title: Total Laparoscopic Hysterectomy With Percutaneous (Percuvance) Instruments: New Frontier of Minimally Invasive Gynecological Surgery.
abstract: OBJECTIVE
  To highlight the first case of laparoscopic hysterectomy performed with percutaneous instruments (The Percuvance System, Teleflex Incorporated, Wayne, PA).
  
  
  METHODS
  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.
  
  
  METHODS
  Catholic University of the Sacred Hearth, Rome, Italy.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  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.
  
  
  CONCLUSIONS
  Percutaneous total hysterectomy is technically feasible, and the use of this novel device permits surgeons to maintain 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.
authors.affiliation: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Catholic University of the Sacred Hearth, Rome, Italy. Electronic address: cristiano.rossitto@gmail.com.
authors.forename: Cristiano
authors.initials: C
authors.lastname: Rossitto
authors.affiliation: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Catholic University of the Sacred Hearth, Rome, Italy.
authors.forename: Salvatore
authors.initials: S
authors.lastname: Gueli Alletti
authors.affiliation: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Catholic University of the Sacred Hearth, Rome, Italy.
authors.forename: Barbara
authors.initials: B
authors.lastname: Costantini
authors.affiliation: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Catholic University of the Sacred Hearth, Rome, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Fanfani
authors.affiliation: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Catholic University of the Sacred Hearth, Rome, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Scambia
mesh_terms: D016889:Endometrial Neoplasms / Q000601:surgery*; D005260:Female; D006176:Gynecology / Q000639:trends; D006801:Humans; D007044:Hysterectomy / Q000295:instrumentation / Q000379:methods; D007558:Italy / Q000453:epidemiology; D010535:Laparoscopy / Q000379:methods; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000295:instrumentation*; D009364:Neoplasm Recurrence, Local / Q000601:surgery; D061646:Operative Time; D011183:Postoperative Complications / Q000601:surgery; D065287:Robotic Surgical Procedures; D016896:Treatment Outcome
keywords: Endometrial cancer; Minilaparoscopy; Needle instruments; Percutaneous laparoscopy