Discussion
Single-port laparoscopic ovarian cystectomy appears to be a promising
minimal invasive technique offering the advantages of fast recovery,
less trauma, and superior cosmetic outcome. On the other hand, the
safety of this technique with respect to aspects of damage to ovarian
reserve has been questioned. Until now this relevant issue has been
poorly investigated, because of difficulties in assessing ovarian
reserve after this kind of surgery in combination with the small number
of study subjects and short follow-up intervals.
The presence of an ovarian cyst may distort and damage the adjacent
healthy ovarian tissue but the laparoscopic stripping of ovarian cysts
may further worsen ovarian reserve ,even if performed by experienced
surgeons, through at least three ways: (i) the accidental removal of
healthy ovarian cortex near the cyst’s capsule (ii) the thermal effect
of diathermy coagulation of small bleeding vessels on the stripping area
with consequent vascular compromise and (iii) a surgery-related local
inflammation22-24.
In single-port laparoscopy (SPL) surgeons often experience difficulties
in handling their instruments due to the unsatisfactory surgical plan.
All instruments are placed in parallel, bump each other for targeting
procedures and also are in line with the vision25.
Nevertheless, the default of triangulation could limit the traction and
counter traction needed for some ovarian cysts (endometriomas). It is
argued that these limitations make the SPL ovarian cystectomy more
technically demanding and difficult than conventional MPL and may cause
more negative impact on preserving the ovarian function after
laparoscopic ovarian cystectomy16. Our results have
highlighted the fact that while total operative time and blood loss
increased using SPL versus MPL ovarian cystectomy, there is not a
remarkable difference in hospital stay and in reduction of postoperative
AMH between SPL ovarian cystectomy and conventional MPL approach.
In our opinion the development of a new surgical approach should always
be compared to the conventional treatment. The majority of studies did
not display a remarkable difference in reduction of postoperative AMH
between SPL ovarian cystectomy and conventional MPL
approach13-15.
It seems that besides the number of laparoscopic ports there are several
factors like histological type of cyst (endometriotic cysts or
non-endometriotic cysts), the hemostatic approach (coagulation,
suturing), location of cyst (unilateral or bilateral), cyst size that
affect postoperatively the ovarian function15. During
cystectomy, it is not always easy to identify and separate the cleavage
plane between the cyst wall and adjacent ovarian cortex tissue due to
fibrotic adhesion. Cystectomy using the stripping technique usually
leads to removal of normal primary follicles and damage of ovarian
reserve. Furthermore, bipolar coagulation at seriously bleeding sites
close to ovarian hilus also leads to destruction of the ovarian blood
supply and reduced ovarian reserve19.
The major limitations of this meta-analysis is that the strength of
evidence is low because of quality issues of available studies and the
heterogeneity in ovary cyst type of four included studies. Currently the
evidence is not strong enough to recommend or discourage the use of
single-incision laparoscopy over conventional laparoscopy. The available
literature suggests that the risk of complications is similar between
procedures. Further randomized studies with larger sample sizes are
required to demonstrate in which degree all these factors contribute to
the loss of the ovarian reserve.