Effect of Transumbilical Laparoendoscopic Single-Site Surgery with Extracorporeal Approach for Benign Ovarian Cysts

By Binzhou Sun, Yanyan Wang, Yanqiong Hu, Rui Li, Luqian Ge

Affiliations

1. Department of Gynaecology, Maternity and Child Health Centre of Qinhuangdao, Qinhuangdao, Hebei, China

doi: 10.29271/jcpsp.2025.08.993

ABSTRACT
Objective: To determine the clinical effect of transumbilical laparoendoscopic single-site surgery (TU-LESS) combined with extracorporeal operation mode in the treatment of noncancerous ovarian cysts.
Study Design: Observational study.
Place and Duration of the Study: Department of Gynaecology, Maternity and Child Health Centre of Qinhuangdao, Qinhuangdao, China, from December 2022 to September 2024.
Methodology: A total of sixty patients undergoing cystectomy were subjected to either the TU-LESS with extracorporeal technique (n = 30) or the multi-port laparoscopic surgery (MPLS) (n = 30). Surgical parameters, inflammatory markers (SAA, CRP, and IL-6), recovery indices, and satisfaction were retrospectively compared using t-test or χ² test.
Results: No significant differences were found in operative duration, blood loss, and complications (p >0.05). The observation group had an earlier postoperative anal exhaust time, a shorter hospital stay, and a reduced incision pain score 24 hours after surgery compared to the comparison group (p <0.05). Inflammatory cytokine concentrations were decreased in the observation group compared to the comparison group (p <0.05). Patient satisfaction regarding surgical incisions was significantly higher in the observation group than in the comparison group (p <0.05).
Conclusion: Compared to the conventional MPLS, TU-LESS with extracorporeal cystectomy accelerates recovery, reduces inflammation, and improves patient satisfaction.

Key Words: Transumbilical laparoendoscopic single-site surgery, Multi-port laparoscopic surgery, Non-cancerous ovarian cyst, Perioperative outcome.

INTRODUCTION

Benign ovarian cysts affect 10-35% of reproductive-aged women, with a rising incidence observed in younger populations.^1,2 Although often asymptomatic, they may cause abdominal pain, menstrual disturbances, or bloating.³ Laparoscopic cystectomy has superseded laparotomy due to its reduced morbidity and faster recovery.^4,5 Transumbilical laparoendo- scopic single-site surgery (TU-LESS) enhances cosmesis and decreases pain, but faces technical challenges with large cysts (>10 cm) due to instrument collision (chopstick effect).^6-8 The hybrid extracorporeal technique—intracorporeal mobilisation combined with extracorporeal resection—addresses these limitations.^9-11

However, little data exist as evidence of the clinical utility of this hybrid technique. The aim of this study was to compare TU-LESS with conventional multi-port laparoscopy (MPLS).

METHODOLOGY

Sixty patients with noncancerous ovarian cysts who underwent laparoscopic ovarian cyst removal at the Department of Gynaecology, Maternity and Child Health Centre of Qinhuangdao, Qinhuangdao, China, from December 2022 to September 2024 were retrospectively reviewed. Patient information was obtained from the hospital’s medical record management system. The Ethical Committee of the Maternity and Child Health Centre of Qinhuangdao approved the study.

Patients diagnosed with noncancerous ovarian cysts, with surgical indications, aged 22-40 years, with good communication ability, and whose family members had provided informed consent to the surgical plan were included. In contrast, those who could not tolerate laparoscopic surgery or had surgical contraindications, with severe pelvic adhesions or pelvic endometriosis, with a history of malignant tumours and family history of ovarian cancer, with potential ovarian malignant tumours indicated by the intraoperative frozen-section pathological examination, and who voluntarily withdrew during the study were excluded.

The majorly used surgical instruments included a TU-LESS system, an optical imaging system (a component of a full-set digital laparoscopic system), and other auxiliary instruments. Fasting for 6 hours before surgery and routine preoperative skin preparation were conducted. The patient drank two doses of 2,000 ml of warm water mixed with two boxes of polyethylene glycol electrolyte powder (I) within 24 hours before surgery for bowel preparation.

The comparison group underwent traditional MPLS. Three trocars (umbilical, McBurney’s point, and suprapubic) were used to establish pneumoperitoneum (12-14 mmHg). Intracorporeal cystectomy was performed using bipolar forceps and scissors (Figure 1A-E).

The observation group underwent TU-LESS combined with extracorporeal operation. A 3-cm umbilical incision permitted laparoscopic exploration. Following adhesiolysis, purse-string sutures secured the cyst surface. The cyst was exteriorised through the umbilicus for extracorporeal resection and ovarian reconstruction (Figure 2A-E).

Age, body mass index, ovarian cyst diameter, intra-operative blood loss, surgical time, anal exhaust time, visual analogue scale (VAS) score for pain evaluation 24 hours after surgery, length of hospital stay, and the incidence of complications between the groups were compared. Moreover, 6 ml of cubital venous blood was collected from each patient to test SAA, CRP, and IL-6 concentrations. Patient satisfaction (very satisfied, satisfied, and dissatisfied) with surgical incisions was evaluated through a survey of the two groups 48 hours after surgery. The degree of satisfaction was calculated as (cases of very satisfied + satisfied) / total cases × 100%.

Statistical analyses were performed using the SPSS version 27.0 software. Quantitative and qualitative data expressed as mean ± SD and [n (%)] were compared using the Chi-square test and independent t-test. A value of p <0.05 indicated statistical significance.

RESULTS

No significant differences were observed in demographic information, intraoperative blood loss, surgical time, and occurrence of complications between the groups (p >0.05, Table I and II). There were a total of 60 patients. According to the Shapiro–Wilk test, all the data were normally distributed. The postoperative time of anal exhaust was earlier, the VAS score of 24 hours after surgery was significantly lower, and the hospitalisation time was shorter in the observation group than in the control group (p <0.05, Table II).

In both groups, SAA, CRP, and IL-6 were markedly increased 24 hours after surgery compared to pre-surgery; however, increase in the observational group was lower than that in the control group (p <0.05, Table II). Satisfaction with the surgical incision was higher in the observational group than in the control group (p <0.05, Table II).
 

Figure 1: Ovarian cystectomy using the MPLS. (A) Ovarian cyst exploration after entering the pelvic cavity. (B) Ovarian cystectomy under multi- port laparoscope. (C) Suturing of the ovary to restore its morphology. (D) Rinsing of the pelvic cavity after surgery. (E) Suture of the four abdominal  incisions.

Figure 2: Extracorporeal ovarian cystectomy using TU-LESS. (A) Ovarian cyst exploration after entering the pelvic cavity. (B) Ovarian cystectomy through an incision at the navel. (C) Returning the ovary to the abdominal cavity. (D) Rinsing of the pelvic cavity, uterus, and bilateral appendages after surgery. (E) Cosmetic suture of the umbilical incision.

Table I: Comparison of the general clinical data.
 

Indices	Observation group (n = 30)	Control group (n = 30)	t/χ2	p-values
aAge (years)	31.56 ± 2.64	31.67 ± 2.79	0.157	0.876
aBMI (kg/m2)	23.03 ± 4.39	22.95 ± 4.78	0.068	0.946
bPathological types of cysts [n (%)]			0.739	0.864
Benign teratoma	5 (16.67)	4 (13.33)
Serous cystadenoma	14 (46.67)	12 (40.00)
Mucinous cystadenoma	8 (26.66)	11 (36.67)
Other benign cysts	3 (10.00)	3 (10.00)
bPelvic surgery history [n (%)]	4 (13.33)	3 (10.00)	0.162	0.688
aMaximum diameter of cysts (cm)	13.92 ± 5.01	13.43 ± 4.80	0.387	0.700
aIndependent t-test; bChi-square test.

Table II: Comparison of the postoperative rehabilitation related indices, inflammatory cytokines, and patient satisfaction.

Parameters	Observation group (n = 30)	Control group (n = 30)	t/χ2	p-values
aIntra-operative blood loss (ml)	45.32 ± 8.72	49.12 ± 9.19	1.642	0.106
aOperation time (minutes)	65.21 ± 7.29	62.08 ± 8.37	1.544	0.128
bComplication incidence	2 (6.67)	4 (13.33)	0.741	0.389
aPostoperative anal exhaust time (hour)	16.23 ± 4.98	21.76 ± 5.86	3.396	<0.001
aVAS score 24 hours after surgery (points)	2.22 ± 3.26	4.63 ± 3.71	2.665	0.010
aLength of hospital stay (d)	3.15 ± 0.93	4.23 ± 1.02	4.275	<0.001
SAA (mg/L)
aBefore surgery	5.51 ± 0.46	5.73 ± 0.83	1.269	0.209
a24 hours after surgery	29.79 ± 2.09	55.16 ± 3.15	36.741	<0.001
CRP (mg/L)
aBefore surgery	4.11 ± 1.93	4.37 ± 1.27	0.616	0.541
a24 hours after surgery	24.98 ± 6.93	49.81 ± 8.02	12.826	<0.001
IL-6 (pg/ml)
aBefore surgery	6.26 ± 7.11	5.77 ± 6.09	0.287	0.775
a24 hours after surgery	36.71 ± 5.33	50.07 ± 5.25	9.779	<0.001
Patient satisfaction
Very satisfied	25 (83.33)	20 (66.67)
Satisfied	4 (13.33)	3 (10.00)
Dissatisfied	1 (3.33)	7 (23.33)
bDegree of satisfaction	29 (96.67)	23 (76.67)	5.192	0.023
aIndependent t-test; bChi-square test.

DISCUSSION

This study demonstrates that TU-LESS with extracorporeal cystectomy provided intra-operative safety compared to the conventional MPLS while offering superior postoperative recovery.^12,13 A recent study specifically comparing single-port and multi-port techniques for benign ovarian cystectomy further supports these findings, confirming comparable operative safety parameters and highlighting advantages in postoperative recovery metrics.¹⁴ The absence of significant differences in blood loss (45.32 ± 8.72 ml vs. 49.12 ± 9.19 ml, p = 0.106) and complication rates (6.67% vs. 13.33%, p = 0.389) is consistent with Karasu et al.’s findings,¹⁵ indicating procedural safety. The extracorporeal component addresses the limitations of pure TU-LESS: It avoids instrument collision (chopstick effect) in confined pelvic spaces and enables accurate cyst manipulation under direct vision, particularly advantageous for large cysts (mean diameter: 13.92 ± 5.01 cm). Accelerated recovery—including earlier bowel function resumption (16.23 ± 4.98 hour vs. 21.76 ± 5.86 hours; p <0.001) and reduced hospitalisation (3.15 ± 0.93 days vs. 4.23 ± 1.02 days; p <0.001)—possibly stemmed from two mechanisms: Minimised thermal spread due to extra-corporeal cold excision, which reduces adjacent tissue trauma,¹¹ and elimination of ancillary trocars,¹⁶ thereby decreasing parietal nerve stimulation.¹⁷ This is substantiated by attenu-ated inflammatory responses, with significantly lower 24-hours postoperative IL-6 (36.71 ± 5.33 pg/ml vs. 50.07 ± 5.25 pg/ml; p <0.001) and CRP (24.98 ± 6.93 mg/L vs. 49.81 ± 8.02 mg/L; p <0.001) levels compared to MPLS.

The present findings contradict those with Lee’s study, who reported prolonged operative times with single-incision techniques.¹⁸ This may be attributed to the hybrid approach: Intracorporeal cyst mobilisation followed by extracorporeal resection is a time-consuming aspect of cystectomy. The high patient satisfaction (96.67% vs. 76.67%; p = 0.023) underscores the cosmetic advantage of umbilical scar concealment, which is critical to the young cohort (mean age: 31.6 years). This high level of satisfaction with the cosmetic outcome of single-incision surgery has been consistently demonstrated in randomised trials comparing patient-reported outcomes between SP-LESS and MPLS for gynaecologic adnexal surgeries.¹⁹ Park et al. reported comparable outcomes for endometriomas.²⁰ The present study extends these findings to diverse benign pathologies, including mucinous cystadenomas (26.66%) and teratomas (16.67%). Technical refinements, such as purse-string suturing of cyst surfaces before extraction, prevented spillage and addressed concerns regarding extracorporeal manipulation.

The study limitations warrant consideration. This single-centre design limits generalisability, sample size restricts subgroup analysis by cyst type, and short-term follow-up precludes ovarian reserve assessment. Future multicentre studies should evaluate the long-term fertility outcomes and cost-effectiveness.

CONCLUSION

TU-LESS combined with extracorporeal operation can reduce surgical trauma, accelerate postoperative recovery, promote scar-free wound healing, and improve patient satisfaction with surgical incisions.

FUNDING:
This study is supported by Medical Science Research Project of Hebe (No. 20251269).

ETHICAL  APPROVAL:
Ethical approval of the study was obtained from the Maternity and Child Health Centre of Qinhuangdao, prior to the initiation of the research work, with approval number (QHDFY-20240902A01).

PATIENTS’ CONSENT:
Informed consent was obtained from the patients to publish the data concerning this study.

COMPETING INTEREST:
The authors declared no conflict of interest.

AUTHORS’ CONTRIBUTION:
BS: Designed the study and prepared the manuscript.
YW, YH: Collected and analysed the clinical data.
RL, LG: Contributed to acquisition, analysis, interpretation of the data, and manuscript drafting.
All authors approved the final version of the manuscript to be published.

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