Cosmesis and Patient Satisfaction Following Laparoscopic Adnexal Surgery.

BACKGROUND AND OBJECTIVES: Laparoendoscopic single site surgery (LESS), a minimally invasive procedure, is performed in many hospitals. Although its cosmetic superiority is widely touted, some authors have disputed this view. Here, we compare the surgical and long-term cosmetic outcomes of and patient satisfaction with postoperative wounds for LESS and over 2-port laparoscopy (OTPL), including 2-port laparoscopy (TPL) and standard laparoscopy (SL), after a 6-mo follow-up period.
METHODS: A total of 125 patients who underwent adnexal surgery performed by the same surgeon at the same institution between March 2005 and May 2017 were included. The patients were divided into 2 groups: the LESS group and the OTPL group. The patients completed an evaluation using the Patient Scar Assessment Scale (PSAS, used to evaluate linear scars) and the Ultimate Question (UQ, used to determine overall patient satisfaction). We evaluated surgical scars using the Observer Scar Assessment Scale, which includes the Umbilical Scar Overall Shape Assessment Scale (USOSAS) and the Vancouver Scar Scale (VSS).
RESULTS: There were no significant differences in the PSAS, UQ, USOSAS, and VSS results between the study groups. The USOSAS score was consistently correlated with VSS scores of 2, 3, and 4 and the total VSS score, indicating that the USOSAS score may be as effective as the VSS score.
CONCLUSIONS: Because the long-term patient satisfaction with and cosmetic wound outcomes of LESS were not significantly different from those achieved by OTPL, surgeons should consider performing LESS after weighing the pros and cons with regard to the patient's condition.

INTRODUCTION

Generally, laparoscopic surgeries are considered to be less minimally invasive than laparotomy. With recently developed minimally invasive techniques, laparoscopic surgeries have been modified to include such techniques as laparoendoscopic single site surgery (LESS) using a single transumbilical incision, which is an alternative to standard laparoscopy (SL), which uses several incision sites for trocar insertion. Although SL using several trocars may be less invasive than laparotomy, patients undergoing this type of SL acquire multiple postoperative scars on the abdominal wall. In LESS, the surgical procedure is performed using a single incision on the umbilicus. Because the incision site can be concealed in the umbilicus, the postoperative wound is minimalized and cosmetically effective. However, LESS has a limited surgical instrument range of motion because all surgical instruments, including the laparoscope, are inserted through a single umbilical incision.

In LESS, the single incision also tends to be larger (approximately 2 cm) so that it can facilitate the insertion of all of the required surgical instruments. Because the trocar hole diameter is a fundamental contributor to the occurrence of trocar-site herniation, a hole ≥ 10 mm must be properly closed at all levels.[1] In a case series, trocar site herniation was not less frequent after single-port laparoscopic cholecystectomy (SPLC) than after SL (and not as infrequent as suggested by the current literature). A small (<5 mm) trocar site was associated with a low morbidity rate and an almost negligible mortality rate. However, the multiple trocar sites required in SL can also lead to trocar-associated complications, such as hematomas, abscesses or bowel herniations. The wound infection rate in SL has been reported to range from 1% to 3%.[2,3]

Some authors have reported that LESS does not have a superior cosmetic effect.[4] Given these findings, some questions have been raised regarding whether LESS should be performed despite its difficulty. Because the operative wound tends to be concealed in the umbilicus in LESS rather than SL and long-term surgical outcomes have not been adequately validated, patient satisfaction with postoperative wounds immediately after surgery may be distorted because of the smaller number of postoperative wounds produced with LESS. Therefore, the author evaluated the postsurgical and long-term patient satisfaction and cosmetic outcomes related to postoperative wounds for LESS and over 2-port laparoscopy (OTPL), including 2-port laparoscopy (TPL) and SL, over a 6-mo follow-up period. A simple tool for evaluating postoperative scarring was proposed and validated.

MATERIALS AND METHODS

Nine hundred twenty-six patients underwent gynecological laparoscopy performed by a single surgeon at a single institute between March 2005 and May 2017. All patients provided written informed consent and permission for surgical treatment before surgery. The author explored the possibility of conversion to laparotomy in cases of severe adhesion, malignancy, or a limited operative field of view. In our institute, LESS and TPL have been performed since July 2007. The operation type is chosen according to the patient's condition. Under laparoscopy through the umbilical incision, the pelvic cavity of the patient is evaluated. In cases of inflammation or severe pelvic adhesion, LESS is not performed. Before 2007, only SL using multiple trocar incisions was performed.

We performed a retrospective cohort study. Patients who visited our outpatient division for follow-up examinations after undergoing gynecological laparoscopy >6 mo previously were recruited for enrollment in this study. After agreeing to participate, 125 patients returned the patient satisfaction tool to our outpatient department and were enrolled in this study. Our institutional research ethics committee approved the study protocol (GNAH 2017–01-001).

The mean age and parity of the enrolled patients were 36.3 ± 11.2 y and 1.1 ± 1.0, respectively. The patients were divided into 2 groups, i.e., the LESS group (n = 70) and the OTPL, including the TPL and the CL group (n = 55). The operative outcomes, including intraoperative complications, operative time, changes in hemoglobin (Hb) concentration, time to the first passage of gas, postoperative hospital stay duration, and wound outcomes, were compared between the groups, and the results were statistically analyzed. The cosmetic outcomes related to the wound and patient satisfaction were evaluated postoperatively using the Observer Scar Assessment Scale and the patient satisfaction assessment tool, respectively, in each study group over a 6-mo period.

Surgical technique

Generally, in Korean hospitals, patients are admitted the day before surgery and prepared for surgery, including bowel and skin preparation. For this study, the patients were also admitted to the hospital the day before surgery, and a Fleet enema was administered at 7 p.m. to evacuate the lower bowel. The laparoscopic procedure was performed using general endotracheal anesthesia with an orogastric tube. The patients' arms were placed at their sides. Women with a coital history were placed in the Trendelenburg position due to the insertion of the manipulator into the uterine cavity. Adolescent and young women without a coital history were placed in a supine position. Before the induction of anesthesia, 1 dose of prophylactic antibiotics was administered.

A Foley catheter was inserted into the urethra of each patient, and a Kronner Manipujector® uterine manipulator (Cooper Surgical, Trumbull, CT) was inserted vaginally. A uterine manipulator was not used in adolescent patients and young women with no coital history. The surgical instruments used during the procedure included 10-mm 0° laparoscopes, bipolar forceps, atraumatic forceps, monopolar hooks, toothed graspers, monopolar scissors, and a suction-irrigation system.

For LESS, an extrasmall Alexis® wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) was placed into the umbilical incision; the incision was vertically oriented and approximately 2 cm in length. Three trocars (two 12-mm trocars and one 5-mm trocar) were inserted into separate fingers of a surgical glove and secured with rubber bands. The wrist portion of the glove covered the wound retractor, and 3 Babcock clamps were placed on the edges of the retractor to prevent carbon dioxide leakage (). For TPL, the secondary trocar was inserted into the left lower abdomen after the umbilical port was prepared using a wound retractor in the same manner as in LESS and with the same size of umbilical port. A 10-mm laparoscope and atraumatic forceps were inserted through the umbilical multichannel port after pneumoperitoneum was created using LESS or TPL. In SL, the umbilical trocar was inserted after pneumoperitoneum was established using a Veress needle. A 10-mm laparoscope was inserted through the umbilical trocar. In addition, 2 or 3 ancillary trocars were inserted under laparoscopy.

An umbilical multichannel port used with the Alexis® wound retractor XS and a surgical glove.

The surgical procedures were performed in the usual manner under laparoscopy. The drain tubes were inserted into the all of the OTL cases. In LESS cases, the drainage tube was not inserted for umbilical wound care. Postoperative wound discharge and delayed healing after drain tube insertion through the umbilical incision site were observed frequently at our outpatient division in patients who underwent LESS at another institute. The patients visited our outpatient division for postoperative wound care. With this procedure, because inserting the drainage tube through the umbilical port wound could lead to wound problems or increase the difficulty of suturing the incision site, we preferred not to insert the drainage tube through the umbilical port. After each surgical procedure, saline irrigation was performed, and the wounds were sutured.

Patient satisfaction and operative wound assessment tools

Over the first 6 mo postoperatively, the patients were asked to fill out the Patient Scar Assessment Scale (PSAS), a tool validated for evaluating linear scars, and the Ultimate Question (UQ), which is correlated with overall patient satisfaction, in the outpatient department ().[5] We evaluated the patients' operative scars using the Observer Scar Assessment Scale, which includes the Umbilical Scar Overall Shape Assessment Scale (USOSAS) and the Vancouver Scar Scale (VSS) (, ). The USOSAS was created at our institute as a simple observer tool for assessing operative scars. We validated the USOSAS via correlation with the VSS.

Postoperative umbilical wound scars with scores according to the Umbilical Scar Overall Shape Assessment Scale (USOSAS): 0, upper left; 1, upper right; 2, lower left; 3, lower right.

Statistics

The data are presented as the mean ± standard deviation unless otherwise stated. All statistical analyses were performed using SPSS version 13.0 for Windows (SPSS, Inc., Chicago, IL, USA). Linear regression models were used to examine the PSAS and UQ scores as continuous dependent variables, with a categorical grouping variable as the primary predictor and with 2 levels, for LESS or OTPL including TPL and SL. Two-tailed Student's t-tests were used to analyze differences between the study groups. Values of p < .05 were considered significant.

RESULTS

The mean age and parity of the patients in the LESS and OTPL groups were 35.0 ± 12.0 vs 37.8 ± 10.0 y and 1.0 ± 1.1 vs 1.1 ± 1.0, respectively. The mean number of previous laparotomies and the postoperative hospital stay duration were significantly lower in the LESS group than in the OTPL group (0.3 ± 0.6 vs 0.8 ± 1.0 and 3.9 ± 0.7 d vs 4.2 ± 1.0 d, respectively). The postoperative hospital stay of our cases was relatively long. The reason for the long hospital stay was not postoperative complications; rather, we did not discharge the patients if they did not want to be discharged due to Korean sentiments and medical service demands.

There were no significant differences in age, parity, height, weight, BMI, or surgical outcomes, such as operative time, changes in the hemoglobin (Hb) concentration, or time to the first passage of gas, between the study groups (). Regarding the previous abdominal operation history, 6 patients had a history of laparoscopic surgery in the LESS group. In the OTPL group, 2 patients had a history of 1 laparoscopic surgery, and 1 patient had a history of 2 laparoscopic operations. In the LESS group, 12 patients had a history of laparotomy, and 6 patients had a history of 2 laparotomies. In the OTPL group, 16 patients had a history of one laparotomy, 8 patients had a history of 2 laparotomies, and 4 patients had a history of 3 or more laparotomies. The differences in surgical history in the LESS and OTPL groups were statistically significant for laparotomy (P < .05) but not for laparoscopy.

The time interval between the operation and assessments of wound outcomes and patient satisfaction in the LESS and OTPL groups was 1055.8 ± 732.5 d and 1221.9 ± 1143.8 d, respectively, and the difference was not significant. In the LESS group, patient age and operative time were correlated with the time to the first passage of gas (R = 0.31, P < .05; R = –0.29, P < .05, respectively). In the OTPL group, patient parity, weight, and BMI were correlated with the time to the first passage of gas (R = 0.37, P < .05; R = 0.29, P < .05; R = 0.35, P < .05, respectively).

There was no significant difference in the USOSAS, VSS, PSAS, or UQ scores between the LESS and OTPL groups.

The UQ score was correlated with patient age in both the LESS and OTPL groups (R = 0.26, P < .05; R = 0.28, P < .05, respectively). However, in the LESS group, the parity and height of the patients were also correlated with the UQ score (R = 0.31, P < .05; R = 0.33, P < .05, respectively). Therefore, patients of advanced age in both study groups tended to recommend both the surgeon and the treatment to family members and friends. In the LESS group, the patients with increased parity and height and an advanced age tended to recommend the surgeon and the treatment to family members and friends.

In the LESS group, the USOSAS score was correlated with VSS scores of 2 (R = 0.44, P < .05), 3 (R = 0.63, P < .05), and 4 (R = 0.55, P < .05) and with the total VSS score (R = 0.61, P < .05).

In the OTPL group, the USOSAS score was correlated with VSS scores of 2 (R = 0.49, P < .05), 3 (R = 0.62, P < .05), and 4 (R = 0.57, P < .05) and with the total VSS score (R = 0.62, P < .05). The number of ports was negatively correlated with a PSAS score of 6 in the OTPL group (R = –0.27, P < .05). The USOSAS score was validated using a postoperative scar assessment tool and was found to be as effective and simple a tool as the VSS score.

Regarding the perception of the postoperative wound scar by the surgeon or observer vs. the patients, the USOSAS score was correlated with a PSAS score of 6 (R = –0.20, P < .05). The VSS score of 2 was correlated with PSAS scores of 3 (R = –0.25, P < .05), 4 (R = –0.34, P < .05), 5 (R = –0.26, P < .05), 6 (R = –0.29, P < .05), and 7 (R = –0.27, P < .05). The VSS score of 3 was correlated with PSAS scores of 3 (R = –0.22, P < .05), 4 (R = –0.31, P < .05), 5 (R = –0.22, P < .05), 6 (R = –0.23, P < .05), and 7 (R = –0.23, P < .05). The VSS score of 4 was correlated with PSAS scores of 4 (R = –0.22, P < .05) and 6 (R = –0.25, P < .05). The total VSS score was correlated with PSAS scores of 3 (R = –0.21, P < .05), 4 (R = –0.33, P < .05), 5 (R = –0.23, P < .05), 6 (R = –0.29, P < .05), and 7 (R = –0.25, P < .05).

In conclusion, the mean number of previous laparotomies and the postoperative hospital stay duration were greater in the OTPL group than in the LESS group. However, there were no significant differences in the postoperative surgical wound outcomes or patient cosmetic satisfaction over the first 6 mo postoperatively between the LESS and OTPL groups. In both the LESS and OTPL groups, the USOSAS score was correlated with VSS scores of 2, 3, and 4 and with the total VSS score; therefore, the USOSAS score may be as effective and simple a tool as the VSS score.

DISCUSSION

Although LESS has been performed in many hospitals following minimally invasive trends, there is still some controversy regarding the superiority of LESS over SL with regard to short- and long-term patient satisfaction and cosmesis.

Lurje et al. performed a double-blinded randomized controlled trial (RCT) to evaluate cosmesis, body image, pain, and quality of life after single-port laparoscopic cholecystectomy (SPLC) versus conventional 4-port laparoscopic cholecystectomy.[4] Although cost-effectiveness remains a subject of ongoing debate, the patients in the SPLC group achieved superior results regarding cosmesis and body image compared with patients in the 4-port laparoscopic cholecystectomy group at 12 wk and 1 y postoperatively.

A comparison between LESS and SL for prophylactic bilateral salpingo-oophorectomy (PBSO) showed that cosmetic satisfaction was significantly better after LESS than after SL and that this may have helped patients to accept PBSO.[6] In appendectomy, a case study showed that single-incision laparoscopic appendectomy or laparoscopic appendectomy was associated with significantly increased cosmetic satisfaction for patients and their families compared with open appendectomy.[5] In LESS nephrectomy and colectomy, meta-analyses have also shown that better cosmetic outcomes were achieved when the single-incision procedure was used.[7,8]

However, some surgeons have reported that SPLC is more stressful and physically demanding to perform than multiport laparoscopic cholecystectomy (MPLC).[9] Moreover, a fear of higher costs and higher rates of port-site hernia may be preventing many clinics from introducing SPLC.[10,11] A meta-analysis of body image and cosmesis after SPLC versus MPLC showed that better outcomes were achieved by SPLC in terms of cosmesis, body image and postoperative pain.[12] However, the risk of incisional hernia was four times higher after SPLC than after MPLC. A significantly higher incidence of port-site hernia was observed in the SPLC group (4.0%) than in the MPLC group (1.1%) over a follow-up period ranging from 1 to 17 mo after surgery. Other systematic reviews have also shown that the risk of port-site hernia is higher with SPLC.[13,14]

Trocar-site incisional hernia is a frequent subclinical complication, and its actual incidence may be much higher than reported in most series. Because the trocar hole diameter is a fundamental contributor to the occurrence of trocar-site herniation, a hole ≥ 10 mm must be properly closed at all levels.[1] In a case series, trocar site herniation did not occur less frequently after SPLC than after SL (and was not as infrequent as suggested by the current literature). Trocar site herniation was also not associated with technical failure or patient comorbidities.[15] Moreover, in a case study of 1145 consecutive transumbilical, single-incision laparoscopic procedures, the incidence of wound complications was acceptably low and was reduced once the surgeon passed the learning curve.[16] In 29 cases (2.53%), wound complications such as infections, early onset hernias (0.09%), and late-onset hernias (1.40%) occurred. The trocar site is usually larger after LESS (>2 cm). Although a standard repair procedure for the trocar site has not been established, the wound should be repaired at each layer, including the peritoneum, fascia, subcutaneous layers and skin, to prevent wound complications. However, repairing the deep portion of the umbilicus is sometimes difficult and tedious for surgeons, especially in obese patients, because of the umbilicus structure. Some wound repair techniques could be useful for easily preventing wound problems.[17]

Schmitt et al. performed a systemic review and meta-analysis of LESS versus SL for treating benign adnexal diseases and showed that while the operative time was different, there was no significant difference between LESS and SL in patients undergoing adnexal surgery in terms of postoperative pain after 6 or 24 h, blood loss, mean length of hospital stay, cosmetic results, or laparotomy conversion rate.[18] Similarly, in our study, there was no difference in the cosmetic outcome, patient satisfaction or operative time between the LESS and OTPL groups.

Our study has some limitations. First, the study was not a randomized prospective case series but a retrospective cohort study. The surgery type was determined according to the patients' preoperative condition or hospital equipment and personnel. Therefore, there were some limitations due to the nature of nonrandomized prospective studies. Patients who were unsatisfied with their postoperative scar or did not follow-up at our outpatient division after the operation may have been missed in the enrolled study group.

Second, the surgeries were performed by the same surgeon, and the patients revisited our outpatient division for follow-up examinations, during which they provided informed consent and completed the PSAS, a validated tool for evaluating linear scars, and the UQ. In this situation, the patients may have tended to provide affirmative answers to the questions. However, because all the patients in the LESS and OTPL groups had undergone surgeries performed by the same surgeon at the same hospital, comparisons between the 2 groups were acceptable in terms of the operative quality and conditions.

Third, one of the limitations of this study is the subjective nature of the questionnaire, which is also not validated. The PSAS and UQ were based on the scales most widely used in the literature, although in most studies, the evaluation is performed by the surgeon or a third-party observer and not the patient. In this study, neither a cosmesis analysis by a third party nor objective measurements of aesthetic results, such as photographs that would allow us to quantify the surgical wounds described by patients, were applied.

Fourth, despite covering a 6-mo follow-up period, the time interval between the operation and evaluation was variable due to the random recruitment of patients who visited the outpatient division. Therefore, a comparison of the 2 groups in terms of cosmetic outcomes and patient satisfaction according to the time interval between the operation and evaluation could not be performed. Because there was no difference in long-term patient satisfaction with postoperative wound scarring between the LESS and OTPL groups, LESS appears to have no definite superiority over TPL or SL in terms of postoperative wound scarring. However, these results may provoke some debate because the OTPL group, as a control group, was small in size and consisted mainly of patients who underwent TPL (n = 47; 85.5%). Regarding the surgical history in the LESS and OTPL groups, the differences in surgical history were statistically significant for laparotomy but not for laparoscopy. In the OTPL group, a history of a greater number of laparotomies may have influenced the patients' perception of their surgical scars. Therefore, a larger TPL and SL case series with similar clinical characteristics in the control group should be included in a future clinical study.

The results of the current meta-analysis show some benefit of LESS over SL in terms of cosmetic patient satisfaction due to the smaller number of trocars inserted into the abdomen in the former method.[12] Because LESS leaves only one postoperative scar on the patient's abdominal wall, short-term patient satisfaction and cosmesis may be affected by the newness of LESS. Therefore, data regarding long-term patient satisfaction could be more reliable for the assessment of postoperative satisfaction and cosmesis by avoiding the novelty of LESS. For this reason, long-term cosmetic outcomes and patient satisfaction were evaluated in this study.

Many authors have compared the reliability of the observer portion of the assessment tool using the VSS and found it to be superior to the most widely accepted scale.[19] We evaluated patient operative scars using the VSS and used these findings to validate our USOSAS as a tool for evaluating patient operative scars in comparison with the Observer Scar Assessment Scale. The results showed that the USOSAS could be used as a simple tool in place of the Observer Scar Assessment Scale. Regarding the perception of surgical scarring held by the surgeon or third party vs. patients in this study, VSS scores were correlated with PSAS scores of 3,4,5,6, and 7. The patients' perceptions of operative scars were similar to those of the surgeon or third party. However, the USOSA score showed a correlation with only the PSAS score of 6. Therefore, the USOSA score may be less correlated with the scar perception of patients than the VSS score is.

In conclusion, the results of this study show that LESS may be an effective minimally invasive surgical technique. Because the long-term patient satisfaction and cosmetic wound outcomes were not significantly different from those achieved with SL, surgeons should consider performing LESS after weighing the pros and cons with regard to the patient's condition. In the future, large-scale randomized and double-blinded prospective trials should be performed to validate the use of LESS in gynecological surgery in terms of short- and long-term patient satisfaction and cosmesis.

Table 1.

The Patient Scar Assessment Scale (PSAS) and Ultimate Question (UQ) questionnaires

	Yes, very much (very different from normal skin)											No, not at all (same as normal skin)
1. Has the scar been painful the past few weeks?		1	2	3	4	5	6	7	8	9	10
2. Has the scar been itching the past few weeks?		1	2	3	4	5	6	7	8	9	10
3. Is the scar color different from the color of your normal skin at present?		1	2	3	4	5	6	7	8	9	10
4. Is the stiffness of the scar different from that of your normal skin at present?		1	2	3	4	5	6	7	8	9	10
5. Is the thickness of the scar different from that of your normal skin at present?		1	2	3	4	5	6	7	8	9	10
6. Is the scar more irregular than your normal skin at present?		1	2	3	4	5	6	7	8	9	10
7. What is your overall opinion of the scar compared to your normal skin?		1	2	3	4	5	6	7	8	9	10
	No, would not recommend											Yes, would definitely recommend
8. Considering your overall experience, how likely are you to recommend your surgeon to a family member or friends?			1	2	3	4	5	6	7	8	9

Table 2.

The Observer Scar Assessment Scale, including the Umbilical Scar Overall Shape Assessment Scale (USOSAS) and the Vancouver Scar Scale (VSS)

Umbilical Scar Overall Shape Assessment Scale
Shape	0 Excellent, no scar observed
	1 Good, linear scar observed, no deformity
	2 Fair, mild scar & deformity observed
	3 Poor, severe scar & deformity observed
	Vancouver Scar Scale
Vascularity	0 Normal
	1 Pink
	2 Red
	3 Purple
Pigmentation	0 Normal
	1 Hypopigmentation
	2 Mixed
	3 Hyperpigmentation
Pliability	0 Normal
	1 Supple
	2 Yielding
	3 Firm
	4 Ropes
	5 Contracture
Height	0 Flat
	1 <2 mm
	2 2–5 mm
	3 >5 mm
Total score

Table 3.

Clinical and Surgical Outcomes Observed for the LESS Group and the OTPL (Including TPL and SL) Group

Clinical and surgical outcomes	LESS (n = 70) Mean ± SD	OTPL (n = 55) Mean ± SD	p-value
Age (years)	35.0 ± 12.0	37.8 ± 10.0	NS*
Parity	1.0 ± 1.1	1.1 ± 1.0	NS
Height (cm)	160.1 ± 6.0	160.6 ± 5.7	NS
Weight (kg)	61.1 ± 11.1	58.3 ± 9.5	NS
BMI (kg/m2)	23.8 ± 4.3	22.6 ± 3.2	NS
Laparotomy Hx	0.3 ± 0.6	0.82 ± 1.0	.003
Laparoscopy Hx	0.9 ± 0.3	0.9 ± 0.3	NS
Operative time (minutes)	81.6 ± 19.7	84.7 ± 25.3	NS
Change in hemoglobin concentration (g/dL)	1.6 ± 1.1	1.9 ± 0.9	NS
Time to the first passage of gas (hours)	42.1 ± 19.4	46.5 ± 15.9	NS
Postoperative hospital stay duration (days)	3.86 ± 0.7	4.2 ± 1.0	.044

LESS = laparoendoscopic single site surgery; OTPL = over 2-port laparoscopy; SL = standard laparoscopy; TPL = 2-port laparoscopy.

NS = nonsignificant.