Original Article

Mini-Laparotomy Versus Laparoscopy for Gynecologic Conditions

Amanika Kumar, MD, and Michael Pearl, MD*
From the Department of Obstetrics and Gynecology, Stony Brook University Medical Center, Stony Brook, New York (both authors).

ABSTRACT Study Objective: To compare conversion rates, operative time, and estimated blood loss in patients undergoing mini-
laparotomy (,4 cm vertical or transverse abdominal incision) versus laparoscopy for treatment of benign gynecologic
conditions.
Design: Retrospective study (Canadian Task Force classification II-2).
Setting: Academic medical center.
Patients: Women who underwent laparoscopy or mini-laparotomy for treatment of gynecologic conditions from January
2002 to March 2011. Patients who underwent hysterectomy as part of the surgery, cancer staging procedure, pregnancy-
related procedure, or diagnostic surgery alone were excluded.
Interventions: Mini-laparotomy or laparoscopy.
Measurement and Main Results: Primary outcomes were operative time and estimated blood loss. Secondary outcomes
were hospital readmission, repeat operation, overnight hospital admission, emergency room visits because of surgery-
related signs or symptoms, and wound complications. Of 950 medical records examined, 493 patients (52%) met the inclusion
criteria, of which 141 (29%) underwent mini-laparotomy and 352 (71%) underwent laparoscopy. The groups had similar in-
dications for surgery and level of surgical assistant. Patients who underwent mini-laparotomy were older than those who un-
derwent laparoscopy. In patients who underwent mini-laparotomy, mean operative time was significantly shorter (49.3 versus
91.5 minutes; p 5 .003), and estimated blood loss was less (20 versus 32 mL; p 5 .001). The cumulative secondary outcome
rate was not statistically different between the 2 groups (15% versus 16%). When each secondary outcome (conversion, repeat
operation, overnight hospital admission, readmission to the hospitalization, emergency department visit, and wound compli-
cation) was examined independently, only the wound complication rate was significantly higher in the mini-laparotomy group
compared with the laparoscopy group (5 of 141 patients versus 1 of 352 patients; p 5 .008).
Conclusions: Mini-laparotomy is a safe alternative to traditional minimally invasive approaches in gynecology and offers the
additional benefits of shorter intraoperative time and less blood loss; however, it is associated with a significantly higher rate of
major wound complications. Mini-laparotomy is an important surgical approach and should be included in gynecologic sur-
gical training. Journal of Minimally Invasive Gynecology (2014) 21, 109–114 Ó 2014 AAGL. All rights reserved.
Keywords: Laparoscopy; Mini-laparotomy; Minimally invasive surgery
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Every year, many women undergo intra-abdominal gyne-
cologic surgery to treat adnexal pathologic conditions
including masses and cysts and for cancer prophylaxis.
The authors report no conflicts of interest.
Corresponding author: Michael Pearl, MD, Department of Obstetrics and
Gynecology, Health Sciences Center T9-020, Stony Brook University Med-
ical Center, Stony Brook, NY 11794.
E-mail: michael.pearl@stonybrook.edu
Submitted May 13, 2013. Accepted for publication June 25, 2013.
Available at www.sciencedirect.com and www.jmig.org
1553-4650/$ - see front matter Ó 2014 AAGL. All rights reserved.
http://dx.doi.org/10.1016/j.jmig.2013.06.008
Other indications for gynecologic surgery include malig-
nancy, ectopic pregnancy, leiomyomas, abnormal uterine
bleeding, infertility, and endometriosis. Approaches to gyne-
cologic surgery include the vaginal route, laparotomy, lapa-
roscopy, and robot-assisted laparoscopy.
Laparotomy is the traditional approach to intra-abdominal
gynecologic surgery and can be performed to treat all intra-
abdominal benign and malignant gynecologic diseases. Lap-
arotomy provides the advantage of rapid, easy access in
a wide range of procedures, but is associated with longer
recovery time and hospital stay. The gynecologist has the
110
unique ability to approach surgery vaginally, which is both
minimally invasive and inexpensive [1,2]. The vaginal
approach to pelvic disease is the original minimally invasive
surgery, and patients are spared abdominal incision, have
quicker return to function, and experience less postoperative
pain [1–4]. The vaginal approach to gynecologic surgery is
still an important minimally invasive option and must be
stressed in resident surgical education.
Contemporary minimally invasive approaches, laparos-
copy and robot-assisted laparoscopy, have become popular
and have become the standard of care at most institutions
[2,3]. Compared with open abdominal surgery, laparoscopy
and robot-assisted laparoscopy offer many advantages to
the gynecologic patient including less overall cost, less
postoperative pain, and shorter length of stay [1–3,5,6].
Laparoscopy, including robot-assisted laparoscopy, has spe-
cific disadvantages including the need for specialized train-
ing and instruments, pain from insufflation, potential for
trocar-associated injury, and the need for morcellation
[2,7,8].
Mini-laparotomy, with an abdominal incision ,4 cm, is
another surgical approach. Mini-laparotomy offers many
of the advantages of minimally invasive surgery including
shorter length of stay and quick return to function, but with-
out the additional costs and complications of laparoscopy
[9,10]. Mini-laparotomy is described in the gynecologic lit-
erature in the management of sterilization [11], myomec-
tomy, benign adnexal disease [12], benign hysterectomy
[13], and early endometrial [14] and cervical cancer.
The objective of the present study was to compare oper-
ative time, estimated blood loss, feasibility, and safety of
laparoscopy versus mini-laparotomy.
Material and Methods
This retrospective cohort study was approved by our in-
stitutional review board. Operating room schedules from
2002 to 2011 were reviewed to identify patients who under-
went laparoscopy or mini-laparotomy on the gynecology or
gynecologic oncology services. Patient operative records
were reviewed using the computerized clinical notes system.
Patients were excluded if the surgery was pregnancy-related
(e.g., ectopic pregnancy), the surgery was diagnostic only, or
the intended procedure also included hysterectomy. Primary
outcomes were operative time (from start of incision to clo-
sure) and estimated blood loss. Other data collected included
repeat operation and readmission rates, wound complica-
tions, emergency room visits, and conversion rates.
After eligible patients were identified, hospital medical
records were examined for additional data. Data for indica-
tion for surgery, size and number of incisions, conversion of
the procedure, and estimated blood loss were obtained from
the attending surgeon’s operative notes. If no specific trocar
size was reported in the operative note, it was assumed
that the trocar was 5 mm because that is the most commonly
used trocar size. Mini-laparotomy skin incision length was
Journal of Minimally Invasive Gynecology, Vol 21, No 1, January/February 2014
obtained from the operative notes. Surgeon information
and operative time were collected from the records of the cir-
culating nurse.
Data on secondary outcomes were collected from the op-
erative notes, discharge summaries, and emergency room
notes available on the computerized medical record within
30 days after surgery. An emergency room visit was included
in analysis only if the reason for the visit was related to the
recent surgery. Repeat operations and readmissions were in-
cluded only if they were related to complications from the
surgery. Additional surgery indicated by the pathology
report from the first surgery was not included as a repeat
operation.
Statistical Analysis
All data were collected in Excel 2010 and analyzed using
SPSS version 18.0 (SPSS, Inc., Chicago, IL). Numerical data
were analyzed using the Mann-Whitney U test. Nominal
data were compared using a c2 test or the Fisher exact test
when appropriate. A p value of %.05 was considered statis-
tically significant. A posteriori power analysis was per-
formed with G*power. The study had 87% power to detect
a difference in estimated blood loss (d 5 0.28) and 99%
power to detect a difference in operating time (d 5 1.00).
Results
A total of 493 patients were identified who met inclusion
criteria: 141 patients (29%) underwent mini-laparotomy and
352 patients (71%) underwent laparoscopy. Patient demo-
graphic characteristics are given in Table 1. Patients undergo-
ing mini-laparotomy and laparoscopy had similar body mass
index, surgical assistant level, and preoperative hematocrit
concentration. There was a statistically significant difference
in patient age between the mini-laparotomy and laparoscopy
groups (48.6 years versus 40.9 years; p 5 ,.000).
Indications for surgery are given in Table 2, and were sim-
ilar in both groups. Overall, in the mini-laparotomy group,
137 of 141 patients (97%) underwent adnexal surgery to
treat an adnexal cyst or mass, or prophylactic bilateral
salpingo-oophorectomy in patients with the BRCA gene
Table 1
Demographic characteristics
Mini-laparotomy Laparoscopy
Variable (n 5 141) (n 5 352) p value
Age, yr 48.6 (12–88) 40.9 (12–88) ,.000
Body mass index 25.7 (13.3–51.6) 26.8 (26.0–49.9) .50
Assistant level, PGY 4 (1–5)a 4 (1–5)a .33
Preoperative hematocrit 38.4 (20.9–46.6) 38.5 (25.4–46.4) .32
concentration
PGY 5 postgraduate year.
a
PGY5 indicates assistant who had graduated from residency at time of surgery.
Kumar and Pearl. Mini-laparotomy vs Laparoscopy 111

Table 2 the laparoscopy group. Normal ovaries or teratomas were

the next most common pathologic findings.
Indications for surgerya Secondary outcomes are given in Table 4 and include
bowel or bladder injury, hemorrhage, conversion to another
Mini-laparotomy Laparoscopy
surgery, need for repeat operation, need for emergency room
Variable (n 5 141) (n 5 352)
visit because of a surgery-related problem, and need for hos-
Adnexal cyst 63 (45) 187 (53) pital admission for surgery. The cumulative secondary out-
Adnexal mass 64 (45) 94 (27) come rate in each group did not differ; 24 of 141 patients
Prophylacticb 10 (7) 25 (7)
(17%) in the mini-laparotomy group experienced at least 1
Infertility 0 4 (1)
secondary outcome, compared with 55 of 352 patients
Pain 1 (1) 14 (4)
Myoma 0 9 (3)
(16%) in the laparoscopy group. There was no difference
Carcinomatosis 2 (1) 7 (2) in conversion rate, readmission to the hospital, visits to the
Other 1 (1) 11 (3) emergency room, or repeat operation.
a
An important difference was noted in wound complica-
Values are given as No. (%).
b
Indicates BRCA gene mutation carriers or patients with a history of breast
tions. Five patients in the mini-laparotomy group had
cancer. a wound complication, compared with only 1 patient in the
laparoscopy group (statistically significant). Wound compli-
cations in the 6 patients included fascial dehiscence requir-
mutation or a history of breast cancer. In the laparoscopy ing repeat operation and superficial wound infections in 3
group, 306 of 352 patients (87%) underwent adnexal patients each. Details of each of these wound complications
surgery. are given in Table 5. In the patient with laparoscopy-related
The primary end points of estimated blood loss and oper- wound complications, the procedure was converted to ex-
ative time are given in Table 3. In patients undergoing mini- ploratory laparotomy because of adhesions, and in 2 of the
laparotomy, mean estimated blood loss was significantly less 4 patients with mini-laparotomy–related wound complica-
than in patients undergoing laparoscopy (20 mL [range, tions, the procedure was converted to full laparotomy.
1–350 mL] versus 32 mL [range, 1–300 mL]; p 5 .003). The ability to perform the intended surgery without con-
Also in patients undergoing mini-laparotomy, operative version is given in Table 6. In 9 of 141 patients (6.3%) in the
time was significantly shorter than in patients undergoing mini-laparotomy group, the procedure was converted to full
laparoscopy (49.2 minutes [range, 16–125 minutes] versus laparotomy, and in 25 of 352 patients (7.1%) in the laparos-
91.5 minutes [range, 20–311 minutes]; p 5 ,.000). copy group, the procedure was converted to mini-laparotomy
Pathology results from each group are given in Table 3. in 2 patients and to full laparotomy in 23. Adhesions were
The most common pathologic condition in each group was cited most frequently as the reason for conversion in both
benign adnexal cyst in 51 of 144 patients (36%) in the groups.
mini-laparotomy group and 136 of 352 patients (39%) in
Discussion

Table 3 Gynecologic surgeons are trained in multiple approaches

to surgery including via the vaginal route, laparotomy, lapa-
Primary outcomes roscopy, and robot-assisted laparoscopy. This ability to offer
various surgical approaches is advantageous because we can
Mini-laparotomy Laparoscopy
Variable (n 5 141) (n 5 352) p value
Table 4
Estimated blood loss, mL 20 (1–350) 32 (1–300) .003
Operative time, min 49.3 (16–125) 91.5 (20–311) ,.000 Secondary outcomesa
No. of incisions 1 3.1 (1–6) ,.000
Total length of 34.3 (20–40) 22.8 (10–65) ,.000 Mini-laparotomy Laparoscopy
incision(s), mm Variable (n 5 141) (n 5 352) p value
Pathologic finding
Conversion 9 (6) 25 (7) .64
Normal ovaries 26 54
Repeat operation 4 (3) 5 (1) .12
Benign adnexal cyst 51 136
Emergency Department visit 8 (6) 21 (6) .22
Ovarian myoma 18 22
Hospitalization 9 (6) 20 (6) .77
Benign fallopian tube 0 14
Wound 5 (4) 1 (0) .008
Teratoma 21 55
Hemorrhage 1 (0) 2 (0) .64
Endometriosis 14 30
Bowel/bladder injury 0 1 (0) .71
Myoma 0 14
Cumulative 24 (17) 55 (16) .67
Malignancy 10 12
a
Other 0 15 Values are given as No. (%).
 112
Table 5
Wound complication

Patient Intended surgical procedure Actual surgical procedure
1 L/S bilateral salpingectomy Exploratory laparotomy
and B/L salpingectomy
2 Mini-laparotomy, RSO Mini-laparotomy RSO,
3 Mini-laparotomy, LSO Exploratory laparotomy,
LSO, appendectomy
Type of wound
Conversion complication Intervention Notes
Yes Superficial wound Wound packing and On POD11, patient came to ED with wound
separation antibiotic therapy drainage. Wound was packed, and patient was
sent home with antibiotic therapy.
No Superficial wound Wound packing and Chronic wound for 3 mo. Repeat operation for
opening antibiotic therapy wound revision 3 mo postoperatively.
Yes Subfascial hematoma Wound packing Postoperative couse complicated by transfusion
and superficial because of subfascial hematoma. At follow-up,

Journal of Minimally Invasive Gynecology, Vol 21, No 1, January/February 2014

4 Mini-laparotomy, LSO Exploratory laparotomy,
LSO
5 Mini-laparotomy, LSO Mini-laparotomy, LSO
6 Mini-laparotomy, BSO Mini-laparotomy, BSO
wound separation 5-cm portion of wound was opened, and
hematoma was drained.
Yes Fascial dehiscence Repeat operation with Patient was 21 weeks pregnant at original
repair of fascia using surgery, and VAC was placed over wound for
placement of mesh several weeks.
No Fascial dehiscence Repeat operation with On POD6, wound opened due to coughing.
repair of fascia Retention sutures were removed weeks after
fascial repair. Wound healed completely by
1 mo postoperatively.
No Fascial dehiscence Repeat operation with On POD3, copious wound drainage after
repair of fascia coughing. Wound healed completely by
POD14.

B/L 5 bilateral; ED 5 Emergency Department; L/S 5 laparoscopy; LSO 5 left salpingo-oophorectomy; POD 5 postoperative day; RSO 5 right salpingo-oophorectomy; VAC 5 vacuum assisted closure.
Kumar and Pearl. Mini-laparotomy vs Laparoscopy
Table 6
Indication for conversion
Mini-laparotomy Laparoscopy
Variable (n 5 9) (n 5 25)
Adhesions 5 18
Size of mass 3 1
Non-gynecologic cancer 1 0
Inability to insufflate 0 4
Suspicion of bowel injury 0 2
better meet the needs and desires of our patients. The present
study demonstrates that mini-laparotomy should be consid-
ered part of the minimally invasive armamentarium of surgi-
cal approaches offered to patients. For this reason, we
believe that learning skills to accomplish adnexal surgery
via mini-laparotomy is an essential part of surgical residency
training.
Mini-laparotomy offers many advantages similar to those
of traditional minimally invasive approaches. Patients un-
dergo ambulatory surgery and go home within hours of com-
pletion of the procedure. They experience small blood loss,
and quickly return to functioning. In the present study, 94%
of surgical procedures performed via mini-laparotomy were
successful, without conversion to laparotomy. Operative
time was statistically improved in the mini-laparotomy co-
hort, without sacrificing other advantages of minimally inva-
sive surgery. Although blood loss was statistically improved
in patients in the mini-laparotomy group, we do not believe
this was clinically significant; both approaches resulted in
minimal blood loss. Patients did not require repeat operation
or hospital admission more frequently when undergoing
mini-laparotomy, although this study was not designed to
detect differences in these secondary outcomes. The present
study confirms the findings of previous studies of mini-
laparotomy that have retrospectively and prospectively
demonstrated short operative times and minimal complica-
tion rates [12–17]. The study was not powered to detect
differences in readmission, repeat operation, wound com-
plications, and emergency room visits; however, there
seems to be a trend toward equivalence. Wound com-
plications were more frequent in the mini-laparotomy group,
and 3 of these complications were major, that is, fascial
dehiscence. Of the 3 patients with fascial dehiscence, 1
was obese, a smoker, and pregnant, and mini-laparotomy
was converted to exploratory laparotomy. The fascial dehis-
cence in 2 patients who underwent mini-laparotomy is an
important major complication to keep in mind when coun-
seling patients for surgery because this complication did
not develop in any patients in the laparoscopy group.
Although the present study did not evaluate costs of sur-
gery, the major cost benefit of laparoscopy, that is, no over-
night hospital stay, is also an advantage in mini-laparotomy.
At our institution, patients undergoing mini-laparotomy or
113
adnexal laparoscopic surgery do not routinely stay over-
night. Mini-laparotomy does not require special operating
room equipment or instruments and thus can be performed
using the most basic and inexpensive surgical tools.
Techniques for mini-laparotomy in gynecology have
been described in the literature and include use of self-
retaining retractors [9], use of narrow instruments in the ver-
tical position, and careful coordination between assistant
and surgeon [15]. Just as resident education continues to fo-
cus on robotic and laparoscopic techniques, the techniques
unique to mini-laparotomy also must be emphasized. This
will enable graduating residents to be skilled in diverse
approaches to surgery. We believe mini-laparotomy is an
important surgical approach and worth the investment in
the surgical education of gynecology residents.
There are limitations to the present study inherent to its
retrospective design. The study relied on the integrity of
medical records and extent of data. We were unable to assess
patient subjective outcomes such as satisfaction, pain, or
return to work.
Further investigation in a prospective randomized study to
evaluate the patient perspective on mini-laparotomy compared
with laparoscopy would help guide our consultation of the sur-
gical patient. Mini-laparotomy has an important role in gyne-
cologic surgery and may provide a less expensive, potentially
shorter surgery that is well-tolerated, safe, and effective.
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