title: Management of large adnexal tumors by isobaric laparoendoscopic single-site surgery with a wound retractor.
abstract: OBJECTIVE
  To report our experience with isobaric transumbilical laparoendoscopic single-site surgery for the management of large adnexal tumors exceeding 500g of excised tissue weight including cystic contents.
  
  
  METHODS
  In each case, a wound retractor was used to make a working port through a 2.5-cm vertical umbilical incision. The surgical view was secured by the abdominal wall-lift method with an intra-abdominal fan retractor system. After the tumor was punctured by a SAND balloon catheter and the cystic contents were aspirated, surgical procedures were performed with conventional laparoscopic instruments under vision with a rigid 30°, 5-mm EndoEYE laparoscope. Clinical data regarding patient demographics and surgical outcomes was retrospectively analyzed.
  
  
  RESULTS
  Between October 2010 and April 2012, 35 patients with large adnexal tumors were treated. The median age of the patients was 31.5 years. Previous abdominal surgery was noted in nine cases. The median tumor diameter was 17.7cm. Emergency surgery was performed in two cases of adnexal torsion and one case of tumor rupture. Three cases with intrauterine pregnancy were treated in the late first trimester. Unilateral salpingo-oophorectomy was performed in 24 cases. Unilateral cystectomy was performed in five cases. Unilateral salpingo-oophorectomy and contralateral cystectomy, and bilateral cystectomy were performed in two cases each. Unilateral salpingectomy, unilateral salpingo-oophorectomy and contralateral salpingectomy were performed in one case each. The median excised tissue weight was 1100g. The median surgical duration was 72min, with median blood loss of 10mL Extended hospitalization was required in two cases due to elevated inflammatory parameters, one case with pregnancy due to hyperemesis gravidarum and one case with pregnancy due to subchorionic hematoma. Readmission due to postoperative pelvic abscess was noted in one case and was conservatively managed. Major surgical complications were not experienced. The present technique yielded a minimal postoperative scar concealed within the umbilicus.
  
  
  CONCLUSIONS
  The transumbilical wound retraction system combined with an intra-abdominal fan retractor appears to contribute favorably to laparoendoscopic single-site surgery for the management of large adnexal tumors, because the device permits flexible and wide circumferential access by efficient wound retraction during instrumentation without the need for closed condition associated with pneumoperitoneum.
authors.affiliation: Department of Obstetrics and Gynecology, Gifu Prefectural Tajimi Hospital, Tajimi, Gifu, Japan. gyendoscopy@gmail.com
authors.forename: Akihiro
authors.initials: A
authors.lastname: Takeda
authors.forename: Sanae
authors.initials: S
authors.lastname: Imoto
authors.forename: Masahiko
authors.initials: M
authors.lastname: Mori
authors.forename: Junko
authors.initials: J
authors.lastname: Yamada
authors.forename: Hiromi
authors.initials: H
authors.lastname: Nakamura
mesh_terms: D000290:Adnexa Uteri / Q000473:pathology; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003537:Cystadenoma / Q000601:surgery*; D005260:Female; D005833:Genital Neoplasms, Female / Q000473:pathology / Q000601:surgery*; D013509:Gynecologic Surgical Procedures / Q000379:methods*; D006801:Humans; D010535:Laparoscopy; D008875:Middle Aged; D010048:Ovarian Cysts / Q000473:pathology / Q000601:surgery*; D012189:Retrospective Studies; D055815:Young Adult