Minimally invasive and rapid recovery are important development directions of modern surgery. Gynecologic oncology surgery has undergone an evolution from open to laparoscopic, from traditional multi-port to single-port laparoscopy (LESS), and from ordinary laparoscopy to robotic laparoscopy. Single-port laparoscopic surgery and its combination with robotic platforms have shown unique advantages in the minimally invasive treatment of gynecological tumor surgery, promoting profound changes in surgical methods. A series of expert consensus has also been issued in relevant fields in China, marking that the technology is moving from exploration to standardized application. The Obstetrics and Gynecology Network is honored to invite Professor Zheng Ying from the Second Hospital of West China of Sichuan University to systematically elaborate on the technical advantages and application development of LESS and robotic single-port surgery (R-LESS) in gynecological tumors, aiming to provide an annual inventory focusing on cutting-edge progress for clinical practice.

In 2014, the FDA banned unprotected electric rotation to break fibroids during minimally invasive surgery, and it was recommended to remove them in a closed bag. TU-LESS can bag the fibroids and remove them through the dilatable umbilical incision with a cold knife to avoid the risk of tumor implantation and metastasis caused by unprotected electric peeling.

(1) For teratomas containing cephaloknots/bones and other components, it is difficult to take specimens with multi-hole laparoscopy, but TU-LESS can be quickly removed;

(2) Benign giant cystic masses (flat umbilical cord/supraumbilicus) can be punctured and pumped under protection through umbilical incision, reduced in volume, and then completely removed by single-port laparoscopy to prevent cyst fluid spillage to the greatest extent and follow the principle of no tumor, and avoid laparotomy;

(3) Pregnancy adnexal surgery, TU-LESS avoids Trocar blind piercing to damage the uterus and other organs. A study by the team showed that TU-LESS was used for 75 cases of pregnancy adnexal diseases and was safe and feasible, and the perioperative indicators and obstetric outcomes were good.

Due to the different positions of the surgeon, the multi-hole laparoscope makes it difficult to handle the contralateral parauterine due to uterine occlusion, while the TU-LESS median approach can be easily handled by both sides of the uterus. From 2017 to 2024, the team completed 1472 cases of large uterus (uterine weight > 280g) under LESS, 314 cases with uterine weight > 500g, and 20 cases with a > of 1000g.

This path achieves a traceless abdominal wall and rapid recovery, and is suitable for day surgery, and for difficult total hysterectomy (such as large uterus, posterior depression closure), the robotic surgical system will help improve the success rate of total vNOTES resection. The team conducted a national multicenter phase III non-inferiority randomized controlled trial and found that the vNOTES pathway was superior to TU-LESS for rapid recovery after non-prolapsed hysterectomy and not inferior to traditional multi-hole laparoscopy.

Since 2009, 77 papers and 3490 patients have been published at home and abroad on LESS for the treatment of endometrial cancer, and studies have shown that TU-LESS can achieve comprehensive staging of early endometrial cancer, with oncological outcomes comparable to porous tumors, and has significant advantages in rapid postoperative recovery. The team used the 4C suspension method to solve the problem of lymph node exposure and shorten the learning curve to 11 cases, and completed the comprehensive staging of endometrial carcinoma under LESS in 850 cases and R-LESS in 277 cases. The application of robots has significantly expanded the application boundaries of complex cases of single-port endometrial carcinoma (such as para-abdominal aortic high lymph nodes/difficult metastasis lymph node resection, etc.). There are also studies that validate that vNOTES can be used in patients with endomal carcinoma who are rigorously assessed as low-risk, but this pathway is limited in para-aortic lymph node exploration.

Minimally invasive cervical cancer surgery has gone through three stages: rapid development, prudent reflection, and technological improvement. Open abdomen is the preferred route for extensive hysterectomy, but experts at home and abroad believe that strictly screened low-risk groups (such as cervical lesions <2cm) should be performed by gynecological oncologists with rich experience in minimally invasive surgery under strict adherence to the principle of tumor-free surgery (such as exemption from lifting the uterus). The multi-hole laparoscope can easily achieve extensive hysterectomy without lifting with the assistance of an assistant, while TU-LESS can only be completed with the help of "cross suspension" and "crab suspension". The team completed 819 cases of LESS cervical cancer surgery, including 374 cases of R-LESS, and conducted a cohort study with the largest single-center sample size (970 cases), which showed that there was no difference in oncological outcomes between single-port no-lift uterus and multi-hole no-lift uterus and open cervical cancer radical resection (4-year OS 94.9% vs. 96.7% vs. 97.6% and DFS 94.0% vs. 94.9% vs. 94.1%, respectively), which had significant advantages in rapid recovery. Since 2009, 53 cases of LESS cervical cancer have been reported in domestic and foreign literature, with 1808 patients. The robot-assisted system promotes the safer and more efficient minimally invasive surgery for cervical cancer, and the enlargement of the field of view is conducive to the identification of parauterine fine structures, which helps to preserve the pelvic autonomic nerves and blood vessels. The "strapping belt pulling exemption method" under the robot single hole is simple and easy, significantly shortening the operation time.

Open laparotomy is a common surgical method for ovarian cancer, but the trauma is high and the recovery is slow and affects the follow-up treatment. The NCCN recommends minimally invasive surgery for full staging of early (I, II) ovarian cancer, intermittent cytoreductive surgery (IDS) for advanced ovarian cancer that has been assessed to be satisfactory for tumor shrinkage, and laparoscopic exploration of diaphragmatic scattered implants is superior to laparotomy. However, the advantages of TU-LESS can make up for the difficulty of multi-hole laparoscopic specimen collection, delayed intraoperative freezing for testing, and puncture hole implant transfer. According to statistics, since 2011, there have been 30 reports on the application of TU-LESS in the treatment of ovarian cancer and 546 patients. The team completed 331 ovarian cancer surgeries with TU-LESS, including 86 cases of R-LESS, summarizing the advantages of LESS in ovarian cancer:

(1) Comprehensive staging of early ovarian cancer: transumbilical specimen collection is efficient and convenient, which is more in line with the principle of tumor-free, especially suitable for ovarian cancer staging surgery that preserves fertility function;

(2) Diagnosis, biopsy and evaluation of advanced ovaries: minimally invasive exploration reduced the rate of ineffective laparotomy from 39% to 10%, and single hole had more advantages in avoiding incision implantation and blind piercing injury.

(3) PDS of non-disseminated advanced ovarian cancer: stage III ovaries scattered in the lesion that have been evaluated by strict preoperative imaging and laparoscopy can be staged surgery or satisfactory tumor reduction surgery under a single hole, and part of the intestine can be removed through the umbilical incision and removed and anastomosed in vitro to improve surgical efficiency and reduce trauma;

(4) Selective advanced ovarian cancer IDS: IDS patients with IDS without diffuse lesions and no palpable resected lesions in the upper abdomen, liver, gallbladder, and deep peripancreas after comprehensive evaluation of adequate preoperative imaging and laparoscopy;

(5) TU-LESS combined with partial laparotomy to complete advanced ovarian cancer tumor reduction: when TU-LESS pelvic tumor reduction is satisfactory, it can be combined with upper abdominal open to remove deep organ lesions; When TU-LESS is satisfied with the upper abdomen and the pelvic rectal involvement requires removal of the fistula, rectal resection can be performed in combination with lower abdominal openness. This method not only guarantees R0, but also meets the minimally invasive requirements to the greatest extent.

(6) Isolated/recurrent ovarian cancer with limited number of lesions: TU-LESS has special advantages when there is no vagina as a specimen collection channel.

In short, LESS has the unique advantages of open and multi-hole laparoscopy in the diagnosis and treatment of ovarian cancer, abandoning the stereotype that ovarian cancer, especially advanced/recurrent ovarian cancer, can only be "big surgery", and adopting stratified precision surgical decisions after strict evaluation can ensure good oncological outcomes and improve the quality of life of patients. At the same time, with the help of robot advantages, the application of single-port minimally invasive port in ovarian cancer surgery can be greatly expanded.