Postoperative Incisional Complications in Gynaecologic Single-Incision Laparoscopic Surgery: Comparing Closure Techniques.

OBJECTIVES: Single-incision laparoscopic surgery (SILS) and robotic SILS (rSILS) have been found to be safe, minimally invasive techniques in gynaecology. However, one major perceived drawback of these techniques is the increased risk of incisional hernia, compared to multiport laparoscopy or robotic surgery. This study's aim was to determine the optimal technique to reduce postoperative incisional complications such as hernia. METHODS: A retrospective cohort study was performed at an academic centre from November 2014 to June 2022 on 1036 women who underwent SILS and rSILS gynaecologic procedures with various closure techniques. Techniques included running absorbable sutures without tagging incision apices (standard closure) and tagging incision apices at the beginning of surgery with the use of permanent suture, absorbable suture, or a combination. RESULTS: Rates of hernia (primary outcome) and incisional issues (secondary outcome) such as separation or infection were analyzed by technique. Hernia rates were lower when incision apices were tagged compared to when not tagged (P < 0.001). Cellulitis/abscess rates were not significantly different. Incision separation was higher when apices were tagged with absorbable and a combination of permanent and absorbable sutures than if apices were tagged with all permanent sutures or not at all. In multivariate analysis, hernia rate decreased in groups with tagged apices, although other incision complications did not vary. CONCLUSIONS: The incidence of incisional hernia after SILS procedures is low, though it does vary by technique. Tagging apices for closure, regardless of suture type, can mitigate one of the biggest concerns of performing SILS by reducing postoperative incisional hernia risk.

Tips and Tricks for Robotic-Assisted Trans-Broad Ligament Abdominal Cerclage in Pregnant Patients.

STUDY OBJECTIVE: To demonstrate the surgical techniques for improving safety in robotic-assisted abdominal cerclage via broad ligament window dissection. DESIGN: Stepwise demonstration with narrated video footage. SETTING: An academic tertiary care hospital. Our patient is a 32-year-old G8P2143, with a history of pregnancy loss at 19 and 23 weeks and 1 failed vaginal cerclage, presented to us at 13 weeks and 5 days for abdominal cerclage. We have completed a total of 5 successful procedures with this technique on pregnant patients ranging from 9 to 14 weeks. INTERVENTIONS: Abdominal cerclage during pregnancy can be very risky and challenging to perform; however, it offers an increased success rate for continuing pregnancy [1]. Excessive bleeding and the rupture of membrane during the procedure could lead to pregnancy loss and a failed abdominal cerclage [2,3]. Therefore, seeking a feasible and safer technique would be preferable for the surgeons to decrease surgical risk and complications. We have developed a trans-broad ligament technique that would allow for the bilateral uterine vessels to be clearly exposed, thereby reducing the possibility of accidental damage to a major vessel and eliminating the risk of blind needle placement piercing through the amniotic sac resulting in rupture of membrane and subsequent pregnancy loss [4,5]. A dense adhesion band from the anterior uterus to the anterior abdominal wall was carefully taken down using the monopolar scissors. The assistant gently performed a digital vaginal examination to assist with the creation of a bladder flap. The bladder was carefully dissected off the lower uterine segment and uterus using the monopolar scissors. Bilateral uterine vessels were further skeletonized and exposed anteriorly using blunt dissection and the monopolar scissors. On the right, a window was created in the broad ligament using the monopolar scissors. The right uterine vessels were then further dissected and lateralized, creating a small window medial to the uterine vessels at the level of the internal cervical os. The mersilene tape was guided through the window from anterior to posterior. In a similar fashion, a window was created on the left; the mersilene tape was then guided from posterior to anterior. The mersilene tape was completely placed around the cervix circumferentially at the level of the internal cervical os, medial to the uterine vessels. Both ends of the mersilene tape were then pulled gently, while ensuring that the tape was lying flat on the anterior of the uterus. The tape was then tied anteriorly at the 12 o'clock position in an appropriate tension. A 2-0 silk was then sutured to the tails of the tape to ensure that it would remain in the correct location and prevent the loosening of the knot of mersilene tape. The pelvis was copiously irrigated, and hemostasis was assured. The fetal heart rate was 126 bpm, and patient was discharge next day. A healthy baby, 6 pounds 14 ounces, was delivered by cesarean section at 36 weeks 5 days because of early contractions and pain (Supplemental Appendix 1-4). CONCLUSION: Robotic-assisted abdominal cerclage via broad ligament window dissection offers a possibly feasible and safe technique for surgeons seeking to reduce risks, although further research is needed.