FIGURE 5 Flexible-tip laparoscope
A flexible-tip laparoscope ensures good visualization of the surgical field.If a flexible laparoscope is not available, a rigid 30-degree or 45-degree angled scope can be used, although visualization may be limited and adequate triangulation of instruments may be difficult to achieve.
When using a rigid laparoscope, a light cord that inserts into the back of the camera is necessary; otherwise, a 90-degree light cord adapter can be purchased.
Design enhancements facilitate coordination of instruments
One of the disadvantages of SPLS has been the restriction of movement that arises because of the close proximity of instruments and instrument handles. The latest designs have made articulation possible for tissue graspers, scissors, vessel sealers, and scopes.9,10 The value of articulation is apparent inside the abdomen, where it allows perfect positioning of the area of dissection. Outside the abdomen, the handles can be arranged in an angled pattern to allow the surgeon and assistant to operate comfortably (FIGURE 1).
In a four-handed procedure, one hand is on the camera, one on the uterine manipulator, and the remaining two hands operate the articulating grasper, vessel sealer, or needle driver, depending on the task.
Standard straight instruments can also be used for portions of the procedure.
Dissection and hemostasis are achieved in a manner similar to that of conventional laparoscopy. Our instrument of choice is an enhanced bipolar instrument, although harmonic and traditional biopolar energy can be used as well, depending on the preference of the surgeon.
The latest instruments are designed to dissect, cauterize, and cut, thereby decreasing the number of instrument exchanges necessary.
With the right aids, suturing can be simplified
Suturing through a single port can be a challenge. When possible, closure of the vaginal cuff following a total laparoscopic or laparoscopic-assisted vaginal hysterectomy should be performed from below. When endoscopic suturing is required, standard suturing using both intracorporeal and extracorporeal methods is possible.
Suturing aids such as the Endo Stitch (Covidien) or Lapra-Ty (Ethicon) are helpful. One author recommends Quill bidirectional, self-retaining suture with barbs (Angiotech) to avoid the need for knot-tying.6 (For more on self-retaining suture, see “Barbed suture, now in the toolbox of minimally invasive gyn surgery,” by Jon I. Einarsson, MD, MPH, and James A. Greenberg, MD, in the September 2009 issue at obgmanagement.com.)
The MiniLap (Stryker) is a 2.3-mm grasper that is inserted percutaneously directly through the abdominal wall without an incision. It can be used to set the needle on the needle driver or manipulate tissue while suturing. The resulting skin incision is barely visible and does not require closure.
Options are varied for specimen removal
Small specimens can be removed directly through a single-port system that has been opened, or they can be extracted after the system is removed, with rapid desufflation (FIGURE 6).
FIGURE 6 Single-incision oophorectomy
An ovary and tube removed through a single incision using the A) TriPort and B) SILS Port systems.Compared with conventional laparoscopy, the larger incision associated with single-port surgery facilitates specimen removal. Larger or potentially malignant specimens can be placed into an EndoCatch bag (Covidien) inserted through the single-incision 10-mm cannula (FIGURE 7).
FIGURE 7 Specimen removal
In this case, the specimen was placed in a 10-mm EndoCatch bag and removed through the 10-mm cannula of the SILS Port.In total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy, the uterus is removed through the vagina. In supracervical hysterectomy, a small uterus can be removed through the cul-de-sac or directly through the single incision after placement in a bag.
When morcellation is required, the instrument can be placed through the cul-desac, cervix, or a single port. The morcellator can be placed directly through the SPLS port while utilizing the flexible scope in an angled direction (looking back toward the morcellator) for complete visualization (note: Covidien does not recommend this usage).
Transcervical tissue morcellation has also been described. In this approach, the cervix is dilated once the uterine body has been amputated, and the tissue morcellator is inserted through the cervix while the surgeon maintains visualization from above.6,13
How to master the technique
Many patients desire SPLS for its superior cosmetic outcome, but the approach may not always be appropriate. Depending on the procedure and characteristics of the patient (TABLE), multiple-port laparoscopy may be a better option. When a surgeon first attempts SPLS, we recommend that it be limited to the treatment of adnexal pathology only.
In your early SPlS cases, look for these patient characteristics
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