Abstract
In the last decade, Ultra-minimally invasive surgery (UMIS) including both minilaparoscopic (MH) and percutaneous (PH) endoscopic surgery achieved widespread use around the world. Despite UMIS has been reported as safe and feasible surgical procedure, most of the available data are drawn from retrospective studies, with a limited number of cases and heterogeneous surgical procedures included in the analysis. This literature review aimed to analyze the most methodologically valid studies concerning major gynecological surgeries performed in UMIS. A literature review was performed double blind from January to April 2021. The keywords ‘minilaparoscopy’; ‘ultra minimally invasive surgery’; ‘3 mm’; ‘percutaneous’; and ‘Hysterectomy’ were selected in Pubmed, Medscape, Scopus, and Google scholar search engines. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were followed for the drafting of the systematic review. The systematic literature research provided 298 studies, of which 9 fell within the inclusion criteria. Two hundred ninety-six total patients were included, 148 for both PH and MH groups. Median age (48 years), BMI (24 kg/m2), OT (90 min), EBL (50 ml), time to discharge (1 day), self scar evaluation (10/10), and VAS (3/10) were reported. The most frequent intraoperative complication in both the PH and MH groups was surgical bleeding. The UMIS approaches were feasible and safe even for complex gynecological procedures. Operative times and complications were superimposable to the “classical” minimally invasive approaches reported in the literature. The reported results apply only to experienced surgeons.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Introduction
In the recent period, minimally invasive surgery (MIS) has been extensively used in all surgical specialities across the globe [1,2,3,4,5,6].
Compared to “traditional” surgical techniques, the reduced number and size of laparoscopic trocars was related to superior aesthetic results and pain tolerance while maintaining the same surgical safety [7,8,9].
Technological advancement has led to an increasing tendency to reduce the invasiveness of surgical experience [10,11,12], resulting in the establishment of a new branch of MIS, namely ultra minimally invasive surgery (UMIS), which includes both minilaparoscopic (3 mm trocar) and percutaneous endoscopic surgery [13, 14].
Suppose this trend towards a growing minimally-invasiveness is globally accepted and continuously developed in benign surgery. Minimal-invasiveness procedures also included another gynecologic area, for example, the hysteroscopic system that transitioned from a traditional approach [15, 16] to a virtual endoscopy that allows uterine cavity visualization without an invasive procedure utilizing a 3-D reconstruction [17,18,19].
In that case, the application of MIS in the management of gynecological malignancies must be carefully proposed in selected cases and paying attention to oncological adequacy [20,21,22,23].
The minimally invasive approach during endometrial cancer surgical staging represents the standard of care supported by the evidence of the international guidelines [24,25,26,27].
The potential of MIS during ovarian cancer surgical staging and debulking surgery [28,29,30,31,32,33,34] is currently under is already being investigated prospectively (Lance study) [35], whereas the discussion on its applicability to early-stage cervical cancers prompted by the LACC trial has yet to reach a consensus [34, 36,37,38].
Several studies [39,40,41] observed UMIS benefits in terms of shorter hospital stay, better aesthetic outcomes, less postoperative discomfort, and increased patient satisfaction compared to traditional laparoscopic or robotic surgery.
Furthermore, major gynecological procedures, such as percutaneous aided hysterectomy (PH) and minilaparoscopic hysterectomy (MH) using a 3 mm trocar, have been found to be safe and feasible in skilled hands [42,43,44,45].
However, most of the available data come from retrospective studies, with a small number of enrolled patients and a range of different surgical procedures included in the same research.
This literature review analyzed the most methodologically valid studies concerning major gynecological surgeries performed in UMIS. Additionally, the disadvantages and advantages of ultra-minimally intrusive techniques have been outlined.
Materials and methods
Two authors performed a literature review double-blind from January to April 2021.
The keywords ‘minilaparoscopy’; ‘ultra minimally invasive surgery’; ‘3 mm’; ‘percutaneous’; and ‘Hysterectomy’ were selected in Pubmed, Medscape, Scopus, and Google scholar search engines.
A third author oversaw the selection of articles by the two previous authors.
All studies in English-language, with more than 15 cases reporting “complex gynecological procedures”, and performed with UMIS technique were included in the analysis.
By “complex gynecological procedures” was meant interventions included at least hysterectomy with bilateral salpingo-oophorectomy with or without pelvic lymph node dissection.
Both MH and PH have been included in the UMIS group. The minilaparoscopic surgical technique involved the placement of a 10 or 5 mm transumbilical trocar and three 3 mm ancillary trocars in the suprapubic area and the right and left flank, respectively.
The percutaneous surgical technique involved one 10 or 5 mm transumbilical optic access, one 5 mm suprapubic trocar, and two needlescopic accesses in the right and left flank.
Author, year of publication, type of device, age, body mass index (BMI), operating time (OT), estimated blood loss (EBL), day of discharge, scar patient assessment, pain visual analog scale (VAS), complication, and the type of the performed procedure were collected for each article.
Patient scar rating was determined by the patient’s subjective assessment on a scale from 0 to 10.
The VAS scale was defined as a visual pain scale ranging from 0 to 10. Complications were classified according to the Clavien-Dindo definition.
All articles not falling within the inclusion criteria, with missing data, or not related to the objective of this review were excluded.
PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) [46] guidelines were followed to draft this systematic review of the literature.
Results
The systematic literature research provided 298 studies, of which 9 fell within the inclusion criteria (3 in PH and 6 MH group) [43, 47,48,49,50,51,52,53,54].
Ten articles were excluded because the cohort series was less than 15 patients. Eighteen case reports and 4 studies containing redundant data were excluded. One hundred and fifty-three studies did not report “complex gynecological procedures” and 111 articles did not adhere to the purpose of this review. The study selection flow chart is shown in Fig. 1. Of the included studies, 6 were retrospective in nature, one prospective, and 2 studies were randomized clinical trials.
Three studies included patients with benign disease, 4 studies involved patients with a benign disease or early-stage endometrial cancer, and 2 articles exclusively analyzed patients with malignant conditions (one included patients with early-stage endometrial cancer and the other one patients with early-stage cervical cancer).
After EC diagnosis, total hysterectomy with or without salpingo-oophorectomy were performed for all benign conditions, while nodal dissection was pursued in malignant cases [55].
Two hundred ninety-six total patients were included, 148 for both PH and MH groups.
Median age (48 years), BMI (24 kg/m2), OT (90 min), EBL (50 ml), time to discharge (1 day), self scar evaluation (10/10), and VAS (3/10) were reported in Tables 1 and 2 for the PH and MH group.
As shown in Table 3, 21 total complications were reported, 2 intraoperative and 6 postoperative in the PH group, and 5 intraoperative and 8 postoperative in the MH group.
The most frequent intraoperative complication in both the PH and MH groups was surgical bleeding (6 cases out of 7 total intraoperative complications). The most commonly reported postoperative complications were bleeding (3 cases), fever (3 cases), and urinary infection (2 cases). All complications were managed with conservative treatment and were classified as Dindo grade 1 or 2.
Discussion and evidence synthesis
Based on the main findings of the literature we stratified the discussion by focusing on the strengths and weaknesses of the UMIS technique.
Strengths
Cosmetic outcomes
Since its introduction in 1998, UMIS was aimed to reduce the size of abdominal scars while simultaneously increasing the quality of life of patients [56].
According to subjective patient perception [57], there is no doubt that the decreased width of the surgical scar in both the PH and the MH groups resulted in superior aesthetic outcomes.
The percutaneous method, in particular, is regarded as the greatest example of “scarless surgery,” with the surgical scar reported on postoperative day 30 as scarcely discernible [58].
In our analysis, all patients showed an extremely high level of cosmetic satisfaction.
Similar results were also obtained for other general and urologic surgeries [59, 60]. Furthermore, as reported by David et al. [61], the same excellent cosmetic outcomes could be achieved for complex upper abdominal procedures.
The effects of abdominal surgical scars had received less attention than those of face surgical scars [36, 54], even though they might have significant physical and psychological consequences [44, 62].
Furthermore, further clinical studies are required to evaluate and further analyze the psychological influence of the abdominal scar on patients’ quality of life [63, 64] in this context.
Pain relief
Excellent pain management was noted in the patients included in the analysis, with a median “mild pain” reflected at the VAS score (VAS score 1–3 defines “mild pain”). These findings are supported by a large amount of scientific research, which includes both the UMIS and the MIS approaches [65,66,67,68].
Donnez et al. [69] found a mean VAS score of 4 (3.5 2.6) at 1 h following surgery in MIS hysterectomy patients.
Furthermore, as hypothesized, the UMIS technique demonstrated a significant increase in pain management with fewer analgesics needed in various types of surgical procedures when compared to their laparotomic equivalent [70,71,72] (Figs. 2 and 3).
Indeed, the progressive reduction in the skin incision size is immediately mirrored in the decrease of parietal neuro-muscular injury with concomitantly reduced incisional pain..
As reported by Cianci et al. [47], referred pain was better in the percutaneous approach than in the minilaparoscopic approach (VAS score 3 vs 5 at 24 h after surgery, respectively).
Overlapping results were also shown by Perrone et al. [73] in a multicentric cohort study comparing percutaneous with “classical laparoscopic surgery”.
Finally, since no clinical trials on this topic are currently available, we can conclude that both the percutaneous and minilaparoscopic approaches represent an opportunity to improve patient-referred pain compared to the “classical” minimally invasive approaches in selected cases and experienced hands (Tables 4, 5, 6, and 7).
Surgical outcomes
In our series, all the papers analyzed showed a comparable median OT, EBL, complication rate, and type of procedures between MIS and UMIS.
Furthermore, even in the setting of advanced surgical procedures, such as pelvic lymphadenectomy, median OT and complications were superimposable to that reported for the standard laparoscopic approach [74,75,76,77].
Besides, only “minor complications” (Clavien-Dindo grade 1–2) were reported in our series.
However, all the analyzed reports were referred to high-volume third-level centers for gynecological malignancies, making more difficult the generalization of the obtained results.
Another technical aspect that contributes to the excellent surgical outcomes is the maintenance of the standard laparoscopic triangulation even in the UMIS approach.
Usually, two needlescopic instruments in the left and right flank (2.9 mm of Percuvance ™ or 2.4 mm of Mini-Grip™) and one 5 mm operative suprapubic trocar are positioned in percutaneous approach while three 3 mm trocar are placed, in the same positions, during minilaparoscopic approach [78].
In this scenario, percutaneous and minilaparoscopic surgery may be more feasible and manageable than other single port MIS in which triangulation is lacking [79].
Weaknesses
Manipulating tissue and coagulation
According to several authors, the fundamental limitation of percutaneous instrumentation is the limiting of tissue mobilization due to the shaft’s diameter [43]. As a result, percutaneous tools may buckle when treating heavy structures such as massive ovarian masses. In addition, the inefficient lever effect is amplified by the abdominal wall’s high resistance, which amplifies the instrument’s flexion.Even the small size of the instrument’s jaw could negatively impact the correct mobilization of enlarged uteri (> 250 g) or adnexal masses [80, 81] while determining an increased risk of tissue laceration [82].
Finally, as pointed out by several authors, the lack of energy in percutaneous instruments makes multifunction devices recommended, even in cases with relatively low technical difficulty [13, 43].
Consequently, if, on the one hand, an excellent surgical performance with reduced operating times was guaranteed through the use of an integrated energy device, on the other, costs were increased.
Feeling in managing tissues
Gueli Alletti et al. [42] has highlighted the lack of tissue manipulation feeling as the primary constraint of percutaneous endoscopic instrumentation in a research including 382 patients who received “complex gynecological procedures.”.
Needleoscopic tools are inserted directly into the abdominal cavity losing the smooth glide of the instrument inside the trocar. In this way, the laparoscopic instrument rubbed with all components of the anterior abdominal wall (skin, subcutaneous fat, fascia, muscles, and peritoneum).
This pitfall together with the small and sharp operating tip makes tissue manipulation less sensitive by increasing the risk of tissue tearing if excessive traction is applied [48].
This limitation was particularly evident in the manipulation of soft tissues, such as in lymph node grasping during nodal dissection in endometrial cancer cases [42].
Review strengths and limitations
There were several limits to our review. First of all, we only considered studies performed at third-level oncological centers. It should be noted that all of the studies included were retrospective in design, and no control groups were included. At the least, the number of described case series is limited. The primary strength of our review was the only complex gynecological surgeries inclusion, hence minimizing the selection bias.
Conclusions
Even for complicated gynecological procedures, the UMIS techniques proved viable and safe.
Operation durations and problems were significantly decreased compared to “classical” minimally invasive procedures mentioned in the literature.
Availability of data and material
On request.
Code availability
Not applicable.
Change history
20 July 2022
Missing Open Access funding information has been added in the Funding Note.
References
Gallotta V, Conte C, Giudice MT, Nero C, Vizzielli G, Gueli Alletti S et al (2018) Secondary laparoscopic cytoreduction in recurrent ovarian cancer: a large, single-institution experience. J Minim Invasive Gynecol 25(4):644–650
Fagotti A, Costantini B, Gallotta V, Cianci S, Ronsini C, Petrillo M et al (2015) Minimally invasive secondary cytoreduction plus HIPEC versus open surgery plus HIPEC in isolated relapse from ovarian cancer: a retrospective cohort study on perioperative outcomes. J Minim Invasive Gynecol 22(3):428–432
Vitale SG (2019) The biopsy snake grasper sec. VITALE: a new tool for office hysteroscopy. J Minim Invasive Gynecol. https://doi.org/10.1016/j.jmig.2019.12.014
Vitale SG, Lagana AS, Caruso S, Garzon S, Vecchio GM, La Rosa VL et al (2021) Comparison of three biopsy forceps for hysteroscopic endometrial biopsy in postmenopausal patients (HYGREB-1): a multicenter, single-blind randomized clinical trial. Int J Gynaecol Obstetr. https://doi.org/10.1002/ijgo.13669
Cianci S, Riemma G, Ronsini C, De Franciscis P, Torella M, Schiattarella A et al (2020) Hyperthermic intraperitoneal chemotherapy (HIPEC) for ovarian cancer recurrence: systematic review and meta-analysis. Gland Surg 9(4):1140
Giampaolino P, Della Corte L, Improda FP, Perna L, Granata M, Di Spiezio SA et al (2021) Robotic hysterectomy as a step of gender affirmative surgery in female-to-male patients. J Invest Surg 34(6):645–650
Gueli Alletti S, Rossitto C, Cianci S, Scambia G (2016) Telelap ALF-X total hysterectomy for early stage endometrial cancer: new frontier of robotic gynecological surgery. Gynecol Oncol 140(3):575–576
Vitale SG, Gasbarro N, Lagana AS, Sapia F, Rapisarda AMC, Valenti G et al (2016) Safe introduction of ancillary trocars in gynecological surgery: the “yellow island” anatomical landmark. Ann Ital Chir 87:608–611
Laganà AS, Vitale SG, Palmara V, Ban Frangež H, Triolo O (2017) Transvaginal specimen removal in minimally invasive surgery: feasibility and possible complications during the incision of the posterior vaginal wall. World J Urol 35(7):1155–1156
Vitale SG, Haimovich S, Riemma G, Ludwin A, Zizolfi B, De Angelis MC et al (2020) Innovations in hysteroscopic surgery: expanding the meaning of “in-office.” Minim Invasive Ther Allied Technol. https://doi.org/10.1080/13645706.2020.1715437
Vitale SG, Bruni S, Chiofalo B, Riemma G, Lasmar RB (2020) Updates in office hysteroscopy: a practical decalogue to perform a correct procedure. Updates Surg. https://doi.org/10.1007/s13304-020-00713-w
Giampaolino P, Della Corte L, Sardo ADS, Zizolfi B, Manzi A, De Angelis C et al (2019) Emergent laparoscopic removal of a perforating intrauterine device during pregnancy under regional anesthesia. J Minim Invasive Gynecol 26(6):1013–1014
Perrone E, Fanfani F, Rossitto C, Cianci S, Fagotti A, Restaino S et al (2020) Laparoscopic vs percutaneous hysterectomy in obese patients: a prospective evaluation. Facts Views Vis Obgyn 11(4):307–313
Gueli Alletti S, Cianci S, Perrone E, Fanfani F, Vascone C, Uccella S et al (2019) Technological innovation and personalized surgical treatment for early-stage endometrial cancer patients: a prospective multicenter Italian experience to evaluate the novel percutaneous approach. Eur J Obstet Gynecol Reprod Biol 234:218–222
De Franciscis P, Riemma G, Schiattarella A, Cobellis L, Colacurci N, Vitale SG et al (2020) Impact of hysteroscopic metroplasty on reproductive outcomes of women with a dysmorphic uterus and recurrent miscarriages: a systematic review and meta-analysis. J Gynecol Obstetr Hum Reprod 49(7):101763
Siristatidis C, Chrelias C, Salamalekis G, Kassanos D (2010) Office hysteroscopy: current trends and potential applications: a critical review. Arch Gynecol Obstet 282(4):383–388
Carugno J, Laganà AS, Vitale SG (2020) Use of 3D ultrasound in the hysteroscopic management of Asherman syndrome. Ann Transl Med. https://doi.org/10.21037/atm.2020.04.18
Saravelos S, Li T (2017) Virtual hysteroscopy with HDlive. Ultrasound Obstet Gynecol 49(2):284–286
Vitale SG, Laganà AS, Török P, Lasmar RB, Carugno J, Palumbo M et al (2021) Virtual sonographic hysteroscopy in assisted reproduction: a retrospective cost-effectiveness analysis. Int J Gynecol Obstetr. https://doi.org/10.1002/ijgo.13651
Uccella S, Franchi MP, Cianci S, Zorzato PC, Bertoli F, Alletti SG et al (2020) Laparotomy vs minimally invasive surgery for ovarian cancer recurrence: a systematic review. Gland Surg 9(4):1130–1139
Scaletta G, Dinoi G, Capozzi V, Cianci S, Pelligra S, Ergasti R et al (2020) Comparison of minimally invasive surgery with laparotomic approach in the treatment of high risk endometrial cancer: a systematic review. Eur J Surg Oncol J Eur Soc Surg Oncol B Assoc Surg Oncol 46(5):782–788
Cosentino F, Vizzielli G, Turco LC, Fagotti A, Cianci S, Vargiu V et al (2018) Near-infrared imaging with indocyanine green for detection of endometriosis lesions (gre-endo trial): a pilot study. J Minim Invasive Gynecol 25(7):1249–1254
Vitale SG, Riemma G, Ciebiera M, Cianci S (2020) Hysteroscopic treatment of submucosal fibroids in perimenopausal women: when, why, and how? Climacteric 23(4):355–359
Network. NCC. Uterine Neoplasms (Version 1.2021). https//www.nccn.org/professionals/physician_gls/pdf/uterine.pdf https//www.nccn.org/professionals/physician_gls/pdf/uterine.pdf. Accessed 14 June 2021
Vitale SG, Rossetti D, Tropea A, Biondi A, Laganà AS (2017) Fertility sparing surgery for stage IA type I and G2 endometrial cancer in reproductive-aged patients: evidence-based approach and future perspectives. Updat Surg 69(1):29–34
Cignini P, Vitale SG, Laganà AS, Biondi A, La Rosa VL, Cutillo G (2017) Preoperative work-up for definition of lymph node risk involvement in early stage endometrial cancer: 5-year follow-up. Updat Surg 69(1):75–82
Vitale SG, Valenti G, Gulino FA, Cignini P, Biondi A (2016) Surgical treatment of high stage endometrial cancer: current perspectives. Updat Surg 68(2):149–154
Gueli Alletti S, Capozzi VA, Rosati A, De Blasis I, Cianci S, Vizzielli G et al (2019) Laparoscopy vs laparotomy for advanced ovarian cancer: a systematic review of the literature. Miner Med 110(4):341–357
Gueli Alletti S, Bottoni C, Fanfani F, Gallotta V, Chiantera V, Costantini B et al (2016) Minimally invasive interval debulking surgery in ovarian neoplasm (MISSION trial-NCT02324595): a feasibility study. Am J Obstetr Gynecol 214(4):503
Plotti F, Terranova C, Luvero D, Bartolone M, Messina G, Feole L et al (2020) Diet and chemotherapy: the effects of fasting and ketogenic diet on cancer treatment. Chemotherapy 65(3–4):77–84
Bizzarri N, du Bois A, Fruscio R, De Felice F, De Iaco P, Casarin J et al (2021) Is there any therapeutic role of pelvic and para-aortic lymphadenectomy in apparent early stage epithelial ovarian cancer? Gynecol Oncol 160(1):56–63
Bellia A, Vitale SG, Laganà AS, Cannone F, Houvenaeghel G, Rua S et al (2016) Feasibility and surgical outcomes of conventional and robot-assisted laparoscopy for early-stage ovarian cancer: a retrospective, multicenter analysis. Arch Gynecol Obstet 294(3):615–622
Rossetti D, Vitale SG, Gulino FA, Rapisarda AMC, Valenti G, Zigarelli M et al (2016) Laparoendoscopic single-site surgery for the assessment of peritoneal carcinomatosis resectability in patients with advanced ovarian cancer. Eur J Gynaecol Oncol 37(5):671–673
Vitale SG, Capriglione S, Zito G, Lopez S, Gulino FA, Di Guardo F et al (2019) Management of endometrial, ovarian and cervical cancer in the elderly: current approach to a challenging condition. Arch Gynecol Obstet 299(2):299–315
Nitecki R, Rauh-Hain JA, Melamed A, Scambia G, Pareja R, Coleman RL et al (2020) Laparoscopic cytoreduction after neoadjuvant chemotherapy (LANCE). Int J Gynecol Cancer 30(9):1450–1454
Uccella S, Zorzato PC, Lanzo G, Fagotti A, Cianci S, Gallina D et al (2019) The role of sentinel node in early ovarian cancer: a systematic review. Miner Med 110(4):358–366
Leitao MM Jr (2018) The LACC trial: has minimally invasive surgery for early-stage cervical cancer been dealt a knockout punch? Int J Gynecol Cancer 28(7):1248–1250
Rossetti D, Vitale SG, Tropea A, Biondi A, Laganà AS (2017) New procedures for the identification of sentinel lymph node: shaping the horizon of future management in early stage uterine cervical cancer. Updat Surg 69(3):383–388
Gueli Alletti S, Perrone E, Cianci S, Rossitto C, Monterossi G, Bernardini F et al (2018) 3 mm Senhance robotic hysterectomy: a step towards future perspectives. J Robot Surg 12(3):575–577
Gueli Alletti S, Rossitto C, Cianci S, Perrone E, Pizzacalla S, Monterossi G et al (2018) The Senhance™ surgical robotic system (“Senhance”) for total hysterectomy in obese patients: a pilot study. J Robot Surg 12(2):229–234
Caruso S, Iraci M, Cianci S, Casella E, Fava V, Cianci A (2015) Quality of life and sexual function of women affected by endometriosis-associated pelvic pain when treated with dienogest. J Endocrinol Invest 38(11):1211–1218
Gueli Alletti S, Perrone E, Creti A, Cianci S, Uccella S, Fedele C et al (2020) Feasibility and perioperative outcomes of percutaneous-assisted laparoscopic hysterectomy: a multicentric Italian experience. Eur J Obstet Gynecol Reprod Biol 245:181–185
Rossitto C, Cianci S, Gueli Alletti S, Perrone E, Pizzacalla S, Scambia G (2017) Laparoscopic, minilaparoscopic, single-port and percutaneous hysterectomy: comparison of perioperative outcomes of minimally invasive approaches in gynecologic surgery. Eur J Obstet Gynecol Reprod Biol 216:125–129
Vitale SG, Ferrero S, Ciebiera M, Barra F, Török P, Tesarik J et al (2020) Hysteroscopic endometrial resection vs hysterectomy for abnormal uterine bleeding: impact on quality of life and sexuality. Evidence from a systematic review of randomized controlled trials. Curr Opin Obstetr Gynecol 32(2):159–165
Rossetti D, Vitale SG, Bogani G, Rapisarda AM, Gulino FA, Frigerio L (2015) Usefulness of vessel-sealing devices for peripartum hysterectomy: a retrospective cohort study. Updat Surg 67(3):301–304
Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 62(10):1006–1012
Cianci S, Perrone E, Rossitto C, Fanfani F, Tropea A, Biondi A et al (2020) Percutaneous-assisted vs mini-laparoscopic hysterectomy: comparison of ultra-minimally invasive approaches. Updates Surg. https://doi.org/10.1007/s13304-020-00893-5
Misirlioglu S, Giray B, Vatansever D, Arslan T, Urman B, Taskiran C (2020) Mini-plus percutaneous setting in total laparoscopic hysterectomy. Minim Invasive Ther Allied Technol. https://doi.org/10.1080/13645706.2020.1794899
Beguinot M, Botchorishvili R, Comptour A, Curinier S, Campagne-Loiseau S, Chauvet P et al (2020) Minilaparoscopic total hysterectomy in current practice feasibility and benefits: a unicentric, randomized controlled trial. J Minim Invasive Gynecol 27(3):673–680
Fanfani F, Fagotti A, Rossitto C, Gagliardi ML, Ercoli A, Gallotta V et al (2012) Laparoscopic, minilaparoscopic and single-port hysterectomy: perioperative outcomes. Surg Endosc 26(12):3592–3596
Uccella S, Cromi A, Casarin J, Bogani G, Serati M, Gisone B et al (2015) Minilaparoscopic versus standard laparoscopic hysterectomy for uteri >/= 16 weeks of gestation: surgical outcomes, postoperative quality of life, and cosmesis. J Laparoendosc Adv Surg Tech A 25(5):386–391
Fagotti A, Ghezzi F, Boruta DM, Scambia G, Escobar P, Fader AN et al (2014) Minilaparoscopic radical hysterectomy (mLPS-RH) vs laparoendoscopic single-site radical hysterectomy (LESS-RH) in early stage cervical cancer: a multicenter retrospective study. J Minim Invasive Gynecol 21(6):1005–1009
Ghezzi F, Cromi A, Siesto G, Uccella S, Boni L, Serati M et al (2011) Minilaparoscopic versus conventional laparoscopic hysterectomy: results of a randomized trial. J Minim Invasive Gynecol 18(4):455–461
Uccella S, Buda A, Morosi C, Di Martino G, Delle Marchette M, Reato C et al (2018) Minilaparoscopy vs Standard laparoscopy for sentinel node dissection: a pilot study. J Minim Invasive Gynecol 25(3):461–466
Vitale SG, Carugno J, Riemma G, Torok P, Cianci S, De Franciscis P et al (2021) Hysteroscopy for assessing fallopian tubal obstruction: a systematic review and diagnostic test accuracy meta-analysis. J Minim Invasive Gynecol 28(4):769–778
Gagner M, Garcia-Ruiz A (1998) Technical aspects of minimally invasive abdominal surgery performed with needlescopic instruments. Surg Laparosc Endosc 8(3):171–179
Cianci S, Rosati A, Capozzi VA, Tarascio M, Uccella S, Palumbo M et al (2021) Quality of life and sexual functioning of patient affected by endometrial cancer. Minerva Med 112(1):81–95
Rossitto C, Gueli Alletti S, Rotolo S, Cianci S, Panico G, Scambia G (2016) Total laparoscopic hysterectomy using a percutaneous surgical system: a pilot study towards scarless surgery. Eur J Obstet Gynecol Reprod Biol 203:132–135
Butticè S, Sener TE, Lucan VC, Lunelli L, Laganà AS, Vitale SG et al (2017) Hybrid transvaginal NOTES nephrectomy: postoperative sexual outcomes. A three-center matched study. Urology 99:131–135
Vitale SG, Laganà AS, Noventa M, Giampaolino P, Zizolfi B, Butticè S et al (2018) Transvaginal bilateral sacrospinous fixation after second recurrence of vaginal vault prolapse: efficacy and impact on quality of life and sexuality. Biomed Res Int 2018:5727165
David G, Boni L, Rausei S, Cassinotti E, Dionigi G, Rovera F et al (2013) Use of 3 mm percutaneous instruments with 5 mm end effectors during different laparoscopic procedures. Int J Surg (London, England) 11(Suppl 1):S61–S63
Brown BC, McKenna SP, Siddhi K, McGrouther DA, Bayat A (2008) The hidden cost of skin scars: quality of life after skin scarring. J Plast Reconstr Aesth Surg JPRAS 61(9):1049–1058
Gueli Alletti S, Vizzielli G, Lafuenti L, Costantini B, Fagotti A, Fedele C et al (2018) Single-institution propensity-matched study to evaluate the psychological effect of minimally invasive interval debulking surgery versus standard laparotomic treatment: from body to mind and back. J Minim Invasive Gynecol 25(5):816–822
Caruso S, Rapisarda AM, Cianci S (2016) Sexuality in menopausal women. Curr Opin Psychiatry 29(6):323–330
Gueli Alletti S, Rossitto C, Cianci S, Restaino S, Costantini B, Fanfani F et al (2016) Telelap ALF-X vs standard laparoscopy for the treatment of early-stage endometrial cancer: a single-institution retrospective cohort study. J Minim Invasive Gynecol 23(3):378–383
Riemma G, Schiattarella A, Colacurci N, Vitale SG, Cianci S, Cianci A et al (2020) Pharmacological and non-pharmacological pain relief for office hysteroscopy: an up-to-date review. Climact J Int Menop Soc 23(4):376–383
Vitale SG, Caruso S, Ciebiera M, Török P, Tesarik J, Vilos GA et al (2020) Management of anxiety and pain perception in women undergoing office hysteroscopy: a systematic review. Arch Gynecol Obstet 301(4):885–894
Amer-Cuenca JJ, Marín-Buck A, Vitale SG, La Rosa VL, Caruso S, Cianci A et al (2020) Non-pharmacological pain control in outpatient hysteroscopies. Minim Invasive Ther Allied Technol Mitat Off J Soc Minim Invasive Ther 29(1):10–19
Donnez O, Donnez J, Dolmans MM, Dethy A, Baeyens M, Mitchell J (2015) Low pain score after total laparoscopic hysterectomy and same-day discharge within less than 5 hours: results of a prospective observational study. J Minim Invasive Gynecol 22(7):1293–1299
Fujita F, Lahmann B, Otsuka K, Lyass S, Hiatt JR, Phillips EH (2004) Quantification of pain and satisfaction following laparoscopic and open hernia repair. Arch Surg (Chicago). 139(6):596–600
Holzer A, Jirecek ST, Illievich UM, Huber J, Wenzl RJ (2006) Laparoscopic versus open myomectomy: a double-blind study to evaluate postoperative pain. Anesth Analg 102(5):1480–1484
Kum CK, Wong CW, Goh PM, Ti TK (1994) Comparative study of pain level and analgesic requirement after laparoscopic and open cholecystectomy. Surg Laparosc Endosc 4(2):139–141
Perrone E, Rossitto C, Fanfani F, Cianci S, Fagotti A, Uccella S et al (2020) Percutaneous-assisted versus laparoscopic hysterectomy: a prospective comparison. Gynecol Obstet Invest 85(4):318–326
Volpi L, Sozzi G, Capozzi VA, Ricco M, Merisio C, Di Serio M et al (2019) Long term complications following pelvic and para-aortic lymphadenectomy for endometrial cancer, incidence and potential risk factors: a single institution experience. Int J Gynecol Cancer Off J Int Gynecol Cancer Soc 29(2):312–319
Holub Z, Jabor A, Bartos P, Eim J, Kliment L (2002) Laparoscopic pelvic lymphadenectomy in the surgical treatment of endometrial cancer: results of a multicenter study. JSLS 6(2):125–131
Togami S, Kawamura T, Fukuda M, Yanazume S, Kamio M, Kobayashi H (2019) Learning curve and surgical outcomes for laparoscopic surgery, including pelvic lymphadenectomy, for early stage endometrial cancer. Jpn J Clin Oncol 49(6):521–524
Capozzi VA, Riemma G, Rosati A, Vargiu V, Granese R, Ercoli A et al (2021) Surgical complications occurring during minimally invasive sentinel lymph node detection in endometrial cancer patients. A systematic review of the literature and metanalysis. Eur J Surg Oncol. https://doi.org/10.1016/j.ejso.2021.03.253
Gueli Alletti S, Rossitto C, Perrone E, Cianci S, De Blasis I, Fagotti A et al (2017) Needleoscopic conservative staging of borderline ovarian tumor. J Minim Invasive Gynecol 24(4):529–530
Cianci S, Rosati A, Rumolo V, Gueli Alletti S, Gallotta V, Turco LC et al (2019) Robotic single-port platform in general, urologic, and gynecologic surgeries: a systematic review of the literature and meta-analysis. World J Surg 43(10):2401–2419
Uccella S, Cromi A, Bogani G, Casarin J, Formenti G, Ghezzi F (2013) Systematic implementation of laparoscopic hysterectomy independent of uterus size: clinical effect. J Minim Invasive Gynecol 20(4):505–516
Giampaolino P, Della Corte L, Foreste V, Vitale SG, Chiofalo B, Cianci S et al (2019) Unraveling a difficult diagnosis: the tricks for early recognition of ovarian cancer. Minerva Med 110(4):279–291
Cianci S, Gueli Alletti S, Rumolo V, Rosati A, Rossitto C, Cosentino F et al (2019) Total laparoscopic hysterectomy for enlarged uteri: factors associated with the rate of conversion to open surgery. J Obstet Gynaecol 39(6):805–810
Funding
Open access funding provided by Università degli Studi della Campania Luigi Vanvitelli within the CRUI-CARE Agreement.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
None of the authors have a conflict of interest to disclose.
Ethics approval
Not applicable.
Informed consent
Not applicable.
Consent for publication
Not applicable.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
La Verde, M., Riemma, G., Tropea, A. et al. Ultra-minimally invasive surgery in gynecological patients: a review of the literature. Updates Surg 74, 843–855 (2022). https://doi.org/10.1007/s13304-022-01248-y
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13304-022-01248-y