Some criticism about laparo-endoscopic single site surgery (LESS) in gynecological surgery for benign and malignant diseases

29 06 2011

To the Editor:

We read with great interest the article by Fagotti et al. (1) on postoperative pain after conventional laparoscopy and laparo-endoscopic single site surgery (LESS) for benign adnexal disease.

We share the opinion of the authors on the good cosmetic results of the new “device” and on the reduced postoperative pain offered by the procedure. In our experience, we have found the same advantages with the use of LESS in patients affected by gender identity disorders and submitted to endoscopic hysterectomy with bilateral salpingovariectomy (2). The scar hidden deep in the umbilical fold may represent a great advancement in sex reassignment surgery, leading to psychological advantages. The absence of pelvic scars, which would identify the type of previous surgery, may help to complete the full integration of these female subjects into the new male role.

Although the article by Fagotti et al. refers mainly to the comparison of post-operative pain of traditional laparoscopy and the LESS, some considerations are necessary.

The authors have not commented on two results: the similar surgical times and a meaningful reduction of the blood loss between the two surgical techniques. In our experience, the use of LESS involves an increase in operating time because of the greater difficulty in performing the normally required surgical movements due to the close proximity of the instruments in the “device.” In our opinion, these critical points have not yet been resolved by the presence of 30° optics and of ergonomic tools of different sizes and lengths, and we think that these difficulties may not lead to a reduction in intra-operative blood loss. Nevertheless, the same authors affirm in the discussion that “future developments, such as pre-curved instruments or new optics, will lead to better results.”

Fagotti et al. affirm that one of the advantages of the LESS is a lower risk of developing hernias in respect to standard laparoscopy due to the reduction of the number of “working ports.” In reality, there is a need to evaluate whether the new device can lead to a greater risk of hernias in the umbilical site because of the need for a larger incision (15-20 mm) in comparison to standard laparoscopy (10-12 mm) in an anatomical site recognized as high risk for hernia (3).

Recently the assessment of tumour resectability in advanced ovarian cancer patients has been proposed by means of laparoscopy (4) associated to single or multiple biopsies.

We believe that the new LESS procedure is very promising and that it can be applied well in this latter set of patients (4). In such pathologies, a single access site can provide three principal advantages: 1) reduced risk of ascites spillage from laparoscopy breaches and greater comfort for the patient; 2) reduction of risk of port-site metastasis; 3) earlier start of chemotherapy due to faster patient recovery.

Anna Myriam Perrone, M.D., Ph.D.
Martina Rossi, M.D.
Pierandrea De Iaco, M.D.
Unit of Oncologic Gynaecology
S. Orsola-Malpighi Hospital
Bologna, Italy

References
1. Fagotti A, Bottoni C, Vizzielli G, Alletti SG, Scambia G, Marana E, Fanfani F. Postoperative pain after conventional laparoscopy and laparoendoscopic single site surgery (LESS) for benign adnexal disease: a randomized trial. Fertil Steril. 2011 May 10. [Epub ahead of print]

2. Perrone AM, Scifo MC, Martelli V, Casadio P, Morselli PG, Pelusi G, Meriggiola MC. Hysterectomy and Bilateral Salpingoovariectomy in a Transsexual Subject without Visible Scarring.Diagn Ther Endosc. 2010;2010. pii: 845029

3. Helgstrand F, Rosenberg J, Kehlet H, Bisgaard T. Low risk of trocar site hernia repair 12 years after primary laparoscopic surgery. Surg Endosc. 2011 Jun 4. [Epub ahead of print]

4. Fagotti A, Gallotta V, Romano F, Fanfani F, Rossitto C, Naldini A, Vigliotta M, Scambia G. Peritoneal carcinosis of ovarian origin. World J Gastrointest Oncol. 2010; 2:102-8.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.06.076

The Authors Respond:

We agree with our colleagues regarding the significant impact of LESS-surgery in compliance with patient’s body image. This reflects not only in women who need surgery for reassignment of sex, as they have described, but it may include other groups of patients such as (i) models, working with their own physicality; (ii) BRCA positive women, who have still received radical surgery for breast cancer and need LESS BSO; and (iii) any cancer women who need to pick up ovarian tissue for freezing, before being submitted to radiotherapy or chemotherapy. In fact, in the last two examples a scare less surgery may avoid unnecessary mark of recognition of their difficult history. Moreover, the use of LESS surgery should not be forgotten in the field of pediatric surgery where, besides body image, the rapid recovery as well as the more rapid decrease in postoperative pain, that this technique provides, may play a fundamental role.

As regards the application of LESS in the role of diagnostic laparoscopy for the assessment of tumor resectability in advanced ovarian cancer patients, is surely clear that using an appropriate laparoscopic technique, the risk of port-site is practically eliminated (1). However, in our experience, the large diffusion of disease in advanced ovarian cancer makes the triangulation obtained with the standard technique essential.

Finally, regarding the perplexities moved in relation to similar operating time and decreased blood loss with LESS surgery with respect to standard laparoscopy, in our experience on more than 100 cases (2,3), we have learned that these results are possible both with a learning curve and an appropriate patient selection.
In the same way, closing the fascia correctly, despite the larger incision (up to 0.5 mm), allows a risk of developing hernias close to 0%.

Anna Fagotti, M.D.
Francesco Fanfani, M.D.
Carolina Bottoni, M.D.
Giovanni Scambia, M.D.
Unit of Gynecologic Oncology
Catholic University of the Sacred Heart
Rome, Italy

References
1. Fagotti A, Vizzielli G, Fanfani F, Scambia G. Comparison of peritoneal carcinomatosis scoring methods in predicting resectability and prognosis in advanced ovarian cancer. Am J Obstet Gynecol. 2010 Feb; 202(2):178.e1-178.e10

2. Fagotti A, Bottoni C, Vizzielli G, Alletti SG, Scambia G, Marana E, Fanfani F. Postoperative pain after conventional laparoscopy and laparoendoscopic single site surgey (LESS) for benign adnexal disease: a randomized trial. Fertil Steril. 2011 May 10. [Epub ahead of print]

3. Fagotti A, Rossitto C, Marocco F, Gallotta V, Bottoni C, Scambia G, Fanfani F. Perioperative outcomes of laparoendoscopic single-site surgery (LESS) versus conventional laparoscopy for adnexal disease: a case-control study. Surg Innov. 2011 Mar; 18(1):29-33 Epub 2011 Jan 18.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.06.077

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