Aims: To define the learning curve for single-port access (SPA) total laparoscopic hysterectomy (TLH) and evaluate the surgical outcomes. Methods: Patient demographics and segmental operating times of all 100 patients who underwent SPA-TLH by a single surgeon were analyzed. Patients were arranged in order based on surgery date. Results: 100 patients underwent SPA-TLH. There was no conversion to conventional laparoscopy or laparotomy. The median time until the removal of a specimen (TR) was 45 min and the median time for closure of the vaginal cuff (TC) was 18 min. The median total operating time from skin opening to closure (TO) was 80 min. TR, TC, and TO decreased significantly over the study period. The TC decreased significantly from the first 20 cases to the next 20 (p = 0.028) and the TO from the second 20 cases to the next 20 (p = 0.029). Conclusions: Proficiency for SPA-TLH was achieved after 40 cases. Operating time and postoperative hemoglobin drop decreased with experience, without increasing complication.

STUDY QUESTION Is hemostasis by hemostatic sealant superior to that achieved by bipolar coagulation in preserving ovarian reserve in patients undergoing laparoscopic ovarian cystectomy? SUMMARY ANSWER Post-operative ovarian reserve, determined by serial serum anti-Müllerian hormone (AMH) levels, was significantly less diminished after ovarian hemostasis when hemostatic sealant was used rather than bipolar coagulation. WHAT IS KNOWN ALREADY Hemostasis achieved with bipolar coagulation at ovarian bleeding site results in damage to the ovarian reserve. STUDY DESIGN, SIZE, DURATION A prospective, multi-center randomized trial was conducted on 100 participants with benign ovarian cysts, between December 2012 and October 2013. PARTICIPANT/MATERIALS, SETTING, METHODS Participants were randomized to undergo hemostasis by use of either hemostatic sealant (FloSeal™) or bipolar coagulation during laparoendoscopic single-site (LESS) ovarian cystectomy. The primary end-point was the rate of decline of ovarian reserve calculated by measuring serum AMH levels preoperatively and 3 months post-operatively. MAIN RESULTS AND THE ROLE OF CHANCE Age, parity, socio-demographic variables, preoperative AMH levels, procedures performed and histologic findings were similar between the two groups of patients. There were also no differences in operative outcomes, such as conversion to other surgical approaches, operative time, estimated blood loss, or perioperative complications between the two groups. In both study groups, post-operative AMH levels were lower than preoperative AMH levels (all P < 0.001). The rate of decline of AMH levels was significantly greater in the bipolar coagulation group than the hemostatic sealant group (41.2% [IQR, 17.2–54.5%] and 16.1% [IQR, 8.3–44.7%], respectively, P = 0.004). LIMITATIONS, REASONS FOR CAUTION Some caution is warranted because other ovarian reserve markers such as serum markers (basal FSH and inhibin-B) or sonographic markers were not assessed. WIDER IMPLICATIONS OF THE FINDINGS The present study shows that the use of a hemostatic sealant during laparoscopic ovarian cystectomy should be considered, as hemostatic sealant provides the additional benefit of preservation of ovarian reserve. STUDY FUNDING/COMPLETING OF INTEREST(S) This study was supported by the Medical Research Funds from Kangbuk Samsung Hospital. No conflict of interest is declared. TRIAL REGISTRATION NUMBER www.clinicaltrials.gov, no. NCT01857466.

Nam EJ, et al. J Gynecol Oncol. 2011 Jun;22(2):120-126. https://doi.org/10.3802/jgo.2011.22.2.120