Total Laparoscopic Hysterectomy With Percutaneous (Percuvance) Instruments: New Frontier of Minimally Invasive Gynecological Surgery

Study Objective: To highlight the first case of laparoscopic hysterectomy performed with percutaneous instruments (The Percuvance System, Teleflex Incorporated, Wayne, PA). Design: The basis of the system is a <3-mm diameter shaft that, when connected to an introducer tool tip, can be inserted percutaneously through the skin. The introducer tool tip can then be exchanged outside the body for a wide variety of 5-mm interchangeable surgical tool tips. The shaft is sufficiently strong to hold structures, and surgeons can use its interchangeable tool tips to grasp, cut, and manipulate tissue. We used a 3-dimensional high-definition 10-mm flexible tip endoscope (ENDOEYE FLEX 3D, Olympus Winter & IBE GMBH, Hamburg, Germany). Background: Minilaparoscopy is an attractive approach for hysterectomy due to advantages such as reduced morbidities and enhanced cosmesis. However, it has not been popularized because of the lack of suitable instruments and high technical demand. The Percuvance system represents a significant advance in minimally invasive surgery. Setting: Catholic University of the Sacred Hearth, Rome, Italy. Patient: A 53-year-old, multiparous patient with endometrial endometroid cancer grade 1, Fédération Internationale de Gynécologie et d'Obstétrique stage IA. The patient provided informed consent to use the images and video of the procedure. Institutional review board approval was not required. Intervention: The patient was hysteroscopically diagnosed with endometrial cancer after removal of an endometrial polyp adnexectomy. Once referred to our center, surgical staging was planned, including total hysterectomy and bilateral adnexectomy. Laparoscopy with 2 lateral percutaneous and 1 soprapubic 3-mm instruments was believed to be feasible to achieve these procedures. Main Results: The operation was performed successfully with no intraoperative or postoperative complications. Operative time was 80 minutes overall, and blood loss was 50 mL. The pathology report confirmed endometrial endometroid cancer grading 1, Fédération Internationale de Gynécologie et d'Obstétrique stage IA. The patient was discharged on day 1. After 2 months, no late complications or recurrence was detected. Conclusion: Percutaneous total hysterectomy is technically feasible, and the use of this novel device permits surgeons to mantain a standard setting. Further studies are mandatory to define the benefits, advantages, and costs of this novel approach with respect to other minimally invasive approaches.