Application Of Laparoendoscopic Single-site Surgery In Deep Infiltrating Endometriosis

Objective: To introduce the application of pelvic space anatomy in deep infiltrating endometriosis(DIE)surgery,to explore the safety and feasibility of Laparoendoscopic single-site surgery(LESS)in the treatment of DIE,and to compare the therapeutic effects of LESS and Conversion laparoscopic surgery(CMPL).Methods: The clinical data of 115 patients who underwent surgical treatment for DIE in the Department of Obstetrics and Gynecology,The Affiliated Changzhou No.2 People’s Hospital of Nanjing Medical University,from January 2017 to January 2021 were retrospectively analyzed.According to the surgical methods,they were divided into LESS(n=55)and CMPL(n=60).The surgical methods of the two groups were based on pelvic space anatomy.The general baseline data,clinical symptoms,disease severity,perioperative data and surgical treatment effects of the two groups were statistically analyzed and compared.Results: A total of 115 patients in the LESS and the CMPL underwent successful surgery.In the LESS,6 patients completed the operation by adding an additional auxiliary operating hole.(1)Comparison of general data: There was a statistical difference in the history of endometriosis surgery(P = 0.048,P < 0.05),and there was no statistical difference in other data.(2)There was no significant difference in non-periodic chronic pelvic pain,dysmenorrhea,deep sexual pain,infertility,urinary system symptoms,and digestive system symptoms.(3)Severity of disease: 2 cases of stage I,3 cases of stage II,13 cases of stage III and 37 cases of stage IV in LESS;there were 1 case of stage I,4 cases of stage II,14 cases of stage III and 41 cases of stage IV in the CMPL.There was no significant difference between the two groups(P = 0.878,P > 0.05).There was no significant difference in r ASRM score between the two groups(56.03 ± 26.53 vs 58.78 ± 24.56,P > 0.05).According to r-ENZIAN classification,123 lesions were found in the LESS and 134 lesions were found in the CMPL.There was no significant difference between the two groups with ovarian endometriosis cyst and adenomyosis.(4)Perioperative data: There was statistical difference in operation time(126.03 ± 52.45 vs 108.01 ± 40.31 min,P < 0.05);the estimated intraoperative blood loss was statistically different(68.00 ± 38.71 vs 63.17 ± 26.79 ml,P< 0.05).The VAS pain score at 24 h after operation was statistically different(3.09 ± 1.11 vs 4.10 ± 1.10,P < 0.01).There was a statistically significant difference in hospital stay(5.54 ± 1.53 vs6.05 ± 1.22 days,P < 0.05).There were 6 cases of operation-related complications in the LESS,4 cases of Clavien Dindo I-II grade,2 cases of Clavien Dindo III-V grade,7cases of operation-related complications in the CMPL,5 cases of Clavien Dindo I-II grade,2 cases of Clavien Dindo III-V grade.All patients recovered after treatment.(5)Surgical treatment effect: The symptoms of non-periodic chronic pelvic pain,dysmenorrhea and deep sexual intercourse pain were significantly relieved before and after operation in both groups.There were significant differences in VAS scores of different pain symptoms before and after operation in LESS(non-periodic chronic pelvic pain: 4.89 ± 2.02 vs 2.00 ± 1.16,P < 0.01;dysmenorrhea: 4.89 ± 1.77 vs 2.25 ±0.84,P < 0.01;deep sexual pain: 5.73 ± 2.05 vs 3.09 ± 1.11,P < 0.01).There were significant differences in VAS scores of different symptoms before and after operation in CMPL(non-periodic chronic pelvic pain: 4.89 ± 2.02 vs 2.00 ± 1.16,P < 0.01;dysmenorrhea: 4.89 ± 1.77 vs 2.25 ± 0.84,P < 0.01;deep sexual intercourse pain: 5.73± 2.05 vs 3.09 ± 1.11,P < 0.01).There was no significant difference in the degree of pain VAS score relief between LESS group and CMPL group in aperiodic chronic pelvic pain,dysmenorrhea and deep sexual intercourse pain(aperiodic chronic pelvic pain: P = 0.190,P > 0.05).Dysmenorrhea: 0.107,P > 0.05;deep sexual pain: P = 0.346,P > 0.05).The symptoms of digestive system and urinary system in the two groups were significantly relieved after operation.The follow-up time of the LESS was 22.89 ± 5.66 months,and the follow-up time of the CMPL was 21.53 ± 5.28 months.There was no significant difference in the follow-up time between the two groups(P=0.184,P > 0.05).The number of recurrences in the LESS was 5 cases,and the recurrence rate was 9.1 %(5 / 55).The number of recurrences in the CMPL was 6 cases,and the recurrence rate was 10.0 %(6 / 60).There was no significant difference in the recurrence rate between the two groups(P = 0.868,P > 0.05).Pregnancy: 7 cases(7 / 8,87.5 %)of 8 patients in LESS were successfully conceived,including 5 cases(5 / 8,62.5 %)of natural conception and 2 cases of artificial assisted reproductive technology.In the CMPL,7patients(7 / 9,77.78 %)were successfully conceived,of which 4 patients(4 / 9,44.44 %)were naturally conceived and 3 patients were conceived by artificial assisted reproductive technology.There were significant differences in surgical scar score VSS,POSAS(OSAS + PSAS)and overall patient satisfaction VAS score between LESS and CMPL(VSS : 3.38 ± 1.23 vs 4.10 ± 1.24,P < 0.01;OSAS : 9.41 ± 2.91 vs 11.46 ±2.71,P < 0.01;PSAS : 7.81 ± 1.95 vs 11.28 ± 2.69,P < 0.01;the VAS score of overall surgical satisfaction was 9.03 ± 1.01 vs 7.98 ± 1.09,P < 0.01).No incisional hernia was found in all patients in the LESS during the follow-up period.Conclusion:The use of LESS in the treatment of DIE has certain safety and feasibility,which can promote the improvement of different pelvic pain symptoms,urinary system and digestive system symptoms and postoperative pregnancy of infertile patients.Compared with CMPL in the treatment of DIE,LESS has the advantages of less pain after operation,shorter hospitalization time,better surgical scar score and better overall satisfaction of patients with surgery,but there are also disadvantages of long operation time and more intraoperative blood loss.In the future,multicenter,large-sample and prospective studies will be conducted to further confirm the safety and feasibility of LESS in the treatment of DIE,and to confirm the effect of LESS on pelvic pain relief,disease recurrence,pregnancy and fertility through longer follow-up.