These outcomes may be a little better than those of standard laparoscopic surgery—they are at least comparable—and the cosmetic results are certainly superior. It may be difficult to demonstrate statistically significant differences in pain and recovery, at least in smaller populations of patients. I am in the process of doing a comparative study of conventional laparoscopy and LESS, but a larger series will be needed to quantify many of the intraoperative and postoperative benefits.
Laparoscopic surgeons have been driven to learn and offer the technique to reduce the minimal but not insignificant risk of complications associated with each incision. Why would I put four incisions in my patient when I can complete the procedure through just one?
For work on the right side, the articulating instrument is placed through the left cannula on the multichannel port.
Source Courtesy Dr. Kevin J. Stepp
Surgical pearl: The gynecologic surgeon can achieve unobstructed views of the pelvis by adjusting the tip of the flexible-tip camera.
A reticulating grasper (left) can be used to elevate the utero-ovarian ligament in order to provide access for a straight vessel-sealing device (right).
Source Images courtesy Dr. Kevin J. Stepp
'Minimal' Minimally Invasive Surgery
So, is it time for an old dog to learn a new trick? That's exactly what I thought to myself as I attended a program on laparoscopic single-site surgery during the annual meeting of the AAGL.
After performing operative laparoscopy for more than a quarter of a century, I questioned whether I was truly ready to convert my midumbilical “closed” technique to a larger infraumbilical “open” technique. At the end of the day, I pondered, are 5-mm lateral incisions really not cosmetic? Once in the abdominal cavity, could I really retrain myself to use articulating instrumentation? Does single-port surgery offer the same triangulation of instrumentation as conventional laparoscopic surgery, or for that matter, robotic-assisted surgery?
As you read this latest edition of the Master Class in Gynecologic Surgery, authored by an excellent young physician, Dr. Kevin J. Stepp, I am sure you will contemplate issues similar to these. Nevertheless, this truly is exciting, thought-provoking technology that is “all the buzz” in minimally invasive surgery.
Dr. Stepp is assistant professor of reproductive biology at Case Western Reserve University, Cleveland. He is the program director for the new urogynecology and minimally invasive surgery fellowship at MetroHealth Medical Center in Cleveland. Dr. Stepp also serves as the director of gynecologic surgical education for the MetroHealth/Cleveland Clinic obstetrics and gynecology residency program. In 2009, he performed the world's first single-surgeon, single-incision robotic-assisted laparoscopic hysterectomy.