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Feasibility of reduced port surgery applying Higuchi’s transverse incision

Objective: Higuchi’s transverse incision is made at a lower position than the Pfannenstiel transverse incision and is superior in terms of cosmetic outcomes. The purpose of this study was to examine the safety and efficacy of novel forms of reduced port surgery for ovarian cysts and uterine fibroids applying Higuchi’s transverse incision. Methods: In 33 patients with ovarian cysts who underwent low-position single-incision laparoscopic surgery (L-SILS)-modified single-port laparoscopy placed in the 2–3-cm Higuchi’s incision above the pubis, patient’s characteristics and perioperative outcomes were compared with those of patients who underwent multiport laparoscopy (n = 53). In addition, 18 patients with uterine fibroids who underwent dual-port laparoscopically assisted myomectomy without using power morcellators and conventional four-port laparoscopically assisted myomectomy were investigated. Results: There were no significant differences between L-SILS and multiport laparoscopy in tumor diameter, bleeding, hospital stay, or postoperative pain. However, the L-SILS group demonstrated significantly shorter operative and pneumoperitoneum times (p < 0.01 and p < 0.01). In comparison with cases of uterine fibroids, no significant differences were found in maximum fibroid diameter, operative time, pneumoperitoneum time, or bleeding. However, the dual-port laparoscopically assisted myomectomy group demonstrated a significantly shorter length of hospital stay than the conventional laparoscopically assisted myomectomy group (p < 0.05). Conclusion: We reported novel forms of reduced port surgery applying Higuchi’s transverse incision. It was suggested that these procedures are relatively simple, but ensure the same safety and efficacy as conventional methods. We intend to increase the number of cases and examine safety, efficacy, and patient satisfaction for these procedures.


Introduction
Compared with laparotomy, laparoscopic surgery results in fewer perioperative complications, less postoperative pain, shorter hospitalization, and faster recovery. 1 Furthermore, as the evolution of energy devices and other medical equipment has led to improved safety and shorter operative times, reduced port surgery (RPS) such as single-port laparoscopy and microlaparoscopy have been developed; these RPS techniques are less invasive and yield superior cosmetic outcomes compared with conventional surgery, and multiple studies have reported their utility. 2,3 In gynecology, single-port laparoscopy is typically performed with an umbilical approach, the utility of which has been reported by several studies. 4e7 However, the surgery is difficult to perform, 8,9 and a number of studies have reported postoperative complications such as umbilical hernias and refractory infections. 10e12 In addition, in April 2014, the United States Food and Drug Administration issued a warning regarding the safety of power morcellators typically used in laparoscopy for uterine fibroids, thus posing problems for the surgical procedure and fibroid removal. 13,14 Higuchi's transverse incision is made at a lower position than the conventional Pfannenstiel transverse incision and is superior in terms of cosmetic outcomes. We perform Higuchi's transverse incision as a standard approach in laparotomy for benign tumors (except for giant tumors) and for cesarean sections.
In the present study, we applied Higuchi's transverse incision in RPS; here, we discuss new surgical procedures with the objective of further improving cosmetic outcomes. We report our introduction of two new operative procedures: low-position single-incision laparoscopic surgery (L-SILS), which does not involve the umbilicus, for ovarian cysts, and dual-port laparoscopically assisted myomectomy (2P-LAM), which does not use a power morcellator, for uterine fibroids.
(1) Skin incision: The incision is made at a low position, 1.5 cm above the pubis. The wound is covered by the pubic hair and thus has a superior cosmetic outcome. This incision also enables easier surgeries on the bladder, cervix, and elsewhere in the pelvis.

L-SILS for ovarian cysts
(1) A platform is placed in the 2e3 cm Higuchi's transverse incision superior margin on the pubis ( Figure 1A).  Figure 2A). (4) The fibroid is enucleated intra-abdominally, and the wound in the uterus is sutured under direct observation. The absence of remaining fibroids is confirmed by palpation. (5) The enucleated fibroid is collected into an isolation bag, morcellated with a scalpel in the bag under direct observation, and removed from the abdominal cavity via the Higuchi's transverse incision without using power morcellators ( Figure 2B).

Results
We began performing cystectomy by L-SILS for ovarian cysts in March 2014. A breakdown of cases is shown in Table 1. Initially, the participants were patients with no adhesions; 85% of cases (28/33) were teratomas. In a comparison with 53 patients who underwent conventional multiport laparoscopic cystectomy during that same period, no significant differences were observed in tumor diameter, bleeding, length of hospital stay, or postoperative pain; however, patients who underwent L-SILS demonstrated significantly shorter operative and pneumoperitoneum times (p < 0.01 and p < 0.01). Additionally, in order to eliminate bias due to adhesions and tumor localization, we compared only cases with unilateral ovarian cysts ( Table 2); we thus found that while L-SILS involved significantly larger tumor diameters (p < 0.05), operative and pneumoperitoneum times were shorter (p < 0.01 and p < 0.01).
We began performing 2P-LAM in December 2014 and have used it in seven patients thereafter (Table 3). In comparison with cases of conventional four-port laparoscopically assisted myomectomy (LAM) performed during the same period, no significant differences were found in maximum fibroid diameter, operative time, pneumoperitoneum time, or bleeding; however, the 2P-LAM group demonstrated a significantly shorter length of hospital stay than the conventional LAM group (p < 0.05).
In addition, neither of these novel procedures resulted in any perioperative complications.

Discussion
The Higuchi's transverse incision was proposed by Shigetsugu Higuchi, the first professor of obstetrics and gynecology at the Jikei University School of Medicine. The incision is comparable with the conventional Pfannenstiel transverse incision in some characteristic ways, as indicated in the methods. The main characteristic of the Higuchi's transverse incision is a T incision of the rectus abdominis fascia; bluntly extending the incision in a transverse direction prevents injury to the perforating branches of the deep arteries and veins of the abdominal wall. Next, a longitudinal incision is made  Values are presented as mean (range) or n (%). CRP ¼ C-reactive protein on the next day; GA ¼ general anesthesia; L-SILS ¼ low-position single-incision laparoscopic surgery; TAP/EP ¼ transversus abdominis plane block/epidural anesthesia; TLC ¼ total laparoscopic cystectomy; VAS ¼ visual analog scale on the next day. a Statistical analysis was performed using the Student t test or the chi-square test. A p value < 0.05 was considered statistically significant.
directly above the pubic symphysis; treatment of the peritoneum while confirming the bladder makes it possible to prevent bladder injury and ensures an adequate visual field. We usually perform Higuchi's transverse abdominal wall incision as a standard approach for laparotomy for benign tumors and cesarean sections. Recently, in response to the demand for reducing invasiveness further, the application of RPS has become widespread. Single-port laparoscopic surgery through the umbilicus, a form of RPS, was reported in 2005 as a new approach to tubal pregnancy 15 ; thereafter, its use has grown beyond laparoscopic surgery for benign tumors, and it has also been introduced for malignant tumors and in robotic surgeries. 16,17 Although many studies have reported on the utility of RPS, 18e20 there are also reports that RPS did not improve the health-related quality of life, 21 and reports of the high degree of difficulty of RPS and problems with umbilical wounds. 8e12 L-SILS, which we introduced in the present study, is an extremely simple method that permits extracorporeal tumor resection and removal of the tumor content in a short time. Despite the small number of cases, an investigation of unilateral teratomas with no adhesions statistically demonstrated that while tumor diameter is significantly larger than in conventional multiport laparoscopic surgery, operative and pneumoperitoneum times are significantly shorter. In addition, applying the Higuchi's transverse incision enables a skin incision above the pubis, which causes the wound to be hidden completely by pubic hair and underwear, thereby providing excellent cosmetic outcomes.
Examples of laparoscopic uterine fibroid enucleation include laparoscopic myomectomy (LM) and LAM. Although LAM is inferior to LM in terms of cosmetic outcomes, it is a technically simple procedure that enables suturing of the uterine wound and removal of fibroids through a small incision. In addition, LAM enables confirmation of small, low-position fibroids by palpation and can also be performed for relatively large fibroids. A study that compared LM and LAM found that LAM involved significantly shorter operative times and significantly smaller uterine incisions. 22 In addition, although power morcellators are typically used to remove enucleated fibroids, they have been implicated in potentially disseminating occult uterine malignancy in the abdominal cavity and causing peritoneal metastasis; thus, in 2014, the United States Food and Drug Administration issued a warning against the use of power morcellators in laparoscopic surgery for uterine fibroids. 13,23 Therefore, in order to avoid using a power morcellator, we introduced a method in which the fibroid is collected into a bag, morcellated in the bag with a scalpel through the LAM incision, and removed. Furthermore, in order to improve cosmetic outcomes, we have applied 2P-LAM, in which a small Higuchi's transverse incision is completely hidden by pubic hair and underwear, and in which a 5-mm camera port is inserted through the umbilicus. Moreover, by making a small incision above the pubis rather than in the umbilicus, a cesarean section can later be performed through a Higuchi's transverse incision at the same site, thus avoiding the need for a new abdominal wound. Despite the small number of cases, our results indicate that compared with conventional four-port LAM, regardless of the lack of a significant difference in maximum fibroid diameter, 2P-LAM shows no significant difference in operative time, bleeding, or perioperative complications; results in significantly shorter length of hospitalization; is equally safe; and is less invasive.

Conclusion
In the present study, we reported on L-SILS and 2P-LAM, novel forms of RPS for ovarian cysts and uterine fibroids that apply Higuchi's transverse incision. In the current environment, in which improved cosmetic outcomes and further reduction in invasiveness are sought in laparoscopic surgery, both these procedures are relatively simple, but ensure the same safety and efficacy as conventional methods; therefore, they have potential as novel forms of RPS. Going forward, we intend to increase the number of cases, and examine the safety and efficacy of, and patient satisfaction with these procedures. Values are presented as mean (range). L-SILS ¼ low-position single-incision laparoscopic surgery; TLC ¼ total laparoscopic cystectomy. a Statistical analysis was performed using the Student t test. A p value < 0.05 was considered statistically significant. Values are presented as mean (range) or n (%). CRP ¼ C-reactive protein on the next day; Hb ¼ hemoglobin level on the next day; LAM ¼ laparoscopically assisted myomectomy; 2P-LAM ¼ dual-port laparoscopically assisted myomectomy. a Statistical analysis was performed using the Student t test or the chi-square test. A p value of <0.05 was considered statistically significant.