Original Article

Gynecol Obstet Invest 2015;79:179183

DOI: 10.1159/000367659

Received: May 12, 2014

Accepted after revision: August 14, 2014
Published online: February 4, 2015

Laparoendoscopic Single-Site Surgery

for Benign Ovarian Cystectomies
Mohamed A. Bedaiwy a, e David Sheyn a Lily Eghdami e Faten F. Abdelhafez a
Jessica G. Volsky c Amanada Nickles-Fader d Pedro F. Escobar b
a

Department of Gynecology, University Hospitals Case Medical Center, Case Western Reserve University, and
Department of OB/GYN and Womens Health Institute, Cleveland Clinic, Cleveland, Ohio, c Department of
Obstetrics and Gynaecology, Mount Sinai Hospital, Chicago, Ill., and d Greater Baltimore Medical Center and Johns
Hopkins Hospital, Baltimore, Md., USA; e Division of Reproductive Endocrinology and Infertility, Department of
Obstetrics and Gynaecology, Faculty of Medicine, The University of British Columbia, Vancouver, B.C., Canada
b

Introduction

Abstract
Background: Single-port laparoscopy (LESS) utilizes a single, multichannel port in an attempt to decrease postoperative pain, while enhancing cosmesis and minimizing the potential risks and morbidities associated with the multiple
ports used in conventional laparoscopy. Methods: We performed a retrospective study examining three tertiary care
referral centers. From September 2009 until March 2013, 31
patients with ovarian cystic lesions were treated using the
LESS technique. A control group of 57 patients who underwent conventional laparoscopic ovarian cystectomy was included for comparison. Results: All patients underwent a
technically successful cystectomy. There were no statistically significant differences in the mean operative time or estimated blood loss between the two groups. Narcotic use during the recovery period was reported in less patients in the
LESS group than in the laparoscopic group (p = 0.05). Conclusions: The LESS technique can be used to safely perform
cystectomies on women with benign ovarian cysts. Additional investigation is needed to evaluate the safety, costeffectiveness and long-term outcomes of this new approach.

Laparoscopic surgery has been one of the greatest advancements in contemporary surgery, as it is associated
with similar operative outcomes to open procedures and
provides the advantage of shorter recovery times, less
postoperative pain and fewer complications [1]. Gynecologic surgeons in particular were both early adopters and
innovators in the field of minimally invasive surgery
[24].
Conventionally, laparoscopic surgery requires three or
four ports for the treatment of benign disease. Since the
adoption of laparoscopic surgery, attempts have been
made to minimize the number of port sites required,
without compromising surgical outcomes. Single-port
laparoscopy utilizes a single, multichannel port in an attempt to decrease postoperative pain, while enhancing
cosmesis and minimizing the potential risks and morbidities associated with multiple ports [5].
Single-port laparoscopy, also known as laparoendoscopic single-site surgery (LESS), was first introduced
over 40 years ago for tubal sterilization [6]. This method,
however, did not become popular due to technical difficulties encountered in adnexal surgeries and because of
the lack of specialized instruments. Recent advances, spe-

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Dr. Mohamed A. Bedaiwy, MD, PhD

Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and
Gynaecology, Faculty of Medicine, The University of British Columbia
D415A-4500 Oak Street, Vancouver, BC V6H 3V4 (Canada)
E-Mail bedaiwymmm@yahoo.com

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Key Words
LESS Ovarian cystectomy Laparoscopy

Materials and Methods

The study was approved by the Institutional Review Boards at
the University Hospitals of Cleveland, The Cleveland Clinic
Foundation, and the Greater Baltimore Medical Center. A retrospective, multi-institutional analysis of 31 consecutive patients
undergoing an ovarian cystectomy for benign disease using the
LESS technique was compared to a control group of 57 patients
who underwent a traditional laparoscopic ovarian cystectomy.
The operative cases were performed between September of 2009
and March 2013 by surgeons with similar experience and operative skills. The decision to use LESS or conventional operative laparoscopy was made according to the preference of the attending
gynecologist. For LESS, all surgical steps were performed through
a 1.5- to 2.0-cm transumbilical incision using a multichannel, single-port devise.
Surgical Technique
After induction of general anesthesia and endotracheal intubation, patient positioning in Allen Stirrups, and the insertion of a
Foley catheter and an orogastric tube, abdominal access was
gained using a modified open Hasson technique with a vertical
1.8- to 2.0-cm infraumbilical incision. The rectus fascia was sharply incised, and a single-access multichannel port (Covidien, Mansfield, Mass., USA) was inserted in the peritoneal cavity. Pneumoperitoneum was attained with the pressure set at 1520 mm Hg.
A 5-mm, 0 lens laparoscope with a flexible tip, the Endoeye
(Olympus Surgical, Orangeburg, N.Y., USA) or a 30 bariatric
length rigid scope were used. Articulating graspers (Covidien)
were helpful in providing efficient retraction to optimize surgical
exposure.
The ovarian cystectomy was begun by grasping the utero-ovarian ligament to stabilize the ovary. The antimesenteric border of
the ovary was then incised using the endoshears (fig.1). Subsequently, the cyst wall was identified and bidirectional dissection of
the surrounding ovarian cortex was performed using a combination of blunt and sharp technique, traction and counter-traction
and electrocoagulation. Once the ovarian cyst was excised, the bed
was then carefully inspected and bleeding areas were secured with
cautery. The cyst bed was left open for spontaneous healing.
The excised ovarian cysts were placed in 5- to 12-mm Endo
Catch bags and removed through the multichannel port after detaching all the trocars from the abdomen. At the end of all the procedures, the fascia of the umbilical incision was closed with 0 Vicryl in a running fashion, and the skin of the umbilicus was closed
with 4-0 Vicryl in a subcuticular fashion. All incisions were injected with 0.5% Marcaine at the end of the procedure.

180

Gynecol Obstet Invest 2015;79:179183

DOI: 10.1159/000367659

Table 1. Patient demographics, ultrasonographic features of the

adnexal masses and surgical outcomes

Age, years
BMI
Previous abdominal surgery
Maximum diameter
of the adnexa, cm
Adhesiolysis
Operative time, min
Estimated blood loss, ml
Spillage
Narcotic use in the
recovery room
Histopathological diagnosis
Serous cyst adenoma
Mucinous cystadenoma
Dermoid cyst
Other

LESS
(n = 31)

Conventional p
laparoscopy value
(n = 57)

32 5
27 3
11 (35.4)

34 5
28 4
19 (33.3)

0.09
0.15
0.7

6.5 2.1
12 (38.7)
79 25.5
50 15
3 (9.8)

7.2 2.1
17 (29.8)
70.9 20.5
65 5
6 (10.5)

0.49
0.09
0.07
0.1
0.08

11 (35.4)

27 (50.9)

0.05

9 (29)
8 (15.7)
10 (32.3)
4 (13)

14 (24.7)
13 (22.9)
21 (37)
9 (15.9)

Values are presented as means SD or n (%).

In the conventional laparoscopy group, three 5-mm ports were

used in all cases; one umbilical port for the scope and two accessory ports in the right and the left lower quadrant. All incisions
were injected with 58 ml of 0.5% Marcaine at the end of the procedure. The use of narcotics in the recovery room was recorded in
the nursing notes, and pain was graded using a visual analogue
scale.
Patients in both groups underwent at least one postoperative
visit 612 weeks after surgery, and at least an additional one in the
6 months after surgery. Incidence of postoperative umbilical complications in the LESS group including hernia formation and incisional cellulitis were recorded. Moreover, other perioperative and
latent complications were also recorded.
Statistical Analysis
Patient demographics and clinical characteristics were compared between group 1 cases (LESS) and group 2 cases (conventional laparoscopy) by the use of either the 2 test for frequency
data or the nonparametric Mann-Whitney U test. Surgical outcomes were compared between the groups in a similar fashion.

Results

A total of 88 patients were included in the study: 31

underwent LESS cystectomy and 57 underwent conventional laparoscopic cystectomy. In both groups, the surgery was considered technically successful.
Bedaiwy/Sheyn/Eghdami/Abdelhafez/
Volsky/Nickles-Fader/Escobar

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cifically the development of laparoscopic cameras and

flexible endoscopes, have minimized the problems associated with the lack of triangulation and instrument
crowding and have made adnexal surgery using the LESS
technique feasible [7].
The objective of this study is to describe surgical outcomes for patients undergoing ovarian cystectomies for
benign disease with the LESS technique, as compared to
conventional multiport laparoscopy.

Color version available online

Fig. 1. LESS for ovarian cyst. a Outside view showing the orientation of the instruments. b Left-sided ovarian
cyst. c Initial incision on the mesenteric border of the ovary. d Combined blunt and sharp dissection of the cyst

Both groups demonstrated similar demographic

characteristics. The mean age of patients in the LESS
group was 32 5 years and 34 5 years in the laparoscopic group. BMI was 27 3 in the LESS group and 28
4 in the laparoscopic group. A history of prior abdominal surgery was obtained in 11 patients (35.4%) in the
LESS group and in 19 patients (33.3%) in the laparoscopic group. The maximum cyst diameter was similar

in both groups: 6.5 2.1 cm in the LESS group and 7.2

2.1 cm in the laparoscopic group (table1).
The most common histologic diagnosis in both groups
was a dermoid cyst. There were 10 (32.3%) dermoids removed in the LESS group and 21 (37%) in the laparoscopic group (table1).
Lysis of adhesions was performed in 12 patients
(38.7%) in the LESS group and in 17 patients (29.8%) in

LESS for Benign Ovarian Cystectomies

Gynecol Obstet Invest 2015;79:179183

DOI: 10.1159/000367659

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wall.

Discussion

Laparoscopic surgery has become the preferred surgical approach for a variety of conditions encountered by
the gynecologic surgeon. The use of multiple small incisions in place of a larger abdominal incision is associated
with shorter recovery times, less postoperative pain and
fewer complications [1]. Even so, the placement of each
additional laparoscopic port increases the risk of bleeding, infection and organ damage and decreases the cosmetic outcome [8]. Ideally, minimally invasive procedures would be performed with as few incision sites as
needed to maintain equivalent surgical outcomes and
safety profiles. LESS provides the opportunity to decrease
operative risks and postoperative pain, while improving
patient satisfaction and cosmesis.
In this preliminary study, we described surgical outcomes for 31 patients who underwent an ovarian cystectomy using the LESS approach, as compared to 57 patients who had a conventional laparoscopic cystectomy.
Our data indicates that there was no statistically significant difference in blood loss, operative time or technical
success of the surgery between the two groups. The only
significant variable was that less patients treated with
LESS required narcotics postoperatively, consistent with
the improvement in postoperative pain control seen in
previous studies [9, 10].
There has been previous literature corroborating our
support of the use of LESS for gynecologic procedures
[1113]. Fagotti et al. [11] performed a large retrospective
study of 125 patients undergoing LESS for unilateral or
bilateral salpingo-oophorectomies or bilateral ovarian cyst
enucleations. Their analysis showed that using the LESS
approach resulted in minimal intraoperative blood loss, no
major surgical complications and optimal postoperative
pain control. In addition, both patients and surgeons were
highly satisfied with the cosmetic end point. Similarly,
Song et al. [12] have recently published a prospective study
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Gynecol Obstet Invest 2015;79:179183

DOI: 10.1159/000367659

outlining the use of LESS for extremely large ovarian cysts

(>15 mm). They were able to show that given appropriate
patient selection, the procedure was technically feasible,
safe and had high rates of patient satisfaction.
A meta-analysis by Murji et al. [14] in 2013 evaluated
the surgical outcomes for 899 gynecological procedures
performed by single-incision laparoscopy compared to
1,186 surgeries performed by conventional multi-incision laparoscopy. The results of the analysis showed
that there was no difference in the risk of complications
between the two groups but that the mean operative
time for adnexal surgery in the LESS group was 6.97 min
longer than in the conventional laparoscopy group.
Although not statistically significant, our results also
indicated that the mean operative time associated with
LESS was approximately 9 min longer than that associated with conventional laparoscopy. This result is corroborated by a study performed by Kim et al. [15] in 2013,
in which they showed that single-port laparoscopy took
longer than both two-port and four-port laparoscopy
(90.4 43.6, 74.7 22.0, and 63.8 30.5, respectively). It
is felt that achieving surgical proficiency with LESS is possible after 1015 cases, and with growing familiarity and
expertise in LESS we believe that operative times will continue to decrease and eventually be on par with conventional laparoscopy [16]. A future cost-benefit analysis
comparing the cost associated with increased operating
times with the decrease in the expenses associated with a
single laparoscopic port would be helpful in delineating
the true significance of this finding.
The primary limitations of our study include the retrospective design, reporting bias due to different surgeons performing the procedures and the relatively small
number of patients included in the analysis. Despite these
study limitations, our results are consistent with the available literature indicating that the use of LESS to perform
gynecological procedures, specifically cystectomies, is
technically feasible with equivalent risks of complications
and reductions in postoperative pain.
Randomized trials powered to assess a multitude of
surgical and postoperative outcomes will be required to
make any firm statements regarding the utility of LESS for
gynecological surgery; however, based on the available literature as well as the results of our study, there is now a
strong suggestion that LESS is at least equivalent to conventional laparoscopy in the setting of ovarian cystectomies.

Bedaiwy/Sheyn/Eghdami/Abdelhafez/
Volsky/Nickles-Fader/Escobar

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the laparoscopic group (p = 0.09). The mean time of

surgery was 79 25.5 min in the LESS group and 70.9
20.5 min in the laparoscopic group (p = 0.07). Estimated
blood loss was likewise not statistically different, with
50 15 ml in the LESS group and 65 5 ml in the laparoscopic group (p = 0.1).
Narcotic use in the postanesthesia care unit, in addition to routine pain control, was reported in 11 patients
(35.4%) in the LESS group and in 27 patients (50.9%) in
the laparoscopic group (p = 0.05).

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Erratum

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In the article by Bedaiwy MA et al., entitled Laparoendoscopic single-site surgery for benign ovarian cystectomies [Gynecol Obstet Invest 2015;79:17983, DOI: 10.1159/
000367659], the following author has been misspelled: Nickles-Fader A. It should be listed as Fader AN.