Deficiencies of current laparoscopic myomectomy
In TU-LESS, the scar of umbilicus is hidden, and the removal of tumor through umbilical incision is fast, safe and convenient. However, myomectomy and uterine suture procedures are more difficult [13], the operation time is longer and bleeding is more than these in CLS. Above factors directly affect the surgeon's choice of operation method [14]. At present, conventional laparoscopic myomectomy is the most popular method. Much more surgical experiences of giant leiomyoma and difficult myomectomy were reported in literatures [1, 14, 15].
Tumor removal is an important procedure in CLS. At present, it is mainly performed with leiomyoma morcellators which was invented in 1973[4].According to the correlative references[3, 5, 10, 16–18], the method may lead to intraabdominal organ damage owing to the incisive procedure is located in the abdominal cavity and lack of experience. More serious, this method may lead to extensive implantation and growth of uterine leiomyoma fragments. If the tumor is unsuspected sarcoma, this method may result in upstaging and decreased survival [19].
To avoid these problems, the consensus of relevant experts[7, 8] and U.S. Food & Drug Administration [9] recommended that tumor-free principle should be followed in the process of tumor removal. On the basis of the current method of tumor removal, a special disposable endoscopic retriever bags should be added to isolate the tumor. The procedures include placing the special bag into the abdominal cavity, bagging the tumor, inflating the bag to establish the operation space, crushing tumor with a morcellator in the bag, and retrieving the tumor and the bag [7].
However, the whole operation process is still in the abdominal cavity, and the risks of intraabdominal organ damages still exist. Meanwhile, the procedures of placing the special bag and bagging tumor are complicated, resulting in an extension of operation time about 20 minutes without calculating the time of crushing and retrieving tumor [7]. Meanwhile, the special bag is disposable material, which is relatively expensive and is not easy to be popularized in clinic.
Advantages and practical value of TPRT
In this study, we performed 111cases of conventional laparoscopic myomectomy by TPRT. Each TPRT was performed in line with the principle of tumor-free. The tumor was pared in the ordinary endoscopic specimen bag, completely isolated from abdominal wall and abdominal visceral organs. Other advantages compared to the recommended method are listed below.
First, TPRT can shorten the operation time. In our study, the mean total time of tumor removal process counted from inserting the ordinary specimen bag to the end of umbilicus repair is 12.60min(SD±3.78; range, 6–28). And the mean time for Paring and retrieving tumor is only 5.70min(SD±2.22; range, 1–14).They are much shorter than the time taken in recommended method that reported by Shi Yu et al [20], which time for placing the special bag plus the puncture catheter plus the tumor in a morcellation was 22.1 min (SD± 8.9; range, 18–45), time for crushing tumor was 33.5 min (SD± 6.5; ;range, 20–55), time for retrieving tumor was 9.3 min (SD± 3.7; range, 5–15), and time for handling the bag was 15.4 min (SD± 8.2; range, 8–25).During the procedure of TPRT, we can clamp the tumor with towel clips directly and remove it with “Pare Apple ”Tumor Extraction[11] which is mastered by most gynecologists and is performed such as in laparoscopic hysterectomy. When the blade is abraded by hard texture or large leiomyomas, the speed of Paring and retrieving tumor can be maintained by properly replacing a new surgical blade. It means that the time of tumor removal is not affected by the texture of tumor.
Second, TPRT has a lower risk of injury to abdominal organs. Different from the recommended method which procedures all performed in abdominal cavity, the possible traumatic excision of TPRT was close to the abdominal wall around umbilicus. In our study, due to lack of experiences and carelessness in the early stage, there were 11 accidental specimen bag breaks, 6 of which damaged the local umbilicus skin. Solved by washing and suturing. There were no other major accidental damages. Local umbilicus skin damage is easy to repair, and in addition, it can be avoided by using thyroid retractor, small S-hook and other general surgical instruments after the specimen bag was pulled open.
Third, TPRT is easy to be popularized due to it is easy to master and it costs a little. Paring tumor through the umbilicus incision is equivalent to a simple laparotomy around umbilicus. So, it is not difficult for most surgeons to master. We removed a leiomyoma with a diameter of 134 mm within 10 minutes by using a 30-mm umbilical incision. TRPT can also be used for the complete and safe removal of other tumors, such as pelvic endometriosis nodule, exfoliated ovarian tumor, and subtotal hysterectomy specimen and so on. Meanwhile, TPRT does not need special disposable endoscopic retriever bags or morcellators. The ordinary instruments, blades and specimen bags are enough for performing TPRT. It should be noted that the length of the incision can be determined according to the size, texture of leiomyoma and the thick of patient’s abdominal wall. For obese patients, the umbilical incision can be extended slightly. For smaller tumor, the incision can be reduced.
Besides, the scars can be seen on the abdomen skin is less, this technique will be accepted by patients easily. In the recommended method, we need to extend the 5-mm puncture hole to be a more than 15 mm incision in order to insert the leiomyoma morcellator. In our method, we extended the umbilicus incision as we did in TU-LESS. Owing to good ductility of the umbilicus, we could restore the normal appearance of the umbilicus after the tumor was removed. There were only two 5-mm scars more than TU-LESS. It is well known that, the difficulty of CLS is much lower than TU-LESS, and the indications of CLS are wider.
Query of TPRT
The key point of the TPRT is to replace the incision that originally needed to be extended in the lower abdomen to the umbilicus during CLS. While optimizing the surgical procedure, the related complications need to be paid attention to. The main query is that the extended umbilical incision has potential postoperative wound infection, scars, and umbilical hernia due to the umbilical region is the weakest part of the abdomen. In a retrospective study by Park JY on the complications of transumbilical single port laparoscopic surgery [21], the incidence of postoperative umbilical hernia was 0.4% (2/515), at 6 months and 8 months after surgery. The median follow-up time was 23.6 months (6.2-145.4) months, which was equivalent to the incidence of multi-port laparoscopic umbilical hernia. The length of the umbilical incision of the umbilical single port laparoscopic is usually 20 mm. When we take the tumor through the umbilical port, in order to quickly finish this step, we often extend the incision to 25~30 mm. It is equivalent to the length of umbilical incision in robotic single hole laparoscopic surgery which length is 25~40 mm [22, 23]. The existing literature [23–25] (the average follow-up time and the number of cases were 13.6 months, 1 month, 12 months and 12 cases, 7 cases, respectively, 129 cases) did not suggest an increase in complications such as infection of the umbilical incision and umbilical hernia after robot-assisted single port laparoscopic surgery. In this study, the umbilical repair suture technique draws on the umbilical operation of TU-LESS. It is necessary to effectively close the peritoneum and fascia layer by layer, and then finish the subcutaneous and skin repair suture. It is necessary to completely stop bleeding during the suture process to avoid hematoma formation and reduce complications such as recent infections.
In conclusion, TPRT optimizes the surgical process in CLS. It is safe, time saving, low cost, easy to learn and to be popularized.