Single-port laparoscopic bilateral uterine arteries pre-ligation, cesarean scar pregnancy resection, and lower uterine segment repair plastic surgery

Introduction

Single-port laparoscopy is an operation mode that uses the natural channels of the human body as the entrance and conceals surgical incision with skin wrinkles, leaving almost no incision scar (1). Single-port laparoscopy relieves patient pain, preserves therapeutic effect, and has good cosmetic results which are satisfying particularly for younger patients. Single-port laparoscopy has been widely applied in minimally invasive gynecological operations, including oophorocystectomy, hysterectomy, myomectomy, and even pelvic lymph node dissection (2,3). However, the application of single-port laparoscopy in the treatment of cesarean scar pregnancy has not been widely reported. In our patients, we performed bilateral uterine artery pre-ligation, cesarean scar pregnancy resection, and lower uterine segment repair plastic surgery under single-port laparoscopy (Figure 1).

Figure 1 This video describes the technique of single-port laparoscopy, including bilateral uterine artery pre-ligation, cesarean scar pregnancy resection, and lower uterine segment repair plastic surgery (4). Available online: http://www.asvide.com/watch/33035

Surgical technique

The patient was given a tracheal cannula and put under general anesthesia. The patient was then asked to take a position with the head low and the hips high or in a horizontal position. The longitudinal incision at the middle of navel was about 1.5–2 cm long, the single-port access platform was inserted into the abdomen under direct view, and CO₂ was injected. Pneumoperitoneum pressure was maintained at 10–12 mmHg. A broad ligament was opened in the triangular region consisting of the adnexa, iliac vessel, and round ligament (Figure 2). An elastic separating plier was inserted slowly. The space from the anterior and posterior lobes of the broad ligament to the base was opened gradually to search the uterine artery, and the ureter was searched and confirmed upon observing arteriopalmus (Figure 3). The uterine artery was dissociated at 0.5–1 cm outside of the bilateral ureter, and a #7 wire was applied for pre-ligation of the bilateral uterine artery (slip knot) (Figure 4). Hypophysin 3U was injected into the uterine to perform the uterine curettage. Next, the vesico-uterine peritoneal reflection was opened, and the bladder was pushed downward in order to expose and cut the incisional pregnancy mass (Figures 5,6). The uterine incision edges were trimmed (Figure 7), and this was followed by continuous suture of 2 layers of the uterine incision and bladder reflected peritoneum (Figure 8). Finally, the slip knot at the bilateral uterine artery was untied, and the wire was taken out (Figure 9). The pelvic cavity was rinsed, and the umbilical region was stitched (Figure 10).

Figure 2 Opening the broad ligament in the triangular region.

Figure 3 Dissociating the uterine artery.

Figure 4 Pre-ligation of the uterine artery.

Figure 5 Opening the reflected peritoneum of the bladder and uterus.

Figure 6 Cutting the incisional pregnancy mass.

Figure 7 Trimming the edges of the uterine incision.

Figure 8 Suturing the uterine incision.

Figure 9 Untying the slip knot.

Figure 10 Stitching the navel for good cosmetic outcome.

Comments

This was a type II cesarean scar pregnancy, and the operation involved cutting the uterine scar tissue while eliminating pregnancy residues. Meanwhile, a repair of the anterior wall of the inferior uterine segment was performed, and the normal anatomical structure was recovered. During the operation, pre-ligation of the uterine artery was performed to reduce bleeding in a short period. Moreover, laparoscopic surgery is conducive to relieving the operative wound. Research has demonstrated that single-port laparoscopy has many advantages compared with traditional laparoscopy, including the relief of post-operation pain, a smaller risk of incision infection, and the better cosmetic effect of a minimally invasive surgery (5).

Acknowledgments

The video was awarded the second prize in the First International Elite Gynecologic Surgery Competition (2019 Masters of Gynecologic Surgery).

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gynecology and Pelvic Medicine for the series “Award-Winning Videos from the First International Elite Gynecologic Surgery Competition (2019 Masters of Gynecologic Surgery)”. The article has undergone external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.org/article/view/10.21037/gpm.2019.12.07/coif). The series “Award-Winning Videos from the First International Elite Gynecologic Surgery Competition (2019 Masters of Gynecologic Surgery)” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Liu X, Wen MK, Liu HY. Clinical retrospective control study of single-port laparoendoscopic and multi-port laparoscopic ovarian cystectomy. Zhonghua Fu Chan Ke Za Zhi 2017;52:675-8. [PubMed]
2. Dursun P, Tezcaner T, Zeyneloglu HB, et al. Adnexal Masses Treated Using a Combination of the SILS Port and Noncurved Straight Laparoscopic Instruments: Turkish Experience and Review of the Literature. Minim Invasive Surg 2013;2013:836380 [Crossref] [PubMed]
3. Park JY, Kim DY, Suh DS, et al. Laparoendoscopic single-site versus conventional laparoscopic surgical staging for early-stage endometrial cancer. Int J Gynecol Cancer 2014;24:358-63. [Crossref] [PubMed]
4. Du X, Zou Q. This video describes the technique of single-port laparoscopy, including bilateral uterine artery pre-ligation, cesarean scar pregnancy resection, and lower uterine segment repair plastic surgery. Asvide 2019;6:350. Available online: http://www.asvide.com/watch/33035
5. Musquera M, Peri L, Izquierdo L, et al. Is LESS/NOTES surgery the new gold standard of minimally invasive surgery? Arch Esp Urol 2013;66:161-7. [PubMed]