Total Laparoscopic Hysterectomy With Percutaneous (Percuvance) Instruments: New Frontier of Minimally Invasive Gynecological Surgery

doi:10.1016/j.jmig.2015.09.004

Journal of Minimally Invasive Gynecology

Volume 23, Issue 1, 1 January 2016, Pages 14-15

https://doi.org/10.1016/j.jmig.2015.09.004 Get rights and content

Abstract

Study Objective

To highlight the first case of laparoscopic hysterectomy performed with percutaneous instruments (The Percuvance System, Teleflex Incorporated, Wayne, PA).

Design

The basis of the system is a <3-mm diameter shaft that, when connected to an introducer tool tip, can be inserted percutaneously through the skin. The introducer tool tip can then be exchanged outside the body for a wide variety of 5-mm interchangeable surgical tool tips. The shaft is sufficiently strong to hold structures, and surgeons can use its interchangeable tool tips to grasp, cut, and manipulate tissue. We used a 3-dimensional high-definition 10-mm flexible tip endoscope (ENDOEYE FLEX 3D, Olympus Winter & IBE GMBH, Hamburg, Germany).

Background

Minilaparoscopy is an attractive approach for hysterectomy due to advantages such as reduced morbidities and enhanced cosmesis. However, it has not been popularized because of the lack of suitable instruments and high technical demand. The Percuvance system represents a significant advance in minimally invasive surgery.

Setting

Catholic University of the Sacred Hearth, Rome, Italy.

Patient

A 53-year-old, multiparous patient with endometrial endometroid cancer grade 1, Fédération Internationale de Gynécologie et d'Obstétrique stage IA. The patient provided informed consent to use the images and video of the procedure. Institutional review board approval was not required.

Intervention

The patient was hysteroscopically diagnosed with endometrial cancer after removal of an endometrial polyp adnexectomy. Once referred to our center, surgical staging was planned, including total hysterectomy and bilateral adnexectomy. Laparoscopy with 2 lateral percutaneous and 1 soprapubic 3-mm instruments was believed to be feasible to achieve these procedures.

Main Results

The operation was performed successfully with no intraoperative or postoperative complications. Operative time was 80 minutes overall, and blood loss was 50 mL. The pathology report confirmed endometrial endometroid cancer grading 1, Fédération Internationale de Gynécologie et d'Obstétrique stage IA. The patient was discharged on day 1. After 2 months, no late complications or recurrence was detected.

Conclusion

Percutaneous total hysterectomy is technically feasible, and the use of this novel device permits surgeons to mantain a standard setting. Further studies are mandatory to define the benefits, advantages, and costs of this novel approach with respect to other minimally invasive approaches.

References (0)

Cited by (23)

Feasibility and perioperative outcomes of percutaneous-assisted laparoscopic hysterectomy: A multicentric Italian experience
2020, European Journal of Obstetrics and Gynecology and Reproductive Biology
This multicentric prospective phase II study aimed to investigate the feasibility, safety, and efficacy of percutaneous-assisted laparoscopic hysterectomy in terms of perioperative outcomes, feasibility, VAS score, and cosmetic outcomes.
Between May 2015 and October 2017, 382 patients were considered eligible for minimally invasive percutaneous-assisted laparoscopic hysterectomy using Percuvance™, Percutaneous Surgical System - PSS, TELEFLEX ltd. Among them, 80 patients (20.9 %) met the inclusion criteria and were enrolled in the study.
The coordinator center was the Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. Enrolled patients underwent total percutaneous-assisted laparoscopic hysterectomy ± bilateral salpingo-oophorectomy ± nodal assessment.
The median age was 52 (range, 32–80) years, and the median body mass index was 25 kg/m² (range, 16–37). Thirty-five patients (43.8 %) had previous surgery. A median operative time of 82.5 (range, 40–190) minutes and a median estimated blood loss of 50 (50–500) mL were registered. We observed 1 (1.3 %) intraoperative complication. The median time to discharge was 1 (range, 1–5) day. Patients were extremely satisfied with the scar evaluation and postoperative pain control. Five (6.25 %) complications were recorded within 30 days after surgery.
Percutaneous-assisted technique for extrafascial hysterectomy achieved excellent results in terms of feasibility, safety, and efficacy, even in complex cases and advanced surgical procedures. Therefore, the technique appears to balance the limitations and advantages of minimal surgical invasiveness and standard approach efficacy.
Technological innovation and personalized surgical treatment for early-stage endometrial cancer patients: A prospective multicenter Italian experience to evaluate the novel percutaneous approach
2019, European Journal of Obstetrics and Gynecology and Reproductive Biology
To investigate the safety, feasibility and oncological adequacy of the Percutaneous Surgical System - PSS in a consecutive series of low-risk endometrial cancer staging.
From May 2015 to April 2017, we prospectively performed 30 consecutive percutaneous staging for low/intermediate risk endometrial cancer (FIGO stage IA G1-G2, IB G1-G2, IA G3). All patients were divided in two different groups on the basis of surgical procedure received: Group A included patients submitted to radical Class A hysterectomy and bilateral salpingo-oophorectomy; Group B concerned patients that received a lymph nodal assessment also.
The time needed to install percutaneous instruments and suprapubic trocar was 4 min. (range 2–10). The recorded median operative time (OT) was 80 min. (range 65–120) for Gr.A and 143 min. (range 107–190) for Gr.B, in which the median time of lymph nodal assessment was 55 min. (range 20–76). The median time for hysterectomy was 60 min. (range 40–110) in all cases. Lymph nodal assessment was performed in 14 (46.6%) cases: 7 sentinel node mapping, 7 pelvic lymphadenectomy. No intraoperative complications or LPS/LPT conversions were recorded. Median discharge time was 2 days (range 1–4), 5 patients were discharged in 3rd post-op day, and only 1 patient was discharged in 4th day for fever. All patients conveyed high satisfaction with the cosmetic results. A progressive overall reduction of pain perception was observed at 24 h after surgery. Median follow-up was of 14 months (range 12–36), no recurrences have been detected.
PSS seems to be a feasible approach for endometrial cancer staging. Larger experiences and prospective comparative studies are important to assess our assumptions and further investigate the real benefits of percutaneous surgical system.
Laparoscopic supracervical hysterectomy and sacral colpopexy for pelvic organ prolapse with percutaneous surgical system: Results from a pilot study
2018, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
Even though in literature the works concerning the surgical procedures performed with PSS system are few, our data appear to be in accordance with the ones already published by others authors. Rossitto et al. [17] already reported a single-institutional study on Total Laparoscopic Hysterectomy With Percutaneous (Percuvance) Instruments compared with conventional laparoscopic. They highlighted the possibility to reproduce with this new tool the traditional LPS without affecting the operative time and intraoperative complications, improving, on the other side, the cosmetic and postoperative outcomes.
The aim of the study was to report our preliminary experience of supracervical 2 hysterectomy followed by sacral colpopexy performed with the Percuvance ™ PSS in terms of feasibility, effectiveness and safety.
Between Jan 2017 and Feb 2017 10 patients affected by POP were enrolled in the present study. All patients undergoing supracervical hysterectomy followed by sacral colpo-cervicopexy with the Percuvance ™ PSS.
The reported series consisted of 10 patients undergoing supracervical hysterectomy followed by sacral colpopexy with a median age of 63 years (range 55–71 years) and a median BMI (body mass index) of 24 (range 21–26). A median operative time of 123 min (range 103–134 min) and a median estimated blood loss (EBL) of 40 ml (range 20–60 ml) were registered. No conversions to standard laparoscopy or laparotomy were required and no intraoperative complications occurred. At the discharge all patients were completely satisfied with the cosmetic result and postoperative pain control. During 3 months urogynecological follow-up no patient showed surgical anatomic failure (>2 POP-Q stage)and the degree of overall satisfaction of the cosmetic results was confirmed by the surgeon and the patient equally.
The PSS supracervical hysterectomy plus sacral colpopexy is a feasible and effective approach with good results in terms of operative time, cosmesis, postoperative pain and length of hospitalization.
Laparoscopic, minilaparoscopic, single-port and percutaneous hysterectomy: Comparison of perioperative outcomes of minimally invasive approaches in gynecologic surgery
2017, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
PSS allows the surgeon to use laparoscopic instruments, with a less than 3 mm wide diameter, that are percutaneously introduced into the abdomen without trocars. Limits of 3 mm devices in manipulating tissues are overcome in PSS, thanks to the 5 mm operative tip that is afterwards locked to the instrument through a 5 mm suprapubic trocar, mimicking standard laparoscopic setting in terms of instruments triangulation and tips dimensions [10,11]. The aim of this study is to compare the most recent MIS techniques (LESS, MiniLPS and PSS) with standard laparoscopy considering perioperative outcomes and complications associated to hysterectomy.
During the last decade endoscopic surgical procedures have been constantly evolving. The latest innovation in ultra-minimally invasive surgery (MIS) is the percutaneous technology (Percuvance™ Percutaneous Surgical System (PSS), Teleflex Inc., USA). We compared surgical outcome of hysterectomy, in a retrospective cohort study using the most recent MIS techniques as single-site (LESS) surgery, 3 mm laparoscopy (MiniLPS) and percutaneous system (PSS) with standard laparoscopy (LPS).
This is a matched retrospective cohort study. Endometrial Hyperplasia/Early stage endometrial cancer or benign pathology were the indication for surgery. Data of laparoscopic hysterectomies performed between May 2013 and April 2016 using PSS, LPS, MiniLPS, and LESS were collected and compared.
The characteristics of each group were similar. The median Operative time (OT) was significantly longer in LESS compared to all other groups (120 min [range 55–165] in LESS, 91 min [range 60–180] in MiniLPS, 70 min [range 55–230] in LPS and 65 [range 40–180] in PSS; p = 0.0001). No significant differences among the 4 groups were observed in terms of estimated blood loss, conversion to laparoscopy or laparotomy, and intra e post-operative complications. Statistically significant differences were recorded in median VAS 24 h (2 [range 0–3] in PSS, 2 [range 0–3] in MiniLPS, 3 [range 2–5] in LESS and 2 [range 1–5] in LPS; p = 0.0001). The average time of discharge was (1 day [range 1–3] in PSS, 1 day [range 1–2] in MiniLPS, 1 days [range 1–2] in LESS and 1 day [range 1–3] in LPS; p = 0.99).
Data show that the effort to minimize the impact of surgical invasiveness can be feasible and could improve the advantages, not only in terms of aesthetic outcomes, even if the differences among the endoscopic approaches have not a relevant clinical impact. The technology innovations like PSS maintain the same triangulation between instruments as standard LPS with an evident decrease of the invasiveness thanks to reduced instruments size, even if the lack of suitability of bipolar energy, that require a multifunction instrument, remain a limit of these instruments.
Reply
2017, Journal of Minimally Invasive Gynecology
Trocar Site Recurrences Following Laparoscopic and Robotic Resection of Gynecologic Malignancies
2017, Journal of Minimally Invasive Gynecology

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