SPA-LAVH for adenomyosis with coexisting myoma (46-year-old woman). (a) Transumbilical single route for surgery using Alexis wound retractor. Distal ring was loaded within the intraperitoneal space and tightly turned inside out of the proximal ring, creating an effective seal and a wider opening of the single-port incision by connecting retractable sleeve between the distal and proximal rings. The fascial edges were tagged with suture for traction prior to port system installation; this was useful for fascial closure at the end of the procedure. (b) Homemade, three-channel, single-port system using the Alexis wound retractor and a surgical glove. A sterile surgical glove was placed over the proximal ring and fixed tightly, and three trocars were inserted through surgical glove with cut edges of the distal fingertips and tied with an elastic string. Varying the height of the trocar head minimized clashing of the bulkiest portion of the trocar head and the instrumental grip (the external handle) extracorporeally overlapping. (c) Laparoscopic finding: huge uterine leiomyoma with coexisting adenomyosis. The largest dimension of the uterus was 15 cm. (d) Photograph showing an extirpated uterus. The weight of the uterus was 750 g. Compared with 50 mL disposable syringe. (e,f) Photograph showing the postoperative umbilical skin wound (postoperative day 1 and 4 weeks).
