Conventional versus single-incision laparoscopy for the surgical treatment of ovarian torsion.

AIM: The aim of the study was to compare the effectiveness of single-incision laparoscopy with conventional laparoscopy in cases of ovarian torsion.
MATERIALS AND METHODS: Patients who were surgically treated for ovarian torsion in our clinic were retrospectively analysed. The demographic information and surgical records of the patients were obtained from the patient files. Patients treated with single-incision laparoscopy and conventional laparoscopy were compared in terms of demographic characteristics, surgical procedure performed, duration of surgery, amount of bleeding, laboratory results, post-operative pain scores and length of hospital stay.
RESULTS: There were 19 patients in the single-incision laparoscopy and 30 in the conventional laparoscopy groups. The two groups were similar in terms of age, obstetric history and body mass index (P > 0.05). The mean operation time was 56.26 ± 15.34 min in the single-incision laparoscopic surgery (SILS) group and 55.07 ± 10.78 min in the conventional laparoscopic surgery group (P > 0.05). There was no significant difference between the two groups in terms of complications, duration of hospital stay, pre- and post-operative haematocrit difference and visual analogue scale-pain scores at hours 0, 6, 12 and 24 (P > 0.05).
CONCLUSION: SILS appears to be as feasible, effective and safe as conventional laparoscopy in the treatment of ovarian torsion cases.

INTRODUCTION

Ovarian torsion is defined as the complete or partial bending of the ovaries on ovarian ligaments, resulting in the disruption of circulation. It is more common in post-menarche patients; however, it can occur at all ages and is the fifth most common gynaecological emergency.[1] Torsion may also be seen in normal ovaries, although it has been shown that the risk of torsion increases in pelvic masses exceeding 5 cm.[2]

In the past, oophorectomy or salpingo-oophorectomy was usually performed in case of torsion, but today, the preservation of the adnexa is essential.[3] Therefore, the early diagnosis and correction of torsion are very important for preserving ovarian function. In the treatment of ovarian torsion, laparoscopic surgery can be performed at all ages and is less invasive. The duration of hospital stay and post-operative pain are less. Patients can return to daily life more quickly.[4]

Various techniques are used to improve the surgical outcomes of minimally invasive surgery. One of the widely used minimally invasive techniques is single-incision laparoscopic surgery (SILS), which has a history dating back to the 1970s.[5] The major advantage of SILS is that multichannel trocars require only a single abdominal incision in the umbilical region with the advances in technology.

Studies in the literature have shown no difference in complication rates between conventional laparoscopic surgery (CLS) and SILS in various gynaecological procedures; however, different results have been reported for the two methods in terms of operation time.[456] SILS has also been considered in the surgical treatment of ovarian torsion, but it has not yet been compared with the standard laparoscopic approach. Thus, the aim of this study was to compare SILS with CLS in the surgical treatment of ovarian torsion.

MATERIALS AND METHODS

After receiving approval from the institutional ethics committee, this retrospective case–control study was conducted with patients who were surgically treated for ovarian torsion in the Gynecology and Obstetrics Clinic of a tertiary Training and Research Hospital between January 2015 and December 2020. The files and records of patients who underwent surgery with a pre-diagnosis of ovarian torsion and were intraoperatively confirmed to have torsion were retrospectively screened.

Age, gravida and parity, body mass index (BMI), complaints, gynaecological and abdominal examination and radiological findings at presentation, pre- and post-operative laboratory parameters, post-operative visual analogue scale (VAS)-pain scores at hours 0, 6, 12 and 24 h after surgery, requirement of an additional analgesic dose and duration of hospital stay were recorded retrospectively. For post-operative analgesia, all patients received 25 mg dexketoprofen (Deksalgin 25 mg/tb, Nobel İlaç, Istanbul, Turkey) during wakening, followed by oral administration every 12 h for 24 h routinely. An additional 25 mg dexketoprofen (Deksalgin 50 mg/amp, Nobel İlaç, Istanbul, Turkey) was administered to when required and noted as an additional analgesic dose.

The types of operations were examined from the operation records, and those involving the use of single port and conventional methods were determined. During SILS, a 20-mm intraumbilical incision was performed, and the Covidien SILS port (Tyco Healthcare Pty Ltd, Lane Cove, NSW) was placed in accordance with the manufacturer's instructions. Then, the port was equipped with a 10-mm camera and 5-mm laparoscopic instruments. In CLS, after the umbilical incision, a 10-mm trocar was inserted for the camera, and then, at least one auxiliary 5-mm trocar for the other instruments was placed at a different point in the abdomen. The type of surgery performed, operation time, complications and final pathology results were recorded. The patients were examined in two groups as SILS and CLS, and the data obtained from the two groups were compared.

Statistical analysis was performed using SPSS for Windows, version 23.0 (SPSS Inc., Chicago, IL, USA). The differences between the numerical variables of the two groups were analysed using the t-test as a parametric method and the Mann–Whitney U test as a non-parametric method. The differences between two or more categorical variables were analysed using Fisher's exact test. A P < 0.05 was considered statistically significant.

RESULTS

The data of 62 patients with an intraoperatively confirmed diagnosis of ovarian torsion were recorded retrospectively. Thirteen patients (21.0%) were treated by laparotomy and 49 (79.0%) laparoscopically. SILS was applied to 19 patients (38.8%), and the conventional method was used in 30 (61.2%). There was no significant difference between the ages of the two groups (27.53 ± 8.79 years in the SILS group and 27.47 ± 9.01 years in the CLS group) (P > 0.05). The demographic characteristics and clinical manifestations of the patients in the two groups are listed in Table 1.

Table 1

Demographic characteristics and findings at the time of presentation

	SILS group (n=19)	CLS group (n=30)	P
Age (years)	27.53±8.79	27.47±9.01	0.982
Gravida	1.58±1.43	1.20±1.34	0.359
Parity	1.00±0.94	0.93±1.23	0.841
BMI (kg/m2)	25.18±4.14	25.78±3.73	0.604
Presentation complaint, n (%)
Abdominal pain	15 (78.9)	23 (76.7)	0.685
Abdominal pain+nausea/vomiting	4 (21.1 )	7 (23.3)
Acute abdominal sign, n (%)	6 (31.6)	12 (40)	0.865
WBC count at presentation (/mm3)	11,154.7±3210.8	10,991.3±3679.1	0.814
Size of adnexal mass (cm)	7.05±1.85	5.72±1.80	0.016
Loss of blood flow in Doppler ultrasound, n (%)	14 (73.7)	14 (46.7)	0.278
Torsion side, n (%)
Right	13 (68.4)	16 (53.3)	0.748
Left	6 (31.6)	14 (46.7)

SILS: Single-incision laparoscopic surgery, CLS: Conventional laparoscopic surgery, BMI: Body mass index, WBC: White blood cell

The mean operation time was 56.08 ± 14.02 min in all patients, 56.26 ± 15.34 min in the SILS group and 55.07 ± 10.78 min in the CLS group (P > 0.05). There was no significant difference between the two groups in terms of operation time, complications, duration of hospitalisation, differences between pre- and post-operative haematocrit difference, VAS-pain scores at hours 0, 6, 12 and 24 h and requirement of an additional analgesic dose (P > 0.05) [Table 2].

Table 2

Data related to the operation and the post-operative period

	SILS group (n=19)	CLS group (n=30)	P
Surgical procedures performed, n (%)
Detorsion	5 (26.3)	14 (46.7)	0.176
Detorsion and cystectomy	10 (52.6)	14 (46.7)
Detorsion and cyst aspiration	3 (15.8)	-
Detorsion and oophoropexy	1 (5.3)	2 (6.6)
Operation time (min)	56.26±15.34	55.07±10.78	0.750
Hospital stay (days)	1.26±0.45	1.50±0.68	0.188
Difference in haematocrit values before and after surgery (%)	2.57±3.53	1.43±0.87	0.970
Complication	-	-	-
VAS pain score (h)
0	5.68±1.25	5.53±1.17	0.670
6	4.26±0.93	3.93±1.20	0.315
12	2.95±1.22	2.90±1.03	0.885
24	1.42±1.30	1.10±0.80	0.291
Additional analgesic dose (mg)	30.25±8.75	33.25±10.50	0.135
Final pathology result, n (%)
Dermoid cyst	3 (23.1)	2 (11.8)	0.388
Benign/haemorrhagic cyst	10 (76.9)	15 (88.2)

SILS: Single-incision laparoscopic surgery, CLS: Conventional laparoscopic surgery, VAS: Visual Analogue Scale

While only detorsion was performed in 19 (38.8%) of the 49 patients, detorsion and ovarian cyst excision were performed in 24 (49.8%) patients. The surgical operations performed are shown in Table 2. In both the SILS and CLS groups, the operation time of the patients who underwent cystectomy with ovarian detorsion was significantly longer than those that underwent ovarian detorsion alone (48.32 ± 7.85 and 64.08 ± 11.84, respectively) (P < 0.001). However, when the pathology results of these patients were examined, it was found that the content of the cyst did not affect the duration of the operation and the other post-operative parameters (P > 0.05).

DISCUSSION

Early diagnosis and treatment are important in ovarian torsion, and laparoscopy is generally preferred as a minimally invasive method in surgical interventions as in other gynaecological operations. Today, SILS is increasingly used in the treatment of gynaecological pathologies;[78] however, there are not many studies in the literature investigating the effectiveness of SILS in the treatment of ovarian torsion. To our knowledge, this is the first study comparing SILS with CLS in the treatment of ovarian torsion.

In some studies on the treatment of adnexal masses, SILS has been shown to be effective and safe.[789101112] Dursun et al. and Lee et al. used SILS safely in pregnant patients with ovarian torsion,[1314] and Lancher et al. also reported that they safely performed SILS in seven cases of ovarian torsion.[15]

In a meta-analysis covering a total of 21 publications, of which 6 belonged to randomised controlled trials (RCTs) and 15 were cohort studies, SILS and CLS were compared in terms of various parameters, and only 3 found single-incision laparoscopy to take 6.97 min longer than conventional laparoscopy.[6] It was noteworthy that these studies with higher operative time were RCTs investigating cases that underwent adnexal surgery. The authors explained this diversity with small sample sizes and severe limitations of the RCT design. Considering that the operation time is closely related to multiple patient factors (e.g. BMI, uterine size, surgical history, pathology and surgical procedure), it can be stated that the operation time does not actually differ between the two methods in gynaecological surgery, and this is also valid in the treatment of ovarian torsion, as shown in our study.

It has been reported that the reduction in the number or size of incisions was associated with better results in healing time, pain after surgery and cosmetic satisfaction.[16] However, with a few exceptions,[71718] it has been shown that post-operative pain in single-incision laparoscopy does not differ from the conventional method in gynaecological surgery,[6] and we also found similar findings in ovarian torsion. In a recent meta-analysis comparing SILS and CLS in benign ovarian masses, the post-operative pain scores using VAS at 4 h after the end of surgery were evaluated in seven studies including 1033 patients, and there was no significant difference between the two groups. However, a significant difference was reported in relation to post-operative analgesic consumption, with the SILS group requiring a lower analgesic dose.[19] In our study, there was no difference in the VAS pain scores, and we also found similar additional analgesic dose requirements for the two groups. Pain sensation is related to several factors, including the amount of gas remaining in the abdomen after laparoscopic surgery, temperature of gas and irrigation fluid used, coagulation or direct tissue trauma, number and size of the ports used and patient-related factors.[11] It is not easy to objectively determine the difference between the two techniques in terms of pain since it is not possible to minimise sociocultural and individual differences between the patients.

It has been suggested that there is no significant difference in the risk of complications between SILS and CLS for gynaecologic surgery.[6] In another meta-analysis comparing the use of SILS and CLS in ectopic pregnancy, it was revealed that there was no difference in surgical outcomes.[4] Similarly, in laparoscopic operations performed, we did not see any complications between the two groups, and there was also no difference in surgical results.

A longer learning curve, limited field of view and longer operating time are the main limitations of SILS.[20] Some authors have reported that SILS is practically more difficult due to the loss of triangulation (greatest challenge in SILS) caused by the proximity of instruments.[212223] Thus, some researchers have considered that strict patient selection criteria should be applied,[24] including smaller adnexal masses, no obesity and no previous history of abdominal surgery.[25] However, in a recent meta-analysis,[19] no significant difference was observed in these characteristics of the patients between SILS and CLS, and disease and patient characteristics were not considered to be a limitation of SILS.[26] In our study, the adnexal masses were significantly larger in the SILS group than in the CLS group, but the other characteristics of the patients were similar. While we acknowledge the presence of certain difficulties, we do not think that they are enough to make a decision against SILS in the treatment of patients with ovarian torsion.

CONCLUSION

SILS presents as a minimally invasive method that can be safely preferred in cases of ovarian torsion, but well-designed and larger randomised controlled studies are needed to confirm our results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.