopic hysterectomy (3). Many authors have commented that the idea, although novel, does not significantly improve intra-operative pain, recovery or surgical cosmesis (4). The most commonly used system is a robotic assisted single port system. All systems, to the knowledge of the authors, require incisions greater than 15 mm in the umbilicus (5,6). We examined different single port systems and combined available instrumentation to create a feasible, repeatable technique for performing a laparoscopic single site hysterectomy using only an 11 mm umbilical incision that is created with a blunt laparoscopic trochar. We have explained the technique in a video for reproducibility.

Objective
We devised a technique for laparoscopic single port hysterectomy based on the concept that a bluntly created incision would be less likely to herniate than a sharply created incision. Therefore, after creating the initial skin incision with an 11-blade scalpel, (Figure 1   previously described techniques because of the usage of an 11 mm blunt trochar to create the umbilical incision. This creates a reproducible footprint in the fascia that should be identical and reproducible, regardless of circumstances. By keeping the incision small and created bluntly we believe the risk of postoperative herniation has been minimized (Figure 7).

Design
A narrated video demonstration of the surgical procedure (Canadian Task Force Classification III). We developed a novel method for performing laparoscopic hysterectomy through a single 11 mm incision that was created with a blunt trochar. The most novel aspects of our procedure involve the placement of a multiport manipulator device through a small, 11 mm incision created by an 11 mm blunt trochar. It is our belief that the small size of this blunt trochar likely makes fascial closure unnecessary, although it is still recommended by the authors.

Interventions
A 32-year-old woman with endometriosis, adenomyosis and chronic pelvic pain with recurrent ovarian cysts presented for laparoscopic hysterectomy with bilateral salpingooophorectomy. The patient had previously tried more conservative surgeries and medical treatments, including a sixmonth course of luprolide acetate and multiple surgeries for fulgaration of endometriosis. The patient completed her desired childbearing and requested definite treatment. The patient had a history of prior bilateral salpingectomy and one prior cesarean section. The patient had confirmed endometriosis at previous laparoscopic exploration, and was suspected to suffer from adenomyosis, based on cyclic pain and pain that seemed to originate from the uterus with gentle palpation with the vaginal ultrasound probe. Patient was extensively counseled to the risks of bilateral salpingo-oophorectomy and offered more conservative surgical options including hysterectomy without bilateral salpingo-oophorectomy. The patient refused more conservative treatments, citing her fear of the necessity of future surgeries for endometriosis or ovarian cysts, the desire for definitive treatment of endometriosis, as well her fear of ovarian cancer in the future, despite there being no family history. Patient politely refused BRCA testing, citing that it would not influence her decision for bilateral salpingo-oophorectomy. The total operative time was 38 minutes, and the estimated blood loss was 100 cc. The patient was discharged 18 hours after surgery and the recovery was uneventful. The final pathology report showed endometriosis and adenomyosis.

Conclusion
Our described technique is a feasible, reproducible procedure for hysterectomy and may improve cosmesis and postoperative pain over traditional laparoscopic and single port techniques.