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Gynaecological laparoscopic surgery for benign conditions: do women care about incisions?
European Journal of Obstetrics & Gynecology and Reproductive Biology, 1, 169, pages 84 - 87
To determine the relevance of the number and location of incisions in women undergoing gynaecologic laparoscopy due to benign conditions.
This study included 141 women, who underwent gynaecologic laparoscopic surgery with 4 incisions due to benign conditions between November 2010 and November 2011 at the University Medical Centre Mannheim, Germany. Women with malign histology were excluded. Demographic parameters, type and duration of surgery, perioperative complications and duration of hospital stay were analysed. Women were contacted using a standardized telephone survey with an interval of at least 22 weeks after surgery. Patients were interviewed regarding the number, postoperative pain and their preferences for omission of incisions.
Eighty-seven women (61.7%) responded to the standardized questionnaire. 38 (43.7%) remembered the number of incisions correctly. 45 of the women (51.7%) thought they had less, 4 (4.6%) thought, they had more incisions as they actually did have. If one of the incisions had to be discarded 28 (32.2%) patients did not have any preferences with regard to the localisation. Of the other 59 patients, 44 (74.6%) would prefer to eliminate the umbilical one.
The majority of the women remembered fewer incisions than actually used. Most of the patients interviewed would, if possible, eliminate the umbilical incision. Therefore from the patient's perspective the skin scars after conventional laparoscopic surgery seem to be of limited importance and the alleged advantage of omission of additional incision using single site surgery remains debatable.
Keywords: Gynaecologic laparoscopic surgery, Incision, Benign conditions, LESS, Survey.
Over the last decades, laparoscopy has evolved from a diagnostic tool to a modality for major surgical procedures. With the introduction of electrosurgical technologies, gynaecological procedures such as hysterectomy, adnexal surgery and uterine myomectomy can be performed as minimally invasive surgery. Nowadays, even women suffering from urinary incontinence, pelvic organ prolapse, or endometrial or cervical cancer can undergo surgery using minimally invasive techniques  . Intensive research and the increasing experience of physicians have led to reduction in the size and number of ports required for gynaecological procedures. As a consequence, laparoendoscopic single-site surgery (LESS), using a single port with a single incision concealed within the umbilicus, has been introduced. This novel, minimally invasive technique has the advantage of fewer incisions, minimizing potential morbidity and providing better cosmetic results  .
Several studies have shown that gynaecological laparoscopic surgery for both benign and malignant conditions results in better surgical outcome and improved quality of life compared with conventional surgery , , and . Most studies have focused on clinical outcomes such as operating time, surgical complications, duration of hospital stay and postoperative pain management. Investigations concerning quality of life and patients’ perceptions of novel methods are scarce. Quality of life has been evaluated in less than 5% of studies investigating surgery for benign conditions, while the importance of patient-centred outcome parameters is emphasized in oncological studies  . From the patient's point of view, results such as symptom resolution, return to daily activities and personal satisfaction are at least as important as the classical outcomes, and should be considered more often in prospective studies.
Interest in single-port surgery has grown exponentially, and the feasibility of this minimally invasive technique has been demonstrated in both malignant and benign gynaecological conditions. This raises the issue of whether women would prefer to have a larger and potentially more painful incision in the umbilicus in order to avoid incisions in other locations. The aim of this study was to determine patients’ perceptions of the number and location of incisions applied during surgery, and their preferences regarding avoidance of incisions during gynaecological laparoscopic surgery for benign conditions.
2. Materials and methods
All patients who underwent gynaecological laparoscopic surgery for benign conditions and required four trocar incisions between November 2010 and November 2011 at the University Medical Centre Mannheim, Germany were included in this study. Women suffering from malignant gynaecological conditions, women who required a conversion to laparotomy, and women who underwent a second procedure between the first laparoscopy and the telephone survey were excluded from this investigation. In addition, women who underwent purely diagnostic laparoscopy were excluded. Clinical and surgical parameters were gathered and entered into a Microsoft Excel spreadsheet. After surgery, the women were contacted by letter regarding the nature of this study, and were asked if they would be willing to participate in a voluntary telephone survey. The letter did not provide any information regarding the questions that would be asked in the telephone survey. The interval between surgery and the telephone survey was 22–68 weeks. Follow-up was defined as the interval between the date of surgery and the date of the telephone call. Every telephone call was made by one of three physicians using a standardized telephone script.
All laparoscopic procedures were performed under general anaesthesia with standardized incisions. A 10-mm optic trocar was inserted beneath the umbilicus, one 5-mm trocar was inserted suprapubically, and two 5-mm trocars were placed laterally in the lower abdomen. Maximum intra-operative pressure was 12 mmHg. All patients received pain relief according to a fixed schedule, and low-molecular-weight heparin for thromboprophylaxis.
Arithmetic means and standard deviations were calculated for normally distributed variables. Qualitative variables were described in terms of frequencies. Differences between the groups in terms of age, body mass index (BMI), duration of surgery (min) and overall hospital stay (days) were analysed using one-way analysis of variance. Chi-squared test was used to compare the remaining categorical and nominal variables. Data were recorded and assessed using GraphPad Prism® Version 5.0 (GraphPad Software, La Jolla, CA, USA). p < 0.05 was taken to indicate statistical significance.
In total, 288 laparoscopies for benign conditions were performed in women aged 18–78 (mean 43) years between November 2010 and November 2011. Of these, 141 women met the inclusion criteria and were contacted by letter. Eighty-seven patients (62%) were contacted successfully by telephone. The women were divided into three groups depending on their perception of the number of incisions in their procedure ( Table 1 ).
|Variable||Study population (n = 87)
Mean ± SD
|Correct perception of number of incisions (38/87, 44%)
Mean ± SD
|Underestimation of number of incisions (45/87, 52%)
Mean ± SD
|Overestimation of number of incisions (4/87, 5%)
Mean ± SD
|Age (years)||43.5 ± 11.6||44.47 ± 12.61||42.58 ± 10.86||43.75 ± 12.92||0.764 a|
|Body mass index (kg/m2)||27.0 ± 6.7||26.98 ± 6.751||26.81 ± 6.871||28.19 ± 6.145||0.927 a|
|Duration of surgery (min)||98.4 ± 48.5||85.89 ± 41.73||109.2 ± 50.01||88.50 ± 60.52||0.0955 a|
|Overall hospital stay (days)||2.3 ± 1.1||2.316 ± 1.358||2.333 ± 0.7977||1.750 ± 1.258||0.5917 a|
|Migratory background||17/87 (20%)||7/38 (18%)||8/45 (18%)||2/4 (50%)||0.2894 b|
|Concomitant diseases||41/87 (47%)||23/38 (61%)||24/45 (53%)||2/4 (50%)||0.7782 b|
|Intra-operative complications||0/87 (0%)||0/38 (0%)||0/45 (0%)||0/4 (0%)||NA|
|Prior abdominal surgery||56/87 (64%)||27/38 (71%)||27/45 (60%)||2/4 (50%)||0.4784 b|
|Duration between surgery and survey (days)||302 ± 99.2||321||302||270||0.4714 a|
a One-way analysis of variance.
b Chi-squared test.
SD, standard deviation; NA, not applicable.
Thirty-eight women (44%) perceived the correct number of incisions, 45 women (52%) thought that they had received fewer incisions than was actually the case, and four (5%) patients thought that they had received more incisions than was actually the case. There were no significant differences in age, BMI, type and duration of surgery, migratory background or prior abdominal surgery among the three groups. The reasons for surgery were as follows: uterine fibroids (39 women, 45%), ovarian cysts (22 women, 22%) and bleeding disorders of other origin (18 patients, 21%). Most surgical procedures were total laparoscopic hysterectomies (23%), followed by laparoscopic uterine fibroid resections (20.7%) and laparoscopic salpingo-oophorectomies (17%), as stated in Table 2 . Patients’ responses regarding their perceptions of the incisions are depicted in detail in Table 3 .
|Type and number of surgical procedures||Correct perception of number of incisions (n = 38)||Underestimated number of incisions (n = 45)||Overestimated number of incisions (n = 4)|
|TLH (20)||11/38 (29%)||9/45 (20%)||0/4 (0%)|
|Uterine fibroid resection (18)||8/38 (21%)||9/45 (20%)||1/4 (25%)|
|Salpingo-oopherectomy(15)||6/38 (16%)||8/45 (18%)||1/4 (25%)|
|LASH (14)||3/38 (8%)||9/45 (20%)||2/4 (50%)|
|Cyst exstirpation (11)||4/38 (11%)||6/45 (13%)||1/4 (25%)|
|Other a (32)||14/38 (37%)||17/45 (38%)||1/4 (25%)|
a Adhesiolysis, salpingectomy, appendectomy, peritoneal biopsy; multiple procedures per patient were possible. Overall Chi-squared p-value: 0.7530.
TLH, total laparoscopic hysterectomy; LASH, laparoscopic supracervical hysterectomy.
|Patients’ responses regarding perceived number of incisions||Study population (n = 87)||Correct perception of number of incisions (n = 38)||Underestimated number of incisions (n = 45)||Overestimated number of incisions (n = 4)|
|Was one incision more painful than the others?|
|No||64 (74%)||25 (66%)||36 (80%)||3 (75%)|
|Yes||23 (26%)||13(34%)||9 (20%)||1 (25%)|
|Left lower abdomen||11||5(39%)||5(56%)||1(100%)|
|Right lower abdomen||2||1 (8%)||1(11%)||0 (0%)|
|Middle (lower abdomen)||0||0 (0%)||0(0%)||0(0%)|
|Umbilical||10||7 (54%)||3 (33%)||0 (0%)|
|Which incision would you eliminate if possible?|
|Left lower abdomen||10 (12%)||6(16%)||3 (7%)||1(25%)|
|Right lower abdomen||3 (3%)||2 (5%)||1(2%)||0 (0%)|
|Middle lower abdomen||9 (10%)||4 (11%)||5 (11%)||0 (0%)|
|Umbilical||37 (43%)||16(42%)||20 (44%)||1(25%)|
|Do not know||28 (32%)||10 (26%)||16 (36%)||2 (50%)|
Median length of follow-up was comparable among the three groups. Thirty-seven women (43%) stated that, if possible, they would have preferred to eliminate the umbilical incision. None of the women reported the occurrence of an incisional hernia. Furthermore, no severe intra- or post-operative complications occurred in the study group.
Nowadays, laparoscopy is the standard treatment for various malignant and benign gynaecological conditions. In a review published in 2010, Medeiros et al. indicated that laparoscopic surgery for women with benign ovarian tumours is associated with reduced pain, fewer adverse events and shorter duration of hospital stay  . It has been reported that women who undergo laparoscopic hysterectomy have lower intra-operative blood loss, a lower percentage of wound infections and a quicker return to normal activities compared with women who undergo an open abdominal approach  . Furthermore, quality of life seems to be better for women who undergo hysterectomy by minimally invasive surgery compared with conventional abdominal approaches  . Interest in single-port surgery has grown exponentially in gynaecological, urological and visceral surgery since its introduction. The feasibility of single-port surgery has been demonstrated for several procedures, such as cholecystectomy, appendectomy, nephrectomy and hemicolectomy  . Use of a single incision for gynaecological laparoscopic surgery is not a novel technique, however, as Pelosi and Pelosi performed the first hysterectomy with bilateral salpingo-oophorectomy using a single umbilical puncture over 20 years ago  .
Recently, studies have been published regarding the feasibility, safety and potential benefits of LESS, but the results have been inconsistent. In addition to decreased postoperative pain scores, the beneficial cosmetic result is one of greatest advantages of LESS compared with conventional laparoscopy  and . In gynaecological surgery, for example, decreased postoperative pain profiles have been reported in women who underwent single-port transumbilical laparoscopic assisted vaginal hysterectomy compared with conventional laparoscopic assisted vaginal hysterectomy  . Additionally, Fagotti et al. stated that women who underwent LESS for benign adnexal conditions had significantly less intra-operative blood loss and had significantly higher satisfaction rates with the cosmetic result compared with women who underwent conventional laparoscopy  . These advantages may be due to the fact that the umbilicus is one of the thinnest regions of the abdominal wall containing few blood vessels, muscles and nerves  .
In contrast, a review published in 2012 found that single-port surgery was not beneficial in urological patients in terms of visual analogue pain scale rating, analgesic use and duration of hospital stay compared with conventional laparoscopic surgery  . The potentially major benefit of single-port surgery, the improved cosmetic outcome, is based almost exclusively on authors’ views with little-to-no supporting data  . In the above-mentioned review, which evaluated 13 publications, only two studies provided data on cosmetic results based on the assessment of questionnaires  .
Undoubtedly, the most important issue when performing surgery is curing the pathology  . From the patient's point of view, the cosmetic result after laparoscopy is less important than postoperative pain, risk of complications, surgical success, convalescence, cost or return to activities of daily life  and . These findings can be strengthened by the present study, which found that 52% of women thought that they had received fewer incisions than was actually the case. Consistent with these results, Bencsath et al. found that 46% of women who underwent laparoscopic cholecystectomy underestimated the number of incisions  . Furthermore, in terms of postoperative pain, most women in this study reported that the umbilical incision was more painful than the other incisions. This should be considered by gynaecological surgeons as female gender, young age and surgery for benign conditions are risk factors for the development of chronic postsurgical pain  . Although the umbilical incision was not significantly more painful than the other incisions, 75% of the women in this study and 63% of the patients in the study by Bencsath et al. retrospectively reported that they would eliminate the umbilical incision if possible  .
Given these findings, one inevitably has to consider whether the omission of two or three small incisions in the lower abdomen in place of one larger umbilical incision for LESS is really favourable  .
In general, the incidence of complications in gynaecological laparoscopic surgery is fairly low at 0.36%  . The present results confirm that healing of the small incisions seems to be so inconspicuous that small scars in the lower abdomen did not affect the general wellbeing of the women. However, young (urological) patients undergoing surgery for benign conditions ranked cosmetic scarring significantly higher than older patients or those with malignant conditions  . One can probably assume that the population of the study by Bencsath et al., the present study population and gynaecological patients in general, including women undergoing surgery for benign conditions, represent a group of patients likely to benefit from the presumed advantage of better cosmetic results when using a single port  .
In summary, many women who have undergone laparoscopic surgery do not perceive the number of incisions correctly, and the majority underestimate the number of incisions postoperatively. This may imply that wound healing, pain and presence of the incisions after laparoscopy are not as important for patients as some physicians may believe. Nevertheless, for gynaecological patients, the use of scar-sparing procedures will be of particular importance in the future, as young women with benign conditions are more interested in minimally invasive surgery than other patient groups.
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a Department of Obstetrics and Gynaecology, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
b Department of Medical Statistics and Biomathematics, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
Corresponding author at: University Medical Centre Mannheim, Department of Obstetrics and Gynaecology, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany. Tel.: +49 621 383 2286; fax: +49 621 383 3814.
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