The intracorporeal suture during single incision laparoscopic surgery is very difficult 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 first 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 first 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 difficult. 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 fixed, but it has the disadvantage of having to move manually using two hands. In this respect, it was difficult 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 (6–9). Although the speed is somewhat slow and it is difficult to select a position, there are some that are operated by foot, voice or head motion instead of hands (10–13). 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 field 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 difficult when the camera field 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 first 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 difficult 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 difficulties because he must use three types of instruments with both hands. When active bleeding occurs, blood may run on the camera lens, making it difficult to secure the camera's field 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 fixed and needs to be changed frequently. When the adhesion site is excised after electrocautery, gas is generated and the camera field of view becomes cloudy. In this situation, it is difficult 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 difficult 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 difficult 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.