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Tang. Mini-invasive Surg 2020;4:24 I http://dx.doi.org/10.20517/2574-1225.2019.60 Page 3 of 13

METHODS
Study design
This was a retrospective chart review of consecutive 31 women without sexual experience who presented
with symptomatic uterine myomas and received single-port laparoscopic myomectomy without using
uterine manipulator between November 2017 and October 2019. The hospital setting is a regional teaching
hospital (Kaohsiung Municipal Ta-Tung Hospital) but all staff are also members of a medical center
(Kaohsiung Medical University Hospital) in Kaohsiung, Taiwan. All surgeries were done by the same
gynecologist who is experienced in minimally invasive gynecologic surgery. The inclusion criteria were
women with myoma uteri and symptoms such as menometrorrhagia, which causes anemia (Hemoglobin
< 11 g/dL), or bulky effect, which cause bearing down sensation, frequency, tenesmus, back soreness,
or a palpable pelvic/abdominal mass. The exclusion criteria were as follows: (1) malignancy could not
be ruled out by image study; (2) patient was found to have severe adhesion or endometriosis requiring
combined major operation at the same time; and (3) patient presented with complex medical condition
before operation that required combined care by physician specialists. The largest diameter of myoma was
recorded by image study (trans-abdominal ultrasound, abdominal CT, or pelvic MRI). The position and
number of myoma was recorded during the operation. The operation time and blood loss were recorded
by circulating nurse. The postoperative pain was recorded by charting nurse at bedside immediately when
the patient arrived at the ward after operation and 24 h later. The pain score was measured by the Visual
Analogue Scale. Postoperative fever over 38 °C and prolonged for 48 h was recorded as a complication.
Other perioperative complications within 30 days were recorded. Patients were discharged from the
hospital after well tolerating oral intake, successful ambulation, and absence of postoperative fever. All
patients were scheduled for follow-up examinations at one week and one month after discharge.

Operation procedure
The patient is in the supine position. General anesthesia is selected and tracheal intubation is performed to
maintain the airway. A single dose of cefazolin (1 g) is given by intravenous bolus method before operation.
The dose is doubled if the patient’s body weight is over 80 kg. A Foley catheter is inserted after anesthesia for
bladder emptying. We do not use uterine manipulator in these women to preserve their virginity. A 1.5-cm
vertical incision is done at umbilicus after sterile preparing and draping of abdomen and within 30 min
TM
of intravenous bolus antibiotics. A multi-instrument laparoscopic port (LagiPort Kit, Lagis, Taichung,
Taiwan) is inserted through the umbilical incision and properly positioned. We insert a 10-mm telescope
to view the pelvic cavity. The circulating nurse records the number and position of myomas. Before uterine
incision is performed, diluted vasopressin (1:200 with normal saline) is injected around myomas until
bleaching change is seen. We use cold knife scissors to cut the uterine surface until the body of the myoma
TM
is reached. An electrothermal bipolar tissue sealing system (LigaSure , Medtronic Parkway, MN, USA) is
used to control bleeding if necessary. After enough of the myoma body is revealed, a laparoscopic myoma
screw is screwed into the myoma body for traction and direction. Then, further dissection of the myoma
can be done step by step. After the myoma is removed from the uterine body, we use barbed suture to close
the uterine wall defect for at least two layers in intramural type myoma. For superficial subserous myoma
or broad ligament myoma, one-layered barbed suture is used if sufficient. After all uterine incisions are
sutured, we apply fibrin sealant (Tisseel, Baxter AG, Vienna, Austria) on the suture surface to improve
healing and decrease oozing. Large myomas are removed from the umbilical incision by cold knife
morcellation. A multi-instrument laparoscopic port is placed again to check for bleeding under telescope.
Then, 800 mL of 4% Icodextrin solution (Adept, Baxter AG, Vienna, Austria) are infused into the pelvic
cavity after clearing blood clot to prevent adhesion. The umbilical incision is sutured layer by layer. All the
apparatuses used in our surgery are conventional laparoscopic instruments; no articulated instruments
were used in our study.