Preface

Now is an exciting time in minimally invasive gynecologic surgery. In May 2021, we have had the first group of OBGYN's to receive a focused practice designation for Minimally Invasive Gynecologic Surgery. Currently, there are more than sixty fellowship programs in the United States for MIGS, split between the Society of Laparoendoscopic Surgeons (SLS) and the American Association of Gynecologic Laparoscopists (AAGL). Many would say we are on our way to becoming a separately boarded specialty. Our mission of providing the most minimally invasive care possible is well underway.

Also, an unexpected ally has shown its face in this battle. Enhanced Recovery After Surgery (ERAS) continues to be an important element in our artform. For a practice that is barely 20 years old, the amount of literature is extremely vast and very useful. All aspects of the preoperative and postoperative periods have been dissected, and minimally invasive surgeons can benefit from this data in almost all procedures. Surgeons and anesthesiologists can manipulate local anesthesia, patient diet, ambulation, and thrombotic prophylaxis. Even gum chewing has been included in regimens to speed patient recovery and decrease the pain and suffering of the surgical process. Many ERAS protocols are so individualized as to apply to one specific surgery. This may be the friend we've always wanted!

That is not to say that there are not challenges, the most serious of which has been the crisis of morcellation. Laparoscopic morcellation, when performed by skilled surgeons in appropriate circumstances, can be life-changing. I have seen it change a disabled invalid with a seven-pound uterus and serious comorbidities into a functional happy woman who walked out of a hospital she needed a wheelchair to get into just six hours earlier. Obviously, morcellation has been misused in situations where malignancy was likely, and even overused in scenarios where uteri have been morcellated even after creating a colpotomy large enough to simply pull it out. As a result, patients have been harmed. Clearly, combining morcellation with an occult malignancy is a terrible event, but I will wager that "conversion to laparotomy," because of the lack of the ability to perform morcellation, has cost many more lives than upstaged leiomyosarcoma ever has. No one knows how many patients have died or remained debilitated the rest of their lives because of the surgeon's decision to create a midline vertical rather than morcellate. I believe there is close to 100 percent consensus among gynecologic surgeons today that laparoscopic morcellation should be reserved for special cases where vaginal removal is simply not feasible and laparotomy would pose a serious threat to the patient's life or speedy recovery. In those cases, with all reasonable measures taken, the procedure is a very valuable tool. Much like chemotherapy, however, if used on the wrong patient it can be harmful or deadly. In my opinion, we need the patient population to understand the foolishness of banning morcellation and bring careful judicious use of laparoscopic morcellation when indicated back into the mainstream of MIGS.

The inspiration for this book is the constant drive to provide patients with the most minimally invasive surgery possible. I was very blessed early on by several colleagues who share this drive. As a result, our discussions turned into an idea for a book, and before long we were finishing up this first edition.

Writing the book was a difficult task, as some of us wanted more of a direct surgical and anatomical guide, whereas others preferred a text that would give more of an overview of the subject without actual operating room value. The former was initially thought to be more valuable, however, the argument that nothing could replace a well-thought-out surgical good demonstrating video was also a concern. As for the latter, we hypothesized it would probably be a more popular text, but of less use on a day-to-day basis. In the end, we looked at what each chapter presented us and tried to pick the option that would best serve the reader. Some chapters resemble UpToDate articles, while others present more like instructional manuals. I hope we have reached the right balance.

We hope this text gives you some insight into the field of single-port gynecologic surgery and helps to form a consensus among surgeons and scholars of what techniques are the most effective, as well as what techniques are holding back the art and science of single-port surgery.

Every effort has been made to assure the reliability and value of the material in this book, and we are grateful that you are reading this first edition.

We are proud that you are on this journey with us and we are proud of where we are going. After all, aren't we just one port away from being right back at the TVH we started with?

I wish to thank Dr. Katelyn Sainz for helping me and putting up with me throughout the task of completing this book! I also extend a big thank you to all my researchers: Alexa King, Giovanna Brazil, Holly Ulibarri, Kelly Ware, Stacy Ruther, Julia Parise, Amanda Arroyo, and Sienna Anderson! I am also grateful to Dr. Ali Azadi, Dr. Hadia Awad, and Dr. Ahmed Taher. Finally, I have to mention Sebastian Snow Marchand, the smartest person I know. Thank you for teaching me so much.

> **Greg J. Marchand MD, FACS, FACOG, FICS** Fellowship Trained in Minimally Invasive Gynecologic Surgery, Mesa, Arizona

> > Accredited Master Surgeon, Minimally Invasive Gynecology, Mesa, Arizona

Director, Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona

> Full Professor, Washington University of Health and Science, San Pedro, Belize

> > Associate Clinical Professor, AT Still University, College of Osteopathic Medicine, Mesa, Arizona

> > Associate Clinical Professor, Midwestern University, College of Osteopathic Medicine, Glendale, Arizona

> > > Associate Clinical Professor, IUHS, Basseterre, Saint Kitts

> > > > **1**

**Chapter 1**

Surgery

**Abstract**

gynecology

**1. Introduction**

Fundamentals of the Currently

Available Single Port Abdominal

and Utility in Minor Gynecologic

*M. Luann Racher and Ann Marie Mercier*

including uterine manipulation, are also reviewed.

techniques in single incision gynecologic surgery.

**gynecologic surgery**

**2. Use of single port abdominal laparoscopy in minor** 

Laparoscopic Gynecologic Systems

Single incision laparoscopic surgery encompasses a plethora of techniques and

**Keywords:** single port, laparoscopy, SILS, LESS, single incision, minimally invasive,

Single incision laparoscopic surgery encompasses a plethora of techniques and styles. Multiple names have been used to describe similar surgical techniques, including single incision laparoscopy (SILS), single port access surgery (SPA), laparoscopic endoscopic single site surgery (LESS), single laparoscopic incision transabdominal (SLIT), one-port umbilical surgery (OPUS), and natural orifice translumenal endoscopic surgery (NOTES). The purpose of this chapter is to review single incision surgery in minor gynecologic surgery and discuss currently available single incision surgical access systems, accessory instruments and surgical

Female sterilization by tubal ligation was the first procedure performed by way of single incision laparoscopy in the late 1960s. Though gynecologists were the first

styles. Single incision laparoscopy has demonstrated outcomes comparable to traditional multiport laparoscopy with the added benefit of improved cosmesis. This book chapter will review single incision surgery for minor gynecologic surgery, including adnexal surgical procedures and myomectomy. The chapter reviews available data in regard to outcomes in single incision laparoscopy. It also discusses the commercially available single incision surgical access systems, laparoscopes, and accessory instruments. Surgical techniques beneficial in single incision laparosocpy,
