Two-trocar adnexal surgery: a ?quasi? scarless operation

Percutaneous Externally Assembled Laparoscopic Instruments: Creation of a New Surgical Paradigm

OBJECTIVES

Laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) produce excellent cosmetic outcomes, but are technically challenging. The objective of this study was to test the functionality and feasibility of a novel minimally invasive surgical paradigm, which maintains triangulation but uses special externally assembled instruments to minimize the postoperative cosmetic impact.

METHODS

Percutaneous Externally Assembled Laparoscopic (PEAL) instruments have specialized 2.96-mm shafts with interchangeable 5-mm working tips that are assembled externally. First, 5-mm laparoscopic, PEAL, and 2-mm needlescopic instruments were tested to determine piercing force on fresh human cadaver organs. In a bench-top study, 20 subjects assembled and used PEAL instruments in five different skills tests that were also compared with the same tasks using conventional laparoscopic instruments. Finally, PEAL instrument functionality was tested in a four-porcine nephrectomy feasibility study.

RESULTS

PEAL (2.80 lbF) and 5-mm laparoscopic instruments (2.28 lbF) had a significantly higher mean organ piercing perforation force compared with needlescopic instruments (1.39 lbF, p < 0.05). Average assembly time of PEAL instruments was 31.08 seconds (range: 19.83-43.85). There were no significant differences in the amount of time needed for completion of the bench-top tasks between laparoscopic and PEAL instruments (p > 0.05 for all tasks). Four-porcine PEAL nephrectomies were completed with no complications and minimal blood loss (mean 7.5 mL). Mean operative time was 98.25 minutes (range 79-116).

CONCLUSION

PEAL tools are easily assembled, have similar safety and efficacy compared with standard laparoscopic tools, and are less likely to injure organs compared with needlescopic instruments. They function well during laparoscopic nephrectomy and may decrease the invasiveness of conventional laparoscopic instrumentation.

Embryonic natural orifice transumbilical endoscopic surgery (E-NOTES) for adnexal tumors

BACKGROUND

Embryonic natural orifice transumbilical endoscopic surgery (E-NOTES) has shown promise as a minimally invasive laparoscopic surgery technique.

OBJECTIVE

To investigate the feasibility and surgical outcome of E-NOTES for adnexal tumors.

METHODS

We performed E-NOTES in 12 patients with adnexal tumors through a 2-cm intraumblical incision. A single-port access system comprising a wound protractor and a surgical glove was used. A prospective data registry was used in this study.

RESULTS

Since 1 July 2008, 12 patients have undergone E-NOTES for adnexal tumors. E-NOTES in all 12 cases was completed successfully without conversion to standard laparoscopic approach. Median operative time for creating an E-NOTES access system and the ensuing operative procedures was 6 min (range 5-15 min) and 73 min (range 25-110 min), respectively. Median blood loss was <10 ml. No complications requiring treatment occurred.

CONCLUSION

E-NOTES is a feasible alternative method for resection of adnexal tumors with better cosmetic outcome. More experience and instrumental improvement suitable for E-NOTES are needed.

Should adnexal mass size influence surgical approach? A series of 186 laparoscopically managed large adnexal masses

OBJECTIVE

To evaluate the feasibility and safety of laparoscopic management of adnexal masses > or = 10 cm in size.

DESIGN

Prospective cohort study.

SETTING

Two Gynecology Departments of University Hospitals.

POPULATION

All women presenting with an adnexal mass > or = 10 cm in diameter were candidates for laparoscopic management. Women were excluded from laparoscopic approach if there was evidence of ascites or gross metastatic disease. Neither the sonographic features of the cyst nor elevated serum CA125 level was used to exclude women from having a laparoscopic approach.

METHODS

A single operative protocol was followed for all women. All removed specimens were sent for immediate pathological evaluation.

MAIN OUTCOME MEASURES

Rate of conversion to laparotomy, incidence of cancer encountered, and operative complications.

RESULTS

One hundred and eighty-six women underwent laparoscopic evaluation for an adnexal mass of 10 cm or larger in size. The average preoperative mass size was 12.1 +/- 4.9 cm. A benign pathological condition was found in 86.6% (161/186) of the women, primary ovarian cancer in 16 (8.6%) women, a metastatic tumour of gastrointestinal origin in 1 (0.5%) woman, and a low malignant potential ovarian tumour in 8 (4.3%) women. Laparoscopic management was successful for 174 (93.5%) women. Reasons for conversion to laparotomy included anticipated technical difficulty (n = 7) and malignancy (n = 5). No intraoperative complications occurred in the entire study group.

CONCLUSIONS

The vast majority of large adnexal masses can be safely resected laparoscopically, provided that there is expertise in laparoscopic surgery, immediate access to frozen section diagnosis, and preparation of patient to receive an adequate cancer surgery where indicated.

Laparoscopy versus laparotomy for the surgical management of apparent early stage ovarian cancer

OBJECTIVE

To compare the results of laparoscopic staging of apparent early ovarian cancer (EOC) with those obtained with comprehensive surgical staging via laparotomy.

METHODS

Consecutive patients undergoing comprehensive laparoscopic staging for presumed EOC (LPS group; N=15) were compared with historical controls selected from consecutive women who have had conventional staging with open surgery (LPT group; N=19).

RESULTS

No difference was found in demographics and preoperative variables between the two groups. There were no significant differences between the two groups with regard to median number of lymph nodes and likelihood of identifying metastatic disease. No conversion to laparotomy and no intraoperative complication occurred in the LPS group. Operative time was significantly longer in the LPS group when compared with the LPT group (377+/-47 vs. 272+/-81 min, P=0.002). One patient in the LPS group had a retroperitoneal haematoma recognized in the postoperative period, and this required laparotomy and ligature of the hypogastric arteries to achieve haemostasis. Minor postoperative complications occurred in 1 (6.7%) patient in the LPS group and in 8 (42.1%) patients in the LPT group (P=0.047). Hospital stay was significantly shorter in the LPS group [3 (2-12) vs. 7 (4-14) days, P=0.001]. Median (range) follow-up time was 16 (4-33) and 60 (32-108) months in the LPS and LPT group, respectively. Eleven (73.3%) patients in the LPS group and 13 (68.4%) in the LPT group received adjuvant treatment. There were no recurrences in the LPS group whereas 4 (7.1%) recurrences occurred in the LPT group. Overall survival was 100% in both groups.

CONCLUSION

Our results suggest that laparoscopic comprehensive surgical staging of EOC is as safe and adequate as the standard surgical staging performed via laparotomy.

Laparoscopic management of endometrial cancer in nonobese and obese women: A consecutive series

STUDY OBJECTIVE

To assess the technical feasibility and surgical outcome of a 5 mm-ports technique in a consecutive series of women with endometrial cancer laparoscopically managed.

DESIGN

Prospective collaborative cohort study (Canadian Task Force classification II-2).

SETTING

Two gynecologic oncology units of university hospitals.

PATIENTS

A series of consecutive patients undergoing laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy for the treatment of endometrial cancer.

INTERVENTIONS

A 10-mm zero-degree umbilical operative laparoscope and three 5-mm suprapubic trocars were used. The lymph nodes were removed with the use of a specimen bag through the umbilical port. Intraoperative and postoperative details and complications were prospectively collected.

MEASUREMENTS AND MAIN RESULTS

A total of 101 patients were enrolled. Twenty-two (21.8%) had a body mass index (BMI) of 30 kg/m2 or higher, and nine (8.9%) were severely obese (BMI > or =35 kg/m2). One hundred procedures (99%) were carried out entirely with only three 5-mm ancillary trocars. In one patient, a 5-mm trocar was replaced with a 10-mm trocar because of a lesion of the external iliac vein requiring the placement of vascular clips. One procedure needed to be converted to laparotomy. Intraoperative complications occurred in three patients (one bladder injury and one iliac vein injury, both managed laparoscopically, and one subcutaneous emphysema). Postoperative complications occurred in 10 (10%) patients. The only complication requiring a subsequent intervention was a symptomatic pelvic lymphocyst. No difference was found in surgical outcomes between obese women and those of ideal BMI.

CONCLUSION

The use of only 5-mm ancillary trocars for the laparoscopic treatment of endometrial cancer can further minimize surgical invasiveness without compromising surgical efficacy and safety in patients with high BMI as well as for women with ideal BMI.

Minimizing ancillary ports size in gynecologic laparoscopy: A randomized trial

STUDY OBJECTIVE

To evaluate the feasibility, safety, and effect on postoperative pain of laparoscopy for the management of adnexal masses by downsizing ancillary trocars from 5- to 3-mm.

DESIGN

Randomized, controlled trial (Canadian Task Force classification I).

SETTING

Gynecologic department of a university hospital

PATIENTS

A total of 102 women with an adnexal mass scheduled for gynecologic laparoscopic procedures were randomized to undergo laparoscopy using either conventional 5-mm ancillary trocars (n=52) or 3-mm instruments (n=50). Preoperative suspicion of malignancy, deep infiltrating endometriosis, and indications for hysterectomy or myomectomy were considered as exclusion criteria.

INTERVENTIONS

Laparoscopic procedures for the treatment of benign adnexal masses.

MEASUREMENTS AND MAIN RESULTS

Both groups were similar in patient age, body mass index, history of abdominal surgery, and type of procedures. Intraoperative complications occurred in no patient (0%) in the 3-mm group and in two patients (3.8%) in the 5-mm group (p=.49). Conversion from 3- to 5-mm instrumentation was necessary in one procedure. No difference was found in the operative time between the 3-mm and the 5-mm groups (54 min [range 15-175 min] vs 50 min [range 20-150 min], p=.89). The severity of incisional pain was evaluated with a 100-mm visual analog scale at 1, 3, and 24 hours after surgery. Postoperative pain was significantly lower in the 3-mm than in the 5-mm group 1 hour after laparoscopy (20 [range 0-60] vs 32.5 [range 0-80], p=.04). The proportion of women requiring analgesia before discharge, the timing of analgesic requirement, and the total amount of medication in the first 24 hours after surgery were similar in the two groups.

CONCLUSION

Three-millimeter ancillary trocars can safely replace traditional-size equipment for the management of adnexal masses without a negative impact on the surgeon's ability to perform gynecologic laparoscopy and are associated with less immediate postoperative pain.

Laparoscopy in patients over 60 years old: a prospective, randomized evaluation of laparoscopic versus open adnexectomy

OBJECTIVE

To compare objective and subjective parameters of surgical stress following laparoscopic and open adnexectomy in patients older than 60 years old.

STUDY DESIGN

Twenty patients with a benign ovarian tumour were prospectively randomized to undergo adnexectomy by a laparoscopic or an open surgical procedure. Measurements included C-reactive protein; interleukin-6 before, during, and after surgery; intensity and duration of postoperative pain; and complications and recovery period. Statistical analysis consisted of analysis of variance and a Mann-Whitney U test.

RESULTS

The levels of the interleukin-6 and C-reactive protein differed significantly between the 2 operative procedures (P = .013) in favor of the laparoscopic approach. The laparoscopic approach was associated with a reduction in operative morbidity, postoperative pain, analgesic requirement, and recovery period.

CONCLUSIONS

Minimally invasive surgery is of particular benefit to elderly patients if there is a plan in place for appropriate staging and treatment by laparotomy for malignancy. It should be the first choice and may help to reduce postoperative complications.

One-trocar salpingectomy for the treatment of tubal pregnancy: a ‘marionette-like’ technique

Laparoscopic salpingectomy for the treatment of tubal pregnancy has traditionally been performed with two ancillary trocars. We report a novel single-port technique requiring only an umbilical operative laparoscope and a percutaneous midline suture, inserted with a straight needle, to retract the affected fallopian tube. A total of 10 ectopic pregnancies have been successfully treated with this approach. The procedure was not technically demanding and the operative time was comparable to that of standard laparoscopic methods. No intraoperative and postoperative complication occurred. Ancillary trocars were not necessary in any of these cases. Our results showed that one-trocar salpingectomy is a feasible and safe technique.