Solo Surgery in Single Incision Laparoscopic Myomectomy

The intracorporeal suture during single incision laparoscopic surgery is challengeable. Since myomectomy requires not only one assistant to hold a camera but also other to hold the uterine manipulator, it is dicult to perform solo in single port laparoscopic myomectomy through intracorporeal The three patients underwent single incision laparoscopic myomectomy. The size of the largest myoma was 4.8-5.6cm. The operation was performed by the surgeon alone without assistants. The passive camera holder was positioned near the Without using the uterus was hung from the abdominal wall using a The was enucleated, which was removed from the with the The was to avoid any uterine defects. The outer suture of wound was by a such simple Lembert or The operation time was 95-105 minutes.There were no specic complications associated with The patients were discharged on the second day after surgery.


Background
Not only the surgeon but also the assistants participate in laparoscopic myomectomy. The assistants play an important role in securing enough space for surgery, removing uterine myoma and suturing the surgical site. Typically, one assistant holds the camera to illuminate the surgical site and the other moves the uterus to an appropriate position using the uterine manipulator. In single incision laparoscopic surgery, if several laparoscopic instruments enter into one narrow space of a single hole, they may bump into each other or the angle required for the operation of each instrument may not come out. Since the intracorporeal suture during single incision laparoscopic surgery is di cult, new attempts to solve them have been sought (1).
Recently, single incision laparoscopic surgery has been reported in which the surgeon performs the operation alone without the help of an assistant (2). For solo approach of single incision laparoscopic surgery, various camera holders are being developed (3). Most of the solo surgery was performed in the department of general surgery, and ovarian cystectomy or oophorectomy were rarely performed in the department of obstetrics and gynecology (4). Since laparoscopic myomectomy requires not only one assistant to hold a camera but also other to hold the uterine manipulator, it is di cult to perform solo surgery in single port laparoscopic myomectomy through intracorporeal suture.
In this paper, a single incision laparoscopic myomectomy using camera holder was successfully performed using the technique of hanging the uterus to the abdominal wall without using a uterine manipulator. As the surgical procedure is shared, it is intended to be a cornerstone for the clinical application of solo surgery in single incision laparoscopic myomectomy(Solo-SILM).

Case 1
A 49-year-old woman came to the hospital due to menorrhagia and dysmenorrhea. The menstruation was periodic, but the amount of menstruation was high. After the hospital visit, hemoglobin level was con rmed to be 8.1 g/dL, and an iron injection was prescribed several times. Ultrasonography revealed a 4.1 cm-sized submucosal type of uterine myoma that pressed the endometrium. Serum CA-125 levels were slightly elevated to 52.7 u/ml. The body mass index was 23.4 kg/m 2 . I had obtained informed consent from the patient for this case. The uterus observed in the operating eld has a thickened posterior wall. There were no speci c abnormalities in both adnexa. The intestine and omentum were adhered to the left low abdominal wall, but did not interfere with the operation. A 10 mm, 30 degree camera(AESCULAP, Tullingen, Germany) was used for the surgical procedure. When the myoma was visible, the myoma were captured using a 5 mm screw. The incision in the uterus was double sutured using V-loc™(Covidien, Mans eld, MA, USA) after the uterus was removed. The inner and outer sutures of uterine wound were simple continuous sutures. (Fig. 1) There were no special complications during and after the surgery. The patient were discharged from the hospital on the second day after surgery.

Case 2
A 58-year-old woman came to the hospital for a general gynecological examination. The patient became menopause at the age 51. Several myomas were found on ultrasound. I had obtained informed consent from the patient for this case. The size of the intramural type myomas was 5.5 cm at posterior part, 1.6 cm, 1.5 cm, and 1.2 cm at the anterior part. The patient was worried about the presence of the uterine myomas and wanted to be removed surgically. The body mass index was 22.0 kg/m 2 . Four myomas were observed in the uterus as a nding of the operating eld. There were no speci c abnormalities in both adnexa. 5 mm, 0 degree camera(AESCULAP, Tullingen, Germany) and 10 mm screw were used for the surgical procedure. The uterine wound was double-sutured with 1.0 vicryl((Ethicon,. Sommerville, USA). The inner suture of wound was made with simple continuous suture and the outer suture was made with Lembert suture (Fig. 2). There were no special complications during and after the surgery. The patient were discharged from the hospital on the second day after surgery.

Case 3
A 48-year-old woman with dysmenorrhea visited the hospital for gynecological management. Intramural type myomas of 4.9 cm, 1.9 cm, 1.3 cm, 1.2 cm and 1.1 cm size were detected by ultrasound. The body mass index was 23.9 kg/m 2 . I had obtained informed consent from the patient for this case. The largest myoma was located in the left posterior part of the uterus. There were no speci c abnormalities in both adnexa. 10 mm, 30 degree camera(AESCULAP, Tullingen, Germany) and 10 mm screw were used for the surgical procedure. The wound on the uterus was double-sutured with V-loc™(Covidien, Mans eld, MA, USA). The inner suture of wound was made with simple continuous suture and the outer suture was made with baseball suture (Fig. 3). There were no special complications during and after the surgery. The patient were discharged from the hospital on the second day after surgery.

Surgical technique
The patient was placed in a lithotripsy position under general anesthesia. The surgeon was placed on the left side of the patient after the patient's left arm was adducted. The diathermy pedal is placed near the surgeon's left foot. The monitor was located below the patient's right leg. The skin at the umbilicus was incised 2.0 cm longitudinally. A glove port with four channels (Nelis, Bucheon-si, Gyeonggi-do, Republic of Korea) was inserted into the incision. The abdomen was insu ated with CO2 to a pressure of 12 mmHg.
The passive camera holder (Endoworld®LAP53 Holding Systems, Karl Storz, Tullingen, Germany) was installed close to the body on the right side of the patient. (Fig. 4) A 10 mm, 30 degree or 5 mm, 0 degree camera(AESCULAP, Tullingen, Germany) was used for the surgical procedure. A needle of 1.0 vicryl((Ethicon, Sommerville, USA) was inserted into the abdominal cavity from the lower part of the abdomen to the outside of the body. The needle that came out of the abdominal cavity was pulled with a needle holder. Suture was made to avoid myoma. In other words, case 1 was sutured in the fundus and case 2 or case 3 was sutured in the uterine anterior body. After suturing, the needle with a thread was pulled out of the skin. The uterus was lifted against the abdominal wall by pulling the two threads that came out of the body (Fig. 5). The two threads with the uterus remaining were xed over the skin with kelly. The method of lifting the uterus was introduced as the hitch technology (5). 20 ml of vasopressin at a concentration of 10 IU/100 ml of saline solution was in ltrated up to at several points at the base of myoma before the incision. The uterus was incised longitudinally using a molopolar scissors. When the myoma was visible, the myoma were captured using a screw. The outer periphery of the uterine myoma was enucleated using an energy device (Caiman®; Aesculap AG, Tuttlingen, Germany). There was hemostasis with bipolar forcep while checking for bleeding in the incision site of the uterus. The incision in the uterus was double sutured using V-loc™(Covidien, Mans eld, MA, USA) or 1.0 vicryl((Ethicon, Sommerville, USA). The outer suture of wound was sutured by a method such as simple continuous suture, Lembert suture, or baseball suture. On the outside of the body, kelly was released and the thread was removed. The bleeding points of the uterus were hemostated with a bipolor forcep. Drainage was inserted to remove blood accumulated in the pelvic cavity and saline that had been irrigated. The uterine myoma was removed from the outside with the umbilicus incision site. After interrupted suturing the fascia and skin of the umbilicus, the operation was completed.

Discussion
The intracorporeal suture during single incision laparoscopic surgery is very di cult because various instruments must be properly triangulated in the narrow single space (1). Since the uterine wound should be closed in double or triple after myoma are removed, the cooperation between the surgeon and the assistant is more important in single incision laparoscopic myomectomy. Recently, various camera holder for solo surgery has been developed, and some cases of solo single incision laparoscopy have been reported in obstetrics and gynecology, but the scope of application is still limited(4). These cases were the rst trial of solo surgery of single incision laparoscopic myomectomy without using a uterine manipulator.
Unlike the case where the operation was accompanied by an assistant, there were several things to consider when performing the operation alone as in these cases. The rst is related to the camera manipulation. When the surgeon's arm and camera holder collided during the suturing process in which both hands must be used freely, the suture was di cult. In this sense, the camera holder needed to be installed close to the patient's body. The camera holder used in these cases has the advantage that the position does not change once the position is xed, but it has the disadvantage of having to move manually using two hands. In this respect, it was di cult to proceed with the surgery when the camera location had to be changed frequently. Fixing the camera as far away from the surgical site in the abdominal cavity as possible was helpful because it would not change its position often. Various types of camera holders have been produced. Some can be operated with one hand even if the position is slightly changed (6)(7)(8)(9). Although the speed is somewhat slow and it is di cult to select a position, there are some that are operated by foot, voice or head motion instead of hands (10)(11)(12)(13). Therefore, it is believed that a suitable camera holder should be selected in surgery where the camera position is frequently changed. Using a 5 mm camera provided more space for surgery in case 2, but the 10 mm camera had a clearer eld of view, which was useful during surgery in case 1 and case 3. The 10 mm screw had good gripping power for the myoma in case 2 and case 3, but the space utilization was lower than the 5 mm screw in case 1. When used with a camera, the best combination was considered a 10 mm, 30 degree camera and a 10 mm screw in case 1. When uterus was hung on the abdominal wall using a thread, the 30 degree camera was more useful than 0 degree when holding the needle or suturing the uterus. Solo surgery was di cult when the camera eld of view was blurred. The use of energy devices created gases and blured the camera's view. If a assistant participated in the surgery, the camera would have been removed from the body and wiped. In solo surgery, the operator rst inserted a suction and irrigation device to remove the gas, then sprayed water on the uterus, and then wiped the camera lens to eliminate the clouding of the camera's vision. Second, it is related to myoma enucleation and suture technique. When the uterus was incised longitudinally rather than transversely, it became easier to close the wound. The reason was that suturing was possible only when the surgical instruments were kept parallel without crossing the abdominal cavity. To reduce the incidence of bleeding during surgery, vasopressin was applied before uterine incision. When enucleating myoma, the use of an energy device was useful because hemostasis and resection were performed at the same time. Even without clamping the uterine artery, the myoma could be enucleated only with the above two methods. Since myoma was removed, a double suture was performed to suture the outer side after suturing the inner side to prevent defects in the uterus. Barbed suture was useful as it prevented the thread from loosening in case 1 and case 3. Lembert suture or baseball suture was used to compensate for intrauterine defects in case 2 and case 3. A rigid conventional instruments in these cases were used for solo surgery. Although the these instruments were not bent, there were no particular problems with the suture process.
There are several limitations that make it di cult to widely apply solo surgery to clinical applications in the future. First, it is an emergency situation where excessive bleeding occurs. In order to stop bleeding, suction and irrigation devices may additionally be used to check the bleeding area as well as the grasping forcep and bipolar forcep. The surgeon may encounter di culties because he must use three types of instruments with both hands. When active bleeding occurs, blood may run on the camera lens, making it di cult to secure the camera's eld of view. To clean the camera lens in the abdominal cavity without removing the blood-stained camera outside, the surgeon may need to use four types of instruments with both hands. There is a limit to controlling the bleeding quickly by the surgeon alone. Secondly, there is severe adhesion in the abdominal cavity. Depending on the area and degree of adhesion, the position of the camera cannot be xed and needs to be changed frequently. When the adhesion site is excised after electrocautery, gas is generated and the camera eld of view becomes cloudy. In this situation, it is di cult to perform the operation by the surgeon alone without an assistant helping to manipulate the camera. Third is the participation of assistant who lack experience in laparoscopic surgery. If solo surgery is performed frequently, the assistant's skills cannot be improved. It is di cult to receive great help from less-trained assistant when the solo surgery is stopped and assistants participate in emergency situations. The fourth is related to uterine myoma. Depending on the location, size, and number of myoma, solo surgery can be di cult during the suture process. If myoma is in the anterior portion of the uterus or the number of myoma is large, the location of the threads should be selected so that the thread that lifts the uterus and the thread that sutures do not overlap.

Conclusions
Solo incision laparoscopic surgery has the advantage of avoiding collision with an assistant during surgery, and allowing surgeon to set the camera direction as desired. And by using the seat where an assistant was, the surgeon can use both hands more widely. In these cases, solo single incision laparoscopic myomectomy was successfully performed without using a uterine manipulator. Availability of data and materials The author declares that they have no competing interests. Authors' interpretation of data or presentation of information is not in uenced by any personal or nancial relationship with other people or organizations.

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