Specimens removed in most cases of laparoscopic resection are originally larger than the port sites. Several studies have shown that the vast majority of laparoscopic wound complications are associated with specimen retrieval at the port extraction site. For decades, gynecologic surgeons used a transvaginal (TV) approach via a posterior colpotomy for extraction. However, this method was never widely adopted largely because of concerns over its presumed technical difficulty, risk for infectious complications, and possible trauma to adjacent structures, as well as concern for lack of patient acceptance, dyspareunia, and compromised fertility due to adhesions. There are few data in the literature comparing the use of the TV approach to extract specimens and removal through an umbilical port site (UV).
This randomized trial compared TV and transumbilical (TU) routes for retrieval of surgical specimens at laparoscopy in women scheduled for resection of an adnexal mass. Subjects were randomized to either the TV (n = 34) or the TU (n = 32) group. The morphology and size of the adnexal mass was determined with ultrasound. After allocation, immediately before starting the procedure, treatment was revealed to the surgeon; allocation was concealed from bedside clinicians and patients. The primary outcome measure, postoperative incisional pain, was assessed using a 10-cm visual analog scale, with 0 being no pain and 10 the worst pain imaginable, at 1, 3, and 24 hours after surgery.
At each time point, patients who had the surgical specimen removed TV reported significantly less pain compared with those undergoing TU removal (visual analog scale score at 1 hour: 1.2 ± 2.0 vs 2.6 ± 2.9 [P = 0.03]; at 2 hours: 1.4 ± 2.0 vs 2.4 ± 2.0 [P = 0.02]; and at 24 hours: 0.5 ± 1.4 vs 1.1 ± 1.5 [P = 0.02]). Compared with the TV group, significantly more women in the TU group reported that the umbilicus was the most painful area at 1 and 3 hours postoperatively (P = 0.01 and P = 0.002, respectively). Two months after the procedure, there were no significant differences between groups in overall satisfaction with surgery, cosmetic appearance of the scars, and dyspareunia upon resumption of intercourse.
These findings indicate that a TV approach for specimen retrieval after laparoscopic resection of adnexal masses causes less postoperative pain than TU removal.
From the Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy.