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Page 6 of 8 Goh et al. Mini-invasive Surg 2021;5:30 https://dx.doi.org/10.20517/2574-1225.2021.42

the last case, even though the patient was taking anti-coagulants and anti-thrombotics, intraoperative
bleeding was minimal (100 cc), possibly reduced by the use of a laparoscopic approach.

Advances in operative techniques were also able to reduce the risk of intraoperative and postoperative
complications in these group of patients. Previously, open laparotomy was the standard approach to
performing hysterectomy. However, in recent years, laparoscopy became the more popular choice.
Advantages of laparoscopy over laparotomy include shorter hospital stay, decreased adhesion formation
and reduced incidence of fever, wound infection, urinary tract infection and pneumonia . This is
[7,8]
especially beneficial in renal transplant recipients because infection is the most common complication of
abdominal hysterectomy . While it was reported that the incidence of bladder injury is higher in
[6]
laparoscopic hysterectomies, this risk can be mitigated when it is performed by an experienced surgeon .
[8]

There are multiple advantages to performing LESS. It leads to a decrease in the risk of visceral and vascular
injury related to multiple incisions and trocar placements. Furthermore, the umbilical incision for port
placement in LESS is hardly noticeable after healing and offers superior cosmetic results. However, we
acknowledge that this may be less important in renal transplant recipients since they already have a large
kidney transplant scar. As there is only one entry site, there is also a reduction in postoperative wound
infection, hernia formation and elimination of multiple trocar site closures. In addition, LESS is associated
with good pain control and lower analgesic requirements, which in turn enhances the recovery of
patients [9,10] . Overall, LESS has been shown to reduce operative and perioperative complications.

Our surgeon also used a homemade single-port system which accommodates the insertion of various types
and sizes of laparoscopic devices, while the elasticity of the glove finger facilitates the retrieval of specimens.
The greatest advantage of a homemade port is its cost effectiveness for the patient, as standard, instead of
articulated, instruments are utilised. This is feasible because the elasticity of the homemade port coupled
with the thin, stretchable umbilical fascia maintains the triangulation, ease of manoeuvre and coordination
of the instruments.

A technically challenging aspect of performing hysterectomy in renal transplant patients is to avoid damage
to the allograft organ intraoperatively since the surgical field is in the pelvic region where the transplanted
kidney is sited. Using LESS is safe because the trocar is only placed at the umbilicus, while a conventional
laparoscopy requires a trocar to be inserted at the ipsilateral lower quadrant of the allograft organ, risking
injury to it. Although the risk can be reduced in a conventional laparoscopy by placing the trocar more
medially in such instances, attention has to be given to identify the inferior epigastric vessels before placing
this port . Similarly, placing the trocar at a higher position may make the surgery less ergonomic for the
[3]
surgeon. This renders a single, umbilical port placement safer and more ideal.

Moreover, there is a risk of injury to the urinary bladder during laparoscopic gynaecological surgery,
attributed to either the entry process (e.g., suprapubic port insertion) or due to its close proximity with the
operating field (e.g., hysterectomy). A previous meta-analysis reported that bladder injury rates range from
[11]
0.02% to 8.3%, making it the most common viscera damaged in conventional laparoscopic pelvic surgery .
Renal transplant recipients undergoing conventional laparoscopy may have an even higher risk of bladder
injury. During renal transplantation, the bladder is lifted supero-anteriorly to allow transplantation of the
ureter to the dome of the bladder. Thus, suprapubic port insertion carries an increased risk of bladder injury
due to its relatively higher position. While high port placement at the level of or above the umbilicus can be
used in place of a suprapubic port, such placements are less ergonomic for the surgeon. On the other hand,
entering the peritoneal cavity through a single umbilical incision in LESS minimises the risk of such port-