Up to now, for gynecological surgery, single-incision surgery has well developed after large incision, small incision and multiple small incisions. Mature cystic teratoma of the ovary is one of the most common benign tumors among women. As the umbilical region is a natural scar of human congenital residual, laparoscopic single-incision surgery is performed simply through this natural scar, with less postoperative pain, faster recovery, and better cosmetic effect as compared with traditional laparotomy and the laparoscopic surgery.
In this study, the operations were completed successfully without switching to laparotomy, and without serious intraoperative and postoperative incision and operation relate complications. For both Hangt-port and multiport group, postoperative umbilical hernia has always been the focus of all kinds of laparoscopic single-site surgery(LESS). In this study, there was a case of delayed umbilical hernia undergoing repair: rectus sheath ruptured, with continuous peritoneum, protruding into hernia sac, most of which occurred within 12 months after surgery(2, 3). The incidence rate of umbilical hernia was also related to the follow-up duration, and most of umbilical hernia occurred within one year. The main differences between LESS approaches include the incision mode and size at the umbilical region. Whether to open the umbilical centrum tendineum or not is important for incision suture and the healing. Postoperative umbilical hernia is one of the main long-term complications. In a study of 109 patients for surgery (using SILS™ Port or TriPort™), the incidence rate of incisional hernia for average 38 months of follow-up was 5.5%, in which 67% was confirmed in the first year of follow-up(4)). Another laparoscopic single-site surgery (LESS) study of 211 patients,113 cases was conducted by PORT, reported 4 umbilical hernia within 30–36 months of follow-up(5). According to a report of single-site laparoscopic cholecystectomy, the incidence rate of postoperative incisional hernia was 5.8%(6),which was at a high level. Because in multiport surgery, the umbilical centrum tendineum was not opened, the fascia damage of the surgery was almost the same as that of traditional laparoscopic umbilical incision. In a report of 5541 patients who underwent traditional laparoscopic surgery, the incidence rate of incisional hernia during a 43-month follow-up was 0.41%(7).According to the statistics of American Association of Gynecologic Laparoscopists, the incidence rate of incisional hernia was 0.021% among 4385,000 patients who were performed laparoscopic surgery(8), which was significantly lower than that for LESS. Most physicians especially emphasized that good closure of fascia layer was beneficial to incisional hernia incidence reduction(9). For transumbilical laparoscopic single incision multiport surgery, the Hangt-port was not used, and the umbilical centrum tendineum was not opened, and so through suturing a single skin incision on one side of the navel, the fascia might be closed better(10, 11) ,and the risk of umbilical hernia or umbilical hernia during pregnancy might be lower in the future. In addition, the use of non-absorbent and delayed absorbent materials was also one of the effective suture methods. Although the incidence of delayed would healing in the Hangt-port group was higher than that in the multiport group, the difference was not reached statistially significance. This might be caused by that parts of patients with higher BMI located in the Hangt-port group, and the risk of incisional hernia and incisional infection in overweight patients, obese and diabetic patients would be higher. The skin incision was hidden in the folds of the umbilical cord and so there was little difference in appearance between the two groups. By clinical observation, most patients were not serious, and recovered after simple dressing change. It may be related to less exposure and poor involution, and we adviced to strength the observation and nursing, and fill a small gauze block in the hilar depression to keep the incision dry, so as to promote the healing. Strengthening preoperative notification and postoperative complication control were also effective for relevant improvement(12).
There was no statistically significant difference between the two groups in operation time, postoperative hemoglobin change, postoperative hospitalization time, postoperative anal exhaust time.However, further subgroup analysis by distinguishging important clinical factor including VAS measuring timing, cyst size and previously operative history. The most important finding was that for patients with cyst size > 6cm, the Hangt-port group had significantly shorten the operative time than the multiport group. The possible explanations were: ①. The abdomen-entering and abdomen-closing time of the multiport group was smaller than that of the Hangt-port group;②. Because of the small incision in multiport group, the sample taking time was longer than that in Hangt-port group, which offset the advantage of short abdomenentering and closing time;③.Some teratomas contain solid components such as hair and cephalic nodes, especially for larger teratomas. The specimen time of multiport is long, while that of Hangt-port is short.Meanwhile, in clinical practce, we also found other potential advantage of Hangt-port approach: ①.The tumor tissues can be completely removed to the maximum extent, and the tumor tissues are not easy to be broken in the abdominal cavity, which is conducive to the principle of tumor-free and pathological examination;②.For myomectomy, subtotal hysterectomy and other operations not suitable for the use of crushing device, Hangt-port approach has an absolute advantage in the removal of tissue;③.Because hangt-port approach is a general surgical approach to the abdomen, compared with the blind puncture of the first torcar in the laparoscopy, it is not suitable to damage the abdominal organs.However, the results on the other hand releaved that patients in the Hangt-port group showed significantly higher VAS scores in 12 hours and delayed postoperative hosptial stay in patients with cyst size less than 6 cm than in the multiport group. This would be simply related to the size of the umbilical region incision that the size of the fascial incision in the multiport group was about 1 cm, while in the Hangt-port group was about 4 cm.